Acute and chronic pain in nonverbal children with neurological disorders. Possibilities of diagnosis and treatment. Systematic review.

A.V. Diordiev1,2, V.L. Ajzenberg3

1 State Budgetary Institution of Health “Scientific and Practical Center for Pediatric Psychoneurology Department of Health of the City of Moscow”, Moscow

2 Federal State Budgetary Educational Institution of Higher Education “Pirogov Russian National Research Medical University” Ministry of Health of Russia, Moscow

3 State Budgetary Institution of Health “Morozov Childrenʼs City Clinical Hospital”, Moscow

For correspondence: Andrey V. Diordiev, Doctor of Med. Sci., Head of Anesthesiology and Resuscitation, Moscow; e-mail:

For citation: Diordiev AV, Ajzenberg VL. Acute and chronic pain in nonverbal children with neurological disorders. Possibilities of diagnosis and treatment. Systematic review. Alexander Saltanov Intensive Care Herald. 2019;1:36–44.

DOI: 10.21320/1818-474X-2019-1-36-44


Acute and chronic pain in nonverbal children with severe pathologies of the central nervous system, including infantile cerebral palsy, is the most common and significant problem that is underestimated throughout the life of these patients. The underestimation of the importance of diagnosing pain and its treatment leads to significant damage to their physical, social and mental well-being. Obstacles to the diagnosis and treatment of pain are the uncertainty in the definition of the fact of the presence of acute pain, the degree of its intensity and the lack of reliable tools for assessing the impact of chronic pain on the quality of life of patients with severe neurological diseases. Problems of pain treatment, along with limited experience with the use of analgesics and adjuvants in this category of patients, are also concerns about the legitimacy of the use of certain drugs. In this review, we analyzed the problem of the current state of diagnosis and treatment of acute and chronic pain in nonverbal patients with severe neurological pathology and formed the main solutions.

Keywords: pain, non-verbal patients, cerebral palsy

Received: 24.12.2018

Accepted: 01.03.2019


  1. Merskey H., Bogduk N. Classification of Chronic Pain Descriptions of Chronic Pain Syndromes and Definitions of Pain Terms. Task Force on Taxonomy of the International Association for the Study of Pain. 2nd ed. Seattle, WA: IASP Press.1994: 14.
  2. Merskey H., AlbeFessard D., Bonica J.J., et al. Pain terms: a list with definitions and notes on usage. Recommended by the IASP subcommittee on taxonomy. Pain.1979; 6: 249–252.
  3. Loeser J.D., Treede R.D. The Kyoto protocol of IASP basic pain terminology. Pain. 2008; 137: 473–477. DOI: 10.1016/j.pain.2008.04.025
  4. Cohen M., Quintner J., van Rysewyk S. Reconsidering the IASP definition of pain. Pain Reports. 2018; 3(2): 634–641. DOI: 10.1097/PR9.0000000000000634
  5. Warlow T.A., Hain R.D.W. ‘Total pain’ in children with severe neurological impairment children. Children.2018; 5(1):13. DOI: 10.3390/children5010013
  6. Finley G.A., Franck L.S., Grunau R.E., von Baeyer C.L. Why Childrenʼs Pain Matters? Pain: Clinical Updates. 2005; 4(13): 2–6.
  7. Fitzgerald M. The development of nociceptive circuits. Nature Reviews Neuroscience. 2005; 6(7): 507–520. DOI: 10.1038/nrn1701
  8. Quigley C., Wiffen P. A systematic review of hydromorphone in acute and chronic pain. Journal of Pain and Symptom Management. 2003; 2(25): 169–178.
  9. World Health Organization (WHO). Guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. Geneva: WHO. 2012; 13. ISBN-13:978-92-4-154812-0.
  10. Dawn M. Chronic Pain — A Primary Care Guide to Practical Management. 2nd ed. 2009.
  11. Engel J.M., Jensen M.P., Hoffman A.J., Kartin D. Pain in persons with cerebral palsy: extension and cross validation. Archives of Physical Medicine and Rehabilitation. 2003; 84(8): 1125–1128.
  12. Nolan J.I., Chalkiadis G.A., Low J., et al. Anaesthesia and pain management in cerebral palsy. Anaesthesia. 2000; 55(1): 32–41.
  13. Hadden K.L., von Baeyer C.L. Pain in children with cerebral palsy: common triggers and expressive behaviours. Pain. 2002; 99: 281–288.
  14. Svedberg L.E., Englund E., Malker H., Stener-Victorin E. Parental perception of cold extremities and other accompanying symptoms in children with cerebral palsy. European Journal of Paediatric Neurology. 2008; 12(2): 89–96. DOI: 10.1016/j.ejpn.2007.06.004
  15. Hauer J., Houtrow A.J. Pain assessment and treatment in children with significant impairment of the central nervous System. Pediatrics. 2017; 139(6): 2–27. DOI: 10.1542/peds.2017-1002
  16. Breau L.M., Camfield C.S., McGrath P.J., Finley G.A. The incidence of pain in children with severe cognitive impairments. Archives of Pediatrics and Adolescent Medicine. 2003; 157: 1219–1226. DOI: 10.1001/archpedi.157.12.1219
  17. Steele R, Siden H, Cadell S, et al. Charting the territory: symptoms and functional assessment in children with progressive, non-curable conditions. Archives of Disease in Childhood. 2014; 99(8): 754–762. DOI: 10.1136/archdischild-2013-305246.
  18. Van Naarden Braun K., Doernberg N., Schieve L., et al. Birth Prevalence of Cerebral Palsy: A Population-Based Study. Pediatrics. 2016; 137(1): 1–9. DOI: 10.1542/peds.2015-2872
  19. Nagara S., Kouwaki M., Togawa T., et al. Neurodevelopmental outcomes at 3 years old for infants with birth weights under 500g. Pediatrics Neonatology. 2018; 59(3): 274–280. DOI: 10.1016/j.pedneo.2017.09.005
  20. Findlay B., Switzer L., Narayanan U., et al. Investigating the impact of pain, age, gross motor function classification system, and sex on health-related quality of life in children with cerebral palsy. Developmental Medicine and Child Neurology. 2016; 58: 292–297. DOI: 10.1111/dmcn.12936
  21. Krigger K.W. Cerebral palsy: an overview. American Family Physician. 2006; 73(1): 91–100.
  22. Penner M., Xie W.Y., Binepal N., et al. Characteristics of pain in children and youth with cerebral palsy. Pediatrics. 2013; 132(2): 38–45. DOI: 10.1542/peds.2013-0224
  23. Breau L.M., Camfield C.S., McGrath P.J., Finley G.A. The incidence of pain in children with severe cognitive impairments. Archives of Pediatrics and Adolescent Medicine. 2003; 157(12): 1219–1226. DOI: 10.1001/archpedi.157.12.1219
  24. Hunt A., Goldman A., Seers K., et al. Clinical validation of the paediatric pain profile. Developmental Medicine and Child Neurology. 2007; 46(1): 9–18. DOI: org/10.1111/j.1469-8749.2004.tb00428.
  25. Palisano R., Rosenbaum P., Walter S., et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Developmental Medicine and Child Neurology. 1997; 39(4): 214–223.
  26. Doralp S., Bartlett D.J. The prevalence, distribution, and effect of pain among adolescents with cerebral palsy. Pediatric Physical Therapy. 2010; 22(1): 26–33. DOI: 10.1097/PEP.0b013e3181ccbabb
  27. Roscigno C.I. Addressing spasticity-related pain in children with spastic cerebral palsy. The Journal of the American Association of Neuroscience Nurses, 2002; 34(3), 123–133.
  28. Sanger T.D., Delgado M.R., Gaebler-Spira D., et al. Task Force on Childhood Motor Disorders. Classification and definition of disorders causing hypertonia in childhood. Pediatrics.2003; 111(1): 89–97.
  29. Jayanath S., Ong L.C., Marret M.J., Fauzi A.A. Parent-reported pain in non-verbal children and adolescents with cerebral palsy. Developmental Medicine and Child Neurology. 2016; 58(4): 395–401. DOI: 10.1111/dmcn.12943
  30. McKearnan K.A., Kieckhefer G.M., Engel. J.M., et al. Pain in children with cerebral palsy: a review. The Journal of Neuroscience Nursing. 2004; 36(5): 252–259.
  31. Zangen T., Ciarla C., Zangen S. Gastrointestinal motility and sensory abnormalities may contribute to food refusal in medically fragile toddlers. Journal Pediatric Gastroenterology Nutrition. 2003; 37(3): 287–293.
  32. Hauer J.M., Solodiuk J.C. Gabapentin for management of recurrent pain in 22 nonverbal children with severe neurological impairment: a retrospective analysis. Journal Palliative Medicine. 2015; 18(5): 453–456. DOI: 10.1089/jpm.2014.0359.
  33. Jilda N. Vargus‐Adams. Pain as a root of the problem: health‐related quality of life in children with cerebral palsy. Developmental Medicine and Child Neurology. 2016; 58(3): 225–226. DOI: org/10.1111/dmcn.12989.
  34. Kennes J., Rosenbaum P., Hanna S.E., et al. Health status of school-aged children with cerebral palsy: information from a population-based sample. Developmental Medicine and Child Neurology. 2002; 44(4): 240–247.
  35. Kingsnorth S., Orava T., Provvidenza C., et al. Chronic Pain Assessment Tools for Cerebral Palsy: A Systematic Review. Pediatrics. 2015; 136(4): 947–960. DOI: 10.1542/peds.2015-0273
  36. McGrath P.A. Evaluating a child’s pain. Journal of Pain and Symptom Management. 1989; 4(4): 198–214.
  37. Gorodzinsky A.Y., Hainsworth K.R., Weisman S.J. School functioning and chronic pain: a review of methods and measures. Journal of Pediatric Psychology. 2011; 36(9): 991–1002. DOI: 10.1093/jpepsy/jsr038
  38. Biersdorff K.K. Incidence of significantly altered pain experience among individuals with developmental disabilities. American Journal Mental Retardation. 1994; 98(5): 619–631.
  39. Jan J.E., Abroms I.F., Freeman R.D., et al. Rapid cycling in severely multidisabled children: a form of bipolar affective disorder? Pediatric Neurology. 1994; 10(1): 34–39.
  40. Ståhle-Oberg L., Fjellman-Wiklund A. Parents’ experience of pain in children with cerebral palsy and multiple disabilities: an interview study. Advances Physiotherapy. 2009; 11(3): 137–144. DOI: org/10.1080/14038190902906318
  41. Carter B., McArthur E., Cunliffe M. Dealing with uncertainty: parental assessment of pain in their children with profound special needs. Journal Advances Nursing. 2002; 38(5): 449–457. DOI: org/10.1046/j.1365-2648.2002.02206
  42. Lee G.Y., Yamada J., Kyololo O., et al. Pediatric clinical practice guidelines for acute procedural pain: a systematic review. Pediatrics. 2014; 133(3): 500–515. DOI: 10.1542/peds.2013-2744
  43. Cramton R.E., Gruchala N.E. Managing procedural pain in pediatric patients. Current Opinion Pediatrics. 2012; 24(4): 530–538. DOI: 10.1097/MOP.0b013e328355b2c5
  44. Kumar R., Sneade C., Littler K. Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injection in children. Developmental medicine and child neurology. 2009; 51(10): 838–839. DOI: org/10.1111/j.1469-8749.2008.03069
  45. Hauer J. Improving comfort in children with severe neurological impairment. Prog Palliative Care. 2012; 20(6): 349–356. DOI: 10.1097/SPC.0000000000000063
  46. Ben-Pazi H., Cohen A., Kroyzer N., et al. Clown care reduces pain in children with cerebral palsy undergoing recurrent botulinum toxin injections — A quasi-randomized controlled crossover study. PLoS One. 2017; 12(4): 1–13. DOI: 10.1371/journal.pone.0175028
  47. Chou R., Gordon D.B., Oscar A. de Leon-Casasola, et al. Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologistsʼ Committee on Regional Anesthesia, Executive Committee, and Administrative Council. The Journal of Pain. 2016; 17(2): 131–157. DOI: 10.1016/j.jpain.2015.12.008
  48. Диордиев А.В., Айзенберг В.Л. Коррекция гемодинамики у детей с церебральным параличом, оперированных в условиях общей и комбинированной эпидуральной анестезии. Анестезиология и реаниматология. 2012; 1: 10–13.
  49. [Diordiev A.V., Ayzenberg V.L. Correction of hemodynamic in children with csip, operated under general and combined epidural anesthesia. Anesteziologiya I reanimatologiya. 2012; 1: 10–13. (In Russ)]
  50. Диордиев А.В., Айзенберг В.Л. Роль периферических регионарных блокад в анестезиологическом обеспечении хирургических вмешательств в ортопедии у детей с церебральным параличом. Анестезиология и реаниматология. 2013; 1: 45–48.
  51. [Diordiev A.V., Ayzenberg V.L. Peripheral regional block role in orthopedics in pediatric patients with cerebral palsy. Anesteziologiya I Reanimatologiya. 2013; 1: 45–48. (In Russ)]
  52. Айзенберг В.Л., Загубера А.В., Диордиев А.В., Филиппова Н.Е. Нарушения когнитивных функций у детей с церебральным параличом, оперированных под комбинированной регионарной анестезией. Российский вестник детской хирургии, анестезиологии и реаниматологии. 2013; 2: 98–102.
  53. [Ayzenberg V.L., Zagubera A.V., Diordiev A.V., Filippova N.E. Impaired cognitive functions in children with cerebral palsy, operated under combined regional anesthesia. Rossijskij vestnik detskoj hirurgii, anesteziologii i reanimatologii. 2013; 2: 98–102. (In Russ)]
  54. Friedrichsdorf S.J., Kang T.I. The management of pain in children with life-limiting illnesses. Pediatric Clinics of North America. 2007; 54(5): 645–672. DOI.: org/10.1016/j.pcl.2007.07.007
  55. Zernikow B., Michel E., Craig F., Anderson B.J. Pediatric palliative care: use of opioids for the management of pain. Pediatric Drugs.2009; 11(2): 129–151. DOI: 10.2165/00148581-200911020-00004
  56. Food and Drug Administration. FDA Drug Safety Communication: FDA restricts use of prescription codeine pain and cough medicines and tramadol pain medicines in children; recommends against use in breastfeeding women. 2017. Available from: (accessed 19.05.2018).
  57. Hauer J.M. Treating dyspnea with morphine sulfate in nonverbal children with neurological impairment. Pediatrics Pulmonology. 2015; 50(4): 9–12. DOI: 10.1002/ppul.23140
  58. Soelberg C.D., Brown R.E. Jr., Du Vivier D., et al. The US Opioid Crisis: Current Federal and State Legal Issues. Anesthesia Analgesia. 2017; 125(5): 1675–1681. DOI: 10.1213/ANE.0000000000002403
  59. Raymond B.L., Kook B.T., Richardson M.G. The opioid epidemic and pregnancy: implications for anesthetic care. Current Opinion Anaesthesiology.2018; 31(3): 243–250. DOI: 10.1097/ACO.0000000000000590
  60. Raffaeli G., Cavallaro G., Allegaert K., et al. Neonatal Abstinence Syndrome: Update on Diagnostic and TherapeuticStrategies.Pharmacotherapy.2017; 37(7): 814–823. DOI: org/10.1002/phar.1954
  61. Moulin D., Boulanger A., Clark A.J., et al. Canadian Pain Society. Pharmacological management of chronic neuropathic pain: revised consensus statement from the Canadian Pain Society. Pain Research Management. 2014; 19(6): 328–335.
  62. Klit H., Finnerup N.B., Jensen T.S. Central post-stroke pain: clinical characteristics, pathophysiology, and management. Lancet Neurology. 2009; 8(9): 857–868. DOI: 10.1016/S1474–4422(09)70176–0
  63. Houghton L.A., Fell C., Whorwell P.J., et al. Effect of a second-generation alpha2delta ligand (pregabalin) on visceral sensation in hypersensitive patients with irritable bowel syndrome. Gut. 2007; 56(9): 1218–1225. DOI: 10.1136/gut.2006.110858
  64. Cutter N.C., Scott D.D., Johnson J.C., Whiteneck G. Gabapentin effect on spasticity in multiple sclerosis: a placebo-controlled, randomized trial. Archives of Physical Medicine Rehabilitation. 2000; 81(2): 164–169.
  65. Hauer J.M., Wical B.S., Charnas L. Gabapentin successfully manages chronic unexplained irritability in children with severe neurologic impairment. Pediatrics. 2007; 119(2): 519–524. DOI: 10.1542/peds.2006-1609
  66. Gilron I., Jensen T.S., Dickenson A.H. Combination pharmacotherapy for management of chronic pain: from bench to bedside. Lancet Neurology. 2013; 12(11): 1084–1095. DOI: 10.1016/S1474–4422(13)70193–5
  67. Croxford J.L. Therapeutic potential of cannabinoids in CNS disease. CNS Drugs. 2003; 17(3): 179–202. DOI: 10.2165/00023210-200317030-00004
  68. Delgado M.R., Hirtz D., Aisen M., et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010; 74(4): 336–343. DOI: 10.1212/WNL.0b013e3181cbcd2f
  69. Hansel D.E., Hansel C.R., Shindle M.K., et al. Oral baclofen in cerebral palsy: possible seizure potentiation? Pediatric Neurology. 2003; 29(3): 203–206. DOI: org/10.1016/S0887–8994(03)00208-x
  70. Love S.C., Novak I., Kentish M., et al. Botulinum toxin assessment, intervention and after-care for lower limb spasticity in children with cerebral palsy: international consensus statement. European Journal Neurology. 2010; 17(2): 9–37. DOI: 10.1111/j.1468-1331.2010.03126.x
  71. Ульрих Г.Э., Красавина Д.А., Орлова О.Р., Алексеева А.Ю. Реабилитация спастических форм ДЦП методом ботулинотерапии: отечественный препарат «Релатокс®». Детская и подростковая реабилитация. 2018; 3: 21–30.
  72. [Ulrich G.E., Krasavina D.A., Orlova O.R., Alexeeva A.Y. Rehabilitation of the spastic forms of cerebral palsy in the botulin therapy method: «Relatox®». Child and adolescent rehabilitation. 2018; 3:21–30 (In Russ)].
  73. Delgado M.R., Hirtz D., Aisen M., et al. Practice parameter: pharmacologic treatment of spasticity in children and adolescents with cerebral palsy (an evidence-based review): report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2010; 74(4): 336–343. DOI: 10.1212/WNL.0b013e3181cbcd2f
  74. Tilton A.H. Management of spasticity in children with cerebral palsy. Seminars in Pediatric Neurology. 2004; 11(1): 58–65. DOI: org/10.1016/j.spen.2004.01.008
  75. Dai A.I., Aksoy S.N., Demiryürek A.T. Comparison of Efficacy and Side Effects of Oral Baclofen Versus Tizanidine Therapy with Adjuvant Botulinum Toxin Type A in Children With Cerebral Palsy and Spastic Equinus Foot Deformity. Journal of Child Neurology. 2016; 31(2): 184–189. DOI: 10.1177/0883073815587030
  76. Pellett S., Yaksh T.L., Ramachandran R. Current Status and Future Directions of Botulinum Neurotoxins for Targeting Pain Processing. Toxins. 2015; 7:4519–4563. DOI: 10.3390/toxins7114519
  77. Lundy C.T., Doherty G.M., Fairhurst C.B. Botulinum toxin type A injections can be an effective treatment for pain in children with hip spasms and cerebral palsy. Developmental Medicine and Child Neurology. 2009; 51: 705–710. DOI: 10.1111/j.1469-8749.2009.03315.x
  78. Michelsen J.S., Normann G., Wong C. Analgesic Effects of Botulinum Toxin in Children with CP. Toxins (Basel). 2018; 10(4): 162. DOI: 10.3390/toxins10040162