How Common Is Chronic Pain in Children?

Pediatric chronic pain, particularly when it develops after surgery, only recently entered the public consciousness as one of the factors contributing to the over-prescribing of opioids. The emerging understanding of the impact of pain on a young person’s functional ability and quality of life reveals a physical, psychological, and social decline mirroring that of adult patients. The incidence of pediatric chronic pain is alarmingly high, with 20% of patients developing post-surgical chronic pain. As our appreciation of the multiplicity of pain presentations matures, we may reveal this to be an underestimation.

What Issue Should Be Considered Given the Preoperative Chronic Opioid Use?

Patients with chronic opioid dependence pose a unique perioperative challenge. Patients on chronic opioid therapy are at risk of suboptimal pain control due to increased opioid requirements, opioid tolerance, and iatrogenic under-dosing.

What Are the Implications of Poorly Controlled Postoperative Pain?

Patients with poorly controlled postoperative pain can have longer recovery times, increased risk of infection, unplanned readmissions, and development of chronic postsurgical pain. Additionally, poor pain control can leave a significant psychological footprint in the patient and family that can color future healthcare transactions. Whenever possible, effective treatment of these patients should include a combination of non-pharmacologic pain strategies (acupuncture, distraction, virtual reality, diaphragmatic breathing), neuraxial/regional anesthesia, multimodal analgesia, and maintenance and optimization of chronic opioid medication delivery during their hospital admission.

Would Your Discussion Be Different if You Learned that the Child Has Chronic Pain from Headaches or Abdominal Pain?

The underlying pathophysiology of pain can range from nociceptive pain or neuropathic pain to “functional pain” which is thought to be a result of an abnormal processing by both central and peripheral components of the nervous system. The International Association for the Study of Pain (IASP) defines pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage,” and can result from a combination of any of the aforementioned sources of pain. A primary pain disorder (often called “functional pain”) is a term that is given to patient-reported pain which may or may not have an identifiable clear organic disease or to pain that is thought to have become its own separate disease or syndrome even when accompanied by a primary pathophysiology. Functional abdominal pain and chronic daily headaches are among the most commonly recognized of these pain disorders, and the perioperative clinician should pay special attention to these issues. Secondary pain disorders include pain states that clearly arise from and accompany an organic process. Examples of secondary pain disorders include polyneuropathy from type 2 diabetes mellitus and chemotherapy-induced neuropathy in blood cancers. The treatment of pediatric chronic pain disorders regardless of classification is anchored in the biopsychosocial model and necessitates an interdisciplinary or multidisciplinary care model that includes a medical, psychological, and functional evaluation. Parental education, cognitive behavioral therapy (CBT), behavior modification, improved coping, and avoidance of triggers have been shown to produce positive treatment responses in multiple pain conditions.

If the clinical environment allows for a preoperative visit and patients with known or suspected chronic pain can be identified, the clinician should obtain a pain consultation, and one preferably in conjunction with the chronic pain team. Given that chronic pain is a disease of the central nervous system which acts to alter and amplify pain messaging, especially in the context of stressful incidents, effective management of pain should also include cataloguing and addressing any mood disturbances, sleep disorders, functional state, family pain history, and stressors. Both pharmacologic and non-pharmacologic recommendations, including the importance of committing to physical therapy and biobehavioral treatment before and after surgery, should be candidly discussed with chronic pain patients and their families.

What Is Your Approach to a Chronic Pain History and Physical in the Perioperative Period?

Prompt recognition of chronic pain is the most important step in the management of chronic pain during the perioperative period. The clinician should begin this process by obtaining a focused history and physical examination that includes a detailed neurologic exam. Pain-related disturbances in sleep onset and maintenance, school functioning (school attendance, grades), physical activity (sports, physical education), mood disturbances (anxiety, depression), and social functioning should also be assessed. Additional high-yield questions are provided below:

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   1. Determine timing and goals of surgery

   
   
   
   
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     Is this a new or a repeat procedure?

     
     
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     Is the timing of the surgical procedure fixed or flexible?

     
     
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     Is the goal of surgery to decrease pain (important for preexisting pain)?

     
     
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     Is the goal of surgery to increase function?

     
     
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     What type of surgery is to occur?

     
     
     
     
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        ◦ Different types of surgeries result in varying levels of pain/chronic pain. Different anatomical approaches may impact the perioperative pain plan.

     
     

   
   
   
   
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   2. Inquire about pain. If pain is present, assess its location, radiation pattern, duration, character, intensity, exacerbation factors, and alleviating factors. If pain started as a result of an injury, it is important to learn about the mechanism of injury and any ongoing rehabilitation (“pre-hab”) efforts.

   
   
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   3. Inquire about previous surgeries and in particular ask about any ongoing pain issues, previous regional anesthetics, and existing nerve damage.

   
   
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   4. Ask about previous and current pain therapies. This includes complementary and alternative medicine therapies (CAM) (e.g., acupuncture, massage), psychological support, pharmacologic therapies.

   
   
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   5. A complete past medical history should be collected to identify any comorbidities that may potentially contribute to pain. Some relevant comorbidities include mood disorders, neurodevelopmental disorders, addiction, hepatic disease, renal disease, pulmonary disease, and gastrointestinal diagnoses.

   
   
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   6. A family history of chronic pain, mood disorders, psychiatric disorders, and addiction should be gathered.

   
   
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   7. Elicit family and patient goals of care for hospitalization. Set expectations for the surgical procedure and post-operative period.