Guidelines on the Management of Chronic Pain in Children

Overview

This new Guidelines summary includes the World Health Organization’s evidence-informed recommendations for the management of chronic pain in children 0–19 years of age, with a focus on physical, psychological, and pharmacological interventions for pain relief.

Interventional procedures for pain were not included in the guideline as these interventions are less commonly delivered to children. Although there may be possible roles for traditional and complementary medicine and practices in chronic pain management, these interventions were not included in the scope of the guideline.

Refer to the full guideline for information on methods, guiding principles, research gaps, and uptake and implementation.

Reflecting on your Learnings

Reflection is important for continuous learning and development, and a critical part of the revalidation process for UK healthcare professionals. Click here to access the Guidelines Reflection Record.

Definition

• Chronic pain is pain that persists or recurs for longer than 3 months
• The 11th revision of the International Classification of Diseases categorises chronic pain as follows:
  • chronic primary pain
  • chronic secondary pain
    • chronic cancer-related pain
    • chronic postsurgical or post-traumatic pain
    • chronic secondary musculoskeletal pain
    • chronic secondary visceral pain 
    • chronic neuropathic pain 
    • chronic secondary headache or orofacial pain
    • chronic pain, unspecified
• Chronic primary pain is characterised by significant emotional or functional disability and is diagnosed independently of identified biological or psychological contributors
• On the other hand, nonprimary or secondary pain has a clear underlying aetiology such as a disease, injury or lesion, or their treatment (for example, surgery, chemotherapy, radiotherapy)
• Pain is a common symptom of many long-term conditions, such as cancer, sickle-cell disease, diabetes, and arthritic conditions.

Best Practices for the Clinical Management of Chronic Pain in Children

These statements apply to all aspects of the clinical care of a child with chronic pain, including the planning, implementation, and delivery of physical, psychological, and pharmacological interventions.

• Children with chronic pain and their families and caregivers must be cared for from a biopsychosocial perspective; pain should not be treated simply as a biomedical problem
• The biopsychosocial model of pain recognises pain as a complex multidimensional experience that is the result of interaction among biological, psychological, and social factors. This model provides a basis for understanding the effects of pain on an individual and their family and caregivers, and the diagnosis and treatment of pain. It takes into account the patient, their family and social context, and the impact of illness on that individual from a societal perspective. Pain management thus requires a multimodal, interdisciplinary, and integrated approach
• A comprehensive biopsychosocial assessment is essential to inform pain management and planning. As a component of this assessment, healthcare providers should use age-, context-, and culturally appropriate tools to screen for, and monitor, pain intensity and its impact on the quality of life of the child and family
• Children with chronic pain must have a thorough evaluation of any underlying conditions and access to appropriate treatment for those conditions, in addition to appropriate interventions for the management of pain. Chronic pain in childhood often exists with comorbid conditions affecting the child’s health and social and emotional wellbeing, which require concurrent management
• Care of children with chronic pain should be child- and family centred. That is, the child’s care should: 
  • focus on, and be organised around, the health needs, preferences, and expectations of the child, and their families and communities
  • be tailored to the family’s values, culture, preferences, and resources
  • promote engagement and support children and their families to play an active role in care through informed and shared decision making
• Families and caregivers must receive timely and accurate information. Shared decision making and clear communication are essential to good clinical care. Communication with patients should correspond to their cognitive, development, and language abilities. There must be adequate time in a comfortable space for discussions and questions regarding care management plans and progress
• The child and their family and caregivers should be treated in a comprehensive and integrated manner: all aspects of the child’s development and wellbeing must be attended to, including their cognitive, emotional, and physical health. Moreover, the child’s educational, cultural, and social needs and goals must be addressed as part of the care management plan
• In children with chronic pain, an interdisciplinary, multimodal approach should be adopted which is tailored to the needs and desires of the child, family, and caregivers, and to available resources. The biopsychosocial model of pain supports the use of multiple modalities to address the management of chronic pain
• Policymakers, programme managers, and healthcare providers, as well as parents and caregivers, must attend to opioid stewardship to ensure the rational and cautious use of opioids. The essential practices of opioid stewardship in children include:
  • opioids must only be used for appropriate indications and prescribed by trained providers, with careful assessments of the benefits and risks
  • the use of opioids by individuals, their impact on pain, and their adverse effects must be continuously monitored and evaluated by trained providers
  • the prescribing provider must have a clear plan for the continuation, tapering, or discontinuation of opioids according to the child’s condition. The child and family must be apprised of the plan and its rationale
  • there must be due attention to procurement, storage, and the disposal of unused opioids.

Recommendations

Recommendation 1

• In children with chronic pain, physical therapies may be used, either alone or in combination with other treatments (conditional recommendation, very low certainty evidence).

Recommendation 2

• Recommendation 2a: in children with chronic pain, psychological management through cognitive behavioural therapy and related interventions (acceptance and commitment therapy, behavioural therapy, and relaxation therapy) may be used (conditional recommendation, moderate certainty evidence)
• Recommendation 2b: psychological therapy may be delivered either face to face or remotely, or using a combined approach (conditional recommendation, moderate certainty evidence).

Recommendation 3

• In children with chronic pain, appropriate pharmacological management, tailored to specific indications and conditions, may be used (conditional recommendation, low certainty evidence).

Recommendation 4

• Recommendation 4a: appropriate pharmacological management tailored to specific indications may include the use of morphine under the principles of opioid stewardship, for end of life care (conditional recommendation, very low certainty evidence)
• Recommendation 4b: In children with chronic pain associated with life-limiting conditions,^[A] morphine may be given by appropriately trained healthcare providers, under the principles of opioid stewardship (conditional recommendation, very low certainty evidence).

For information on research gaps and uptake and implementation, refer to the full guideline.

Footnote

[A] Life-limiting conditions are illnesses for which there is no cure and an early death is expected, but with which a person may continue to live for several more years.