Pain in Children and Teens

Article Translations: (Spanish) (Hmong) (Somali)

Our commitment to pain management

We believe children and teens have a right to the best level of pain relief that can be safely provided. The Children’s Comfort Promise™ states we will do everything possible to prevent and treat pain, so we take a team approach to pain and anxiety management, using medicine and non-medicine therapies. Our goal is to have staff and families work together to assess pain promptly and treat it effectively.

What causes pain?

Pain can have many causes, including:

• soreness after surgery caused by:
• the incision (an opening made in surgery)
• stretching or swelling of tissue or organs
• procedures such as starting an IV or drawing blood for a lab test
• nerves that sense tissue damage or swelling
• an achy feeling that can be caused by an infection
• sore muscles from stretching, overuse or being in bed for a long time
• the combination of physical and emotional discomfort

Pain can be treated, and your health care team will do all they can to relieve pain and increase comfort for your child.

How do we know a child or teen is in pain?

We can measure pain with special tools. Children as young as four years old can reliably tell us where they hurt and how it feels. Children and teens can rate their pain using a number scale or an expressive face scale, which corresponds to how they feel.

If children cannot tell us, or if they are reluctant to tell us about their pain, we can look for clues by watching their behaviors like sleep, movement, eating, activities/play, mood, and vital signs (heart rate, breathing rate or blood pressure). Staff will use these observations and partner with you to assess your child for pain.

What are the signs of pain?

Signs of pain may vary for different ages. Look for clues listed below.

Toddlers (1-3 years) may:

• describe the pain
• cry or whine
• show facial grimacing
• keep their body rigid, refuse to crawl or walk
• be more easily frustrated
• be aggressive
• be restless or unable to sleep
• have poor appetite

Preschool children (4-5 years) may:

• describe the pain
• show facial grimacing
• keep body rigid or refuse to move
• not want the area touched
• cry or whine
• be restless or irritable
• have nightmares
• have poor appetite
• not report pain if they think they are being punished, or fear the treatment.

School-age children (6-12 years) can talk more directly about the cause, type, and amount of pain. Common behaviors may include:

• holding still or guarding the area that hurts
• flat-faced expression
• facial grimacing or crying
• emotional withdrawal
• irritability
• restlessness, thrashing
• disrupted sleep
• poor appetite
• nightmares
• not report pain if they fear the treatment

Teens (13-18 years) may show a combination of adult and childlike behavior. Look for:

• change in activity level
• decreased cooperation or participation
• change in eating or sleeping patterns
• irritability, restlessness
• inability to focus or concentrate
• anger or withdrawal

What can parents do?

Parents have a very important role in pain management. Because you know your child best, you can work closely with Children's staff (such as doctors, nurses, or child life specialists) to make decisions about managing pain. You are the best person to help them with new or difficult situations.

To help your child cope with pain, you can:

• Be present, or ask others who know your child to visit.
• Tell the staff if you feel the pain is not being controlled, or if your child is ready to have pain medicine decreased because he or she is too sleepy or more active.
• Give your child as much control as possible; offer choices that are realistic.
• Give praise, even when it's a small success; praise gives encouragement that helps children cope.
• Use routine calming activities before and after a stressful event.

What can be done to reduce pain?

Non-medicine methods

Pain is both a physical and emotional state. Children and teens feel pain in their body, but they also think about it in their head. Some of the things they feel are sensations like burning, throbbing, pressure, or cramping. Some of the things they might think are: "Why do I hurt," "How long will it last," "Why can't someone take it away," and "Do I hurt because I was bad?" They might wonder if it will get worse, or if it will ever be gone.

This worry or anxiety can actually make the pain seem worse and this, in turn, causes even more worry. How can we break this "pain-anxiety-pain" cycle? Some things that can help reduce worry and pain are:

• Preparation for procedures (according to age and development) helps prevent emotional and physical pain, and increase understanding and coping.
• Distractions like music, stories, games, or videos can take a child's attention away from the pain or the procedure.
• Exercise or walking
• Holding or cuddling your child
• Relaxation techniques such as blowing bubbles, pin wheels, or focusing on deep breathing, can reduce anxiety.
• Rubbing or gentle massage helps relax the muscles and the nerves that send pain messages to the brain, soothe brain does not sense as much pain.
• Putting something warm or cold, like a warm wrap or an ice pack, on an injured area can reduce pain from inflammation or sore muscles.
• Imagery, biofeedback, or hypnosis can help people relax and imagine that they are somewhere else.

We will help you and/or your child learn how to use any or all of these techniques. Talk with your nurse or provider to learn more.

Medicines

There are many types of pain medicines we can use. Which type is best will depend on many things including the cause and type of pain, and how long it will last. Often we use medicines together, and some common medicines are described below.

Numbing cream, such as 4% lidocaine, can be put on the skin to numb it. It should be offered before needle procedures such as an IV start, lab draw or injection. It needs to be on for at least 30 minutes to work best, and helps reduce discomfort with needles. (See the education sheet "Anesthetic (numbing) cream.")

Non-steroidal anti-inflammatory drugs (NSAIDs) reduce pain and inflammation. They can be bought over the counter and help manage mild to moderate pain. To reduce stomachache, they should be taken with food when possible. Ibuprofen (Motrin®, Advil®, or another brand) is an example of an NSAID.

Acetaminophen (Tylenol® or another brand) is another over-the-counter medicine that helps treat mild to moderate pain. It has fewer side effects than NSAIDs but does not reduce inflammation.

Opioids are strong medicines used to treat moderate to severe pain, often used after surgery. They may be given by IV or taken by mouth. Opioids can have side effects of itching, nausea, and constipation. They can cause sleepiness and slower breathing. Sometimes NSAIDs or acetaminophen and opioids are used together. When opioids are taken by mouth, they should be taken with food to prevent nausea. To prevent constipation, children and teens may need to drink lots of fluids or take a stool softener.

In the hospital, there are some other options for receiving pain medicines. Children and teens may use a patient-controlled analgesia (PCA) pump in which they push a button to deliver a controlled amount of medicine. Children and teens who have had surgery may have a small catheter (tube) placed in the epidural space next to the spinal cord and have medicine sent directly to the nerve endings. (See the education sheet "Epidural analgesia.")

After your child or teen goes home, follow your doctor's instructions about giving pain medicines. Give the medicine as soon as the pain starts. Severe pain is harder to take away. Be sure to give medicine at bedtime to promote comfortable sleep. Some medicines need to be given around the clock. Your doctor will tell you the schedule for this if it is needed.

Be sure to call the doctor if the medicine does not seem to help the pain or if it becomes worse. If you call the doctor about pain you might be asked about fever, how severe the pain is based on your scale, and what the wound or surgical site looks like (if there is one).

Questions?

This is not specific to your child but provides general information. If you have any questions or concerns, please talk to the doctor or the staff working with your child. Your doctor or nurse can also access other pain experts in the hospital. Good pain management is a team effort.

Last Reviewed 6/2020

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