World Health Organization Guidelines for Managing Chronic Pain in Pediatric Patients

Chronic pain in children should be viewed as more than just a biomedical condition, according to new World Health Organization (WHO) guidelines.¹Instead, choosing appropriate pain treatments should include a holistic view of the patient and include biopsychosocial factors such as the child’s age, social environment, and cultural background.²

Scope of Children’s Pain

“Chronic pain in children is a significant public health problem globally and a leading cause of morbidity in children, with a negative impact on their emotional, physical, and social development and function,” the guideline authors wrote. “The lives of families and caregivers are also significantly impacted.”

Chronic pain management in adults can be challenging; managing pain in children adds an additional layer of complexity — particularly with the current dearth of high-quality research studies focused on treatment interventions and management approaches. Within the small body of published literature, study populations vary by age, sample size, and pain definition used, and data from low- and middle-income countries are severely lacking.

The currently available studies suggest that between one-fourth and one-third of children experience chronic pain. Among those children, roughly 1 in 20 experiences moderate to high levels of pain and pain-related disability. Data about adolescents’ pain, including headache, back, abdominal, musculoskeletal, and multisite pain, indicate significant variability in its prevalence.

“Exposure to chronic pain early in life may have implications for the incidence, severity, and duration of chronic pain, and may be associated with long-term, maladaptive neurological changes,” the guideline authors wrote, citing neuroimaging studies of children with acute pain indicating that chronic pain may be associated with changes in nervous system structure, function, and chemistry, “correlated with subsequent cognitive, behavioral, and somatosensory outcomes.”

Goals and Barriers

The goal of the WHO guidelines is to provide evidence-informed recommendations for chronic pain management in pediatric patients. They were developed through a systematic review of the currently available evidence about benefits, harms, feasibility, and acceptability of recommendations, in addition to considerations surrounding equity and resources.

“There are a number of barriers to providing adequate access to pain management strategies…for vulnerable populations such as children,” the authors wrote. “These barriers include the medical community and policy maker’s focus on extending life and productivity, opiophobia (prejudice and misinformation about the appropriate medical use of opioids), limited attention globally to non-communicable diseases, poor knowledge on the part of health professionals, and concerns about the nonmedical use of controlled substances.”

Per the WHO, these guidelines are intended for use in children between 0 and 19 years of age who require management of primary or secondary chronic pain. Particular focus is placed on physical, psychological, and pharmacologic pain relief interventions.

Guiding Principles

Three key principles were outlined by the Guideline Development Group to serve as best practice statements and “guide all aspects of the care of children with chronic pain.” These key principles are summarized as follows:

Pain management access is a fundamental human right
Children have the right to enjoy the highest attainable standard of health
Healthcare providers should ensure that children, families, and caregivers are aware of their rights to self-determination, nondiscrimination, confidentiality, and appropriate and accessible health services

Best Practices

The Guideline Development Group also created 10 best practice statements for clinical management of pediatric chronic pain. These statements apply to all aspects of clinical care, including planning, implementation, and delivery of physical, psychological, and pharmacologic interventions. These statements are summarized below:

Children and their families and/or caregivers must be cared for from a biopsychosocial perspective; pain should not be treated as only a biomedical problem.
A comprehensive biopsychosocial assessment is essential to inform pain management and planning. Healthcare providers should use age-, context-, and culturally appropriate tools to monitor pain intensity and quality of life impacts.
Children must undergo a thorough evaluation for any underlying conditions, and receive treatment for those conditions, as well as appropriate pain management. Comorbidities that affect social and emotional well-being require concurrent management.
Children with chronic pain should be assessed by healthcare providers with skill in and experience with the evaluation, diagnosis, and management of chronic pain.
Management, regardless of methodology, should be tailored to the child’s health, taking into consideration underlying conditions, developmental abilities, and social and emotional needs.
Care for children with chronic pain should be child- and family-centered. That is, it should be focused on and organized around the health needs, preferences, and expectations of the child and their family; be tailored to each family’s values, cultural preferences, and resources; and promote active, whole-family engagement in the child’s care.
Families must receive timely, accurate information. Shared decision-making and clear communication are both essential to good clinical care. Patient-focused communication should be tailored to the patient’s cognitive, developmental, and language abilities.
Patients and their families should be treated in a comprehensive, integrative manner. Cognitive, emotional, and physical health, as well as educational, cultural, and social needs and goals, should be incorporated into the care management plan.
An interdisciplinary, multimodal approach should be adopted and tailored to the needs and desires of the child and the family and caregivers.
In addition to families and caregivers, policymakers, program managers, and healthcare providers must incorporate opioid stewardship to ensure the “rational and cautious” use of opioids. Opioids must be used only for appropriate indications and prescribed by trained providers with a clear plan for continuation, tapering, or discontinuation.

Recommendations and Their Rationales

The guideline creation process included a systematic review of studies across the 3 intervention types (physical, psychosocial, and pharmacologic). Quantitative data were reviewed for all domains and were used to create pediatric chronic pain management guidelines. These recommendations are summarized below.

Recommendation 1. Children with chronic pain may be treated with physical therapy, either alone or in combination with other treatments. This recommendation is conditional, based on very low certainty evidence.

Recommendation 2. (A) Psychological management via cognitive behavioral therapy and related interventions — such as acceptance and commitment, behavioral, and relaxation therapy — may be used. (B) Psychological therapy may be delivered either face to face or remotely, or via a combined approach. These recommendations are conditional, based on moderate certainty evidence.

Recommendation 3. Appropriate pharmacologic management, tailored to specific indications and conditions, may be used to treat this patient population. This recommendation is conditional, based on low certainty evidence.

Recommendation 4. (A) Under the principles of opioid stewardship, appropriate pharmacologic management may include morphine use for end-of-life care. (B) Children with chronic pain due to life-limiting conditions (eg, illnesses for which there is no cure and for which an early death is expected) may also receive morphine distributed by appropriately trained healthcare providers. These recommendations are conditional, based on very low certainty evidence.

Eye on the Future

Gaps in research were also identified by the Guideline Development Group. Addressing these gaps in future studies will aid in the creation of future evidence-based guidelines to direct decision-making. Areas for future study include large multicenter trials examining individual and multimodal therapies in variable settings, individual-level analyses of children’s responses to interventions at different phases of treatment or illness, study population characteristic reporting, the catalog of validated tools for pain assessment, and a standardized set of patient- and family-centered outcomes. Long-term follow-up data are also needed.

“The WHO Steering Group will continue to follow research developments in the management of chronic pain in children, particularly for interventions in which the certainty of the evidence was found to be low or very low,” the study authors wrote.

“The management of pain requires a broad, multimodal and interdisciplinary approach that addresses its physical, psychosocial, and social dimensions,” they concluded. “Children, including adolescents, have the right to appropriate treatments…for pain management, and policy makers and providers need to ensure appropriate access to the management strategies while minimizing the potential harms of inappropriate use in society.”