Pain in children with significant neurological impairment

The pain experience in the child with a significant neurological impairment is complex and confusing, and it raises many questions about the very natu re of pain itself. Early work in this field suggests that the pain experien ce may be blunted. The neurological impairment associated with conditions s uch as cerebral palsy may alter the neurological system and hence the abili ty to comprehend and communicate pain; there is no evidence to date that th is reflects true pain insensitivity or indifference. From recent work, the emerging body of evidence supports a relationship between the pain system a nd the motor, sensory, and autonomic systems and demonstrates how alteratio ns to these systems may have a profound and unique impact on the pain exper ience. Beyond the altered neurological substrate, communication disabilitie s and social/environmental factors also seem to alter the pain experience. Establishing a clear pain history, including baseline information of child- specific patterns of behaviors and ongoing comparative use of this informat ion over time, can provide clinically meaningful measures. Pain management should be directed at the underlying sources of pain and should include the analgesic ladder for everyday pain, opioids for acute/procedural pain (+/- benzodiazepine adjuvants), and antispasticity medications for high tone. W ith appropriate monitoring, demand and regional analgesic techniques can pr ovide effective and safe postoperative pain control. The lack of basic and clinical knowledge in this field, however, adds another challenge to the cl inician.