Management of Chronic Pain In Children
Zeev N. Kain MD1
Stephen Rimar MD2
1 Assistant Professor of Anesthesiology and Pediatrics
2 Associate Professor of Anesthesiology and Pediatrics, and Chief, Section of Pediatric Anesthesiology, Yale University School of Medicine and Yale-New Haven Hospital, New Haven, CT.
Pain relief has received considerable attention in recent years, but pain in neonates and children has been underreported, undertreated, and misunderstood. Several reviews have dealt with the recognition and treatment of acute pain, but much less has been written about chronic pain in children. Here we will address general considerations of pain management in children and specific chronic and recurrent pain syndromes of childhood.
Developmental Considerations
The perception of pain includes both a sensory component, involving neural pathway activation in response to noxious stimuli, and an affective/cognitive response, involving several behavioral aspects.
Cutaneous sensory perception has been reported in the perioral area of human fetuses as early as the seventh week of gestation and spreads to include cutaneous and mucosal surfaces by the twentieth week. Incomplete myelinization of nerve fibers and immature synaptic connections have been thought to indicate a lack of maturity in the neonatal nervous system, but this phenomenon merely implies a slower conduction velocity, with much shorter traveling distance in newborns.
Development of the fetal neocortex begins during the eighth week of gestation; by 20 weeks, each cortex has a full complement of neurons. Sensory pathways required for pain transmission can be traced from receptors in the skin to sensory areas in the cerebral cortex of infants. Functional development of the cerebral cortex is suggested by specific features of both the fetal and the neonatal electroencephalogram.
