Pain in Children: A COVID-19 Paradox

By Kayt Sukel | April 18, 2024 | Posted in

A new analysis shows decreased prevalence of pediatric chronic pain during the first year of the pandemic, compared to 2019. Less school bullying, as well as higher family resilience and more frequent family meals, may have contributed to the surprising finding.

Researchers are learning that the COVID-19 pandemic took a significant toll on children. A number of studies have now shown that lockdowns and virtual classes led to an uptick in developmental delays and learning disabilities, significant learning losses, and increases in mental health issues including anxiety and depression.

Yet, intriguingly, the pandemic seemed to improve one aspect of children’s health: chronic pain. For instance, data from the National Survey of Children’s Health suggested that chronic pain prevalence had decreased between 2019 and 2020, the first year of the pandemic.

Now, researchers from Seattle Children’s Research Institute, US, have examined this change in prevalence in more detail. In a new cross-sectional study of more than 50,000 American children aged 6 to 17 years, they discovered that the overall prevalence of chronic pain had substantially dropped in 2020 compared to 2019 – despite the many hardships that the pandemic brought with it.

An exploratory analysis also suggested that the drop was associated with more frequent family meals and higher family resilience. A reduction in bullying may have also played a role.

In an interview with Migraine Science Collaborative, Serena Orr, University of Calgary, Canada, a pediatric headache specialist who was not involved with the research, said the study provides “accumulating evidence” of a strong relationship between bullying and chronic pain, and of the protective effect of strong family relationships.

“We know that humans have evolved as social animals. We rely on each other for survival,” said Orr. “There’s a lot of talk and data about social isolation in the elderly and how bad it is for health outcomes. Bullying is another form of social isolation that is detrimental to health. Therefore, having less exposure to bullying, which is highly prevalent at school, and/or more family support at home to buffer the effects of bullying, may actually be protective when it comes to chronic pain.”

The study appeared January 1, 2024, in the journal Pain.

A surprising result
Flavia Kapos, a clinician-scientist in pain epidemiology and population health equity at Duke University School of Medicine, Durham, US, and the first author of the new work, told MSC in an interview that she was doing her postdoctoral training at Seattle Children’s Research Institute when one of her colleagues, current study co-author Cornelius Groenewald, presented some intriguing data about the prevalence of pediatric pain in the United States.

“This preliminary analysis of data from the National Survey of Children’s Health showed the prevalence of chronic pain in children had gone down from 2019 to 2020,” she said. “As an epidemiologist starting my postdoc, I thought there must be an error in the analysis – the finding could not be right – and I wanted to find the error.”

Conducted by the US Department of Health and Human Services, the National Survey of Children’s Health (NSCH) is an annual survey of the physical and emotional health of children up to the age of 17 years. Parents or caregivers of children fill out the survey, which reaches approximately 50,000 families each year. (The 2020 version of the survey was fielded from June 2020 to January 2021.)

One of the survey questions is, “During the past 12 months, has this child had frequent or chronic difficulty with repeated or chronic physical pain including headaches or other back or body pain?” Those who respond yes are categorized as having chronic pain.

Given the havoc that the COVID pandemic wreaked on American society with school and work shutdowns, and other associated stressors, many experts expected the number of children experiencing chronic pain to increase. As such, Kapos took a deep dive into Groenewald’s prevalence analysis, expecting to find some flaw.

Instead, she found that the finding held: Pediatric chronic pain prevalence dropped from 10.8% to 7.6% from 2019 to 2020, with 5.2 million children having chronic pain in 2019 versus 3.6 million in 2020, a decrease of 1.6 million. The authors noted in their paper that this was the lowest prevalence estimate since the annual NSCH began in 2016, and also represented a reversal of the increased prevalence seen from 2017 to 2019. When the researchers adjusted for sociodemographic factors, the prevalence of chronic pain in 2020 was 31% lower than a year earlier.

The investigators also saw that the change in chronic pain prevalence was similar by age, sex, race or ethnicity, caregiver education, neighborhood park or playground access, and census region.

An exploratory analysis
The researchers were incredibly curious to understand what might be behind the findings.

“The decrease in prevalence really got my attention. So I started collaborating with Dr. Groenewald and suggested changes to the analytical approach because I knew the big question would be, What factors were driving the change?” she said.

Kapos and colleagues would conduct an exploratory analysis looking at child and family factors that may have played a role.

“The data from this survey don’t allow us to look at things that change over time that might influence pediatric pain. Each person only responds to the survey once. There are different sets of kids and parents or caregivers. But this kind of exploratory analysis could let us identify factors that could potentially be contributing to the change in prevalence we were seeing – which factors were associated with chronic pain at baseline and which ones increased or got better from one year to the next.”

The exploratory analysis pointed to three factors that might explain the decrease in pain prevalence.

One was a lower prevalence of bullying, which had decreased from 20% in 2019 to 14.2% in 2020. The exploratory analysis found that children who had experienced bullying had 1.83 times the prevalence of chronic pain than those who hadn’t. This result was perhaps unsurprising, considering numerous studies have shown that bullying is associated with chronic pain, including migraine and headache.

Family aspects mattered, too. For instance, while the proportion of families who did not meet all four items of a family resilience measure decreased from 18.7% in 2019 to 16.8% in 2020, indicating improved resilience, kids whose families did not meet all of the resilience items were 1.48 times more likely to have chronic pain compared to those who did meet them.

Another family factor that might have contributed was shared meals. In 2020, compared to 2019, more families shared meals together with all members of the family who lived in the same household. When children had shared meals fewer than four days over the past week, they had a 1.14 times higher prevalence of chronic pain than those who shared meals on four or more days.

“We saw this improvement in pain happening across all these different demographics – and it was counterintuitive – but we found these potential factors that may make pain better,” said Kapos.

“Children are more resilient than we think,” she continued. “And we can learn from these analyses, let them inform future studies, and dive deeper into the hints these results give us to determine what we can do in the future to support this kind of resilience.”

New avenues of study
The continuing accumulation of evidence of the relationship between bullying and chronic pain, including migraine and headache, is important, said Orr. But to establish causality between those and other contributing social factors, the field needs to invest in large-scale, longitudinal studies.

“We’re getting closer to saying there may be a causal link here,” she said. “But to really determine that’s the case, we need to be able to see whether children are exposed to more or less bullying before they develop pain or headaches and see if it has an impact on chronic pain incidence, frequency, or impairment over time. Those studies are hard to do, but they are important.”

Kapos would also like to see such studies, as well as pursue other avenues of inquiry to identify potential protective factors that can prevent the development of chronic pain in children.

“There’s a lot more work that needs to be done,” she said. “But I think we can see that there are some things that came out of the pandemic that could be good, like the reduction in school bullying and the increased family time, that could help increase resiliency in children. These are things that could be explored further.”

Orr agreed, and, of interest to headache researchers, some of her own recent work showed the importance of other factors in kids that may increase the risk of headache. In a large cross-sectional study published in Neurology, she and her colleagues found that different lifestyle behaviors, such as prolonged screen exposure, vaping, and frequent substance use, were all associated with increased headache frequency. The odds of frequent headaches decreased with meal regularity.

As far as the current study from Kapos and colleagues goes, it puts a focus squarely on the social environment.

“More and more, we see that the social environment likely plays an important role in the development of chronic pain,” Orr said. “There’s something about social exclusion that has a negative cascade on health outcomes. But that may also mean that there’s something about social inclusion that could have the opposite, buffering effect. It’s something we should be looking at closely in future studies.”

Kayt Sukel is a freelance writer based outside Houston, Texas.

Comparing the prevalence of chronic pain in school-aged children in the United States from 2019 to 2020: a nationally representative study examining differences associated with the COVID-19 pandemic.
Kapos et al.
Pain. 2024 Jan 1;165(1):233-242.

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Kayt Sukel is a passionate traveler and science writer who has no problem tackling interesting (and often taboo) subjects spanning love, sex, science, technology, travel and politics. Her work has appeared in the Atlantic Monthly, New Scientist, USA Today, Pacific Standard, the Washington Post, ISLANDS, Parenting, the Bark, American Baby, National Geographic Traveler, and the AARP Bulletin, among others. She has written stories about out-of-body experiences, artificial intelligence in medicine, new advances in pain treatments, and why one should travel to exotic lands with young children.

She is the author of two books: Dirty Minds: How Our Brains Influence Love, Sex, and Relationships (re-titled as This Is Your Brain on Sex: The Science Behind the Search for Love in paperback) and The Art of Risk: The New Science of Courage, Caution, and Chance.



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