World Health Organization Guidelines on the Management of Chronic Pain in Children – Creating guidance despite a global pandemic

Photo credit: Dr. Megan Doherty

These Guidelines address the management of primary and secondary chronic pain in children 0-19 years of age with a focus on physical, psychological, and pharmacological interventions for pain relief.

The audience for the Guidance is a global one: it is intended for a wide range of settings with varied perspectives and resources. The recommendations are for use by national and local policymakers, healthcare providers as well as patients and their families.

This Guideline consists of:

https://apps.who.int/iris/bitstream/handle/10665/337999/9789240017870-eng.pdf?sequence=1&isAllowed=y

• Guiding principles
• Best practice statements
• Four key recommendations
• Identified research gaps
• Uptake & Implementation guidance

Annexes are also provided containing evidence reports: https://apps.who.int/iris/bitstream/handle/10665/337644/9789240017894-eng.pdf?sequence=1&isAllowed=y

Why write this guidance?

It is universally recognised that chronic pain in children is a significant public health problem globally and a leading cause of morbidity in children. Pain in children differs from that in adults for physiological, cognitive, developmental, and social reasons. Furthermore, pain experienced early in childhood has long reaching impacts causing maladaptive neurological changes which in turn lead to poor worse health outcomes in adult life.

These guidelines have defined chronic pain as any pain that persists or recurs for more than three months, thus including cancer pain as well as pain of uncertain origin. These guidelines advocate for multi-modal approach. Recommendations for management with analgesics are made keeping in mind the principle of balance, accepting the principle of balance – aiming at optimal control of pain, at the same time minimising harm, especially with long term use of opioids.

The management of chronic pain in children is complex and challenging for a number of reasons:

1. Paucity of high-quality research studies on the treatment of pain in children and adolescents, leading to extrapolation from adult research;
2. The approach needs to be tailored to the child and their context, taking in to account the multiplicity of pain aetiologies and of patients and their families;
3. Requirement for a multimodal interdisciplinary approach;
4. Chronic pain in children and adolescents impacts all aspects of the child’s and family’s lives;
5. Diagnosis and treatment may be adversely affected by societal misperceptions and misinformation; and
6. Use of inappropriate polypharmacy, drug marketing, and the risk of opioid additions.

Meeting as a Guideline Development Group (GDG) and Scoping the work

The scope for this guidance was developed in the wake of the United Nations Office of Drugs and Crime World Drug Report (2019), which highlighted ‘the global paradox of too much and not enough’, describing the difficulty of ensuring appropriate access to controlled substances for medical purposes while preventing their diversion and misuse. It is worthy of note that while Canada, Europe and the US comprise only 17% of the word’s population, they consume 89% of the world’s supply of morphine.

The guideline development group (GDG) was composed of individuals with diverse expertise in the topic and/or in implementation of policies or programmes related to pain management in children, drawn from a wide international pool. The GDG was Chaired by a Rheumatologist from Manila (Philippines), Dr Leonilla Dans, and Dr Emily Harrop, a Paediatric Palliative Care Consultant from Oxford (UK)The group consisted of up to 40 specialists and WHO representatives from all continents and socio-economics of the world. Due to the constraints of the COVID-19 pandemic, all meetings were conducted via Zoom. The work also involved a patient representative from the stage of scoping onwards, her input was crucial, particularly with respect to fashioning the best practice statements.

The GDG first determined the scope of the guidance in response to member states’ needs and stakeholder consultation. This included defining key questions for systematic review and prioritised potentially relevant outcomes. The resulting scope can be summarised as: ’The management of primary and secondary chronic pain in children aged 0-19 years, with a focus on physical, psychological, and pharmacological interventions for pain relief’.

Based on this scope, WHO commissioned two reviews from the Cochrane group examining:

1. The quantitative evidence of benefits and harms of physical, psychological and pharmacological interventions
2. The qualitative evidence on patient, family, caregiver and healthcare provider experiences with, and perceptions of, benefits, harms and sociocultural acceptability of those interventions

An economic impact evaluation was also conducted by the UK based National Guideline Alliance (NGA), a multi-speciality guideline development centre who usually provide reviews for NICE (National Centre for Health and Care Excellence).

The GDG formulated final recommendation in September 2020 through a series of virtual meetings. Evidence to decision frameworks were used to ensure a transparent process and comprehensive discussion. Recommendations could be ‘for’ or ‘against’ a specific intervention, and either ‘strong’ or ‘conditional’. Overall, the GDG discussed and agreed on the final recommendation by consensus, meaning that all members agreed to the final wording. On the rare occasions when consensus could not be reached within a meeting, anonymised voting occurred via Email, organised and tabulated by the WHO team. They set a decision threshold of 80% agreement for this.

The GDG members were very mindful of current events and needs associated with Covid and other financial and social factors, for example, we asked for further analysis to examine the effectiveness of delivering psychological interventions remotely.

There was a strong feeling that we needed to appreciate the differences between some types of chronic pain such as migraine/ ME etc and palliative /EOL in terms of management. There was poor evidence in the treatment of the former group but hardly any in the later. Yet addressing the needs of children with palliative care / EOL in chronic pain was critical to these guidelines.

The GDG was also mindful that resources did not allow investigation into other types of treatment such as music therapy, occupational therapy etc that we know are also used for chronic pain management as part of a MDT approach.

Overall, the recommendations strongly advocate for a comprehensive biopsychosocial approach to the management of pain, with guiding principles stating that access to pain management is a fundamental right and that children should have the right to enjoyment of the highest attainable standards of health.

 

Specific Recommendations:

Recommendation 1: Physical therapies are recommended for use either alone or in combination with other treatments. This recommendation was made by consensus, but it was acknowledged that it was based on very low certainty evidence. Whilst the qualitative review suggested that physical interventions were well tolerated, children sometimes reported boredom with exercises and reluctance to practice new skills in front of peers. Physical therapy experts within the group discussed possible mitigations involving tailoring the interventions around the individual child’s daily routine.

Recommendation 2: Psychological management through cognitive behavioural therapy and related interventions (Acceptance and commitment therapy, behavioural therapy and relaxation therapy) may be used. This recommendation was also reached by consensus, with moderate certainty evidence. The GDG further examined the evidence to be able to add that this therapy could be delivered face to face, remotely, or by a combination of both, as the effects did not differ.

It was acknowledged that the cost and availability of both physical and psychological interventions would be likely to vary internationally, and that in some cases this may create barriers to overcome.

Recommendation 3: Appropriate pharmacological management, tailored to specific indications and conditions may be used. Here the evidence was of low certainty and the GDG reached consensus with the agreement that further recommendations would be made specifically relating to the use of opioids (see below).

Recommendation 4a: Appropriate pharmacological management tailored to specific indications may include the use of morphine under the principles of opioid stewardship, for end-of-life-care.

Recommendation 4b. In children with chronic pain associated with life-limiting conditions*, morphine may be given by appropriately trained healthcare providers, under the principles of opioid stewardship

(*) Life-limiting conditions are illnesses for which there is no cure and an early death is expected, but with which a person may continue to live for several more years.

The essential practices of opioid stewardship in children are fourfold:i. Opioids must only be used for appropriate indications and prescribed by trained providers, with careful assessments of the benefits and risks. ii. The use of opioids by individuals, their impact on pain and their adverse effects must be continuously monitored and evaluated by trained providers. iii. The prescribing provider must have a clear plan for the continuation, tapering or discontinuation of opioids according to the child’s condition. The child and family must be apprised of the plan and its rationale. iv. There must be due attention to procurement, storage and the disposal of unused opioids.

Whilst these final recommendations were required to be ‘conditional’ and were based on very low certainty evidence, they were crucial to the GDG agreeing recommendations about pharmacological management. This was unsurprisingly that area in which voting was needed to reach agreement, weighing very real concerns about the potential for abuse and addiction with need for dying children to access strong pain relief. The principles of opioid stewardship and the adequacy of staff training were felt to be very important in ensuring these objectives.

Best Practice Statements
The GDG also formulated several statements which represent best practice for the clinical management of chronic pain in children. These statements apply to all aspects of the clinical care of a child with chronic pain, including the planning, implementation and delivery of physical, psychological and pharmacological interventions. These statements cover areas such as:

• Family centred care
• Biopsychosocial (rather than biomedical) assessment
• Evaluation of any underlying conditions which may need specifically targeted treatment
• Timely and accurate sharing of information with families, supporting shared decision making
• The interdisciplinary, multimodal approach to care
• Re-affirmation of the principles of opioid stewardship

Research Gaps
As mentioned above, the evidence achieved moderate certainty only in the area of psychological interventions. There was a real lack of good quality research with respect to physical and pharmacological therapies. Recommendations are made for research in a wider range of settings, combined modalities, and examining the real-world resource implications.

Specific populations of children were identified, where research is particularly lacking:

1. Younger children, under 10 years of age.
2. Vulnerable children such as those with developmental or intellectual disabilities, exposed to trauma or challenging life experiences, living in humanitarian settings, and with comorbid mental health conditions.
3. Children with chronic cancer-related pain during or following cancer treatment
4. Children with life-limiting conditions or those requiring end-of-life pain management both in inpatient settings and in the community.
5. Indigenous populations, and family members including siblings and caregivers of children with chronic pain.

The lack of clear evidence for the effectiveness and safety of opioids in children was highlighted as a particular concern, with key gaps including:

1. The effectiveness and safety of opioids including morphine in end-of-life care and in life-limiting conditions, including longer-term use in the latter condition.
2. The effectiveness and safety of longer-acting opioids and subcutaneous infusions of morphine in children needing end-of-life care.
3. Population-level surveillance for adverse events including overdose and misuse.
4. Studies of societal attitudes towards the appropriate use of opioids for chronic pain in children, as well as overdose, misuse and addiction

It is clearly difficult to summarise the information contained in such a large piece of work, but we hope that this article may whet your appetite to access the full guidance, and to understand its relevance to your own area of practice, as well as giving some insight in to the process of creating it.

We would like to end by saying what a privilege it was to work with colleagues at WHO, Cochrane, NGA, and of course the members of the GDG who were generous with their wisdom and insight and taught us a lot about the needs of children facing chronic pain in a world wide context.

This article was co-authored by:

1. Dr Megan Doherty, Paediatric Palliative Director – South Asia, Two Worlds Cancer – Program Director, Palliative Care, Children’s Hospital of Eastern Ontario, Ottawa
2. Dr Emily Harrop – Consultant in Paediatric Palliative Care & Medical Director at Helen & Douglas House – UK
3. Dr Sat Jassal (Medical Director, Rainbows Hospice for Children and Young People)
4. Dr Gayatri Palat, DA, DNB( Anesthesiology) Consultant, Pain and Palliative Medicine  – MNJ Institute of Oncology and RCC, Hyderabad, India
5. Dr M R Rajagopal – Chairman, Pallium India

This article was originally published on the ehospice Children’s International edition.