Summary
The difficulty of assessing pain is incomparably greater in children than in adults,but there is no longer any doubt that even highly immature infants born from week 25 of gestation onward can feel pain and that their vegetative reactions to pain are similar to those of older children.
Pain is always partly a subjective phenomenon, and how pain is processed depends heavily on the developmental stage reached in behaviour and in cognitive ability at any one time. One instrument that has proved very helpful in the assessment of reactions to pain in children (by analogy with Sanders’ categories of pain response in adults) is the differentiation described by Izard of three different components of pain:
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1.
Physiological involvement (this can be checked objectively by measurement of such physiological parameters as pulse rate, blood pressure, respiratory frequency, partial pressure of oxygen, sweating, or plasma levels of endorphins and cortisol).
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2.
Behaviour.
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3.
Cognitive component
There are various options for ascertainment and interpretation of pain in childhood, depending on the child’s sensorimotor and cognitive development.
Even in neonates (in the first month of life) it is possible to recognize deliberate defence reactions to pain and distinguished facial expression by clinical observation; further information can be gleaned from cry analysis and measurements of physiological stress parameters.
In young infants (1–4 months) long periods of crying and undirected activity can be observed as reactions to pain.
In older infants (4–8 months) conditioning by aversive pain stimuli and features of the environment (e.g. white coats) add to this.
At 7–9 months of age infants achieve the ability to anticipate painful procedures and display anticipatory pain avoidance behaviour.
While they are still toddlers (1.5–2 years), children start to be able to differentiate between pain caused by illness and pain imposed on them from outside. This phase is also characterized by more controlled interest in the source of pain, shorter crying spells and more controlled movements aimed at pain avoidance than in children up to 1 year old.
At the age of 2–4 years, children do not yet understand the connection between pain and illness. The abdomen and the head are the two sites to which pain is actually projected. Up to the age of about 7 years no discrimination is made between causes of pain and environmental conditions. Between the ages of 4 and 7 years is the time when children first become able to allocate symbols or colours to different painful states.
Between the 7th and 10th years of life the child also becomes able to tell the difference between the external causes and the internal consequences of a (painful) illness. Pain is now understood as something peculiar to the child’s body and is underlaid with different kinds of feelings.
From the age of about 11 years onward, children can describe pain in physical, psychic and psychosocial terms, in a similar way to adults.
Of course, the developmental phases described above can overlap, and in the course of a (painful) illness regressive behaviour more in keeping with developmental stages already considered to be in the past can arise.
A detailed pain history taking account of the entire case history with reference to the psychosocial variables must always be at the heart of the diagnosis when the leading symptom is pain. The purpose of the various methods of clinical pain measurement in paediatric patients should be a description of the pain, including the resulting restrictions on the child’s enjoyment of life. Only in these circumstances pain measurement can play a part, as an aid to descision making, in the improvement of pain therapy.
From the 3rd to the 5th year of life children are not able to quantify pain verbally, or at least not adequately, so that recourse to observation scales recorded by others (parents, nurses, doctors) is necessary. Various validated methods are now available. The Johnston and Strada or Grunau and Craig method is suitable for infants up to 1 year of age, and the multidimensional method described by Gouvain-Piquard et al., Pothmann’s rating scale based on external observations and the CHEOPS scale (which also includes physiological parameters) for 2- to 6-year-olds. The emotionally responsive quality of colours can also be used in toddlers (the ability to differentiate between colours starts between the 2nd and the 3rd year of life) for ascertainment of pain intensity, “red” being often used to express the most intense pain.
In older toddlers self-completed information scales can be used to measure pain, e.g. faces with different expressions (Smiley Analog Scale or SAS). From the age of 4–7 years onward most children can also cope with the classic Visual Analog Scale (VAS).
An optimal multidimensional pain behaviour test includes self-observation of pain (e.g. SAS, VAS), observation of behaviour (e.g. FES, CBCL), physiological/medical parameters and development or intelligence tests; only in this way the multidimensional phenomenon of pain can be ascertained.
Algesimetry means the attempt to determine the most objective measurement possible of the pain perception threshold by apparative techniques. Various methods have proved their worth in children as well as in adults. In the tourniquet test (vein distension test), for example, a blood pressure cuff is used to induce painful ischaemia. The pain is assessed at intervals of 10–20 s by means of the VAS or, for smaller children, the SAS. In pressure algesimetry the pressure is measured that can be applied to tender spots and trigger points in the muscles before the pain threshold is reached.
The range of pain experienced by children depends heavily on their age. In early childhood abdominal pain is dominant, such as 3-month colic in young babies or benign recurrent idiopathic abdominal pain in children aged 2 years and over.
Once children reach school age headaches occur with increasing frequency. The incidence of migraine in childhood is given variously as between 1% and 19% by different investigators, depending on age. The age at first occurrence is lower in boys (average 10.2 years) than in girls (average 14.1 years). Childhood migraine differs from that in adults insofar as the pain is not unilateral, especially at first, the attacks are more frequent, and the course is not severe and involves no brain infarcts. In about two-thirds of all children with migraine the symptoms must be expected to continue into adulthood. The differential diagnosis must take account of symptomatic headaches (e.g. in the presence of brain tumours, chronic sinusitis, defective vision), headaches caused by orthostatic hypotension, pain following injury to the cervical spine and/or cranium/brain, and finally tension headaches (these usually are bilateral, pressing and without the character of attacks, and the vegetative symptoms that typically accompany migraine are also not present).
In children with malignant tumours, pain requiring treatment is about as frequent as in adults (in about 62%). In the terminal stage (82%) and during tumour recurrences the vast majority of children suffer intense pain that must be treated. In the treatment of tumour pain it is especially important to avoid a negative pain-learning process at the start.
Chest pain and pain resulting from pathologic conditions of nerves, muscles and joints involve specific problems, in particular in the diagnosis.
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Pothmann, R. (1993). Klinische Schmerzmessung und Schmerzformen bei Kindern — Ein Indianer kennt keinen Schmerz. In: Meier, H., Kaiser, R., Moir, C.R. (eds) Schmerz beim Kind. Springer, Berlin, Heidelberg. https://doi.org/10.1007/978-3-642-84898-8_2
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