Beyond the band-aid: understanding children’s pain


teddy bear with band-aid on head

Pharmacists are ideally placed to help children and their parents understand the source and severity of pain as well as presenting options to alleviate it. By Leanne Philpott

Much to parents’ or carers’ dismay, every child will experience pain at some point. Whether the child is suffering from intense abdominal pain or the dull ache associated with growing pains, it’s important they’re taken seriously and treated appropriately.

Diagnosing pain in children can be challenging, particularly if the child is young and unable to communicate the level and intensity of pain they are feeling. However, studies in paediatric pain have recognised that untreated pain can have a major impact later in life.

Nurse practitioner and lecturer at The Royal Children’s Hospital in Melbourne Dianne Crellin recently completed a PhD, which looked at procedural pain assessment and management in infants and young children.

She explains, “Our view of pain has changed markedly and we now recognise that children experience pain just as much as adults and there can be developmental problems down the line if we don’t address and manage their pain.”

When it comes to assessing a child’s pain, Crellin says self-reporting is the ‘gold standard’. “What we really want is for the patient to be able to report their own pain. You want the child to be able to tell you how bad it is, but younger children are not able to quantify and communicate their pain.

“The perception is that once a child is around seven years of age they can self report; they can quantify their pain on a zero to 10 scale, albeit using faces to point at to convey the level of pain they’re experiencing.

“Children aged three to five can only manage a scale that has three levels; three faces or three levels of pain—a little bit of pain, quite a bit of pain, a lot of pain—but for a pharmacist who hasn’t got access to fancy tools, even just giving a child a simple example can be useful.

“With the help of the parent you might be able to ask, ‘is it like when you bang your knee or when you fell off the monkey bars?’ You’re looking for an example that’s meaningful for the child.

“If the child is a bit older you might ask them about the worst pain they’ve felt and then quantify their current pain based on that past experience.

“In an infant or young toddler who can’t make any verbal contribution you’re entirely reliant on being able to observe signs and that can be really difficult. For a pharmacist the best source of information is often the parent’s view.”

Addressing abdominal pain

Abdominal pain is a common ailment amongst children but being able to offer an appropriate treatment relies on identifying the underlying cause.

Dr Charlotte Middleton, an integrative medical practitioner specialising in pediatric healthcare, explains, “The most widespread medical cause is gastroenteritis and the most common surgical cause is appendicitis. Other causes of abdominal pain in the 5-12 year-old age group include constipation, food poisoning and infections, such as a urinary tract infection or pneumonia. Functional abdominal pain (often caused by stress or worry) also needs to be considered, particularly in this age group.

“In most surgical causes of abdominal pain, pain generally precedes vomiting. The opposite is often true of medical causes such as gastroenteritis. Fever indicates an underlying infection or inflammation. Diarrhoea is usually a feature of gastroenteritis or food poisoning but there is also often a history of other family members or close contacts being similarly affected.

“In constipation the pain is most often left sided or suprapubic and intermittently recurrent and the constipation itself is indicated by less than three bowel motions per week. Other constipation symptoms may include: pain made worse with eating; associated nausea; painful bowel actions; crying or refusing to use their bowels and soiling. 

“Urinary symptoms such as increased frequency, stinging or burning with urination or haematuria would point to a possible urinary tract infection, and warrant a GP review. Upper abdominal pain with associated cough, shortness of breath and chest pain could point to a lung infection and would also require a doctor’s assessment. 

“The myriad of symptoms a child might present with, demonstrates that inquiry into the location, timing of onset, character, severity, duration, radiation of pain and associated symptoms are all important points that need to considered (in the context of the child’s age).”

To alleviate the pain associated with constipation, gastroenteritis or food poisoning, Dr Middleton offers the following advice:

Constipation—encourage higher intake of fibre-rich foods, drink more water, diluted apple, pear or prune juice can help (no more than 1-2 glasses a day); exercise or move more. If none of the previous measures help, a trial of laxatives can be commenced. If laxatives are needed for more than 3-4 days, refer to a GP for review.

Gastroenteritis or food poisoning—suggest small amounts of clear fluid often, for example a few mouthfuls every 15minutes. Older children can have one cup (150-200ml) of fluid for every big vomit or episode of diarrhoea. Oral rehydration fluids such as Gastrolyte or Hydrolyte can be used to replace fluids and body salts. For mild gastro without dehydration you can also give water or diluted cordial.  Give the child small amounts of food when they are hungry. Medications are usually not warranted (except perhaps paracetamol or ibuprofen for high temps or headaches), and if symptoms persist they will need to be seen by a doctor.

“For all children presenting with abdominal pain where there is any doubt as to its origin or the child’s condition, a GP review is warranted. The diagnosis can often require a thorough history as well as an extensive examination by a medical practitioner.”

She says the other condition to be aware of is appendicitis. “Any child with abdominal pain that is localised to the right lower quadrant should be suspected of having appendicitis.

“On questioning, the pain will often have originated in the umbilical region. Other possible signs of appendicitis include: pain increasing in severity and made worse by moving; guarding or rebound tenderness; high temperatures; associated nausea and vomiting; loss of appetite; diarrhoea or constipation. If appendicitis is suspected, the patient should be referred to the local emergency department.”  

The grief of growing pains

According to The Royal Children’s Hospital, Melbourne, growing pains occur in 15-30 per cent of children. Pain or severe aching usually presents in the calves or front of the thighs and can be intense enough to stop the child from sleeping or to wake them up at night.

Joshua Burns, Professor of Allied Health (Paediatrics) at the University of Sydney and Sydney Children’s Hospitals Network, says that while growing pains are a common childhood musculoskeletal condition, the cause and treatment has puzzled the healthcare profession.

In an article published on The Conversation last year he says, “There is no single diagnostic test for growing pains. As a result, it continues to be diagnosed more by exclusion than inclusion of symptoms. Namely: intermittent (non-persistent) aches of muscles (not joints) in both legs presenting later in the day or evening (disappearing by morning) in an otherwise healthy child generally between the age of three and 12 years.”

The term ‘growing pains’ seems to have added to the confusion as many dispute that physical growth is the underlying cause of the pain. As such, treatment must be largely concentrated on reassurance and symptomatic relief.

Professor Burns advises that stretching of the affected muscles, massage and gentle heat can be helpful with the addition of paracetamol or ibuprofen if needed.

He adds, “Evaluating children’s pain is a difficult task. The pharmacist should be mindful that if the child has atypical symptoms, such as persistent joint pain, it’s important to carefully rule out more serious conditions.”

Crellin says, “Traditionally we tended to think about pain relief in terms of pharmacological agents only. However, there’s an increasing body of evidence that promotes the use of other methods.

“Alongside alternative coping strategies such as distraction, there are non-pharmacological approaches such as limb immobilisation, particularly in the case of an arm or leg injury, hot packs for earache, dressings for burns as well as ice or massage,” adds Crellin.

 

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