Chapter 11: A General Approach to Pediatric Pain

ESSENTIALS OF DIAGNOSIS AND TYPICAL FEATURES

1. Pain is an experience, not just nociceptive stimulation. As such, is it modifiable by a wide range of factors? The biopsychosocial model of pain accounts for this and can be applied to treatment of both acute and chronic pain.

2. Pain is generally classified as primary and secondary, imperfectly correlating with chronic and acute pain, although the two can overlap.

3. Chronic pain is found in children more often than generally believed and can cause significant morbidity and diminishment of quality of life. A functional rehabilitative approach can be used very effectively to restore developmentally appropriate functioning and reduce pain.

GENERAL CONSIDERATIONS

It is most instructive to start with the basic definition of pain, as defined by the International Association for the Study of Pain, most recently revised in 2020: “An unpleasant sensory and emotional experience associated with, or resembling that associated with, actual or potential tissue damage.”¹

Some critical items are noteworthy that will aid and guide assessment and therapy. First is the term experience. Pain is not nociception; pain comprises biologic, cognitive, social, and emotional elements. It is for that reason the Biopsychosocial (BPS) Model has been developed for purposes of assessment and treatment of pain. Response to and expression of pain develop over a lifetime and have many influences. The second point is that the manner of expression of pain will vary and does not rely on verbal description or any particular behavior, and the way one person expresses pain may vary tremendously from that of another. Reports of pain need to be respected for what they are, harking back to the age-old expression, “Pain is what the patient says it is.” Respecting the patient’s right to experience their world as they alone can will promote freer communication (and hence accurate reporting, enhancing the diagnostic process) and generate rapport with the patient and their family in a way that predetermined expectations about what should or should not be painful or “how much is too much” cannot.

The BPS Model of pain was developed to account for the myriad factors that affect pain. Gatchel et al² provide a review of the early history of and foundation for this model. The basic premise is that for chronic pain, as for many illnesses, social and psychological factors will affect the experience of pain beyond the stimulus of the biologic insult alone. A simple example would be getting a paper cut on a winning lottery ticket versus the same cut obtained while opening a letter containing bad news. The biologic insult would be the same, yet the person would experience the pain differently based on the extenuating cognitive and emotional situation. While conceived to better explain chronic pain, BPS applies to acute pain as well, as suggested by the example above.

The experience of pain can be grossly divided ...