PHILADELPHIA—Chronic pain, including back pain, headaches, and abdominal pain, are on the rise in children. Fortunately, they can often be resolved through a combination of mind-body techniques, dietary changes, and family interventions, said Robert Bonakdar, MD, at the annual meeting of the American Holistic Medical Association.

“We are starting to see more ‘adult’ type pain problems like back pain and migraine in kids,” said Dr. Bonakdar, Director of Pain Management at the Scripps Center for Integrative Medicine, La Jolla, CA. This is in addition to the “expected” childhood pain related to sports injuries or trauma.

A survey of more than 6,600 school children showed that 54% had recurrent pain of some kind, and 25% had chronic, often severe pain lasting 3 months or more. Prevalence increased with age, and there was a strong female predominance (Perquin CW, et al. Pain. 2000 Jul; 87(1): 51–58). This corroborates an earlier study of pediatric inpatients showing that 50% were admitted for pain problems of some sort; 21% were for chronic pain (Cummings E, et al. Pain. 1996; 68: 25–31).

Back pain is a growing concern. A 1997 survey of school kids showed that 6% of all 10-year-olds and 18% of all 14–16-year-olds had chronic low back pain. A recent Israeli study of 10,000 children showed up to half routinely carried more than 15% of total body weight in their book bags. Further, 15%–20% had ill-fitting chairs (Limon S, et al. Spine. 2004; 29(6): 697–702).

Abdominal pain is still the top pain-related reason parents bring kids to doctors, and it is not all in their heads. El Matary and colleagues studied children over age 3 with abdominal pain, and found 30% had identifiable pathologies. “The likelihood (of identifiable pathology) increases with nocturnal symptoms and point-specific abdominal tenderness.” Of those with non-specific complaints, 51% fit the criteria for irritable bowel syndrome (El Matary W, et al. Eur J Pediatr. 2004 Oct; 163(10): 584–588). (For more on pediatric abdominal pain, join www.holisticprimarycare.net and read “Cutting the CRAP: Natural Therapies Improve Abdominal Pain in Children” from the 3rd International Pediatric Integrative Medicine Conference.)

Headache is the second most common pain problem in kids. A recent Norwegian study of more than 10,000 teens showed 77% experienced a severe headache at least once in the last year, and 29% had recurrent headaches. Seven percent had recurrent migraines (Zwart JA, et al. Cephalalgia. 2004; 24(5): 373–379).

Pain Is a Family Affair

Familial history of chronic pain predicts pain and poor health in children. “If a kid has chronic low back pain, there’s a 90% chance that one or both parents has low back pain or some type of chronic pain.” In one study, over 90% of first-degree relatives of children with chronic pain also had chronic pain conditions.

“The worse the parental pain, the worse the child’s pain tends to be,” said Dr. Bonakdar. “If you don’t take a careful history of what’s going on in the family, you won’t really understand what is going on for the kid. You really need to assess how the child and the other family members cope.” While evaluating a child, ask parent(s) about any pain they might be experiencing, and how they deal with it. Even if a child’s pain has an “organic” cause, coping behavior is largely learned from parents. If a parent copes poorly, the child will learn to behave similarly.

Treatment should likewise be a family affair. “If you don’t deal with the parental pain, you are not really going to be able to help break the familial pain cycle, and it becomes difficult to help the kid.”

Dr. Bonakdar recommended a number of easy-to-use assessment tools including the FLACC Scale (Face, Legs, Activity, Cry, Consolability), and the Pain Experience History Scale. He has also found the Pain Ruler, a simple device with a visual analog scale on one side and a scale made of cartoon faces (from happy to grimacing) on the other side. FLACC and other useful tools, developed to evaluate cancer pain in kids, can be found at www.childcancerpain.org.

Dietary Factors

Diets play a far greater role in chronic pain than most physicians realize. Many kids today have poor, pro-inflammatory diets heavy on refined carbs and trans fats and low in fiber, omega-3 fatty acids, and plant-based foods. “Kids today eat astonishingly low levels of fruit and vegetables. When French fries are the most common ‘vegetable’ eaten by 15- to 18-month-olds, as indicated by a 2004 study in the Journal of the American Dietetic Association, we have a problem.”

Anything you can do to get more fruit, vegetables and whole grains into a kid’s diet, while reducing refined carbs, processed meats and trans fats, will help in reducing inflammatory pain. This is, admittedly, difficult, unless you get the parents to make changes as well.

Dr. Bonakdar has found riboflavin, magnesium, omega-3 fatty acids, and fiber supplements to be beneficial for children with chronic inflammatory pain. Riboflavin (Vitamin B2) is extremely helpful for kids with chronic headaches.

Though riboflavin has not yet been studied in children with headaches, data from adults are compelling. At a dose of 400 mg, it markedly reduced mean headache days per month. Fifty-nine percent of patients had 50% fewer headache days, compared with only 15% of those on placebo. There was, however, no change in intensity (Schoener J, et al. Neurology. 1998; 50: 466–470).

“Riboflavin is inexpensive, safe and effective. I start with 25–50 mg per day and increase up to 400. You don’t want to go too much higher or you cause diarrhea, the main adverse effect.” But riboflavin is not a quick fix. “In the Schoener study, it took until the 4th month to really show a benefit.”

Magnesium also helps kids with headaches or chronic muscle pain. “It keeps smooth muscle tone where it should be.” Many American children are magnesium-deficient, but that is often missed with standard blood tests. “You need to look at intracellular calcium and magnesium. If you check, you’ll see a lot of kids with headaches are low in magnesium, calcium and co-enzyme Q10. Plasma levels don’t fully reflect what is going on physiologically.” Dr. Bonakdar recommended Spectracell Laboratories, a functional testing lab specializing in intracellular nutrient assessment (www.spectracell.com or 800-227-5227). “I use this lab all the time.”

When giving magnesium to children, he advised using magnesium glycinate, a chelated form that is easier on the gastrointestinal tract.

Biofeedback & Guided Imagery

Young children in pain are highly responsive to mind-body strategies, especially those involving guided imagery or some sort of biofeedback tool. In one recent study, investigators taught 36 children and teens with migraines simple biofeedback using a contact thermal meter, which measures skin temperature on the hand. After 4 sessions, the kids who mastered the ability to induce hand-warming had fewer headaches (Scharff L, et al. J Ped Psych. 2002; 27: 109–119). Dr. Bonakdar explained the hand warming reflects reduced sympathetic stress.

“The contact thermal gauge costs about $15. So it is a very low-tech, affordable guidance tool. Most kids can easily master the hand-warming technique.”

Ball and colleagues showed that young children with abdominal pain had far fewer episodes following four weekly sessions practicing guided imagery. The 10 kids in this pilot project, all of whom had pain refractory to drugs, showed a 67% reduction in self-reported pain (Ball TM, et al. Clin Pediatr. 2003; 42(6): 527–532).

Heart Rate Variability

Journey to the Wild Divine, a sophisticated biofeedback system fronting as a video game, is an excellent tool for helping children with chronic pain problems.

Dr. Bonakdar is a big fan of biofeedback based on heart rate variability (HRV). “HRV is a great tool. It tells you so much about sympathetic to parasympathetic balance, and gives you information in auditory and visual forms.”

HRV systems measure very small beat-to-beat variations in heart rate, a reliable indicator of sympathetic versus parasympathetic activity. It also shows how emotional states affect heart and respiratory function. A number of patient-friendly HRV tools are now available, the most widely known and well-studied being the HeartMath system (www.heartmath.com).

For children and teens, though, Dr. Bonakdar strongly recommended the Journey to the Wild Divine, a sophisticated HRV-based biofeedback system packaged as a colorful video game. “The developers were upset about the negative impact video games have on kids, especially knowing that the same energy could be channeled into something positive.” Wild Divine costs around $160. “It is a great value, and very do-able for most families.”

Though Wild Divine does not yet have any clinical indications, the company has indicated clinical studies are in the offing. “This is a great tool for working with kids.” (To find out more about HRV, join www.holisticprimarycare.net and download our Winter 2004 issue. To learn more about Journey to the Wild Divine, visit www.wilddivine.com.)

Dr. Bonakdar has also had good success with a tool called RespirAid, a stress-reduction and relaxation technique based on guidance of a patient’s breathing. “RespirAid is great for Type A adults, and also for high-stress kids. It entrains relaxation, and the effects can be very long-lasting.”

Avoid Either-Or Thinking

Dr. Bonakdar expressed concern about wanton use of pharmaceuticals in children. At the same time, there are situations in which medications are necessary. But even if one opts to go with a drug-based therapy, it should be part of a comprehensive approach that includes mind-body therapies and nutritional interventions.

“We really need to get away from Either/Or thinking, that would lead us to use either pharmacology or biofeedback. All of these things are tools, and we need to use all available tools when they are appropriate.”