Efficacy and Safety of Pharmacological, Physical, and Psychological Interventions for the Management of Chronic Pain in Children

A WHO Systematic Review and Meta-analysis

Emma Fisher; Gemma Villanueva; Nicholas Henschke; Sarah J. Nevitt; William Zempsky; Katrin Probyn; Brian Buckley; Tess E. Cooper; Navil Sethna; Christopher Eccleston


Pain. 2022;163(1):e1-e19. 

In This Article


Chronic pain, defined as pain lasting for longer than 3 months, is common in children and adolescents (henceforth referred to as children),[26] and the challenges faced by these children across the developmental lifespan have recently been highlighted in a Lancet Child and Adolescent Health Commission.[11] Pain is a common symptom of many long-term conditions, such as cancer, sickle cell disease, and juvenile idiopathic arthritis. Estimates for the economic burden of idiopathic chronic pain extend to $19.5 billion annually,[19] which is likely to increase when pain associated with long-term conditions is also considered. Around 5% to 8% of children are moderately or severely disabled by their chronic pain,[22] with negative impacts on children's emotional, physical, and social functioning[15,18,24,25,28] and on family members who report a higher burden of care economically and emotionally.[23] As such, chronic pain during childhood is a costly condition that negatively impacts the child and their family making management essential.

Accessing treatment for the management of chronic pain can be a frustrating and lengthy process.[33] The Lancet Commission identified a need for better treatments and better access to treatment.[11] Typically, pharmacological interventions are the first approach to managing pain, although interdisciplinary treatment is considered the gold standard for this population. A recent overview review of the evidence for pharmacological interventions has highlighted a dearth of evidence in this field.[10] Physical and psychological treatments often form part of interdisciplinary treatment for long-term pain in children,[29] but although there is evidence for the use of psychological interventions,[13,14] trials investigating physical interventions are lacking.

There are shortcomings in populations included in the summaries of evidence for efficacy and harm for pharmacological and psychological therapies. The most recent Cochrane reviews of pharmacological therapies, published in 2017,[3–7,9,39] included children with chronic pain and cancer-related pain, but excluded other disease-related pain conditions and children with headache. Cochrane reviews of psychological therapies excluded children with cancer and life-limiting conditions.[14,13] The evidence also separates face-to-face and remotely delivered interventions, hampering the interpretation of the efficacy and harms of all psychological therapies for children with chronic pain. There is no current high-quality systematic review for physical therapies.

The 2012 "WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses"[39] was withdrawn in 2019. The revision considers pharmacological, physical, and psychological interventions,[41] which often form part of interdisciplinary care in pain clinics in high-income settings.[40] This systematic review and meta-analysis provided the evidence base for the new guidelines and is complemented by the qualitative synthesis of values and preferences of patients for treatment.[16] We aimed to investigate the effectiveness and harms of pharmacological, physical, and psychological interventions for chronic pain in children compared with active or placebo control.