Persisting pain in childhood medical illness

Persistent pain in childhood and medical illness can be challenging to manage. The chapter has been revised to give a brief overview of the approach to pain management in some childhood diseases. Better understanding of the etiology of pain mechanisms guide the management of pain. In addition, an understanding of the pathophysiology of the underlying processes and utilizing a stepwise assessment and treatment approach is important. Discussion around the multifaceted approach to childhood pain management incorporating the understanding of the role and place of analgesics in managing these medical illnesses is outline. In addition, appropriate medication or analgesia prescription and the role of nonpharmacological approaches has been considered in this revision.

The development of central nociceptive processing and descending modulation of pain

Newborn mammals display robust responses to noxious or tissue-damaging stimulation. These nociceptive or “pain” responses arise from neural activity at different levels of the central nervous system. Protective reflex movements and physiological reactions mediated by spinal cord and brainstem circuits are essential for the preservation of life and well-being but should not be equated with pain awareness. The unique sensation of pain and its unpleasant, threatening quality requires activity in the cortical and subcortical regions of the brain. These brain regions also have the potential to actively increase or decrease pain experience by exerting top-down control of spinal cord and brainstem nociceptive circuits. This chapter summarizes our current knowledge of the development of central nociceptive pathways in the young mammalian brain and the postnatal maturation of top-down pain control. It aims to provide a scientific, mechanistic understanding of infant and childhood pain experience, and their ability to cope with painful events.

Developmental pharmacology of opioids

Recognition of the need for alternative analgesic regimens for managing neonatal and childhood pain has led to a rich literature concerning the ways in which early life pain differs from that at older ages. As in adults, opiates are often considered the gold-standard analgesic class of drugs, of which morphine is the prototypical agent. There is a wealth of data detailing clinical observations, measurements, and interventions with regard to the use of opioids in treating pain in children. Studies in the early part of this century have highlighted that, in humans, age is an important factor that influences the morphine requirement of neonates following surgery, and dose requirements are influenced by both pharmacokinetic and pharmacodynamic factors. Laboratory studies have extended our understanding of changes within the peripheral and central nervous systems that underlie alterations in nociception in early life. This chapter will review what is currently known about the actions of opioids upon nociceptive and nociresponsive elements of the nervous system in early life, how they differ from adult responses, and ask whether manipulating endogenous opioid systems in early life may have consequences on neurodevelopment.

Management of procedural pain in children

: In recent years there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.