Julie Hauer has long been a leader in helping us understand pain behaviors in children with severe neurologic impairment and describing useful approaches to its treatment.  Her writing on this topic has been invaluable to many of us confronting challenging clinical cases in children with severe neurologic impairment (SNI). In this article she and Amy Houtrow, with the advice of an experienced group of AAP contributors, do beautiful job of reviewing the topic.  The article begins “Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to under recognition and undertreatment of pain.”  Barriers they point out,  include the uncertainty that often accompanies attempts to diagnose the cause, the lack of definitive tests for neuropathic pain and inexperience with potential remedies.

The article is comprehensive, reviewing pain scales and how they can be used in this population, common causes to consider and a clinical approach to assessment and treatment that emphasizes careful history and physical exam and consideration of the parents’ current and past experience of the child’s pain episodes. Many specific syndromes are discussed in detail, including approaches to differential diagnosis and logical, informed approaches to pain management in the face of uncertainty. This careful and comprehensive review reminds us that simple answers are not common in these cases and that, while there is not a standard approach to assessment and treatment of pain in children with SNI, a logical and careful approach over time is important and can improve outcomes.  The point is well made that  “Although pain can often be improved by implementing the interventions discussed previously, the optimal treatment of pain in children with SNI often requires considerable time and effort to achieve and is most likely accomplished if the overall treatment of pain for the child is guided by some broader management strategies and considerations.”  Both Complex Care teams and Palliative Care teams are in a position to provide such care and practitioners in both fields stand to benefit from a careful reading of this article, returning to it as they confront difficult cases.

Mary McCord, MD MPH

Complex Care, Bellevue Complex Care Clinic

Hauer J and Howtrou AJ. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics. 2017 Jun;139(6).