Pain Management

Arkansas Children’s Hospital Division of Pediatric Pain Medicine uses a multidisciplinary model to treat children's pain. We combine clinical services, research, and education to provide care to children with numerous types of pain conditions including, but not limited to:

Inpatient Pain and Symptom Management Consultation Service (Acute Pain Service)

Acute pain is one of the most common adverse symptoms experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is often associated with increased anxiety, avoidance, somatic symptoms, and parental distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated.

Pediatric Pain and Symptom Management Clinic (Chronic Pain Service)

Chronic pain is a significant problem in the pediatric population, conservatively estimated to affect 15% to 20% of children and adolescents. Children and their families experience significant emotional and social consequences as a result of pain and disability.

Our faculty has lectured locally, nationally, and internationally about many different pediatric pain management topics. By focusing on clinical care, research, education, and advocacy, we hope to ensure that the children of Arkansas benefit from the best pain management available.

We are fortunate to have a very talented multidisciplinary team that brings together experience and expertise from rehabilitation/physical therapy, nursing, psychology, and anesthesiology to treat pediatric pain in an integrated manner. We believe the most effective and long lasting results can be achieved using this multidisciplinary approach.

Arkansas Children's Hospital Pain Medicine Team

Pediatric Acute Pain Service

We provide inpatient pain management services for children in the hospital with a variety of pain problems. These range from postoperative pain to acute exacerbations of pain associated with chronic medical problems (such as cancer), and pain associated with medical procedures. Although the primary physicians who care for these patients often provide very good pain treatment, we are available to provide consultation for more complex patients or for specific therapeutic questions.

We provide a number of methods to control pain, including:

Our goal is to keep the children safe and comfortable, so we have a variety of safety protocols in place, as well as 24-hour-a-day physician coverage.

If your child will be having an operation that requires him or her to be admitted to the hospital afterwards, ask your doctor how pain will be controlled and if the Acute Pain Service might be of benefit. We are not always needed, but we are always available and willing to help.

Pediatric Chronic Pain

Evaluation and Consultation

Our weekly multidisciplinary Pediatric Pain clinic is intended to provide consultation and treatment services to pediatric patients with painful conditions. All patients undergo a thorough initial assessment by our pain management team, including:

Treatment

We believe the most effective way to manage any chronic pain problem is with a comprehensive multidisciplinary approach. Our weekly clinic is intended to assist children and families develop and improve their abilities to cope with pain and other medical symptoms through teaching non-pharmacological pain management techniques and treating co-morbid depression, anxiety, and secondary sleep disturbances.

Treatment programs often include:

All patients undergo an initial psychological evaluation and receive treatment services including:

Arkansas Children's Hospital Pediatric Pain Medicine offers a variety of procedures to treat pain, including various neural blocks and several innovative procedures. Depending on your particular condition, you may be referred for single or ongoing procedural appointments. These procedures may also be used in combination with other therapies.

Frequently Asked Questions Regarding Pain Medicine Services


What is Pain?

Pain is an unpleasant feeling or emotion that signals the danger of injury or damage to someone's body. It is one of the body’s warning signals that indicate a problem that needs attention. Pain starts in receptor nerve cells located beneath the skin and in organs throughout the body. When illness, injury, or other types of problem, these receptor cells send messages along nerve pathways to the spinal cord, which carries the message to the brain. Pain can be anything from a slight headache to something excruciating and emergent. Simply put, pain is what hurts.

  Most pain is temporary, fading away as the problem is fixed. Occasionally, pain outlives its purpose and becomes "useless pain". This type of pain takes on a life of its own, and can be very debilitating. The reason for this is not always known.

What causes pain?
Pain has many causes including illness, surgery, tests and injury. Sometimes, no cause for pain can be found.

What are the symptoms of pain?

Children describe their pain in many ways. Words such as achy, sharp, dull, electrical, burning, throbbing, pressure or stabbing can help your child's doctor find the right medicine to treat the pain.

Older children will say they hurt, but sometimes they cannot describe their pain clearly. Younger children may cry or hold very still and try not to move. They may have a poor appetite, or be irritable, or cranky. They may not be able to sleep well, or they may want to sleep a lot.

Children in pain usually do not do the things they would be doing if they were not in pain. They may choose not to play, read, talk with you, or watch TV.


How is pain measured?

Babies and young children cannot tell their doctors and nurses that they are having pain, or if their pain medicine is working. So, measuring scales have been created to help.

Arkansas Children's Hospital uses the following pain scales:

Modified Objective Pain Scale

(For use with patients 0-4 years of age)

FACIAL EXPRESSION

Composed/Relaxed muscles/Smile

Grimace

Extreme expression/very tight facial muscles

CRYING

Not crying

Crying, but easily consolable, responds to tender loving care (TLC)

Crying but does not respond to TLC

MOVING

None

Restless

Thrashing

AGITATION

Patient asleep or calm

Mild

Hysterical

VERBAL EVALUATION OF BODY LANGUAGE

Patient asleep or states no pain

Mild pain (cannot localize)

Moderate pain (can localize) verbally or by pointing
 
1
2
3


Faces Rating Scale

Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also helpful for elderly patients who may be cognitively impaired. If offers a visual description for those who don't have the verbal skills to explain how their symptoms make them feel. Although pain is subjective and can vary from one patient to another and from one day to the next, health care providers attempt to measure pain as objectively as possible. Pain is usually determined by asking the patient what their pain is like and relating that pain level to a scale.

Wong-Baker Faces Pain Rating Scale

From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission.


Numerical Rating Scale

A numerical pain scale allows you to describe the intensity of your discomfort in numbers ranging from 0 to 10 (or greater, depending on the scale). Rating the intensity of sensation is one way of helping your doctor determine treatment

Numerical Pain Scale

From Margo McCaffery, RN,MS, FAAN and Chris Pasero, RN MSNc: Pain Clinical Manual, 2nd Edition, 1999, p. 63. Copyrighted by Mosby, Inc. Reprinted by permission.

Numerical pain scales may include words or descriptions to better label your symptoms, from feeling no pain to experiencing excruciating pain. Some researchers believe that this type of combination scale may be most sensitive to gender and ethnic differences in describing pain.


Why is treating pain important?

Treating pain is more than just making a nasty sensation feel better. Pain can affect your child's ability to breathe well, move around or even eat normally. Pain can affect activity, sleep and energy levels as well as alter moods and make it hard for you to talk with your child. Pain, management can help get your child home sooner by speeding up the healing process.

Blood pressure, pulse, respiration and temperature have been defined for many centuries as the basic "vital signs" that indicates good health. These vital signs are important clues for doctors to diagnose and treat illness and they also provide doctors with a simple, baseline compass to determine if a patient is ill. It is now recognized that pain is also a sign of illness. Pain can provide a useful tool for doctors to measure and monitor a patient’s state of health, illness, and well-being.

Pain scales are useful indicators for doctors to get a sense how much pain the patient is experiencing. They are also very important measures that can help determine if treatments are effective or simply not working to combat pain. Because pain is such an important part of diagnosis and treatment, the need for doctors, nurses and other health care providers to register pain as a vital sign is becoming a mandated part of medical care. These efforts are just one indication of the heightened awareness of pain as a potentially overlooked source of suffering. Adding pain as the 5th vital sign may help overcome needless suffering from pain that is treatable, if we are just aware of it.


What is chronic pain?

Chronic pain is long standing pain that persists beyond the usual recovery period or occurs along with a chronic health condition, such as arthritis. Chronic pain may be intermittent or continuous. It may affect people to the point that they cannot work, eat properly, participate in physical activity, or enjoy life.

Chronic pain is considered a major medical condition that can and should be treated.


What causes chronic pain?

There are many causes of chronic pain. It may have started from an illness or accident, from which a person has long since recovered. Or there may be an ongoing cause of pain. Many people suffer chronic pain in the absence of any past injury or evidence of illness.

Common diagnoses seen in our clinic are:

  • Back Pain
  • Neck Pain
  • Complex Regional Pain Syndrome (CRPS)
  • Headaches/Migraines
  • Joint Pain
  • Cancer Related Pain
  • Scar Neuroma
  • Pelvic Pain
  • Peripheral Neuropathies
  • Phantom limb and stump pain
  • Myofascial Pain
  • Central Pain States due to spinal cord, stroke and brain injuries

Chronic pain involves all aspects of a person's life; therefore, the most effective treatment includes not only relief of symptoms, but also other types of support. A multidisciplinary approach to pain management can often provide the needed interventions to help manage the pain. Pain management programs are usually conducted on an outpatient basis. Many skilled professionals are part of the pain management rehabilitation team, including any/all of the following:

  • anesthesiologists
  • nurses
  • physical therapists
  • psychologists/psychiatrists
  • social workers
  • case managers
  • vocational counselors

How is pain treated?

The treatment of pain includes many therapies based on the cause. Mild pain is often managed with single therapies. Severe and complex pain requires combined therapies including medication, physical therapy, psychology and relaxation training. Treatments include the following:

  • Some pain is due to inflammation. An anti-inflammatory medication would be useful to treat this type of pain.
  • Nerve injury can bring a different type of pain, which will respond to medicine designed to calm misfiring nerves.
  • Pain is made worse by depression and tension, so relaxation training, massage and healing touch can be helpful.
  • Biofeedback, acupuncture and TENS units are other ways to treat pain. "TENS" stands for Transcutaneous Electrical Nerve Stimulation. This is a palm-sized device that uses a small amount of electrical current to help the body shut down incoming pain messages at the level of the spinal cord. It can be useful for localized pain (pain in a specific area), and has few side effects.

Medical Library

Pain is...
An unpleasant sensory and emotional experience arising from actual or potential tissue damage or described in terms of such damage.

Chronic Pain
Pain that last for more than 6 months and may continue for the rest of the patients life.

Neuropathic Pain
Pain that starts or is caused by a primary lesion or dysfunction in the nervous system

Opioid
Preferred to the term "narcotic"; refers medications that relieve pain by binding to the opioid receptors in the nervous system.

Adjuvant
A drug that has a primary purpose other than pain relief (like an antidepressant or seizure medication) but can also serve as an analgesic for some painful conditions.

Complex Regional Pain Syndrome
Characterized by pain, abnormal regulation of blood flow and sweating, changes in skin and nails, may involve swelling and color change to the limb. CRPS/RSD may or may not be associated with an injury.

Non-Pharmacologic Methods of pain relief
Non-medicine intervention or treatment for pain management. May increase sleep, reduce anxiety, improve mood and increase sense of control.

Cognitive-Behavioral therapy
Used to assist patients to change their view of their pain and suffering from overwhelming to manageable and to teach patients coping techniques and skills and how to utilize these adaptive methods.

Complementary therapy
Include non-medication modalities such as heat, cold, vibration, distraction, relaxation, used for pain management.

Tolerance
A process characterized by decreasing effects of a drug at the initial dose, or the need for a higher dose of a drug to maintain an effect.

Physical Dependence
Physical reliance on an opioid evidenced by withdrawal symptoms if the opioid is abruptly stopped or an antagonist is administered.

Addiction
Psychological dependence; a pattern of compulsive drug use characterized by a continual craving for an opioid and the need to use the opioid for effects other than pain relief.

Blocks & Injections
Trigger point injection can be done in the office if needed for chronic headache. Blocks and injections such as lumbar sympathetic, stellate ganglion & epidural steroid injections may be used for diagnosis or to facilitated physical therapy and rehabilitation.


Procedural Therapy:

  • Epidural Steroid Injection
  • Occipital Nerve Block
  • Brachial Plexus Block
  • Peripheral Nerve Block
  • Facet block
  • Stellate ganglion block
  • Celiac plexus block
  • Lumbar sympathetic block
  • Selective nerve block

Pediatric Pain Clinic


Arkansas Children's Hospital
1 Children’s Way, Slot 203
Little Rock, Arkansas 72202

Clinic Hours

We are available by phone: Monday through Friday, 8:00AM -4:00PM
We are open for appointments on Tuesdays

Contact Us

Phone (501) 364-3100
Fax (501) 364-2939

Frequently ask Pain Management Questions for parent/caregiver


Who should treat pain in children?

Most common painful conditions of childhood have been and should continue to be managed by pediatricians and family practitioners. Occasionally, a child will develop a pain that does not resolve with time or simple interventions. The pain that results from cancer or other complicated medical problems can also be difficult to control and need special expertise. For those times, a pediatric pain clinic/specialist can provide more comprehensive pain care.

Why is a psychologist involved?

Pain is not just physical. It causes stress and it causes suffering. Depression and anxiety can result from pain or make it worse.

The family is always involved in the stress and suffering, because of the love the family has for its children. Taking care of these issues is very important. Often pain does not go away quickly, and coping skills training helps the child and the family to go on with life until the pain resolves.

Finally, there are pathways in the brain and spinal cord whose job it is to suppress pain. There are several ways the psychologist can help the child connect these neurologic defenses to actually feel less pain.

Treatments that are available include biofeedback, relaxation training, coping skills training and psychotherapy. All of our patients have at least an evaluation by our pain psychologist when they first come to clinic. This can also be provided as an inpatient service if needed.

Why is a physical therapist involved?

Pain affects the way the body functions. Whether they know it or not, people may change the way they walk, sit, use their legs or arms, or hold their head. They may simply become "out of shape."

Our physical therapist is an expert in assessing these changes and designing a course of therapy to optimize the body's function. There are actually severe pain conditions that seem to improve because of physical therapy as much as everything else put together!

One thing to know is that the increase in activity that may be recommended often briefly increases the pain before it helps.

We can help with this, but it is to be expected and you will need to help your child stick with the program in order to get the long-term benefits from it.

What is a TENS unit?

TENS stands for Transcutaneous Electrical Nerve Stimulation. It is a pain-relief device that uses two small patches that stick to the skin, providing a tapping or tingly sensation to the painful area. The nervous system handles sensation on a "first-come, first-serve" basis. The sensation provided by the TENS unit travels faster than pain sensations and helps the spinal cord block out the pain.

The TENS device can be worn under clothing for use at work or school, and it is very safe.

Can children become addicted to pain medications?

We use opioid (narcotic) pain medicines for certain pain conditions, especially after surgery and for patients with cancer pain. The number of children who become addicts is extraordinarily small.

Most people of any age will become tolerant to opioid medications. They may need more and more to get the same effect; they may say "this medicine doesn't work for me any more."

They may have withdrawal if they stop the medicine suddenly (withdrawal can be avoided by following a medication schedule provided by the pain service). This is a physical phenomenon that happens to almost everyone and is different from addiction.

As a matter of policy, though, we do have patients and parents sign a "controlled substances contract" when these medicines are prescribed through the pain clinic for non-cancer pain and enforce the rules strictly, but problems are rare.

Isn't methadone for drug abusers?

Methadone is a long-acting opioid medication that is the same strength as morphine. Because it does not cause a "high" and because it is long acting, it is used in drug clinics to keep former users off of heroin.

In our pain practice, it is a very useful medication because it works well for pain, lasts a long time, comes as a liquid (for those who can not take pills), and has special properties as a pain medicine that other opioids do not. It often has fewer side effects for those patients who have had problems with other medications.

Lastly, we often use methadone to help prevent withdrawal symptoms in patients who are discontinuing opioid medications after taking them for a long time. We monitor the use carefully, including obtaining electrocardiograms.

Why are medications used to treat seizures and depression used to treat pain?

An interesting thing about pain is that many of the same chemicals the body uses to transmit or block pain signals are the same as those that seem to be out of balance when a person becomes depressed. Other sorts of pain act a bit like seizures, where nerves fire at times and in ways that are inappropriate.

Antidepressants and anticonvulsants have been shown to help many different pain conditions. They also help with sleep (which is often disturbed by pain) and have a helpful effect on mood. They do have side effects (like almost everything), and we monitor their use carefully, including obtaining electrocardiograms and blood tests, depending on the medication.

What is RSD (Reflex Sympathetic Dystrophy)?

RSD (now called Complex Regional Pain Syndrome Type I) is a type of neuropathic (relating to nerves) pain that is infrequent in adults and children, and can be very severe.

There are several differences in pediatric RSD from that in adults. Most children recover. It is most common in active (athletes, dancers) female adolescents of high-achievement oriented families. It tends to occur in the lower legs and feet and usually does not progress to the "crippled up," withered appearance that can occur in adults with the syndrome.

RSD in children appears to respond well to aggressive physical therapy, medication and behavioral medicine. Sometimes nerve blocks are used to interrupt the pain cycle or to allow physical therapy to be done if it is otherwise too painful.

We stress that the information available on the Internet is predominantly from adults and often paints a picture that does not apply to children with this pain syndrome.

What causes pelvic pain?

Pelvic pain is more common in adolescent girls than once thought. Often endometriosis is the cause. Endometriosis is a condition in which the clusters of cells that usually form the lining of the uterus come to be lodged in the pelvis and abdomen and cause pain.

Other causes of pain include menstrual cramps, ovarian cysts, venereal diseases and adhesions from surgery. Sometimes extensive testing reveals no obvious cause.

Treatment involves medications (often including oral contraceptive pills), TENS, physical therapy, behavioral medicine and other non-traditional treatments such has acupuncture.

What causes recurrent abdominal pain?

This is one of the more frustrating kinds of pain in children not only because it is extremely common (even Peanuts lead character Charlie Brown complains, "my stomach hurts"), but also because the reason for the pain is often not known.

Sometimes conditions such as lactose intolerance, visceral hyperalgesia, intestinal pseudo-obstruction, pancreatitis, diabetes and gallbladder disease can be found to explain the pain.

As with most complex pain in children, a multidisciplinary approach is required to manage the pain.

What can be done for cancer pain in children?

Pain is assumed to be a natural part of having cancer; it is one reason why cancer is so feared as a disease. In addition, many of the treatments and tests for cancer are painful.

Fortunately, we have many things to offer for controlling cancer pain, as well as the pain and fear that result from the tests and treatments. We believed very strongly that cancer pain should be brought under control to the greatest degree possible for all children, regardless of the prognosis.

We use a combination of medications, behavioral medicine techniques to reduce stress.

We make ourselves available around the clock to all our cancer pain patients.

What can be done for the pain of surgery in children?

Children hurt after surgery. That seems so obvious, but for a long time, children received much less pain control after surgery than adults did. We have an active acute pain service to advocate for the children who need special pain care.

We use epidural catheters for a wide range of operations, both in the operating room and afterwards. For children age 5 and up, PCA pumps can be very effective.

For children who are either too young to use a PCA or are handicapped and cannot use a PCA, we have other means of making sure all patients on our service receive the proper pain medications.

Even with the latest advances on medicine and technology, we cannot promise that there will be no pain after surgery. We do promise to do our best to keep the pain to the least possible amount. We also look after side effects and have safety guidelines that are used throughout the hospital for the patients on our service.

What is a PCA (Patient-Controlled Analgesia) pump?

PCAs are computerized pumps that can be set to deliver a specific amount of medication when a button is pushed by a patient. Children as young as 4 years old have used PCAs effectively, although generally we only offer it to children over the age of 5.

Safety settings include limits on how often the pump will deliver the medication, how much is given at a time. Several medications can be used this way. Only the patient is allowed to press the button, so that if they become too sleepy, they fall asleep and do not press the button.

Pressing the button while a patient is asleep is a dangerous thing to do (no matter how old the patient is) and we prohibit that, a policy we strictly enforce.

With proper education, an identified parent/caregiver can be instructed on how and when to push the pca button for extra medication. Instruction will also be given on signs and symptom that should be reported to the nurse.

What is an epidural?

Most people know of epidural analgesia as a way to keep women comfortable during childbirth. The epidural is a length of thin tubing that is placed in a space between the bones of the spine and the spinal cord. Medications can be given as an infusion to keep people comfortable after surgery.

Children are generally quite afraid of needles and would move during catheter placement (which could be dangerous), so we place the catheter while the child is asleep under general anesthesia. Abdominal, chest, hip and leg surgery are the types of surgery most appropriate for an epidural. Epidurals can be used after surgery on patients from the first day of life and through adulthood.