Jamie Fleming, MD, discusses the underrecognition of pediatric chronic pain, urges earlier referral

Chronic pain affects approximately one in five children and adolescents, yet many patients experience delays in recognition and treatment that can lead to worsening disability and persistent symptoms into adulthood, according to Jamie Fleming, MD, section chief of Pain Management and director of Interventional Pain Management at Phoenix Children's.

Fleming said misconceptions about pediatric chronic pain continue to contribute to delayed diagnosis, despite growing recognition that pain can become a disease process of the nervous system rather than simply a symptom of tissue injury.

Phoenix Children's recently expanded its pediatric pain services with a dedicated interventional pain procedural suite designed specifically for children. The multidisciplinary program combines physical therapy, occupational therapy, pain psychology, anesthesiology, interventional pain, integrative medicine, and palliative care to restore function while minimizing opioid use whenever possible.

Why is pediatric chronic pain often overlooked?

Fleming said one of the greatest barriers to care is the misconception that chronic pain is uncommon in children.

"That brings me to the first and big misconception, which is pediatric pain is rare," Fleming said. "That's actually not true. It's very common, and when you look at the numbers, really 1 in 5 pediatric patients actually has chronic pain, so this is something that everyone's going to see in their clinic, and it is really important to recognize that it is so common."

She said delayed recognition has important consequences because untreated pain may persist well beyond childhood.

"The thing that is important for treating it early is that it can persist in adulthood and cause disability that's long lasting for these kids," Fleming said.

According to Fleming, limited access to pediatric pain programs compounds the problem.

"What I've seen a lot in medicine is it's really underrecognized and underserved," She said. "So what that means is when these kids are out there, oftentimes it's taking a really long time to recognize that they have chronic pain that needs treatment. And even if you do, there's not often local resources to really treat it effectively."

When should pediatricians suspect chronic pain?

Fleming encouraged pediatricians to consider chronic pain when symptoms persist despite healing of the original injury and begin interfering with daily life.

She described a common scenario of an adolescent who continues to experience disabling pain after a relatively minor injury.

"For example, a teenager or an adolescent that comes in with persistent pain after a minor injury, something like a minor ankle sprain... they've had all kinds of imaging, labs, and a workup, which really doesn't show any ongoing injury. And despite this, they're still not walking. They're not returning to sports. They're sometimes missing school, and it's really impacting their life."

She cautioned against dismissing persistent pain when diagnostic studies are unrevealing.

"I think when this happens, sometimes these patients have heard things like, 'Oh, you know, there's nothing on these studies, so there's nothing wrong, and you know, this may be all in your head.' And it's really important to not give patients that message because it really invalidates them."

How should pediatricians explain chronic pain to families?

Fleming said helping families understand the role of the nervous system is central to treatment.

"And really, pain is your nervous system processing signals and giving you a response, and it's there to try to protect you. But sometimes it gets it wrong, and it still keeps sending these signals even when the injury itself is healed," she said.

She also emphasized that persistent pain does not necessarily indicate ongoing tissue injury.

"The amount of pain that you have does not equate to tissue damage," Fleming said. "Just because there are pain signals doesn't always mean that you're damaging or injuring something, and that's a really important aspect of their care."

What role do physical therapy and pain psychology play?

Fleming said families often misunderstand the role of pain psychology within multidisciplinary care.

"The foundation really is physical therapy or occupational therapy and pain psychology," she said. "Pain psychology does not mean it's all in your head."

Instead, she said, pain psychologists help children understand how chronic pain develops and teach strategies to regain control.

"What they really do is they help children really understand this nervous system process and learn how to control it better," Fleming said. "Both physical therapy and pain psychology teach children to regain confidence in the body, to gain control over their nervous system, to help retrain these processes."

When should pediatricians refer patients to a pediatric pain program?

Rather than focusing solely on pain severity, Fleming encouraged pediatricians to assess how pain affects a child's daily functioning.

"I think when you're looking at what should prompt a referral for a pediatrician, you really have to look at how is this pain impacting that child's life," S said. "If it's impacting it and they're changing their routines and avoiding these because of it, it's time to get help, and it's time to refer."

Fleming said recognizing chronic pain early and connecting children with multidisciplinary care may help prevent long-term disability while improving quality of life and restoring participation in school, sports, and other daily activities.