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320 George CHALKIADIS
Plain local anaesthetic (2–4 ml levobupivacaine
0.25%) is injected either side of the suspensory
ligament into this space as communication across
the suspensory ligament is variable.
Caudal epidural block
Caudal epidural blockade provides effective
analgesia for sub-umbilical surgery. It is a technique
that is easily learnt. Its safety has been established
in a large series [65]. No special equipment is
necessary. A 23G hypodermic needle or the
advancement of a 22G intravenous cannula once
the sacrococcygeal membrane is penetrated, are
commonly used techniques. Specifically designed
needles are also available. For instance 20G, 22G
and 25G caudal needles that incorporate a 32° bevel
are commercially available (B.Braun Melsungen
AG, Germany).
Figure 19.02 Lateral view demonstrating the triangle bounded by the symphysis pubis, corpus cavernosum
and membranous layer of superficial fascia through which the dorsal nerve of the penis passes and into which
local anaesthetic is injected. The needle is inserted to hit the symphysis pubis (1) and then redirected through
the fascia a few millimetres deeper (2).
(This Figure was originally published in Anaesthesia for Children, 2nd edn. Blackwell Scientific Publications, Oxford 1992,
edited by TCK Brown and GC Fisk. Permission to use in this Chapter is granted from Blackwell Scientific Publications).
To perform caudal epidural blockade, the
sacrococcygeal membrane is located by feeling
for the sacral cornua and the sacral notch. is
corresponds to the apex of an equilateral triangle
formed by the posterior superior iliac spines and
the membrane itself. Another simple technique
is to place the pulp of the third finger over the
coccyx with the finger pointing towards the feet.
e position of the proximal interphalangeal joint
will be located over the sacrococcygeal membrane
regardless of age, as this distance does not change
after birth.
Many studies have been published seeking to
determine the optimal volume, concentration and
agents needed to prolong duration and reduce
sedation, nausea, urinary retention and motor
blockade. Unfortunately, conclusions are limited
by most studies including any sub-umbilical
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Pain in Children and Adolescents 321
procedure and wide age ranges, not having the
ability to accurately determine block height in
non-verbal children and using proxy measures such
as time to first analgesia to determine the duration
of caudal block. Studies are difficult to perform as
most suitable procedures are these days performed
as day cases with children often discharged from
hospital within 4 hours of their procedure. Studies
also provide conflicting evidence regarding choice
of local anaesthetic agent. Recent studies comparing
motor block after levobupivacaine and bupivacaine
caudal anaesthesia demonstrated no difference
between the two agents in one study [59], and
significantly greater incidence of motor block
after racemic bupivacaine in two others [27, 92].
Furthermore, many studies compare either the same
concentration [77, 92] or a lower concentration
[78] of ropivacaine to levobupivacaine, despite
evidence suggesting that levobupivacaine is 19%
more potent than ropivacaine [20].
It is possible, however, to conclude that bupivacaine,
ropivacaine and levobupivacaine provide effective
analgesia which lasts for several hours [92]. Motor
block is more likely when more concentrated
solutions of local anaesthetic agents are used [27,
44, 59, 92]. In neonates and infants, blockade
can reliably be achieved to the low thoracic
dermatomes while in older children, it cannot. e
literature supporting the prolongation of analgesia
by adding adjunct analgesics such as opioids,
clonidine, tramadol, neostigmine, S-ketamine,
midazolam or adrenaline is vast and inconsistent
[10, 42]. e caudal administration of S-ketamine
with or without the addition of clonidine, and
without local anaesthetic, seems promising [69,
120]. Adrenaline 5 mcg.ml
-1
is also used to detect
inadvertent intravascular injection by monitoring
blood pressure, the electrocardiograph trace and
pulse rate by some. Sensitivity is improved by
pre-treatment with atropine, 5 minutes prior to
the injection of the adrenaline-containing local
anaesthetic solution [139].
A rough guide to dosage is 0.5 ml/kg for surgery
in the perineal and genital region, 1–1.25 ml/
kg for inguinal and lower limb surgery, up to a
maximum volume of 20 ml. A 0.2–0.25% solution
of levobupivacaine is effective. Precautions should
include establishment of intravenous access and the
use of a sterile technique. e needle or cannula
should be withdrawn if blood is encountered in the
hub and re-inserted to avoid intravascular injection,
while minimal advancement of the needle once the
sacrococcygeal membrane is penetrated reduces the
risk of the intrathecal injection.
Femoral nerve block
Continuous femoral nerve block is relatively simple
to perform by inserting a catheter in children [79].
After the application of topical local anaesthetic
cream and/or skin and subcutaneous tissue local
anaesthetic infiltration, an 18G Tuohy needle is
inserted immediately lateral to the femoral artery,
distal to the inguinal ligament. After the needle
passes through the skin, two distinct “pops” can be
felt as the needle pierces the fascia lata and then,
fascia iliaca. Correct positioning can be confirmed
using a saline-filled syringe; a loss of resistance
and easy injection of saline should occur after
penetration of the fascia iliaca. Should the needle
be inserted too deeply, it enters the iliopsoas
muscle and saline injection is difficult. An epidural
catheter is then advanced 3–5 cm beyond the tip
of the Tuohy needle. An initial dose of 0.25 ml/
kg 0.5% bupivacaine, 0.5% levobupivacaine or
0.75% ropivacaine can be administered to establish
the block and topped up intermittently as the
block recedes or 0.2 ml/kg/h 0.125% bupivacaine,
0.125% levobupivacaine or 0.2% ropivacaine can
be administered by continuous infusion.
A single-shot femoral nerve block can also be
performed using a short bevelled needle to facilitate
the appreciation of the “pops” using the same
landmarks. A nerve stimulator and ultrasound can
also be used to localise the nerve. Femoral nerve
block provides excellent analgesia in patients with
femoral shaft fractures. ey can then be X-rayed,
transferred and manipulated in comfort. e
sensory distribution of the femoral nerve covers
the anterior aspect of the thigh and by blocking
the saphenous nerve, extends distally to the medial
aspect of the lower leg.
Local anaesthetic wound inltration
Wound infiltration with local anaesthetic at the
start or end of surgery is routine practice in many
hospitals. It is a useful adjunct to superficial and
deep laceration repair, providing focal analgesia
both in the operating theatre and in emergency
departments. It is used after most procedures,
including open and laparascopic general surgery,
neurosurgery, orthopaedic and plastic surgery.
Dentists commonly inject local anaesthetic to
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322 George CHALKIADIS
incidence of complications is low, but that children
undergoing defined procedures actually benefit
from epidural analgesia. Children with cerebral
palsy undergoing multilevel surgery, neonates
undergoing thoracic or abdominal surgery who
would otherwise remain intubated postoperatively
and adolescents undergoing the NUSS procedure
are all likely to show improved postoperative
outcome with epidural analgesia [119], but well-
designed, randomised, controlled studies are
lacking at this time.
Intrathecal (spinal) block
Spinal anaesthesia is used in some centres to
provide surgical anaesthesia in neonates undergoing
inguinal herniorraphy. Levobupivacaine 0.5% 1.25
mg/kg provided a mean duration of lower limb
motor blockade of 81.7 minutes (range 75.8–87.6
min) [60], significantly longer than that attained
from ropivacaine 1.08 mg/kg (mean 60 min,
range 51.5–68.5 min) [58]. Racemic bupivacaine
0.5% 0.2 ml/kg (with a minimum volume of 0.5
the base of teeth, avoiding the uncomfortable
numbness such that accompanies inferior alveolar
or lingual nerve block.
e addition of adrenaline to the local anaesthetic
solution is utilised by surgeons to reduce bleeding
especially with cleft lip or palate repair, craniotomy
and suturing of facial lacerations. Adrenaline-
containing solutions must never be injected into
the digits, nose, ear or penis, where end arterial
supply may be compromised leading to ischaemia.
e volume of local anaesthetic used is limited by
the safe dose limits which can be found in Table
19.01.
Intra-articular local anaesthetic installation
Intra-articular injection of local anaesthetic is
useful after arthroscopic procedures on joints.
After knee arthroscopy, 20 ml of local anaesthetic
with or without adrenaline or clonidine, but not
intra-articular morphine [131], has been shown
to provide effective analgesia in adults [28, 134].
In younger patients, the dose will need to be
scaled down so that the safe dose limit will not be
exceeded.
Epidural
Epidural analgesia in paediatric patients is safe
despite the fact that it is performed while patients
are under general anaesthesia [88]. e overall safety
record may have been enhanced, as it is generally
very experienced proceduralists who will insert
epidural catheters in anaesthetised children. In
children, epidural analgesia has been shown in two
retrospective studies to improve outcome after open
fundoplication [104, 110]; many centres would of
course now offer the laparoscopic technique. An
editorial highlighting the lack of objective outcome
data supporting the use of epidural analgesia in
children generated much correspondence [32].
ere is no greater satisfaction for the paediatric
anaesthetist than to see the child they anaesthetised
sitting up, smiling in bed after a major procedure.
Epidural analgesia can be extremely effective, to
the point where complications such as pressure
sores or compartment syndrome, may result. On
the other hand, epidural analgesia is sometimes
ineffective, with some figures quoting problems in
up to 20% [179, 183]. Like all areas in medicine,
it is necessary to demonstrate not only that the
Table 19.02 Commonly used nerve blocks in
children, and their indications
Block Indications
Ilioinguinal block Inguinal herniorraphy
Orchidopexy
Hydrocoele repair
Rectus sheath block Umbilical hernia repair
Penile block* Circumcision
Caudal epidural block Sub-umbilical surgery
including lower limb
surgery
Femoral block Femoral shaft fracture
Femoral osteotomy
Brachial plexus block Interscalene approach
for shoulder surgery
Axillary approach for
forearm surgery
Supraorbital/
infraorbital/mental
nerve block
Minor facial surgery
Digital nerve block* Finger or toe surgery
Ankle block Foot surgery
* Plain local anaesthetic solutions must be used for these
blocks.
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Pain in Children and Adolescents 323
ml) has also been used successfully. Administering
a sucrose-dipped pacifier is helpful as well as
supporting theatre drapes over the baby’s head to
attain a darkened environment. Spinal anaesthesia
should be performed through the L4–L5 or L5S1
to avoid trauma to the spinal cord that terminates
at the lower border of L3 at the time of birth.
Atropine (10 mcg/kg) administered prior to the
procedure reduces the likelihood of bradycardia
which may occur with a high block [81]. Aseptic
and bacterial meningitis have been reported after
spinal anaesthesia in infants, mandating an aseptic
technique [47, 94].
Special considerations
Burns
Children with severe burns require resuscitation in
the intensive care unit (ICU) and in our experience
have a rapidly escalating analgesic requirement
receiving at times up to 100 mcg/kg/h of morphine
in addition to ketamine and midazolam by
continuous infusion for sedation and analgesia.
Rapid reduction in opioid dose may precipitate
withdrawal symptoms. Accumulated metabolites
such as morphine-3-glucuronide may also be
responsible for the neurological sequelae that are
often interpreted as seizure activity [167]. Clonidine
is helpful in this setting to attenuate jitteriness and
sleep issues that ensue when children are transferred
to the ward from the ICU setting. In addition to
its sedative, anxiolytic and analgesic actions [117],
clonidine blunts the sympathetic overactivity
(tachycardia and hypertension) that occurs during
drug withdrawal [5]. Dexmedetomidine is 200
times more alpha-2 selective and has been used
successfully for sedation in the setting of escalating
sedation requirements in children with burns
in ICU [168] and to treat symptoms of opioid
withdrawal [156].
Primary and secondary hyperalgesia occur after
burns injuries. Local inflammation at the site of
injury causes the induction of cyclo-oxygenase-2
(COX-2) leading to the release of prostanoids which
sensitise peripheral nociceptors, producing localised
pain and hypersensitivity. Cyclo-oxygenase-2
induction may also occur centrally, and is mediated
by the rapid and long-lasting increase of CSF
interleukin-1 beta, as well as elevating cerebrospinal
fluid prostaglandin E2. Hypersensitivity to pain is
strongly inhibited by COX-2 inhibitors [17, 135].
Using selective COX-2 inhibitors (e.g. celecoxib)
or NSAIDs with a stronger COX-2 inhibitory
profile such as meloxicam, may be more effective
than non-selective NSAIDs, and less likely to result
in gastric irritation.
Children with burns injuries undergo frequent and
painful skin grafting and burns dressing changes.
Depending upon how well these are managed,
children may experience procedural anxiety. Further,
up to one-third of children with burns injuries
develop post-traumatic stress disorder and more
than half exhibit post-traumatic symptoms [148].
Pruritis is often intense for which antihistamines
and gabapentin may be helpful [106].
Opioids such as morphine administered by
intravenous infusion or a PCA, if appropriate,
in combination with ketamine infusion are the
mainstay of analgesia in the initial phase and
after grafting and dressings. Also, NSAIDs may
be helpful. ere may be a role for gabapentin or
antidepressant medications too.
Adequate sleep is important with prolonged
hospitalisation. Melatonin, clonidine, amitriptyline
and non-pharmacological techniques such
as soothing music, relaxation techniques and
assessment and treatment for any psychiatric issues
may be helpful.
Cerebral palsy
Cerebral palsy is the most common condition
associated with childhood disability. Children
with cerebral palsy frequently undergo orthopaedic
procedures to treat deformity. ese children have
increased muscular tone and are prone to intensely
painful muscle spasms which are more likely to
occur if the child experiences discomfort [118].
Epidural analgesia by continuous infusion or
intermittent bolus can work well to treat pain in
this setting. No pain means no muscle spasm. Oral
diazepam (0.1 mg/kg) or midazolam (0.5 mg/kg)
are used to treat muscle spasms when they occur.
With an epidural catheter in situ, sudden pain
(regardless of aetiology) should be rapidly managed
by administering a bolus of the epidural solution
and by an increase in infusion rate. e addition
of clonidine to the local anaesthetic may also be
helpful.
Single event multilevel surgery refers to multiple
lower limb operations (osteotomies, tendon
releases, tendon transfers) performed under the
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324 George CHALKIADIS
one anaesthetic, often bilaterally, based on findings
from gait analysis. Multiple dermatomes (T12–S2)
may need to be covered depending on the actual
procedures. It is helpful when bony surgery is
performed at the hips and the feet, to insert two
epidural catheters, one at L1/2 and the other at L4/5
to improve the reliability of epidural blockade (Fig.
19.03). e total dose of local anaesthetic remains
the same, but is divided between the two catheters.
Postoperatively, smaller boluses, through the
catheter whose tip is closest to the nerves supplying
the dermatomes where breakthrough pain occurs,
are required than if one catheter is sited at L2/3 or
L3/4 [118].
A prolonged rehabilitation is necessary after
multilevel surgery. Neuropathic pain following
nerve stretch injury as contractures are released
may interfere significantly with rehabilitation.
Gabapentin may be helpful [90].
e administration of botulinum toxin A at the
time of adductor surgery decreases postoperative
pain scores, mean analgesic consumption and
the length of hospital stay, indicating that muscle
spasms play a significant role [18].
A survey of non-ambulatory adolescents and
young adults with cerebral palsy found that half
experienced hip pain, and although it interfered
with daily activity in one-quarter of these, analgesia
was infrequently administered [72]. Many children
with spastic diplegic and spastic quadraplegic
cerebral palsy develop progressive hip subluxation
that over time leads to painful hip dislocation (Fig.
19.04). Subluxation may occur from the age of 18
months and dislocation by 6 years. Joint capsulitis
and arthritis eventually also contribute to pain (Fig.
19.05). Pain at rest and on transferring patients is
common, as is interrupted sleep for the child and
their family. Unfortunately once hip dislocation
has occurred, orthopaedic management is limited.
Early detection and management is necessary.
Hip surveillance clinics, early intervention with
botulinum toxin, adductor tenotomies or obturator
nerve neurolysis with phenol are helpful in the early
stages of subluxation [46]. Femoral osteotomies are
performed when skeletal maturity is reached.
Neuromuscular weakness
Children and adolescents with Duchenne’s
muscular dystrophy or spinal muscular atrophy
Figure 19.03 Non-ionic contrast injected into the
upper and lower epidural catheters demonstrating
large spread. Note that the contrast meets in
between to cover many dermatomes.
may undergo surgery for progressive kyphoscoliosis.
Concerns regarding their ventilatory capacity have
led some centres to use tramadol, paracetamol
and ketamine as the mainstay of postoperative
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Pain in Children and Adolescents 325
analgesia, supplemented if needed by low-dose
opioid.
Procedural Pain Management
Fear, anxiety, pain and distress often accompany
minor medical procedures. Poorly managed, these
“minor” procedures can lead to severe psychological
trauma, needle phobias and refusal to attend
hospital, especially in children who undergo
repeated procedures. In young children, inadequate
analgesia for initial procedures may diminish
the effect of adequate analgesia in subsequent
procedures [170]. Even neonates exposed to
repeated heel lances in the first 24 to 36 hours of
life learn to anticipate pain and exhibit more pain
behaviour during subsequent venepuncture [152].
Neonates, infants and children in ICUs often
undergo multiple procedures, often several times
each day. is remains poorly managed [169].
Contributing factors include the skill of the
proceduralist, failure to consider analgesia, the
fact that small children can be overcome by brute
force, threatening environments, cultural attitudes
and ineffective treatments for brief, noxious insults
[30].
Non-pharmacological strategies
A number of non-pharmacological strategies are
useful in children, including holding for comfort
[145] and distraction, such as play therapy [127],
television [19] and virtual reality [63]. Soothing
music may reduce the child’s hypervigilance [39,
171]. Preparation of the child and parent is useful.
In particular, parents should be educated prior
to procedures in what are helpful and unhelpful
things to say. Likewise health care providers must
be educated how they can reduce anticipatory fear
using simple strategies such as the language they
use to explain what they are about to do. In the
emergency department setting, consideration must
be given to the subtleties which are often not alluded
to, that is how to least threaten a frightened child
[186]. Useful strategies include bobbing down to
the child’s eye level, nursing the child in the parent’s
arms, commenting on the toys the child may have
brought in, gaining trust by talking to the child,
as well as to the parents, and explaining what is
happening in a manner appropriate for the child’s
age, distraction and dealing with pain early by using
analgesics and/or splinting. Preparing equipment
prior to the child entering the treatment room and
hiding intimidating equipment from the child’s
view is important. Combining these techniques
Figure 19.04 Hip dislocation in a young
adolescent with cerebral palsy that was not detected
early.
Figure 19.05 A dysplastic femoral head excised
from an older adolescent with cerebral palsy. It
is not surprising that this individual experienced
persistent pain.
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326 George CHALKIADIS
with effective use of topical local anaesthetic
creams can, for example, reduce pain and distress
around venepuncture or intravenous cannulation
completely (Fig. 19.06).
Pharmacological strategies
Topical local anaesthesia, nitrous oxide (50–70%)
[56, 82] and ketamine [50] can be used to manage
mild procedural pain. In neonates, sucrose has been
shown to be effective [147].
e transdermal route has become popular for the
application of topical local anaesthetic agents such
as amethocaine and lignocaine, with prilocaine
facilitating painless intravenous cannulation [101],
cannulation of central venous ports [109], lumbar
puncture [83] and insertion of subcutaneous
cannulae. e local anaesthetic drugs must be
applied under an occlusive dressing, which needs to
remain on the skin for around 60 minutes to ensure
anaesthesia of the skin. Iontophoresis of lignocaine
is more rapidly effective (within 10 minutes) but
disposable electrodes are expensive [108, 116].
Consideration to more effective analgesia should be
given to children undergoing fracture manipulation.
Both prilocaine and lignocaine administered via
intravenous regional anaesthesia at a dose of 3
mg/kg have been used to treat forearm fractures
in children. Both are effective, although lignocaine
provided superior analgesia [41].
A number of solutions which can be instilled
without injection have been used for many years to
provide analgesia to suture lacerations in paediatric
emergency departments. ere does not seem to
be a significant difference in their efficacy [137,
140]. ese include combinations of: tetracaine
(amethocaine) 0.5%, adrenaline 1:2000 and cocaine
11.8% (TAC); lignocaine 4%, adrenaline 1:2000
and tetracaine 2% (LAT); adrenaline 1:1000,
lignocaine 4% and amethocaine 0.5% (ALA); and
bupivacaine/noradrenaline (BN). e maximum
dose of LAT and ALA is 0.1 ml/kg, to a maximum
of 3 ml. e solution is applied on a piece of gauze
or cotton wool, placed in the wound and held in
place by an occlusive clear plastic dressing such as
Opsite® or Tegaderm®. It is left in place for 20 to 30
minutes. Anaesthesia lasts about 60 minutes.
Should these be unavailable or contraindicated
(areas of end artery supply), topical anaesthesia can
be applied first using amethocaine or EMLA. Fine
gauge needles (27–32G) can then be used to slowly
inject lignocaine or bupivacaine into the lacerated
surface (not intact skin).
Percutaneous supraorbital, infraorbital or mental
block for facial lacerations is less painful than local
infiltration and has been demonstrated to be more
effective [153].
In the distressed child, consideration should also
be given to sedation during the procedure [84].
For facial suturing in 2- to 6-year-old children,
continuous-flow nitrous oxide was more effective
in reducing distress, and had fewer adverse effects
and shorter recovery times, than midazolam [93].
General anaesthesia may be preferred by parents
and children, especially when multiple procedures
are required [38].
Inhaled methoxyflurane (0.1–0.2%) administered
by paramedical staff has been shown to be effective
for pre-hospital analgesia in children [15].
Figure 19.06 Child undergoing intravenous
cannulation. The topical local anaesthetic
amethocaine was removed after 60 minutes, and
the child sat on the mother’s lap with the hand to
be cannulated placed under the mother’s axilla
facilitating distress free and painless intravenous
cannulation. Distraction in the form of play or music
therapy or television can help to further guide the
child’s attention away from the procedure.
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Pain in Children and Adolescents 327
When sedative agents are administered in addition
to analgesia, an appreciation of the continuum and
the potential for progression from minimal sedation
to general anaesthesia is necessary. Adequate pre-
sedation assessment and patient monitoring during
sedation and post-sedation are necessary. Various
bodies have issued sedation guidelines including
recommendations regarding fasting prior to the
administration of sedative drugs, practitioner and
practice guidelines; however, no clear consensus
exists. A recent review of the topic highlights many
of these controversies [89].
Persistent Pain Management
Epidemiology
European data from Holland [122] and Germany
[132] suggest that over one-quarter of children and
adolescents experience persistent pain, although
only a few develop pain-associated disability
syndrome. Attempts to identify consistent patterns
and factors that predict functional disability have
failed [62]. is is not surprising given the multiple
and heterogenous aetiologies that contribute to
persistent pain in childhood and adolescence (Fig.
19.07).
Persistent pain is not a single condition, making
its classification and generalisations regarding
treatment difficult. Children referred for
management of persistent pain fall into three broad
categories:
• Persistent pain with no clear diagnosis from
clinical examination and investigations, e.g.
recurrent abdominal pain, chronic daily
headache
• Persistent pain with identifiable pathology,
e.g. hip pain in children with cerebral palsy,
benign intracranial hypertension, rheumatoid
arthritis, chondromalacia patellae,
epidermolysis bullosa
• Sympathetic maintained or neuropathic pain,
complex regional pain syndrome (CRPS) type
I or II.
Regardless of which category the child belongs to,
thorough biopsychosocial assessment will identify
factors that have predisposed and led the child to
developing a persistent pain problem, factors that
have resulted from experiencing persistent pain and
allow an interdisciplinary group to optimise pain
management.
Persistent pain is associated with a significant
socioeconomic burden which is borne by the child
and its family [142]. In adults, days off work can be
measured and costed, with insurers often bearing
the financial costs of work- or motor vehicle-
related injuries. In children, school absenteeism
may result in poor academic performance, possibly
having to repeat the academic year with the social
ramifications that follow, such as teasing and loss of
self-esteem. Parents may need to take carer’s leave or
cease employment to care for their child and attend
medical appointments. Well-intentioned families
seeking to rid the child of pain often spend vast
sums attending a variety of practitioners including
physiotherapists, general practitioners, medical or
surgical specialists and alternative practitioners,
and trialing a variety of medications and treatments
without success.
Assessment
e biopsychosocial model helps conceptualise
both assessment and management and highlights
the need for an interdisciplinary approach. ere is a
bi-directional relationship between biopsychosocial
factors which contribute to and maintain pain, and
which result in and from pain-associated disability
(Fig. 19.07). In childhood and adolescence,
pain disability is often manifested by school
absenteeism, social withdrawal and reluctance to
engage in sport [33]. e complexity of persistent
pain in childhood mandates comprehensive
multidisciplinary assessment and treatment.
An interdisciplinary model in which a team of
diverse specialist health care providers integrate
information about the child and its family, and
jointly develop a comprehensive treatment plan,
affords synergistic benefits over a multidisciplinary
approach with serial involvement involving the
same disciplines [163].
e interdisciplinary approach acknowledges
that persistent pain in childhood and adolescence
may be caused, contributed to and maintained
by a diverse range of biopsychosocial factors (Fig.
19.07). Elucidating their relative contribution
helps formulate an integrated, individualised goal-
oriented treatment plan, that when delivered with
intensity, constitutes a therapeutic tidal wave. It is
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328 George CHALKIADIS
Figure 19.07 Biopsychosocial model for persistent pain. This model shows the complex and bi-directional
nature of factors contributing to and maintaining persistent pain and its consequences. These factors guide
assessment and direct treatment. Copyright.
PAIN
Social
Biological Psychological
Social consequences:
• Social withdrawal
• Poor academic
performance
• School absenteeism
• Reduced leisure
activity
• Behavioural problems
Social causes:
• Bullying
• Parental and sibling disharmony/
conflict
• Intellectual disability
• Poor school performance
• Poor social skills
• Parental illness and role modelling
• Parenting style
• Parental expectation
Psychological
consequences:
• Depression
• Fear
• Anxiety
• Loss of self-esteem
Psychological causes:
• Depression
• Anxiety
• Low self-esteem
• Poor body image
• Parent and
child emotional
regulation
• Fear
• Individual and
family coping
strategies
PAIN ASSOCIATED DISABILITY
Biological consequences:
• Physical deconditioning
• Poor posture
• Secondary discomfort
• Poor concentration
• Sleep disruption
Biological causes:
• Trauma
• Inflammation
• Neuralgia
• Posture
• Workstation
— lighting,
seating, desk
and computer
screen height
• Post viral
• Visual acuity
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Pain in Children and Adolescents 329
and osteopaenia compared with the child with
recurrent abdominal pain who has withdrawn from
life and physical activities. is is an important
point when comparing and interpreting results
from different centres.
At the Royal Children’s Hospital in Melbourne,
Australia, there is no facility to conduct regular
inpatient programmes. e acute ward environment
and bed shortage situation is such that treatment
goals (which include return to normal functioning
and escape from the sickness role) are best achieved
in the outpatient setting. Children and parents
therefore have an opportunity to practice strategies
in their home and school environment. Initial
treatment intensity if required can be provided,
although most children and their parents attend
weekly sessions. e occasional patient will be
admitted for intense behavioural modification
and mobilisation programmes. ese patients are
selected either on the basis of an unhelpful home
environment, distance from the hospital and/or
failure to progress in the outpatient setting.
All three centres report good results [33, 45, 48]
indicating that different models may be successfully
adapted to administer similar treatments depending
on environmental and cultural factors, the patient
cohort and financial constraints.
e integrated interdisciplinary treatment may
comprise one or more of the following therapies,
depending on the pain diagnosis and the distance
patients live from where integrated therapy can be
offered.
Psychological therapies
Evidence supports the effectiveness of relaxation
and cognitive behavioural therapy in reducing
the severity and frequency of chronic headache in
children and adolescents [49].
e treatment of persistent pain is difficult to study
given the multitude of factors that contribute. e
administration of, and attitudes towards, certain
therapies will vary between practitioners and clinics,
and we are yet to study the effect of cultural differences
on presentation and treatment, limiting the application
of findings from other countries and cultures.
Nevertheless, consistent themes emerge. If
the cause of pain cannot be elucidated or no
often useful to directly contact the school to obtain
their evaluation of the child’s academic, social and
physical functioning.
Some key differences exist between persistent
pain and its management in adults and children
providing opportunities for intervention:
• Parents and schools can be engaged, giving
therapists the opportunity to explore if either
are contributing to the pain presentation, or
engage them in its management
• Attendance during and successful completion
of the academic school year provides health
care providers, children and their families
an opportunity for goal setting that all agree
upon and can work together towards.
Treatment
Facilitation of treatment goals
As school absenteeism is common in children
with persistent pain, one of the therapists’ goals
should be to facilitate return to school through the
coordination and timing of interdisciplinary team
appointments so that they occur on the same day.
Planned either around less important lessons or
scheduling towards the end of the day or even after
school finishes is helpful. Additional advantages
include the opportunity for therapists to capitalise
on each other’s therapy and less disruption and
time off work for parents accompanying their child
to appointments.
Inpatient or outpatient therapy?
e Pain Management Unit at the Royal National
Hospital for Rheumatic Diseases, in Bath, United
Kingdom, and the Vodafone Stiftungsinstitut
fuer Kinderschmerztherapie und Paediatrische
Palliativmedezin in Datteln, Germany, both conduct
3-week interdisciplinary inpatient programmes for
children and adolescents with persistent pain [45,
48]. e centres attract referrals from throughout
their respective countries. Parents accompany their
children in the Bath programme and undergo
treatment too. ere is a greater emphasis on
physical therapy in Bath, most likely a reflection
of the different pain conditions seen. In Datteln,
CRPS Type I presents uncommonly, whereas 37%
of 110 patients were diagnosed with this condition
in Bath [62]. e functional disability which results
will be different for a child suffering from lower
limb CRPS Type I with allodynia, muscle wasting
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