Treating severe pain in children

Moderate to severe pain can be treated and relieved well over 90% of the time, yet most patients in severe pain don’t get adequate treatment. (Google ‘pain is undertreated’ and you get 130,000 hits, including many to respected medical journals.) This situation is even more pronounced in children — many, perhaps most, of children in severe pain don’t get enough treatment to relieve it. We love our children: how can this be so?

A large part of the answer is that pain is a subjective experience, and children, particularly pre-verbal children, can’t express that experience as adults can. Young children also don’t have the capacity to understand that their pain can be relieved. Children with chronic pain may even come to think of pain as the normal state of things.

Another reason for under-treatment of children in pain is that, until quite recently, we thought children didn’t experience pain in the same way as adults. Or, if they did, they would have little or no memory of it afterwards. When I was in training 30 years ago, even major surgery was sometimes done on infants with minimal pain relief. (You can read about those days, as well as how infants perceive pain, here.)

There were several other reasons given for under-treating pain in small children, summarized here. Chief among these was an irrational (and unsubstantiated) fear of addicting children to narcotics, the most useful agents for relieving severe pain. This fear of addiction was not confined to physicians — parents sometimes did not want these medications for their children because of it. Extensive research has now shown that this fear is groundless. There were other excuses. Powerful pain-killers have side-effects, one of which can be decreased breathing. But this occurs in both children and adults, and we have ways of dealing with it. So it is not a reason to withhold adequate pain relief from anyone, especially children who cannot speak for themselves.

There are other reasons to treat severe pain besides our ethical imperative to be compassionate — pain is bad for you. It interferes with tissue healing and recovery following surgery. It depresses the immune system, making infection more likely. It has long-standing effects on mental health later, especially in children. You can read more about the bad effects pain has on the body here and here.

If you are a parent and you believe your child is in significant pain, know that doctors can always do something about it, often relieving nearly all of the pain. Here is how we do it. Speak up, even if your child cannot.