SUPPLEMENT ARTICLENeuropathic Pain in Children: Special Considerations
Section snippets
COMPLEX REGIONAL PAIN SYNDROMES
Formerly known as reflex sympathetic dystrophy, CRPS type 1 has been well described in the pediatric population. Formerly referred to as causalgia, CRPS type 2 is less common, with only sparse reports in the literature. Although causal factors for CRPS type 1 in both children and adults remain elusive,2 a handful of case studies and clinical series purport to identify coincident or correlational effects. Included among these are case studies of a 15-year-old girl whose symptoms were attributed
PLEXUS AVULSION AND PHANTOM LIMB PAIN
On the basis of clinical anecdote, phantom limb pain is not unusual in children who have undergone amputations related to either neoplasm or trauma. Krane and Heller41 conducted a retrospective survey of 5- to 19-year-olds who had undergone limb amputation in the preceding 10 years because of congenital deformity, trauma or infection, or cancer. Phantom sensations were experienced in all patients, and most stated that they experienced phantom pain as well; 35% continued to have phantom pain at
TRAUMA AND SURGERY
Trauma is a general category and may actually reflect an array of insults with implications for neuropathic pain. Atherton et al48 followed up 49 children who presented with distal upper limb nerve injury resulting from fracture, knife wounds, crush, or lacerations from broken glass at an average of 2.25 years after their injury. Patients younger than 5 years (n=15) did not report chronic neuropathic pain or allodynia. Patients with allodynia on sensory testing but no chronic neuropathic pain
AUTOIMMUNE DISORDERS
Guillain-Barré syndrome is thought to occur when the body's immune system attacks native proteins in the peripheral nervous system. Korinthenberg et al53 prospectively followed up 95 children (median age, 6.2 years) with Guillain-Barré syndrome. Most often the first symptom was disturbance of gait or neuropathic pain, which progressed for a median of 7 days. Of note, 79% experienced neuropathic pain that was often severe. All but 8 children were treated with intravenous immunoglobulin, and
METABOLIC DISEASES
Fabry disease is an X-linked lysosomal disease caused by deficiency of α-galactosidase A. Hopkin et al54 evaluated signs and symptoms occurring during childhood and adolescence in 352 Fabry registry patients. At enrollment, 77% of male patients and 51% of female patients reported symptoms, with a median age of symptom onset of 6 and 9 years, respectively. Neuropathic pain was the most frequent symptom (59% of male patients; median age, 7 years; 41% of female patients; median age, 9 years).
ADDITIONAL TREATMENT REPORTS
As previously mentioned, few controlled studies have been performed on interventions for neuropathic pain in children. Even the most commonly used first-line interventions,59 certain types of antidepressants and antiepileptic drugs, are almost exclusively prescribed on the basis of data from adults. In 2006, Golden et al60 published a review of nonepileptic uses of antiepileptic drugs in the pediatric population and found no published trials evaluating the safety or efficacy of antiepileptic
CLINICAL IMPLICATIONS
The paucity of research on neuropathic pain in children leaves us with many important and unanswered questions regarding clinical practice. Assessment of pain and sensory testing in children may be challenging, but appropriate tools have been developed and validated for pain other than that of neuropathic origin: recurrent or chronic musculoskeletal, abdominal, or headache pain.73, 74, 75 Validated indices of neuropathic pain in adults76, 77, 78 may be useful in children as well, but the
RESEARCH IMPLICATIONS
In pursuing research of pharmacological and interventional strategies in children, a number of ethical and practical factors must be considered. For example, as previously discussed, many of these syndromes are rare in children and often present with heterogeneous symptom clusters. As a result, sufficiently powering a study with clear and meaningful inclusion criteria is difficult. Without sufficient power, the study lacks validity and is therefore unethical to pursue.
In addition, many
CONCLUSION
Neuropathic pain conditions are relatively uncommon in children. In conditions typically associated with neuropathic pain in adults, such as diabetic neuropathy and postherpetic neuralgia, this may be due to a disease duration that is too short for the development of late complications; nevertheless, preventive measures would be indicated to lower the incidence of neuropathic pain persisting to adulthood. In conditions such as plexus avulsion and nerve trauma, some evidence shows that the
REFERENCES (90)
- et al.
Complex regional pain syndrome type-I after rubella vaccine
Eur J Pain
(2005) - et al.
Cutaneous sensory abnormalities in children and adolescents with complex regional pain syndromes
Pain
(2007) - et al.
Reflex sympathetic dystrophy: successful treatment by transcutaneous nerve stimulation
J Pediatr
(1978) - et al.
Physical therapy and cognitive-behavioral treatment for complex regional pain syndromes
J Pediatr
(2002) - et al.
Computed tomography guided lumbar sympathetic block for complex regional pain syndrome in a child: a case report and review
Eur J Pain
(2006) Intravenous phentolamine test: diagnostic and prognostic use in reflex sympathetic dystrophy
Pain
(1991)- et al.
Use of gabapentin in the treatment of childhood reflex sympathetic dystrophy
Pediatr Neurol
(2000) - et al.
Use of oxcarbazepine to treat a pediatric patient with resistant complex regional pain syndrome
J Pain
(2005) - et al.
An effective treatment of severe complex regional pain syndrome type 1 in a child using high doses of intrathecal ziconotide
J Pain Symptom Manage
(2006) - et al.
Spinal cord stimulation in adolescents with complex regional pain syndrome type I (CRPS-I)
Eur J Pain
(2008)
The prevalence of phantom sensation and pain in pediatric amputees
J Pain Symptom Manage
Phantom limb sensations and phantom limb pain in child and adolescent amputees
Pain
Self-mutilation in young children following brachial plexus birth injury
Pain
Gabapentin in phantom limb pain management in children and young adults: report of seven cases
J Pain Symptom Manage
Beneficial effects of ketamine in a chronic pain state with allodynia, possibly due to central sensitization
Pain
Neuropathic symptoms and findings in women with Fabry disease
Clin Neurophysiol
Pharmacologic management of neuropathic pain: evidence-based recommendations
Pain
Nonepileptic uses of antiepileptic drugs in children and adolescents
Pediatr Neurol
The NMDA-receptor antagonist ketamine abolishes neuropathic pain after epidural administration in a clinical case
Pain
Systemic adenosine infusions alleviated neuropathic pain
Pain
Peripheral glycerol injection for the relief of facial neuralgia in children
Int J Pediatr Otorhinolaryngol
Nerve resection and re-location may relieve causalgia: a case report
Pain
PedIMMPACT. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations
J Pain
The LANSS Pain Scale: the Leeds assessment of neuropathic symptoms and signs
Pain
Using screening tools to identify neuropathic pain
Pain
Quantitative sensory testing: a comprehensive protocol for clinical trials
Eur J Pain
Quantitative sensory testing in children: practical considerations for research and clinical practice
Pain
When do the federal regulations allow placebo-controlled trials in children?
J Pediatr
Altered chloride homeostasis in neurological disorders: a new target
Curr Opin Pharmacol
Oxford Centre for Evidence Based Medicine. Levels of Evidence (March 2009). CEBM Web site
Reflex sympathetic dystrophy in adolescents: lessons for adults
Arthritis Rheum
Reflex sympathetic dystrophy and posttraumatic stress disorder: multidisciplinary evaluation and treatment
Clin J Pain
Munchausen's syndrome simulating reflex sympathetic dystrophy
Ann Rheum Dis
Recurrent migratory sympathetically maintained pain syndrome in a child: a case report
J Pediatr Orthop B
Reflex sympathetic dystrophy syndrome in children and adolescents: report of 18 cases and review of the literature
Am J Dis Child
Reflex sympathetic dystrophy in children: clinical characteristics and follow-up of seventy patients
J Bone Joint Surg Am
Pediatric complex regional pain syndrome
J Pediatr Orthop
Morbidity in reflex sympathetic dystrophy
Arch Dis Child
Complex regional pain syndrome type I in children
Acta Paediatr
fMRI reveals distinct CNS processing during symptomatic and recovered complex regional pain syndrome in children
Brain
Reflex sympathetic dystrophy in a 6-year-old: successful treatment by transcutaneous nerve stimulation
Anesth Analg
Reflex sympathetic dystrophy in children: treatment with transcutaneous electric nerve stimulation
Pediatrics
Thermal biofeedback in the treatment of symptoms associated with reflex sympathetic dystrophy
J Child Neurol
Short- and long-term outcomes of children with complex regional pain syndrome type I treated with exercise therapy
Clin J Pain
Reflex sympathetic dystrophy: a multidisciplinary approach
Arthritis Rheum
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2022, World NeurosurgeryCitation Excerpt :Evidence on treating pediatric patients with neuropathic pain is limited, but described treatment options include neuromodulation agents such as gabapentin, pregabalin, and tricyclic antidepressants.32 Additional treatment options include transcutaneous electrical nerve stimulation, therapy focusing on biofeedback mechanisms, and topical medications.32 We recommend careful evaluation for neuropathic pain in pediatric patients so that they can be appropriately treated or referred to a pain specialist as needed.
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This article is the result of a meeting supported by an unrestricted educational grant from Endo Pharmaceuticals. Dr Walco has served as a consultant for Neuromed, Pfizer, and Purdue Pharma; Dr Dworkin has received in the past 12 months research support from Arcion, Montel Williams Foundation, and NeurogesX and consulting fees from Allergan, Astellas, AstraZeneca, Boehringer Ingelheim, Durect, Eisai, Endo Pharmaceuticals, Epicept, Forest, Genzyme, Johnson & Johnson, Eli Lilly, Michael J. Fox Foundation for Parkinson's Research, NeurogesX, Nuvo, Pfizer, PainReform, Philips Respironics, Sanofi Aventis, Solace, Solvay, Spinifex, UCB Pharma, US Department of Veterans Affairs, US National Institutes of Health, Wyeth, and Xenon; Dr Krane has no financial arrangement or affiliation with a corporate organization or a manfacturer of a product discussed in this supplement; Dr LeBel has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this supplement; Dr Treede has received grant/research support from Kade and Boehringer Ingelheim and has served as a consultant for Grünenthal, UCB, AWD pharma, GmbH & Co, and Kade.