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330 George CHALKIADIS
definitive treatment to eliminate it exists, then the
emphasis of treatment is to manage pain, thereby
restoring function. Recent concepts include
mindfulness (not altering the content of what is
experienced but changing how it is experienced
and its influence on behaviour). Acceptance
of pain and possibly limitation of activity by
both the parents and their child is required first
[102]. Contextualising cognitive behavioural
therapy to change behaviour in relation to what
is felt (as pain) using an individual goal-directed
approach to restore normal functioning seems
logical [102]. e concept of pain demanding
attention and the unintentional hypervigilance
that results in fear avoidant behaviour also
allows the possibility for learning to accept that
a meaningful life is possible despite the presence
of persistent pain.
Physiotherapy
A thorough physical assessment in addition to
specific attention directed to the painful site often
reveals deconditioning. Frequently, tight hip
flexors, tight hamstrings and poor core strength are
discovered irrespective of where the pain is located.
In conditions such as CRPS, physiotherapy is a
vital part of treatment.
Occupational therapy
While the psychologist continues his or her
assessment and looks towards acceptance and then
utilising mindfulness, the occupational therapist
at the Royal Children’s Hospital, Melbourne,
embarks on a pain education session with the
child and its parents. e function of this session
is to lay the foundation for treatment, and includes
information on how pain is transmitted, what it
means, how the child can take responsibility and
manage it, and the importance of pacing activity
and return to normal functioning. e occupational
therapist also establishes goals to work towards
with the child. Occupational therapists play an
important role with regards school visits to first
garner information, and then come up with a plan
to maintain school attendance, working with the
child, the parent and the school. Attention to the
ergonomics of the work station at school and home
can be useful in reducing pain.
Medical therapy
Persistent pain results from many conditions.
Simple analgesics such as paracetamol, codeine and
NSAIDs are often reported to be ineffective.
Tricyclic antidepressants such as amitriptyline
(up to 1 mg/kg) may provide analgesia, help sleep
initiation if administered at night and elevate
mood. Initial doses are low (e.g. 10 mg), and slowly
increased every 2 to 3 days until the therapeutic goal
(improved sleep or analgesia) is achieved, hoping
to avoid intolerable side effects such as difficulty
in waking, postural hypotension, dry mouth and
clouded mentation. Some centres routinely perform
a baseline electrocardiogram to exclude prolonged
QT syndrome before initiating tricyclics. Tricyclic
antidepressants have been implicated in the sudden
deaths of children [166].
Anticonvulsants such as carbamazepine, sodium
valproate and gabapentin have also been used.
Gabapentin, although costly, is the agent of choice
due to its better side-effect profile. e potential
to cause hepatic dysfunction with sodium valproate
and aplastic anaemia or agranulocytosis with
carbamazepine necessitate regular blood tests.
Although there is now an abundance of case reports
in the literature regarding gabapentin in paediatric
persistent pain management, good trials are
lacking. For the management of neuropathic pain,
gabapentin is the drug of first choice at doses of up
to 70 mg/kg per day. Pregabalin is now available but
as yet no case reports have been published regarding
its use in children with neuropathic pain.
Sympathetic nerve blocks are reserved to
temporarily relieve pain to facilitate physiotherapy
when allodynia, hyperalgesia and loss of function
prevent any therapeutic progress.
In contrast to adults, CRPS Type I occurs more
commonly in the lower limbs in children and
adolescents. Sympathetic nerve blockade can be
achieved either with a single-shot or continuous
lumbar sympathetic nerve or epidural block. e
quality and intensity of physiotherapy input with
appropriate interdisciplinary support is probably
more important than the means by which sympathetic
block is achieved. Upper limb CRPS Type I is
amenable to stellate ganglion blockade. Rarely would
cervical epidural blockade be indicated.
In adolescents with dystonic cerebral palsy that
use head controls for communication devices,
https://t.me/medicina_free
Pain in Children and Adolescents 331
headaches that interfere with daily functioning
may respond to medical intervention. After greater
occipital nerve blockade temporarily eliminated
pain, botulinum toxin A injections into the scalp
were helpful although the duration of effectiveness
progressively shortened. Subsequently, implanting
an occipital nerve stimulator has been beneficial.
Alternative and complementary therapies
Alternative and complementary therapies may
provide symptomatic relief for short periods.
Parents’ beliefs and disillusionment with Western
medicine (especially if their child’s pain and disability
problem persists despite multiple consultations)
may encourage them to seek for the answer that
has been overlooked by mainstream medicine.
Unfortunately, most of these therapies are passive,
and involve someone else doing something for the
child’s pain rather than encouraging the child to
take responsibility for managing the pain.
Cancer Pain
Children with cancer often receive aggressive
treatment towards the end of life that results
in substantial suffering [181]. A World Health
Organization directive [172] to adopt the palliative
care paradigm for all children with cancer
irrespective of their geographical location must
overcome significant barriers to succeed in reducing
pain and suffering [36].
A World Perspective
Much of the information on the epidemiology
and treatment of persistent pain in children and
adolescents comes from a handful of developed
countries. Perspective is important. Of the earth’s 6
billion inhabitants, 5.1 billion live in lesser developed
countries and 3.7 billion are aged less than 19 years.
Many of these children face quite different causes
for persistent pain including injuries sustained from
landmines, war or terrorism, malnutrition, diseases
such as human immunovirus (HIV) and cultural
practices such as genital mutilation.
Little has been published regarding the incidence
of childhood pain in these situations. Adult data
suggest that 64% of landmine survivors experience
persistent pain [76]. Rickets may cause carpopedal
spasm or diffuse limb pain and scurvy can cause
bone pain too [113]. Twenty per cent of children in
the USA with HIV have pain [112]. In Africa, HIV
is the leading cause of death and 50% of sufferers
are aged less than 25 years.
Sickle cell disease occurs most commonly in people
of African, Middle Eastern and Mediterranean
descent and causes pain that is intermittent, severe
and recurrent. Oral analgesics such as paracetamol,
NSAIDs and an opioid alone or in combination
may be sufficient, but severe crises often require
intravenous opioid analgesia,
Glucose-6-phosphate dehydrogenase deficiency
occurs most commonly in people of African, Asian,
Mediterranean and Middle Eastern descent. Some
analgesic drugs (aspirin, paraminosalicylic acid,
phenacetin, acetanilide and phenazopyridine) may
precipitate acute haemolysis and should be avoided.
Paracetamol in conventional doses is reported to be
of low risk. A comprehensive list of drugs to avoid
can be found on www.g6pd.org.
Resource availability limits future study and
direction with regards to the management of
persistent pain in children and adolescents in lesser
developed countries.
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Objectives of Pharmacological
Pain Management
Pain is an experience unique to the individual concerned. It
is a multidimensional phenomenon with physio-psycho-social
(biopsychosocial) components [9]. Pharmacological treatment
is one of several important modalities of an integrated
multimodal pain therapy which aims not only at pain
symptom relief but also the management of other comorbid
conditions, such as insomnia and mood disturbances, and
psychiatric disorders, such as anxiety and depression [15]. It
is important to discuss with the patient a realistic expectation
of pain relief using optimised analgesic regimens together with
other therapies. e aim of treatment is to alleviate pain to an
extent such that the patient can cope with daily activities and
minimise any comorbid conditions, especially mood disorders
and sleep disturbance [16]. e latter is very common in the
chronic pain patient and usually requires medication adjuvant
to analgesia [17, 20, 22]. It is important to conduct frequent
reassessments and to review the patient’s pain, underlying
pathology, expectations, lifestyle adjustment, employment
and social life [14]
Patient Evaluation
One of the principles of pharmacological therapy is to prescribe
medication only after a thorough patient evaluation, so as to
ensure that the management is appropriate for the diagnosis
and that the treatment regimen balances therapeutic and
side effects. An agreement should be made with the patient
to achieve a set goal for the therapy. e aim of pain control
should be not only to reduce the pain score, but to improve
the patient’s sleep, mood, social and physical function, and
overall quality of life.
OBJECTIVES OF
PHARMACOLOGICAL PAIN
MANAGEMENT
PATIENT EVALUATION
PRINCIPLES OF DRUG SELECTION
AND ADMINISTRATION
Types of pain
Pattern of pain
Adverse effects
Age considerations
Pregnancy
Route of administration
MULTIMODAL THERAPY
Expectation of treatment
Individualised prescription plans
Drug compliance
Drug interactions
PLACEBO EFFECT
CONCLUSION
REFERENCES
Principles of Pharmacological
Treatment
20
Carina Ching Fan LI
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