Management of chronic pain in children and young people: summary
A summary of the available evidence, combined with a consensus group agreement on key recommendations and suggested patient pathways.
2. Summary of Recommendations
2.1 Assessment and Planning of Care
- Use of a screening tool to identify children and young people at risk of adverse outcomes due to chronic pain should be considered to aid in planning intensity and type of intervention.
- Early biopsychosocial assessment and psychological intervention should be considered, particularly where the risk of disability and distress is high.
- The potential effects (both positive and negative) of children’s interactions with family, clinicians, educators and peers on assessment and management of chronic pain should be considered. Regarding the nature of interactions with healthcare providers and clinical interventions, remote or online delivery may be considered as an alternative to face to face.
2.2 Pharmacological Management
- Pharmacological treatment should only be started after careful assessment. If being used, it should be part of a wider approach utilising supported self-management strategies within the context of a multidisciplinary approach.
- If pharmacological therapy is being used, then there should be regular review with planned reassessment of ongoing efficacy and side effects. Treatment should only be continued if benefits outweigh risks, and limited to the shortest possible duration. Review should be a minimum of once per year, to assess continued benefit in terms of pain relief and improvement in function and/or quality of life.
- Paracetamol and non-steroidal anti-inflammatory drugs ( NSAIDs) should be considered in the treatment of chronic non-malignant pain in children and young people. Use should be limited to the shortest possible duration, such as during acute on chronic pain episodes.
- Topical NSAIDs should be considered for treatment of children and young people with localised, non CRPS and non-neuropathic pain.
- 5% lidocaine patches should be considered in the management of children and young people with localised neuropathic pain, particularly when aiming to improve compliance with physiotherapy regimes. They are well accepted, with a low incidence of side effects, restricted to occasional hypersensitivity reactions.
- Antiepileptic drugs should be considered as part of a multi-modal approach in the management of children and young people with neuropathic pain:
- Gabapentin should be considered as first line anti-convulsant (specialist use only). It should be used in the lowest effective dose, with ongoing monitoring for efficacy and adverse effects.
- Pregabalin should be considered as a second line anti-convulsant drug if gabapentin is not tolerated or is ineffective (specialist use only).
- Low dose amitriptyline should be considered in the treatment of children and young people with functional gastrointestinal disorders.
- Low dose amitriptyline should be considered in the treatment of children and young people with chronic daily headache, chronic widespread pain and mixed nociceptive/neuropathic back pain.
- If amitriptyline is effective but particularly sedative in an individual, nortriptyline should be considered as a less sedating alternative.
- Bisphosphonates should be considered in the management of children and young people with osteogenesis imperfecta who have bone pain.
- Intrathecal baclofen should be considered for reducing spasticity-related pain in children and young people with cerebral palsy.
- In children and young people with recurrent abdominal pain pizotifen should be considered for abdominal migraine; famotidine for dyspepsia; and peppermint oil for irritable bowel syndrome.
- Opioids and compound analgesics containing opioids are rarely indicated for chronic pain because of their adverse effect profile. Be aware of MHRA advice on codeine. Strong opioids should be used with caution and only with specialist advice or assessment.
- Use of opioids should be for as short a time as possible with regular review and monitoring of efficacy and side effects.
- The use of codeine is not recommended in children under the age of 12 ( MHRA), as it can be associated with a risk of opioid toxicity and respiratory side effects. In general it should also be avoided in adolescents, particularly if they have respiratory problems and individuals known to be CYP2D6 rapid metabolisers should also avoid codeine. Caution is also needed with tramadol use due to genetic variability in metabolism, and production of active metabolites.
- Exercise should be considered as a key component of chronic pain management in children and young people.
- There should be consideration of early interventions to increase movement, physical activity and restore function.
- Exercise should be used with the aim of producing functional improvement in children and young people with CRPS. Mirror therapy should be considered.
- Exercise therapy should be considered for children and young people with Patellofemoral Pain Syndrome ( PFPS) to enhance long term recovery and reduce pain.
- Relaxation and TENS are low risk interventions that should be considered for the treatment of children and young people with chronic pain.
- Psychological interventions should be part of a multi-disciplinary approach to managing chronic pain in children and young people.
- Face-to-face psychological interventions should be delivered by suitably trained and supervised practitioners.
- Online or computerised delivery of Cognitive Behavioural Therapy ( CBT) interventions should be considered if face-to-face therapy is not suitable or not available.
- Local anaesthetic blockade or other interventions should be considered on an individual patient basis in specialist centres.
- The use of probiotics ( LGG and VSL#3) should be considered in children and young people with functional gastro-intestinal disorders.
2.7 Complementary and Alternative Therapies
- Acupuncture may be considered for managing chronic pain in children and young people, for back pain and headache. If used, efficacy should be formally assessed.
- While evidence is very limited, music therapy may be considered for children and young people with chronic migraine.
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