Chronic primary and secondary pain in children

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Target exams

Red flags

• Chronic pain with weight loss, night waking from pain, persistent fever, fatigue or systemic features is not primary pain until malignancy, inflammatory disease and infection are excluded
• Chronic back pain with neurological signs, bowel or bladder dysfunction, gait change or midline spinal tenderness needs urgent imaging to exclude cord compression or an intraspinal lesion
• A child with chronic pain who is steadily withdrawing from school, activity and friends is functionally decompensating and needs active interdisciplinary rehabilitation, not more analgesia
• Initiating an opioid for chronic primary, non-cancer pain in a child is outside recommended practice; the risks of dependence, adverse effects and lack of efficacy outweigh any benefit
• Repeated normal scans and multiple specialist referrals in chronic primary pain reinforce the disease model, amplify disability and must be interrupted

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines chronic pain in a child as pain lasting more than three months and separates chronic primary pain, where the pain is the disease, from chronic secondary pain, where the pain arises from an identifiable cause
• Recognises that chronic pain in children is common, frequently coexists with sleep disturbance, low mood and school absence, and is assessed through function rather than pain intensity alone
• Names juvenile fibromyalgia, complex regional pain syndrome, chronic daily headache and functional abdominal pain as common chronic primary pain presentations
• Explains the three chronic pain mechanisms of nociceptive, neuropathic and nociplastic pain and applies central sensitisation to explain how chronic primary pain arises, persists and amplifies
• Coordinates an interdisciplinary rehabilitation plan built on graded physical reactivation, psychological therapy and judicious, mechanism-based pharmacology, with opioids avoided for chronic primary pain
• Distinguishes the red flags that mandate investigation from the over-investigation that reinforces disability, and integrates the biopsychosocial assessment into a function-focused plan
• Chronic pain in a child is defined as pain persisting or recurring for more than three months
• Chronic primary pain, coded MG30.0 in ICD-11, is pain in one or more regions with significant emotional distress and functional disability that is not better explained by another condition, and it is nociplastic
• Opioids are not recommended first-line for chronic primary, non-cancer pain in children; management is interdisciplinary with physical and psychological therapy as the core
• Counsels an adolescent with chronic primary pain and their family on a biopsychosocial explanation of pain, the rehabilitation goal of restored function rather than pain elimination, and a planned return to school and activity
• Builds the multidisciplinary plan linking paediatrics, psychology, physiotherapy, the school and the family, and sets functional outcome goals around sleep, mood, attendance and participation
• Synthesises the long-case child with chronic pain into an assessment, a red-flag screen, a biopsychosocial formulation and a graded interdisciplinary rehabilitation plan
• Level 1: Recognition of chronic pain in a child, the common presentations and the functional impact on sleep, mood and school
• Level 2: Application of the biopsychosocial assessment, the three pain mechanisms and the red-flag screen that distinguishes pain needing investigation from pain needing rehabilitation
• Level 3: Coordination of an interdisciplinary rehabilitation plan with graded physical reactivation, psychological therapy, mechanism-based pharmacology and functional outcome goals
• The ICD-11 split of chronic pain into chronic primary pain and chronic secondary pain with the secondary subgroups of cancer-related, postsurgical or posttraumatic, neuropathic, secondary headache or orofacial, secondary visceral and secondary musculoskeletal
• The three mechanisms of nociceptive, neuropathic and nociplastic pain and the concept of central sensitisation
• The limited role of pharmacology, the avoidance of opioids for chronic primary pain, and the evidence for cognitive behavioural therapy and graded physical reactivation
• Structured biopsychosocial assessment of a child with chronic pain covering pain, mood, sleep, school attendance, family and function
• Communication of a biopsychosocial explanation of chronic pain to a young person and family with validation, hope and a function-focused plan
• Recognition of the red flags that mandate investigation and the pitfalls of over-investigation and opioid prescribing in chronic primary pain
• Chronic pain in children as a biopsychosocial problem with nociceptive, neuropathic and nociplastic mechanisms
• The high prevalence of chronic pain in children and adolescents and its association with disability, school absence, sleep and mood disturbance
• An interdisciplinary rehabilitation approach emphasising physical and psychological therapy and the avoidance of opioids for chronic non-cancer pain
• Recognition of chronic primary and secondary pain in children and the functional assessment that guides management
• Application of the biopsychosocial model, the red-flag screen and the interdisciplinary plan built on physical reactivation and psychological therapy
• Safe prescribing that avoids opioids for chronic primary pain and uses mechanism-based pharmacology judiciously
• Canadian approach to chronic pain in children as a biopsychosocial condition requiring interdisciplinary rehabilitation
• The distinction of chronic primary from chronic secondary pain using the ICD-11 framework and the three pain mechanisms
• Functional outcome goals and the avoidance of opioids for chronic primary paediatric pain