WHO Updates Pain Management Protocols for Children

The World Health Organization has issued updated guidelines for the management of chronic pain in children and adolescents aged 0 to 19 years. The new guidelines focus on physical, psychological, and pharmacological interventions for both primary and secondary chronic pain, with the updates replacing two discontinued documents, “Ensuring balance in national policies on controlled substances,” (2011) and the WHO’s guidelines on “the pharmacological treatment of persisting pain in children with medical illnesses” (2012).

The new guidelines are meant to reach “a wide range of settings with varied perspectives and resources,” wrote the steering committee members, including Bernadette Daelmans, MD. Practical Pain Management spoke to Dr. Daelmans, who serves as the lead for child health and development within WHO’s Department of Maternal, Newborn, Child and Adolescent Health and Aging, about the importance and implications of the updated guidelines.

Why New Pain Management Guidelines for Children Are Needed Now, Even in Pandemic

PPM: Why was it important to update the child-specific pain management guidelines at this time?

Dr. Daelmans: The new guidelines reflect a commitment to help WHO Member States provide appropriate clinical care to children with severe pain across a range of physical, psychological and pharmacological interventions. The [updates] encompass more specific guidance on effective and appropriate pain control medication, taking into account the needs and expectations of children and their families, and differing country capacities and contexts.

PPM: How has the COVID pandemic impacted what's stated in the guidelines?

Dr. Daelmans: There are no direct effects of COVID-19 on pain in children, but children with chronic pain may have experienced indirect effects through reduced access to clinical care and medication because of impacts on non-emergency health services. WHO has addressed this concern in the document Maintaining essential services: operational guidance for the COVID-19 context.

Multidimensional Pain and Opioid Use in Children

PPM: What do you perceive as the most significant changes from the 2012 guidelines on the pharmacological treatment for persisting pain in children?

Dr. Daelmans: The new guidelines recognize that pain is a multidimensional experience, the result of a complex interaction of biological, psychological and social factors. Pain management in turn requires a multimodal, interdisciplinary approach. Following a holistic approach to palliative care, the guidelines therefore provide best practice statements that apply across physical, psychological, and pharmacological interventions.

As part of the latter, the new guidelines also spell out the dimensions of appropriate opioid stewardship for children in chronic pain, which was not included in the previous guidance.

Editor’s Note: The opioid stewardship section outlines four essential practices:

1. Opioids must only be used for appropriate indications and prescribed by trained providers, with careful assessments of the benefits and risks.

2. The use of opioids by individuals, their impact on pain and their adverse effects must be continuously monitored and evaluated by trained providers.

3. 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.

4. There must be due attention to procurement, storage and the disposal of unused opioids.

PPM: Regarding opioids, data on their use for pain management in children are limited. The guidelines allow for their rational and cautious use, but is there additional guidance you can offer clinicians on how to limit the potential for abuse and accidental overdose?

Dr. Daelmans: We will work with partners on complementary tools to facilitate the implementation of the guidelines

Mental Health in Children with Chronic Pain

PPM: The updated recommendations include the use of remote psychological therapy for pain management. Was psychological therapy part of the previous guidelines? How might clinicians optimize remote psychotherapy in areas where it is possible?

Dr. Daelmans: The previous guidelines did not address psychological therapy, but the current guidelines state that psychological therapy may be delivered either face-to-face or remotely, or using a combined approach. WHO is consolidating a systematic review on digital consultations in childhood and adolescence that will bring together best practices related to remote therapies and support.

In Practice

PPM: How do you envision the guidelines impacting clinical practice? For example, the recommendation to consider chronic pain as multidimensional – rather than biomedical – suggests the need for a team approach to care that may have been lacking in many areas. How might such an approach be implemented in areas with limited resources?

Dr. Daelmans: It is important that Member States’ national policies and regulations ensure wide and equitable access to appropriate and high-quality services for children with chronic pain. Treatment costs and bureaucratic processes must not preclude or discourage equitable access to appropriate therapies, since health services for chronic pain are an essential part of universal health coverage (UHC). National packages of essential services should be accompanied by an appropriate budget allocation, and include the range of therapies recommended in these guidelines, as well as access to specialist providers and referral services, when indicated.

To achieve optimal access to effective and cost-effective services for children with chronic pain and their families, significant strengthening of capacity may be needed, particularly in low- and middle-income countries. As noted in the report, ‘Capacity is needed both in terms of healthcare providers and in health systems capable of delivering high-quality recommended services. Training of healthcare providers in chronic pain management in children may need to be augmented. This includes education and training at the undergraduate and postgraduate levels, and in continuing education curricula, and applies across the range of providers involved in caring for these children.’

PPM: What's next in terms of implementation?

Dr. Daelmans: WHO will continue to work with experts and partners to develop operational guidance to facilitate capacity development for the use of the guidelines, and to assist countries in their operationalization.