Neuropathic pain in children

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Target exams

Red flags

• A child whose neuropathic pain is rapidly progressive, asymmetric, or accompanied by a new focal neurological deficit, weakness, or sphincter disturbance has a structural lesion of the nervous system until proven otherwise and needs urgent imaging
• A warm, swollen, painful limb in a febrile child is septic arthritis or osteomyelitis until proven otherwise, not complex regional pain syndrome, and must not be masked by neuropathic analgesia
• Sudden, severe, bilateral leg pain with saddle anaesthesia, bladder or bowel dysfunction, and progressive leg weakness is cauda equina or conus medullaris compression and is a surgical emergency
• A child with burning limb pain after cancer chemotherapy may have an evolving vincristine or platinum-induced neuropathy that must be distinguished from a tumour compressing a nerve or the spinal cord
• Sleep disturbance, school refusal, and low mood accompanying chronic neuropathic pain signal a child at risk of significant disability and functional decline who needs multidisciplinary input, not escalation of analgesia alone
• Gabapentin and pregabalin must never be stopped abruptly because abrupt withdrawal can precipitate anxiety, sweating, nausea, and seizures, even after only short courses

Life stages

Care settings

Clinical exam formats

Board mappings

• Defines neuropathic pain as pain caused by a lesion or disease of the somatosensory nervous system using the IASP and NeuPSIG definition
• Distinguishes neuropathic from nociceptive pain at the bedside through the presence of allodynia, hyperalgesia, and a plausible neuroanatomic distribution
• Recognises the common paediatric causes, including peripheral nerve injury, post-surgical pain, central neurological disease, and complex regional pain syndrome
• Applies the NeuPSIG grading system to classify a child's pain as possible, probable, or confirmed neuropathic pain
• Builds a multidisciplinary stepped plan with rehabilitation and psychology as the foundation and gabapentinoids and amitriptyline as off-label pharmacological adjuncts
• Confronts the limited paediatric evidence base for pharmacotherapy and the off-label status of gabapentin, informed by the GABA-1 trial and the Cooper Cochrane reviews
• The IASP and NeuPSIG definition and grading system for neuropathic pain and how it differs from nociceptive pain
• The dosing, titration, renal and cardiac monitoring, and withdrawal cautions for gabapentin and amitriptyline in children
• The central role of exercise-based rehabilitation for complex regional pain syndrome and the red flags that demand imaging
• Takes a neuropathic pain history and performs a bedside sensory examination for allodynia, hyperalgesia, and sensory loss
• Communicates the mechanism-based explanation of neuropathic pain and the stepped rehabilitation-first plan to a child and family
• Coordinates care with physiotherapy, psychology, and paediatric pain services across rural and remote settings
• Level 1: Recognition of neuropathic pain features and exclusion of serious neurological disease
• Level 2: Multidisciplinary stepped management with rehabilitation, psychology, and cautious pharmacotherapy
• Level 3: Long-term management of chronic neuropathic pain and complex regional pain syndrome, disability assessment, and transition to adult services
• The IASP and NeuPSIG definition and grading system for neuropathic pain and its application in children
• The dosing, monitoring, and off-label evidence base for gabapentin and amitriptyline in paediatric neuropathic pain
• The clinical features and rehabilitation-first management of complex regional pain syndrome in children
• Assessment of the child with chronic limb or trunk pain and the bedside sensory examination
• Interpretation of allodynia, hyperalgesia, and a neuroanatomic distribution for family counselling
• Structured explanation of the rehabilitation-first stepped plan and the cautious role of pharmacotherapy
• American Academy of Pediatrics recognition of chronic and neuropathic pain in children and the principle of multimodal, multidisciplinary care
• Off-label pharmacotherapy with gabapentinoids and tricyclic antidepressants and the importance of rehabilitation
• Recognition and rehabilitation-first management of complex regional pain syndrome
• Recognition of neuropathic pain as a distinct mechanism requiring mechanism-targeted, non-opioid management
• Stepped multidisciplinary care built on physiotherapy, psychology, and cautious off-label pharmacotherapy
• Red-flag recognition and the avoidance of opioid escalation in chronic neuropathic pain
• Canadian approach to paediatric chronic neuropathic pain and the restrained, multimodal use of pharmacotherapy
• Rehabilitation-first management of complex regional pain syndrome with exercise therapy
• Equitable access to multidisciplinary paediatric pain services across rural and remote communities