Understanding Chronic Pain in Kids

Dr. Richard So, MD:

Welcome to Little Health, a Cleveland Clinic Children's podcast that helps navigate the complexities of child health one chapter at a time. In each session, we'll explore a specific area of pediatric care and feature a new host with specialized expertise. We'll address parental concerns, answer questions, and offer guidance on raising healthy, happy children. Now, here's today's host.

Dr. Deepak Lachhwani, MD:

As a parent, you know your child's normal better than anyone else, which makes it so upsetting when they're struggling with pain that feels complicated and unpredictable. I'm Dr. Deepak Lachhwani. I'm a child neurologist with focus on Epilepsy at Cleveland Clinic. Today, we're talking about kids living with neurological pain, how their nervous system processes it and the latest treatments available to help. Joining me is my colleague, Dr. Desimir Mijatovic. He's a pediatric and adult pain medicine doctor at Cleveland Clinic who is board certified in psychiatry, child psychiatry, and pain medicine. Welcome to Little Health, Dr. Mijatovic. Please tell us a little bit about yourself.

Dr. Desimir Mijatovic, MD:

Thank you, Dr. Lachhwani. So my name is Dr. Desmir Mijatovic. I'm a pediatric and adult pain management doctor. I've been here at Cleveland Clinic for just over three years now. I practice out of the Neurological Institute and the adult side through the comprehensive pain recovery and on the pediatric side through our pediatric neurology department. My training is actually through psychiatry. So I was trained as a psychiatrist and a child psychiatrist before I did my pain management training. And so I bring a little bit of a different background and different thought process to chronic pain and I think that comes out in the way that I treat patients.

Dr. Deepak Lachhwani, MD:

Which is perfect. I think you're being able to bridge the body and the mind is probably exactly what we need in an expert who's able to treat pain. What is a difference that you would like to suggest between acute pain and neurological pain?

Dr. Desimir Mijatovic, MD:

Pain itself is one of the body's alarm systems. And the big difference between acute pain and chronic pain is how the body uses that alarm. So in acute pain, you have some kind of injury or illness, which if you think about in an alarm system, for example, a fire alarm, the alarm senses that there's smoke, that there's a fire, and then the alarm goes off. Acute pain is very similar in the body. The difference with that with chronic pain is that with chronic pain, the body's alarm system is sensing that fire, so to speak, for so long that eventually it starts to malfunction. And then the alarm system has a problem of itself that also needs to be treated separately or differently. The interesting thing about this is that when you treat the underlying cause of the chronic pain, sometimes that pain can still stick around.

And that's what I treat often in patients that come to see me who have chronic pain and either the underlying cause has been treated already, the underlying problem has healed or they've re- the patient's recovered from it, but they're still suffering in pain. And so that means that the neurological system or the alarm system itself needs to be treated separately.

Dr. Deepak Lachhwani, MD:

That's fascinating. And I think, you know, as a neurologist myself, I still like to unpack it in a way that is simple. So what I hear you say, correct me if I'm wrong, acute pain is like you stub your toe or you, you break a bone and immediately in the aftermath there is a tsunami of, you know, messages that the damaged tissue or the bone is releasing and that causes the pain that is acute. Chronic pain, it seems like it is the interpretation of this pain by the brain in a way that over a period of time that itself becomes more of a dysfunction rather than the proper way that the brain would anal- the brain would analyze those signals. Am I thinking about it correctly? That's-

Dr. Desimir Mijatovic, MD:

Yeah. The way I describe it to patients is it's a malfunction of the body's alarm systems where they're being activated inappropriately. In the scientific literature, there's several names for this, central sensitization, nociplastic pain, wind up phenomen, where basically these repeated stimulations of the pain nerves changes the resting membrane potential of these nerves so that they're now constantly being activated at a higher level or it doesn't take as much stimulus to set off that action potential down those nerves. And so I sometimes will explain this with patients that the nerves themselves that signal pain are actually the problem, not so much the original injury that may have caused it.

Dr. Deepak Lachhwani, MD:

Interesting. Well, thank you so much for clarifying that. You know, arguably, probably this is the commonest reason why patients would come to doctors is because of pain of some kind and it is a huge topic and I think that our listeners would really appreciate, uh, what we can offer to them. Maybe they can make this at the speed dial for a go- to podcast to be able to learn from your experience and we certainly appreciate that.

Shifting gears a little bit, you know, children two, three, five, 10 years of age and they've just barely started life. When we say chronic pain, it almost sounds like something that is something that shouldn't belong in somebody whose life has just started of a few years age. What is chronic pain in kids? How do you define that? How can a parent understand chronic pain in kids?

Dr. Desimir Mijatovic, MD:

Yeah. So chronic pain is defined as any pain that's lasting over three months. Now, this could be a constant pain or a recurrent pain that goes away and comes back, but regardless that going away and coming back or constant pain has to last over three months. Chronic pain is more common in adults. However, the studies show that up to 10% of kids will experience some form of chronic pain.

In children, this can be headaches, abdominal pain, back pain, other musculoskeletal like arm or leg pains. So it's fairly common. The hard part with kids is the communication can be missing sometimes where kids don't often know how to communicate this to their parents or their caregivers. So oftentimes it's missed or kids don't even know that it's a problem or they don't even know that it's not normal to experience pain.

Dr. Deepak Lachhwani, MD:

Well, and it may manifest in the way that they adjust to it or maladjust to it. And I think again, you wear that hat of being a psychiatrist so you can see through these things better than most other practitioners would. Now, you know, often we think about any kind of symptom or disease that there are tests that can prove it. You know, you have a certain test that tells you what's wrong and you move on with trying to solve for that. In pain though, how do you understand what is wrong if the MRI looks normal, a routine set of lab works doesn't really show anything egregious and still the pain is there, debilitating pain. What's happening when tests actually cannot see the pain?

Dr. Desimir Mijatovic, MD:

So this is one of the most frustrating things I think for patients and families when they come through to see doctors and especially to see pain management doctors. Usually I'm not the first doctor to see patients with pain. I think the studies say that around 70 to 80% of visits to the doctor are because of some kind of pain complaint. So generally patients will either start off with a pediatrician or for example, a GI doctor, if it's stomach pain, a neurologist if it's headaches, other specialties, rheumatology that also treats pain. Usually the, the patients will start with those specialists and that's where the investigations start. Now, of course, anytime you have some kind of complaint, you want your doctor to evaluate it and look for underlying causes. Unfortunately, as you said, sometimes those investigations don't come up with anything or the lab tests, the MRIs, the imaging, the specialized tests all come back normal, but that pain or those symptoms are still present.

All of that information is important to come to these conclusions on what to do next. Oftentimes, those negative tests are actually, in my mind, reassuring that we're not also dealing with some other structural problem or a scary condition like a tumor or some kind of severe injury. And so knowing that those tests are negative or normal points more to this central sensitization type pain or chronic pain as the nervous system being the problem itself. Unfortunately, in clinical practice, we don't have testing that's sophisticated enough to be able to see these changes in the nerves yet. I do know that in research and in the lab, there are ways to test for these things, but it hasn't been available clinically.

Dr. Deepak Lachhwani, MD:

Interesting. Yeah. For a complex topic like this, maybe we should start by talking some, you know, examples where we can wrap our head around what is pain. How about some simple things like in children, for instance, specifically a pulled muscle or a bruise or, you know, or, or a pain in the bone or in the back. You know, we think about these pains as daily garden variety musculoskeletal pains. Let's talk a litle bit about musculoskeletal pains. What kind of things should parents look for or they might be missing unless they are primed with the information that you would share with us. How to go about just knowing what is going on and then how to seek the appropriate help.

Dr. Desimir Mijatovic, MD:

Yeah. So for musculoskeletal injuries, oftentimes we look at all the information that we have available. So if the injury happened during a sporting event or during some kind of activity where there is a clear connection to the injury, you can see that. You can see normal signs of an injury like tenderness to touch, swelling, bruising. Those things typically get better over days to weeks where the child is still able to generally function pretty normally. Maybe they're sore, maybe they have some pain, but it's getting better. When we get concerned that it's something more severe is when that pattern isn't followed, when maybe the pain keeps getting worse instead of getting better over time, or if the swelling or redness or other symptoms that come along with it are so bad that maybe the child is not able to use the limb anymore or is not able to walk anymore.

And so those are more severe signs that would require maybe a visit to the emergency or a visit with a specialist to evaluate. At that point, those evaluations would look for more severe fractures, ligament, or tendon injuries, muscle tears, things like that. This is also the time where we see nerve injuries or nervous system problems like n- neuropathy, neuritis, or more severe syndromes like CRPS, or complex regional pain syndrome. And so those don't follow that typical pattern that a normal injury would.

Dr. Deepak Lachhwani, MD:

Got it. Now that certainly helps to start thinking about the garden variety, everyday life-related pains, and when to start worrying about it. If I hear you correctly, it is about the symptoms persisting or getting worse over and above what a parent or a care provider might think is just a normal stub or injury that should start to get better. What about the use of over-the-counter medications for something that just started out as a pain that was just not there and now it is? Is there any good guidelines about over-the-counter medications, how much to use, how often to use, or when should it be a reason for worrying to use them beyond a certain number of doses or days?

Dr. Desimir Mijatovic, MD:

So that's a great question. There are several different types of over-the-counter medications that are available both for children as well as adults. In adults, the dosing is usually pretty standard and it's right on the bottles when you buy them. When you look at medications for children, oftentimes the dosing is very dependent on the size of the child, the age of the child and the weight of the child. And so those things are very important to follow to make sure that the child isn't getting too much of the medication. Too much of anything, even a good thing can be harmful and so we wanna be very careful with that. And so usually I will recommend that either they're, they follow the recommendations on the bottle or they ask their pediatrician or their family doctor how much medicine should be used. Now, generally these medications, the recommendation is one to two weeks and if the regular use after a couple weeks isn't improving the problem or the problem isn't getting better, then that's another sign that something more severe or significant is going on that requires an evaluation.

Dr. Deepak Lachhwani, MD:

Got it. That helps. Yeah, this is, you know, what might be most commonly encountered, playground, park, uh, sport, and boom, there is a certain injury, most likely musculoskeletal. So these guidelines certainly help our listeners that routine rest, relax, pain medications for a certain number of days are probably okay, but if things persist or get worse, I think certainly time to look for something more.

Now, what I think about is like the complex situations and I know there's a few unique complexities. You briefly alluded to one a few minutes ago when you talked about the CRPS or the complex regional pain syndrome. Now, obviously we have limited time and some of these issues might require more time, maybe we will think about a separate podcast, but at least let's help our listeners demystify or at least prevent them from going down the wrong rabbit hole when they bring this term to your clinic, CRPS, that's what my child has.

How would you explain that it is not just a simple limb pain and it starts to look something more complex like CRPS?

Dr. Desimir Mijatovic, MD:

So that's a great point. CRPS is an excellent topic for us to maybe talk about in the future as well, but CRPS, I describe it to families and to, to patients as a nerve condition where the nerves are malfunctioning so much to the point that they think that there's a severe limb injury. And so just like if someone broke their leg, they would get redness, swelling, severe sensitivity to touch, inability to move that limb, potentially temperature changes where the limb is either really warm or really cold, they can't use it or walk on it anymore. Basically CRPS is when you have all of those same symptoms in the leg but there isn't a fracture there or there isn't a severe structural injury to the leg. The nerves are sending all of the same signals chemically and electrically that would signal a fracture in that leg but there isn't one there.

And so this is a severe condition and it requires pretty intense treatment and so when I see these patients come into my clinic, I'm usually very quick and aggressive to get that treatment. It is unfortunately a condition that can last a long time and the faster that we can treat it and get it under control, the better the outcomes are.

Dr. Deepak Lachhwani, MD:

Got it. So yeah, you know, obviously the treatment part might take a long discussion, but at least off the bat, CRPS is not something that starts the first day after injury. Maybe there's, I know exceptions are there to everything in medicine, but CRPS, would you agree it's something that might stay, that might be considered after a certain length of time or y- you know, you can have CRPS right off the bat after the first evidence of injury.

Dr. Desimir Mijatovic, MD:

I do have cases, like you said, it's unusual, but I do have cases where I've caught CRPS within the first week of it developing and getting onto the treatment as quickly as possible has been extremely beneficial for these patients. So I do think that there are signs and it can be discovered quickly, but it requires patients coming to their doctor quickly and the evaluation's happening quickly and those patients have to get in front of a, a pain management provider or somebody who knows the condition to get that treatment started.

Dr. Deepak Lachhwani, MD:

Yeah. I think that close followup, there is no substitute to that and we always encourage our families to make sure that they can ask questions and they can have access to their medical providers. Another common situation or relatively common, you know, a 12, 13 year old athlete who loves to play and play hard and suddenly there is an episode that might border on what looks like a concussion or a minor head injury even, not even a concussion. Why do some kids just get up like nothing happened because it was just a quick thing for them to recover from while others may linger on with what looks like a brain fog or a persistent pain after what you can think back as maybe even a minor head injury. What is it that is different about one versus the other group of kids and how can you help our parents understand what goes on?

Dr. Desimir Mijatovic, MD:

One thing we always look for as doctors is risk factors for certain conditions and so much like anything, I think certain kids are more at risk of long-term symptoms after a concussion than other kids are. Some of these things we understand, some of them we don't. As you are very well aware, the brain is a complex structure and so the mechanism of injury, depending on which parts of the brain were concussed more than others, I'm sure that plays a role as well. And then the other thing that we look for is how is the recovery afterwards? And so are these kids able to follow the concussion protocols afterwards? Are they able to kind of take the break from activity and allow their brain some time to heal? Generally, we try to be able to predict these things, but sometimes we can't. But I think having good care where you are able to be seen after a concussion and getting the recovery protocols in place, I think that helps prevent long-term symptoms in these kids as much as possible.

Of course, the more concussions you have, the higher risk there is of developing more, and so concussion prevention is also very important.

Dr. Deepak Lachhwani, MD:

You know, now I know I'm gonna jump to yet another, what seems to be a complex situation. I'm almost like doing a potpourri of subcategories of pains, but at the cost of not being able to be too detailed, can you please elaborate on abdominal migraines, another source of some confusion in families when they come to us. What is an abdominal migraine and why does a neurologist treat them? What does the brain actually have to got to do with an abdominal migraine?

Dr. Desimir Mijatovic, MD:

Abdominal pain and abdominal migraines is something I see very commonly in my clinic. The thing that I tell patients is the biggest collection of nerves that we have is our brain, but the second biggest collection of nerves that we have is actually inside of our stomach. And much like the normal migraines that people can get where they have head pain, they have other, we call them autonomic symptoms with feeling tired, pale, nausea, sensitivity to light and sound, all of these things, you can have similar problems go on in the stomach. And oftentimes these start in a school-aged children where they will get episodes of severe abdominal pain. They may also get blood pressure changes, they might feel flushed or pale, lightheaded, dizzy, all of these things. And then those episodes kind of go away much, much like abdominal migraine would. Usually these children end up seeing GI specialists first, gastrointestinal specialists who evaluate the stomach organs and usually don't find anything wrong with those stomach organs.

And so then we can look at the other structure that's in the stomach, which is the nerves of the stomach as the culprit. And so if the pattern is typical for abdominal migraines and the symptoms line up with that, then we treat it as an abdominal migraine, which is actually treated very similar to regular migraines. These children, usually as they age, they go on to, those abdominal migraines actually shift to become normal head migraines and can linger for a while before they get better.

Dr. Deepak Lachhwani, MD:

Well, another curveball, and I promise you this will be the last one <laugh> another curve ball when it comes to the pain entities, which is also often, I think misunderstood or misquoted at least is PANDA, which is, you know, basically an abbreviation, P-A-N-D-A or PANS, P-A-N-S. Some families would come with knowledge about this entity and they're obviously quite worried if their child has PANDA or PANDAS. Could you briefly elaborate on what is this entity and how can we steer away from a misconception that that's what they have?

Dr. Desimir Mijatovic, MD:

So these conditions can be quite debilitating for, for families and children and can be very difficult to treat and find the right treatment for them. In my opinion, in my experience, they belong in a family of conditions where there's long-term symptoms after infections. And so there's a lot of other conditions in this family, long COVID being one of them, PANS, PANDAS, there's several others that people talk about.

The way that I think about these conditions is while the infection was going on, it caused some changes or some irritation of the nervous system and now even though that infection is gone and not present anymore, they still have some long-term symptoms. With PANS and PANDAS, it's usually neurological symptoms, whether it's pain, movement disorders, other types of problems that can come up. And the way that I treat them is by treating the symptoms and trying to improve functional restoration and getting the children's functioning back to be able to go back to school, to be able to go back to sports or whatever activity they were playing before and to allow the nervous system time to heal itself.

And the good thing is most of these conditions do have good long-term outcomes. To me, that's reassuring and that can be really reassuring to these families, but you have to be quite familiar with these conditions to be able to help these families as well.

Dr. Deepak Lachhwani, MD:

Great. Well, I'm just going to add the full form of this just to be satisfied those listeners who want to know what PANS stands for. It's Pediatric Acute Onset Neuropsychiatric Syndrome, PANS, or the Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal infection, which is quite a mouthful, but that's what P-A-N-D-A-S stands for, for those that care to know.

Well, thank you so much, Dr. Mijatovic. This has been very informative. I know we don't have too much time left, but why don't we touch upon some aspects of treatment of pain as it pertains to young patients. What are some of the latest treatments in pain? Medications or natural options or non-medication options has two big buckets. Can you please elaborate on these two aspects of pain management?

Dr. Desimir Mijatovic, MD:

Absolutely. So for full-spectrum pain treatment, it really is a multidisciplinary approach. And so there's kind of, you can think about it as a ladder of how involved treatments are. And so of course, there's non-interventional or non-medication treatments. Those are things like physical therapy, occupational therapy to get the, get the body stronger, get the nervous system stronger so that the body can heal itself. We also oftentimes include our psychology colleagues to work on improving that functioning, the typical daily functioning that oftentimes gets affected when you have chronic pain. They also will address mood issues that come along with having long-term severe pain, depression, anxiety, frustration, sometimes PTSD is also a problem that comes up depending on the mechanism if they had a traumatic injury that caused the pain.

Then we can move up to non-pharmacologic, things like supplements. So as part of a complete evaluation, we do check for vitamin and mineral deficiencies at times depending on the condition. And so sometimes supplements are an important part or natural treatments in that way.

Medications, there are several different classes of medications that can start from acute as needed medications for pain when it comes up versus preventive medications or daily controlling medications that help bring down the general pain level. As we keep escalating up, I also do perform different types of injections or interventional procedures that can be helpful depending on what the pain syndrome is. We call it the pain generator or what is the structure that's causing pain in this case.

Sometimes these children do need to get surgeries. For example, if there's a severe musculoskeletal injury or severe spine injury that does require surgery where the other treatments that we've tried, medications, injections haven't helped, where they do still need to end up getting surgery. On the more intensive level we do at our hospital here, we have a pediatric pain rehabilitation program, which is a three week intensive program to restore function in these kids who have severe pain that's affected their lives greatly.

And so there are several different levels of pain treatment that we use.

Dr. Deepak Lachhwani, MD:

That is so heartening to know that there is a lot of help that can be tapped into from specific medicines that are safe to use in children to supplements that could be helpful from a nutritional or a vitamin supplement standpoint. But I think I also really appreciate how you painted the picture of a multi-specialty involvement of the psychologist or a physical therapist and together with the medication intervention, they really make a beautiful team approach to helping our young patients get better. And of course when needed as clinically indicated, maybe a surgical intervention if that is the more appropriate thing to remove the reason or the generator of the pain.

Thank you so much. You know, we also think and hear too much about measures of distraction or active relaxation. Can you elaborate a litle bit on that and how does a parent know what is better or what's the difference between these two modalities of handling pain?

Dr. Desimir Mijatovic, MD:

Yeah. Generally distraction is when you take your attention and you focus it on something else. So for example, if a child has a bad pain day doing something fun, watching something funny on television or going somewhere to the mall or somewhere fun like a sports game, that's distraction. Active relaxation is something that's done purposefully where the child will then instead of focusing on their pain, they will focus on other parts of their body, perhaps techniques that they've learned with either a physical therapist or psychological therapist on muscle relaxation, biofeedback. These are all techniques that can be used to actually reduce the level of pain in the body as well as the other potentially with biofeedback, like re- reducing heart rate, calming the heart down, calming the body down, but it's a more active process whereas distraction is just, it's doing something fun that helps get your mind off of your symptoms.

Dr. Deepak Lachhwani, MD:

Great. But, you know, again, these are beautiful tools for parents and family members to know that they can avail of. Perhaps the difference would be that distraction is something a little more easy that doesn't require as much participation, whereas active relaxation like breathing exercises or biofeedback or cognitive behavioral therapy, things that you're alluding upon might be somewhat of a maturation level dependent and so they may need a certain level of participation on the part of maybe not a young child, but maybe an older child or adolescent patient.

Excellent. Well, you know, I think all of this really gives a lot of hope to certainly me as I'm learning about pain with you as well as hopefully to our listeners as we start thinking about, you know, watching for red flags that it's not just a garden variety pain to seeking out help with the appropriate specialists.

Would you care to tell us what is the best way to find an appointment with a specialist like you if there is a parent who is in dire need for looking for help for their child's pain?

Dr. Desimir Mijatovic, MD:

Absolutely. So like I said, I work here at the Main Campus. I am in the pediatric neurology department so contacting our neurological institute, phone number is 216.636.5860. If they call and say that their child is in pain, they want to see a pain specialist, that's the best way to reach out to me. The other way is starting off with their pediatrician or one of their other doctors that they see and mentioning that the pain is a significant problem and that they want to address the pain as well as the other things that are going on and then their pediatrician or other doctor will get them connected to our services here.

Dr. Deepak Lachhwani, MD:

Great. Well, time certainly flew and I think rightfully so, it is such a common ailment and, uh, reason to seek out medical help. We certainly appreciate you and your time here. To our listeners, I would like to say that your child's brain is incredibly resilient and capable of healing so don't lose hope on difficult days. And if you would like to schedule an appointment with a pediatric neurologist at Cleveland Clinic, please call 216.636.5860. That's 216.636.5860. This is your host, Dr. Lachhwani, taking leave and wishing you a good, healthy life with hopefully manageable pain, if not no pain.

Dr. Desimir Mijatovic, MD:

Thank you, Dr. Lachhwani.

Dr. Richard So, MD:

Thanks for listening to Little Health. We hope you enjoyed this episode. To keep the little health tips coming, subscribe wherever you get your podcasts or visit clevelandclinicchildrens.org/littlehealth.