SUPPLEMENT ARTICLE
Neuropathic Pain in Children: Special Considerations

https://doi.org/10.4065/mcp.2009.0647Get rights and content

Neuropathic pain is relatively uncommon in children. Although some syndromes closely resemble those found in adults, the incidence and course of the condition can vary substantially in children, depending on developmental status and contextual factors. There are some neuropathic pain syndromes that are rare and relatively unique to the pediatric population. This article discusses the array of neuropathic pain conditions in children and available treatment strategies. Data are limited by small numbers and few randomized controlled trials. Research and clinical implications are discussed.

Section snippets

COMPLEX REGIONAL PAIN SYNDROMES

Formerly known as reflex sympathetic dystrophy, CRPS type 1 has been well described in the pediatric population. Formerly referred to as causalgia, CRPS type 2 is less common, with only sparse reports in the literature. Although causal factors for CRPS type 1 in both children and adults remain elusive,2 a handful of case studies and clinical series purport to identify coincident or correlational effects. Included among these are case studies of a 15-year-old girl whose symptoms were attributed

PLEXUS AVULSION AND PHANTOM LIMB PAIN

On the basis of clinical anecdote, phantom limb pain is not unusual in children who have undergone amputations related to either neoplasm or trauma. Krane and Heller41 conducted a retrospective survey of 5- to 19-year-olds who had undergone limb amputation in the preceding 10 years because of congenital deformity, trauma or infection, or cancer. Phantom sensations were experienced in all patients, and most stated that they experienced phantom pain as well; 35% continued to have phantom pain at

TRAUMA AND SURGERY

Trauma is a general category and may actually reflect an array of insults with implications for neuropathic pain. Atherton et al48 followed up 49 children who presented with distal upper limb nerve injury resulting from fracture, knife wounds, crush, or lacerations from broken glass at an average of 2.25 years after their injury. Patients younger than 5 years (n=15) did not report chronic neuropathic pain or allodynia. Patients with allodynia on sensory testing but no chronic neuropathic pain

AUTOIMMUNE DISORDERS

Guillain-Barré syndrome is thought to occur when the body's immune system attacks native proteins in the peripheral nervous system. Korinthenberg et al53 prospectively followed up 95 children (median age, 6.2 years) with Guillain-Barré syndrome. Most often the first symptom was disturbance of gait or neuropathic pain, which progressed for a median of 7 days. Of note, 79% experienced neuropathic pain that was often severe. All but 8 children were treated with intravenous immunoglobulin, and

METABOLIC DISEASES

Fabry disease is an X-linked lysosomal disease caused by deficiency of α-galactosidase A. Hopkin et al54 evaluated signs and symptoms occurring during childhood and adolescence in 352 Fabry registry patients. At enrollment, 77% of male patients and 51% of female patients reported symptoms, with a median age of symptom onset of 6 and 9 years, respectively. Neuropathic pain was the most frequent symptom (59% of male patients; median age, 7 years; 41% of female patients; median age, 9 years).

ADDITIONAL TREATMENT REPORTS

As previously mentioned, few controlled studies have been performed on interventions for neuropathic pain in children. Even the most commonly used first-line interventions,59 certain types of antidepressants and antiepileptic drugs, are almost exclusively prescribed on the basis of data from adults. In 2006, Golden et al60 published a review of nonepileptic uses of antiepileptic drugs in the pediatric population and found no published trials evaluating the safety or efficacy of antiepileptic

CLINICAL IMPLICATIONS

The paucity of research on neuropathic pain in children leaves us with many important and unanswered questions regarding clinical practice. Assessment of pain and sensory testing in children may be challenging, but appropriate tools have been developed and validated for pain other than that of neuropathic origin: recurrent or chronic musculoskeletal, abdominal, or headache pain.73, 74, 75 Validated indices of neuropathic pain in adults76, 77, 78 may be useful in children as well, but the

RESEARCH IMPLICATIONS

In pursuing research of pharmacological and interventional strategies in children, a number of ethical and practical factors must be considered. For example, as previously discussed, many of these syndromes are rare in children and often present with heterogeneous symptom clusters. As a result, sufficiently powering a study with clear and meaningful inclusion criteria is difficult. Without sufficient power, the study lacks validity and is therefore unethical to pursue.

In addition, many

CONCLUSION

Neuropathic pain conditions are relatively uncommon in children. In conditions typically associated with neuropathic pain in adults, such as diabetic neuropathy and postherpetic neuralgia, this may be due to a disease duration that is too short for the development of late complications; nevertheless, preventive measures would be indicated to lower the incidence of neuropathic pain persisting to adulthood. In conditions such as plexus avulsion and nerve trauma, some evidence shows that the

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    This article is the result of a meeting supported by an unrestricted educational grant from Endo Pharmaceuticals. Dr Walco has served as a consultant for Neuromed, Pfizer, and Purdue Pharma; Dr Dworkin has received in the past 12 months research support from Arcion, Montel Williams Foundation, and NeurogesX and consulting fees from Allergan, Astellas, AstraZeneca, Boehringer Ingelheim, Durect, Eisai, Endo Pharmaceuticals, Epicept, Forest, Genzyme, Johnson & Johnson, Eli Lilly, Michael J. Fox Foundation for Parkinson's Research, NeurogesX, Nuvo, Pfizer, PainReform, Philips Respironics, Sanofi Aventis, Solace, Solvay, Spinifex, UCB Pharma, US Department of Veterans Affairs, US National Institutes of Health, Wyeth, and Xenon; Dr Krane has no financial arrangement or affiliation with a corporate organization or a manfacturer of a product discussed in this supplement; Dr LeBel has no financial arrangement or affiliation with a corporate organization or a manufacturer of a product discussed in this supplement; Dr Treede has received grant/research support from Kade and Boehringer Ingelheim and has served as a consultant for Grünenthal, UCB, AWD pharma, GmbH & Co, and Kade.

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