Rheumatology
pAIN IN cHILDREN
Children feel pain differently than adults. There are many degrees of "pain" such as mild, moderate or severe. Also, pain has many different types: it may be sharp, dull, aching, intermittent, constant, or throbbing, and it can also occur suddenly, or develop slowly.
Since we use words to describe pain, adults have learned about different kinds of pain. These words are actually concepts or learned descriptions of how we feel. However, concept formation and recall or memory, develop slowly throughout childhood. Therefore, children often don't understand or clearly describe pain.
A young child will cry if stuck with a needle or if accidentally burned by touching a hot stove. But, for many years children's memories are short, and thus if a dull, constant, slow to develop type of discomfort occurs, such as in arthritis, a child may complain little, or not at all. This is because they quickly forget when it didn't hurt. This may occur within a few days, and almost always within several weeks.
"Growing (limb) pains" is an excellent example of a memory-related problem. The pains cause severe discomfort in the evening or at night, are gone the next morning, require little treatment, but cause great parental concern. In fact, the vast majority of these limb pains are due to the normal "rough and tumble" of age-appropriate childhood activities from the day before. Children fall, crash into many things and people, are often in constant motion, and a few hours later have little recall of what they have done. But, over night they pay the same price of discomfort that the out of condition, weekend athletic adult does: Bruises, small sprains, muscle pulls, and so forth. The only difference is, the adult remembers and understands at 3:00 AM, the child doesn't.
The primary "work" of younger children is what is called "growth and development." A big part of this is play. However, if one finger, or arm, or foot is uncomfortable, a child often just uses the other one more, without thinking about it, and gets on with doing what is fun. This is called substitution. Also, when discomfort worsens in a child, they simply stop doing their activity, and rest. We usually see this as normal behavior, the child hasn't complained, and so the real reason for stopping goes unrecognized. In contrast, adults have jobs, responsibilities, and deadlines. We may complain, but we are used to moving on, even if we have an aching flu, a sprain, or a pulled muscle.
It is only at 10-15 years old that children begin to realize how pain, or a joint or muscle problem, may affect their future. They begin to see how a disability may limit school, athletics, getting a job, and other adult activities. In contrast, adults are always aware of the potential impact of an illness on our future. Thus, we seek assistance for muscle and joint difficulties more quickly, and describe them in detail, so they can be rapidly diagnosed and treated.
Also, "pain" is subjective. Children and adults vary widely is how much an identical injury "hurts". Some children are more stoic than others. Psychological factors in the child, how parents respond to complaints, and how many children are competing for attention are important. A good indicator of pain in a young child may be a change in how she/he performs a routine behavior. These are called "activities of daily living", and subtle alterations suggest that a child is not feeling well.
Often, parents are upset that "they took so long to see what was wrong". This is an understandable, except it happens to almost all parents. Children adapt quickly to pain, they change their activities due to subtle discomfort, perhaps they become more "quiet" in style, and it all just seems to be part of their evolving personality. The key is to recognize that children will change their perceptions of pain only slowly, with maturity and experience. The doctor can help with education about this, and treatment may change a child's function, even as he/she says "nothing is different".
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