Pain in Children

reis_evelyn_md_pd_20090401One of the most fundamental desires of parents is to comfort their children when they are in pain. Here are steps that parents can take to relieve common types of pain in children.

Pain with vaccines
Pain with vaccine injections is one of the most common types of pain that children experience. In addition to discomfort, untreated injection or “shot” pain can lead to anxiety about going to the doctor. In fact, many adults don’t get the medical care that they need due to their fear of shots. The good news is that there are simple ways to ease the “ouch” of injections that help kids (and kids at heart) feel less anxious about future doctor visits. Here are tips for each age group:

Research by my colleagues and I has shown that babies who are snuggled closely in their parents’ arms during vaccine injections and allowed to breastfeed or suck on a bottle or pacifier stop crying much faster than babies who are vaccinated on an exam table. Parents should feel empowered to tell nurses that they want to hold their babies for vaccines, if this is not the office’s routine practice. Giving babies a small amount of a sweet liquid, such as Sweet Ease, to drink before injections provides additional pain relief. Finally, after injections, parents can take a few minutes to calm and settle their babies before dressing them to leave. Once home, parents should plan to give extra TLC in the first 48 hours after vaccines to help relieve fussiness and discomfort. A warm washcloth applied to the legs can help with muscle soreness and cool washcloth can reduce swelling. It is important not to give over-the-counter pain medication unless the baby’s doctor advises it. Research shows that giving acetaminophen after vaccines can reduce 2 month babies’ immune response, making the vaccines less protective.

Parents can hold toddlers on their laps and use active distraction such as a reading a pop up book, singing a song together or blowing on a pinwheel. Young children often take words literally, so avoid using the term “shot”. Instead, explain that the nurse will give the child medicine in his arm or leg to keep him healthy. It is normal for toddlers to be wary of vaccines. Reassurance from parents during the procedure (“I’m right here with you”) and congratulations afterward (“Good job!”) help young children learn self-mastery of challenging experiences. As with infants, applying a warm washcloth or allowing the child to play in a warm bath after vaccines can ease muscle discomfort. Parents can give an over-the-counter pain medication (acetaminophen or ibuprofen, not aspirin) if advised by their child’s doctor.

Older children and teens:
My research has found that combining active distraction (such as blowing on a pinwheel or counting to 10) with a numbing cooling spray to the skin allowed many 4 and 5 year old children to get their pre-Kindergarten vaccines without a single tear. Cooling spray, such as Pain Ease spray, works in a few seconds and costs less than 50 cents per application. Parents can ask their child’s doctor to order this for routine use. It helps children to prepare for the cold sensation by asking them to name their favorite cold item, such as a snowball or popsicle or even a kiss from a polar bear! Cooling spray has been very helpful during the current influenza vaccine season as only the injection, not the nasal spray, is recommended.

Pain with illness
Pain is a common symptom of infectious illness in children, such as ear infections, strep throat, stomach viruses, skin infections, and pneumonia. Typically, there
are other signs of infection, such as fever, runny nose, vomiting, diarrhea, drainage of pus or cough. Parents should call their child’s doctor promptly to discuss these symptoms, especially if the child is an infant, if activity, drinking, or breathing are affected, or if symptoms are worsening. If the doctor advises it, parents can give over-the-counter pain medication (acetaminophen or ibuprofen, not aspirin) and fluids, encourage rest and closely monitor symptoms. 

Pain with teething
Babies often appear uncomfortable when their teeth are erupting (cutting through gum tissue). Here are some suggestions about how to help babies through this normal phase:

• Give babies a cool teething ring or cloth to chew on (be sure that parts cannot break off)
• If bottle fed, put prepared bottles in the refrigerator to chill them
• Give over-the-counter pain medication, if advised by the baby’s doctor
• Try a small amount of numbing gel on the sore gum tissue

• Don’t give babies frozen teething rings to hold as they can cause frostbite if held in contact with the skin; instead, hold teething rings on baby’s gums for them
• Don’t give babies frozen foods to chew on as they can break when they thaw, becoming choking hazards
• Don’t give babies chicken bones to chew on, as they can also break apart and often are contaminated with salmonella (which causes serious bacterial diarrheal illness)

Pain with injury
Pain often accompanies minor injuries, such as a twisted ankle. If the child is feeling and acting normally, parents can try RICE: Rest, Ice, Compression and Elevation of the injured body part. However, parents should seek emergency medical treatment for:

• Head injuries, especially if there was loss of consciousness or if the child complains of dizziness, nausea, vomiting or is less alert
• Abnormal shape or deformation of a long bone in the arm or leg
• Sharp pain to touch of a specific area which may indicate a broken bone
• Bleeding that cannot be controlled with pressure

Pain that comes back
Children often have recurrent pains, such as headaches and stomachaches, which are not due to acute infections or injuries. Here are some common causes of recurrent pains:

Children of parents with migraines are more likely to develop migraine headaches themselves. Lifestyle approaches are helpful in reducing headache frequency, including regular and adequate sleep habits, eating breakfast every morning, drinking plenty of water, getting daily exercise, and limiting screen time, especially before bedtime. Parents should seek prompt medical care if children complain of headaches accompanied by vision changes, vomiting, or balance changes, and headaches that wake the child at night, occur with getting up in the morning or with coughing or sneezing. 

A common cause of frequent stomachaches is constipation, which can be associated with eating a low-fiber diet and not drinking sufficient water. Parents should call their child’s doctor to discuss stomachaches in the setting of hard bowel movements. The doctor may recommend slowly increasing fiber intake, such as whole grain cereals and breads, increasing water intake, and establishing a regular toilet sitting schedule after meals. If necessary, the doctor can prescribe a stool softener. Parents should seek emergent care for stomachaches and constipation if the child’s belly is hard or tender to touch or if he develops vomiting.

Emotional causes:
For some children with recurrent pains, the discomfort is real, but the cause is emotional, rather than physical. The clue is often in the timing of the discomfort. For example, pain that arises only the night before or the morning of school days could be due to a child’s fear of a classroom bully, difficulty learning a subject, or anxiety about separation from a family member. Changes in the child’s household or living arrangement are common triggers, including a new baby sibling, divorce or remarriage, or a seriously ill parent. Parents should schedule a non-emergent visit with the child’s doctor to discuss the recurrent symptoms, as well as any changes in the child’s environment.

In general, parents should be concerned if a child’s pain:
• Wakes the child from sleep
• Prevents participation in normal activities, especially activities the child enjoys
• Is worsening over time
• Does not respond to the treatment advised by the child’s doctor

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