Consequences in Not Treating Pain in Children

All it takes is a few painful medical experiences in childhood to greatly impact how a patient will react to future instances of pain and medical procedures, according to Michelle A. Fortier, PhD. Fortier is a licensed clinical psychologist and assistant professor at the University of California, Irvine School of Medicine.

Fortier’s presentation, “Consequences of Not Treating Pain in Children,” (a good follow-up to her presentation yesterday, "Assessment and Diagnosis of Pediatric Pain") discussed why assessing and treating pain in pediatric patients is essential in helping children to develop healthy appraisals of pain. Fortier reviewed some of the short- and long-term physiological consequences of untreated pain as well the short- and long-term behavioral and social consequences of untreated pain.

Historically, infants and children received less analgesia while being treated for pain conditions, she said. Until recently, it was believed that neonates did not feel pain. Recent statistics show that pain can be experienced as early as 26 weeks gestation. Fortier also discussed a study revealing that nearly 40% of neonates received no analgesia while in the NICU.

Not only is the pain of pediatric patients undertreated by health professionals, but studies demonstrate that parents also under-treat children at home. Fortier highlighted one of her studies, “Pain After Surgery,” (2009) to demonstrate the point. The study involved a sample of 260 children who underwent tonsil removal or appendectomies. The research team followed the patients two weeks following their surgery to assess how much medication was given. The results demonstrated that 71% of the children received fewer than half the medications they were supposed to receive. Parents provided the children with fewer doses, stretched the time between doses, or provided less potent doses.

Fortier said there are a number of instances of childhood procedural pain, including immunization schedules. About 93% of infants show serious distress during immunization procedures. Among the barriers to pediatric pain control is the belief that children and, more specifically, infants do not experience pain the way adults do, she said. Lack of routine pain assessment, lack of knowledge in pain treatment, and fear of adverse effects of analgesia also play a role, she said.

There are three main ways children demonstrate pain, according to Fortier. These include: vocal pain (crying or saying “ouch”), verbal fear (saying “this is scary”), and escape behavior (attempts to run away). Although some procedures may be short, Fortier says there may be delayed outcomes. Painful procedures in childhood may lead to less cooperation during later procedures, more reports of pain during adulthood, avoidance of healthcare, and altered sensitivity to pain.

Experiences of untreated pain may have physiological effects as well, Fortier said. Children with pain that is not well controlled have difficulty functioning, she said. These children may develop wind-up and sensitization, hyperalgesia, allodynia, and more.

Long-term effects can occur on nociceptive circuits as well, Fortier noted, and alterations in circuitry can impact future pain processing. There can also be prolonged changes to somatosensory function and hypersensitivity or decreased sensitivity to painful stimuli.

Inadequate pain treatment in postoperative surgery can also have major effects, including the development of chronic pain. After surgery, 85% of patients can develop chronic pain, she said. Currently, there are a number of pharmacological techniques and non-pharmacological techniques that can be used to adequately treat pediatric pain.

For simple procedures, pharmacological techniques include using topical anesthetics such as lidocaine cream or a tetracaine/lidocaine patch. Yet, only 0.8% of physicians always use anesthetics for these procedures, 61.9% rarely ever use any analgesics, and 26.4% never use any, she said.

Nonpharmacological treatments include preparing kids for procedures by talking with them about what they are about to experience or using distraction techniques. Fortier recommends that healthcare providers be clear and concise, and describe both sensory and procedural expectations. It is important to not use the words “pain” or “hurt.” Reassuring kids is not recommended either, she said. Saying “I know this hurts,” or “it’s going to be over soon,” are not helpful.