Charlie Brown may be the most famous young sufferer of undiagnosed chronic pain -- his constant complaints of stomachaches when something went wrong could have indicated a more serious problem.
While the lovable Peanuts character is fictional, pain in children is very real. The American Pain Society found that 15 percent to 20 percent of children are affected by chronic pain. Experts say, though, that many kids suffer because the cause of their pain is left undiagnosed.
There are about 30 clinics across the United States that focus on pediatric pain, leaving much of the country with no specialized treatment available.
A child's pain may be ignored because they may not be able to communicate adequately. Or parents and teachers may think they are seeking attention. Some children even see their pain as punishment for doing something wrong and are scared to complain.
Whatever the excuse, children feel pain too, even if it cannot be pinpointed to a specific problem.
"Pain is what a person says it is," said Kenneth R. Goldschneider, director of pain management at the Cincinnati Children's Hospital Medical Center. "If a child says they are hurting, there is no one on the planet who can say otherwise. The question is what's driving the pain, where it comes from and how intense it is."
Communication Makes Assessment of Children Tricky
Experts in pediatric pain say the biggest difference between assessing and treating pain in children and adults is the child's difficulty in communicating what they are suffering from and how much it hurts.
"With adults you just ask them, assuming they have the ability to communicate," explained Goldschneider.
A doctor may use different scales of assessment depending on the developmental stages of a child, said Michael Joseph, associate director of the Comfort and Pain Management Program at Children's Hospital Los Angeles.
Infants, for example, tend to react in particular ways when suffering from real pain, according to Joseph. They will furrow their brow and shut their eyes tightly while crying. The corners of their mouth could be pulled up tightly, their tongue cupped while crying and they could cry in a slightly higher pitch.
"We must observe because we can't actually ask them," Joseph said.
Toddlers and children may be able to say that they hurt, but may not be able to explain the intensity of their pain. Goldschneider stressed that how you ask a child about pain is important.
"Asking a 5-year-old, 'Do you hurt?' you may get a completely different answer than if you ask 'You hurt, don't you?' " Goldschneider explained.
For children aged about 3 and up, Joseph uses what he called a "faces system" of assessing the intensity of their pain. The child is presented with photos of five to 10 children showing different levels of distress in their facial expressions and asked to point to which one most closely resembles what they feel, he said.
Even When Tests Come Back Negative, the Pain Is Still There
A child may go through a number of doctors and a number of tests, and the diagnosis may be that there's nothing wrong with them.
The experts explain that if a child is complaining of a stomachache and every test shows there is nothing wrong with the stomach, that does not mean that something is not wrong.
"If the doctors had an electrical engineer take a look, he would find what the problem is that is causing the pain," explained Lonnie Zeltzer, director of the Pediatric Pain Program at Mattel Children's Hospital at UCLA. "It is a nerve signaling problem. There are pain signals getting to the brain so the child really feels pain, but the body's control system is not working well."
Zeltzer gives a hypothetical example of a family coming down with the stomach flu. Everyone in the family has the belly pain, diarrhea, nausea, etc. While everyone else gets better, the child -- who has not necessarily had pain before -- may continue suffering the stomach pain without the other symptoms.
"This is because … the brain-gut nervous system has become [un]regulated, causing increased sensitivity of the intestinal tract," she said.
Goldschneider agreed. "Just because we can't measure, X-ray or test to find the pain, doesn't mean it's not real. It means that in 2005, we don't yet have a way to measure it."
"Pain is a signal that something is wrong, the body is being harmed, so do something," he said.
'Most Parents Know'
Parents are key to their child's diagnosis, according to experts. They are the ones who spend the most time with them and know their reactions and facial expressions.
"Most parents know," Goldschneider said succinctly.
Zeltzer has written a book called "Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood." She said parents' contributions are important.
"... Parents play a significant role in helping their child to climb out of chronic pain or even help buffer their child from developing pain," Zeltzer said.
Parents and family also contribute to coping skills, Zeltzer said. An anxious mother who becomes alarmed whenever her child complains about pain could teach her child how to pay attention to physical body systems differently than a mother who tells her child that it's just a normal ache and it will go away.
A parent will know if there is sibling rivalry, if there are problems at home, a bully at school or an injury that happened years ago that could have started the process.
If a child keeps complaining of pain, even after test after test after test, a parent should know not to give up.
A Multidisciplinary Approach to Treatment Is Key
So how does one treat pain in a child when they cannot pinpoint exactly what's causing it?
All three experts agreed that the key to treating chronic pain in children is taking a multidisciplinary approach -- physical and psychological -- to help the child function with the pain they are feeling.
"Most physicians approach kids differently," Joseph said. Children get the appropriate pain medication at a rate of 20 percent to 30 percent less than adults do, he said.
Doctors fear two things when treating a child with pain medication: overdose and addiction. A number of physicians fear giving a child too much pain medication, so they give them too little, Joseph explained.
In addition, medications most often used to treat pain in adults have not been studied in children. "So those of us treating pain in children often have to rely on the adult studies for drugs in which there are no FDA [Food and Drug Administration]-approved indications in children," Zeltzer said.
But treatment should not be limited to medication.
"Our goal is not always to treat the pain, but to facilitate function," Joseph said. "To help the child become happy, healthy people, we treat the pain to help them get to that point."
Zeltzer noted non-drug strategies such as hypnotherapy, biofeedback, massage, yoga and acupuncture.
Goldschneider said it's important to look at the whole picture to treat pain effectively. His clinic gives children a functional assessment, a physical assessment, a psychological assessment, looks at how they are able to cope with the pain and more.
"When you have a complete picture," he says, "deciding how to treat it becomes easier."