About twenty years ago, infants and young children received minimal anesthesia during surgical procedures, and perhaps even less postoperative pain management. Interestingly, a survey taken in 1986 found that half of pediatricians, surgeons, and family practitioners assumed that infants did not experience pain in the first month of life.
Should the healthcare-and in particular, the psychology-communities be concerned about this? Maybe so.
A symposium of sorts regarding pain was held at the National Institutes of Health (NIH) a few months back, and a variety of interesting topics were discussed. This blog will deal with the issue of pain in children; future blogs will discuss some of the other current issues in chronic pain in cohorts of the population that seemingly are ignored by popular press and researchers alike.
Infants respond to painful stimuli with easily verifiable physical signs, including an increase in blood pressure and heart rate, a decrease in blood oxygen saturation, and a surge of stress hormones. Behavioral changes that are seen include complications with sleep, feeding and self-regulation.
As described by Dr. Laura Schanberg of Duke University, acute pain during childhood may result in adverse changes in future pain processing, an aversion to doctors and healthcare in general, reduced effectiveness of analgesics, reduced effectiveness of future surgical procedures, and, of course, genuine distress on the part of healthcare providers and parents who must deal with the ramifications of this fallout. Preterm infants, who often because of their precarious clinical situation receive any number of noxious stimuli in the form of procedures to keep them alive, show increased stress responses later in life to any subsequent procedures, in addition to demonstrating higher somatization scores and increased thermal pain sensitivity.
Circumcised infants tend to show more robust pain responses during routine vaccinations. Young children in general who are exposed to repeated painful procedures of any kind experience more pain and anxiety with future procedures. And as we further consider the lifecycle, The Danish Prospective Study (which included 650 children) demonstrated that low back pain in children at age 14 years predicted low back pain, disability, and hospitalization 25 years later.
Not surprisingly, there are challenges facing those who treat pain in the pediatric population. It is no easy task to devise an age-appropriate pain assessment tool, as there are so many confounding variables that can interfere with a true measurement of pain:
• changes that come with growth
• the onset of puberty
• the genetic makeup of a given individual
• numerous immunologic, neurologic, and psychosocial variables.
Finally, there are ethical sensitivities to be overcome when studying pain in children; as this is a vulnerable population requiring vigilant research oversight.
Interestingly, pain in children is more plastic than that of adults: Environmental and psychological factors appear to exert a more potent influence on pain perception when compared to the adult population. Negative mood, stress and its accompanying anxiety were shown by Dr. Schanberg to increase daily symptoms of pain, fatigue, and stiffness in juvenile idiopathic arthritis patients. In contrast, when considering adults with chronic pain, stress and mood predict pain tomorrow and the following day; but in children such psychological factors only predict pain today. Perhaps children live more in the moment, and are a little more free of the rumination that comes with the burdens of adulthood.
This last point deserves rumination, as stress in the parent is positively correlated with pain and depression in his or her child. In a similar vein, children fare better when their parents respond to their pain sympathetically. However, parents who catastrophize about their child's pain tend to put too much energy into their own distress regarding the situation, resulting in higher incidences of disability in the children.
The bottom line is that we must all remember that pain starts early in life, and those pain experiences in young children have a significant role in the construction of the pain processing system that will serve them throughout their lives, impacting pain perception and pain coping---with all the financial and psychosocial outcomes that surely must follow.