Children and Pain

If you've ever watched a nurse take a blood sample from a newborn's heel, you already know that even the youngest children can feel pain. Babies and toddlers may not always be able to put their feelings into words, but their pain is real. According to a report from Toronto's Hospital for Sick Children, young children may be even more sensitive to pain than adults.

Pain relief can be elusive at any age, but children pose many special challenges. Babies and young toddlers can't describe their pain or ask for help. Older children might keep their pain to themselves, perhaps because they want to be "good" or don't want to worry mom or dad. Even when pain is impossible to ignore, both parents and doctors might be reluctant to give children pain medications, even when they offer the only real hope for relief.

Despite these challenges, children are as deserving of comfort and relief as anyone else, perhaps even more so. Children are especially vulnerable to fears and anxieties that only heighten their pain. Chronic pain during childhood may even change the wiring in the brain, leaving a person more vulnerable to pain years or decades down the road. Managing a child's pain may do a lot more than provide comfort today -- it just might prevent much misery in the future.

How to recognize pain symptoms

Recognizing pain is the first step. Whether it stems from a scratch or a bump or accompanies a chronic disease such as arthritis or cancer, pain in children may not always be obvious.

As a parent, though, you're in an ideal position to assess your child's symptoms. Keep in mind that children sometimes avoid talking about pain, often because they fear going to the doctor or hospital. So be patient, and don't rush when you ask about where it hurts. Be on the watch for nonverbal signals of pain.

Babies, for example, use high-pitched wails and grimaces to show pain. They may curl up, their arms and legs may be tense, and they may seem unusually irritable. In some cases, they may even stop eating.

Toddlers will also use cries, frowns, and grimaces to get their point across. They may be cranky and less active. Small children between two and four may not be able to explain how much pain they're feeling without help. Using a doll, you can ask your youngster to point to which part of the body hurts. As children grow older, they can describe the location and intensity of their pain -- but rarely do so unless you ask.

Cognitively impaired children -- those with mental disabilities -- may have particular problems telling you they're in pain. A 2002 study published in the Journal of Pediatric Psychology reported the following pain cues in 29 cognitively impaired children: crying, yelling, distressed facial expressions, listlessness, flinching when touched, wanting to be cuddled, acting withdrawn, agitated, or irritable, being tense or stiff, dull eyes, flushed skin, and changes in breathing.

If you're concerned about your child's pain, schedule an appointment with a doctor. Doctors have special tricks for measuring pain in young children. For example, a 3-year-old may be asked to describe the intensity of pain by pointing to one of a series of pain chart faces ranging from smiling (no hurt) to frowning and crying (hurts worst). Your child's doctor can also recommend treatments and determine if your child's pain may be a sign of a serious problem.

How to treat the pain

Over-the-counter medications can give a child much-needed comfort, but they must be used with caution. Acetaminophen, a commonly used pain reliever for infants and young children, effectively relieves mild pains, but it can also cause liver damage in large doses. As with any medication, be sure to read the instructions carefully, and never give your child more than the recommended dose. (Be sure not to mix up infant drops and children's Tylenol; infant drops are more concentrated.) Aspirin should NEVER be given to children or teenagers unless a doctor says it's okay, since it can cause a life-threatening illness called Reye's syndrome if the children have a virus.

Children in serious pain need serious relief. Opioid (aka narcotic) pain relievers such as morphine are often prescribed to children with severe injuries or chronic pain caused by cancer or other illnesses. Parents shouldn't worry that their children will get "hooked" on morphine or similar medications. Once the pain goes away, so will the need for medication. However, in a child who has been taking opioids for awhile, the body will have adapted to the medication and will need to be slowly weaned from it over time. This is normal and expected, and not the same thing as addiction -- a psychological disorder where a person craves and uses a substance for nonmedical reasons.

Although opioid medications are safe for your child, you'll still want to watch out for potential side effects such as constipation, drowsiness, and nausea and vomiting. Be sure to discuss any side effects with your child's doctor, but don't stop giving your child the medication without a go-ahead from the doctor. If you suddenly stop your child's pain treatments, the pain may come roaring back.

A cream such as EMLA, which contains the painkillers lidocaine and prilocaine can help take the sting out of some medical procedures. Discuss the options with a doctor before the procedure. And if you're having your baby boy circumcised, be sure the doctor uses a local anesthetic; in addition to the anesthetic, some other doctors have also recommended using oral sucrose.

Helping a child in pain

Medication should be only one part of your approach to your child's pain. There are many other things you can try to make a child more comfortable:

For typical childhood cuts and scrapes, cool water or a cool compress can ease aches and pain, and an ice pack can take the pain out of insect stings, bruises, and pulled or strained muscles.

Small children are easily distracted, even when it comes to pain. A toy, an engaging activity, a snack, a band-aid, or even just a hug and some gentle words from a parent can help push pain into the background.

"I think more than half the benefit from a band-aid is usually the comfort of the [child] who puts it on, plus the distraction of seeing your favorite cartoon hero," says Michael Potter, MD, a family practitioner and associate professor at UCSF Medical Center in San Francisco. "I'm a big fan of comfort plus distraction for minor types of pain."

For babies, nursing may be the best distraction of all -- a soothing meal and a comforting touch from mom all at the same time.

Older kids can get their mind off pain by playing a game or even just watching a light-hearted TV show. A widely publicized study of 7- to 12-year-olds published in 2006 in the Archives of Diseases in Childhood found that watching television cartoons eased the pain of a needle stick.

As it does in infants and toddlers, a comforting touch from mom and dad can help ease pain in older children as well. Children of all ages may appreciate pats on the back, hand-holding, or even backrubs. Older children with strained or pulled muscles may feel better after a gentle massage.

Distraction can be helpful, but it's no cure-all. As reported by the Hospital for Sick Children, a child may still be in pain even if he or she is playing or seems to be thinking about something else. It's important to watch out for wincing, flinching, and other warning signs. If your child experiences continued or increased pain symptoms, call your child's doctor promptly. Pain is something to take seriously at any age. Children need and deserve relief, but they can't get it on their own.

References

Bellieni, C.V. et al. Analgesic effect of TV watching during venipuncture. Archives of Diseases in Childhood.

Hospital for Sick Children. Myths vs. facts of children's pain. http://www.iasp-pain.org/GD2005parentlist.pdf

American Academy of Pediatrics. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 108(3): 793-797.

University of Michigan. Pain and your infant. http://www.med.umich.edu/1libr/yourchild/paininf.htm

Howard, R.F. Current status of pain management in children. Journal of the American Medical Association. 290(18): 2464-2469.

eMedicineHealth. Abdominal pain in children.

University of Mississippi Medical Center. Information on Children and Pain: Did You Know ...?

National Coalition for Cancer Survivorship. Pain. http://www.canceradvocacy.org/resources/essential/children/pain.aspx

Astra Zeneca. EMLA. http://www.emla-us.com/facts/

Stallard P, et al. Brief report: Behaviors identified by caregivers to detect pain in noncommunicating children. Journal of Pediatric Psychology. 27(2): 209-214.

Nemours Foundation. Reye Syndrome. http://www.kidshealth.org/parent/system/medicine/reye.html

American Academy of Family Physicians. Pain relievers: understanding your OTC options. http://familydoctor.org/862.xml

National Coalition for Cancer Survivorship. Myths about managing pain. http://www.canceradvocacy.org/resources/essential/pain/basics.aspx#addiction