American Society of Regional Anesthesia and Pain Medicine August 2017 - 13

Integrated Approach to Pediatric Chronic Pain Management
The International Association for
the Study of Pain (ISAP) defines
pain as "an unpleasant sensory
and emotional experience
associated with actual or potential
tissue damage, or described in
terms of such damage."1 The
American Pain Society defines
chronic pain in children as "the
result of dynamic integration of
biological processes, psychological
factors, and social/cultural context
considered within a developmental
trajectory."2 It is important to note
that according to these definitions,
tissue damage does not need to
be present for one to experience
pain and that there is an affective
component to pain.3

acupuncture, relaxation techniques (breathing exercises, guided
imagery, progressive muscle relaxation), tai chi, healing touch,
hypnosis, and movement therapies.7 The goal of mind and body
practices is to integrate mind processes with body function and
experience to promote health. Active distraction techniques-such
as imagery-release endorphins, increase activity of descending
inhibiting pathways, decrease nociception, and thus modulate
pain.8

Floria E. Chae, MD
Attending Physician
Arcadia Anesthesia
Dallas, TX
Section Editor: Andrea Nicol, MD

The most common pediatric chronic pain conditions include
headache, functional abdominal pain, and musculoskeletal pain,
including back pain.4-5 Chronic pediatric pain has a negative
impact on the child's activities of daily life, emotional well-being,
and health care system. Groenewald et al obtained information
from 149 adolescents (ages 10-17) who went for evaluation
and treatment at pain clinics across the United States.6 Parents
reported on health service use and productivity losses due to
their child's chronic pain retrospectively over 12 months. The
cost on the health care system is estimated to be $19.5 billion
annually in the United States.6 The following is a brief overview of
selected nonpharmacologic and pharmacologic therapies for the
management of chronic pain in a pediatric population.
NONPHARMACOLOGIC THERAPY
Therapies outside mainstream medicine have been called by
many different terms, such as complementary, alternative, and
integrative medicine. The National Center for Complementary
and Integrative Health (NCCIH) defines complementary as a
nonmainstream practice used together with conventional medicine,
while alternative as a nonmainstream practice used in place
of conventional medicine. The NCCIH prefers to use the term
complementary health approaches, as most nonmainstream
approaches are used in conjunction with conventional treatments.
The term integrative health is used when complementary
approaches are incorporated into mainstream health care.7
Most complementary health approaches can be divided into
natural products or mind and body practices. Natural products
include herbs, vitamins and minerals, and probiotics. Mind and
body practices include a large and diverse array of procedures
or techniques, such as yoga, meditation, massage therapy,

Hypnosis has been used alone and with analgesics in a variety of
painful situations such as burns,9 fractures,10 recurrent abdominal
pain,11 migraines,12 and sickle cell disease.13 Many studies
demonstrate the efficacy of hypnosis in alleviating pain and anxiety
during needle-related procedures14 and reducing chemotherapy
related nausea and vomiting.15
Massage therapy has been investigated in children and adults
with acute and chronic pain conditions. Studies have shown pain
reduction in children with burns;16 decreased stress hormones
(cortisol and norepinephrine), increased quiet sleep, and increased
cytotoxic capacity in children with juvenile rheumatoid arthritis.17 A
Cochrane review on preterm infants and massage showed improved
infant weight gain, improved infant behavior responses, deceased
length of hospitalization, improved performance on developmental
scales, decreased postnatal complication scores, decreased length
of stay, and improved caregiver health and satisfaction.18
There are many active areas of research looking at the mechanism
of acupuncture. Three main theories are the release of endogenous
endorphins,19 physiologic changes in electrical resistance at
acupoints,20-21 and changes in brain flow and normalization
of activity in limbic system.22-24 Acupuncture can be used to
treat headache, abdominal pain, fibromyalgia, juvenile arthritis,
complex regional pain syndrome, cancer pain, chemotherapyrelated nausea, and perioperative pain.25 Adams et al reviewed
the safety of acupuncture in pediatric population and concluded
that acupuncture is safe when performed by appropriately trained
practitioners.26
PHARMACOLOGIC THERAPY
Acetaminophen (APAP) works by inhibiting cyclooxygenase enzymes
in the central nervous system (CNS), which leads to an inhibition
of prostaglandin synthesis and suppresses central and peripheral
neuronal excitability.27-28 APAP is commonly used for both acute and
chronic pain and is generally well tolerated. Rectal APAP has variable
absorption and may lead to toxicity.29 Oral and intravenous routes
of administration have more predicable uptake. Due to an immature
hepatic system, APAP metabolism is decreased in newborns and
young children as compared to adolescents and adults.30
Aspirin (ASA) was common historically for children, but due to
concerns of Reyes Syndrome, it is no longer recommended for use

American Society of Regional Anesthesia and Pain Medicine
2017

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