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Preventing Long-Term Harm: Pediatric Pain Management in Primary Care · Pediatrics in Practice: A CME Podcast

• 0:03
  Dr. Mike Smith (Host):
• 0:03
  Welcome to Pediatrics in Practice, a CME podcast.
• 0:06
  I'm Dr.
• 0:07
  Mike.
• 0:07
  And with me is Dr.
• 0:09
  Amanda Deacy, Clinical Director of the Abdominal Pain Program and pediatric
• 0:14
  psychologist at Children's Mercy.
• 0:17
  And today, we're going to be talking about pediatric pain management
• 0:20
  in primary care, exploring how clinicians can better recognize,
• 0:25
  prevent, and treat pain and distress in everyday visits and procedures.
• 0:30
  Dr.
• 0:30
  Deacy, welcome to the show.
• 0:31
  Dr. Amanda Deacy:
• 0:31
  Thanks so much for having me.
• 0:33
  Host: How should pediatricians think about both pain and emotional distress
• 0:38
  during routine primary care visits?
• 0:42
  Dr. Amanda Deacy:
• 0:42
  Well, the first thing I'd encourage pediatricians to consider, which may
• 0:45
  be a big shift, is that not addressing pain and emotional distress during
• 0:50
  primary care visits is not benign.
• 0:53
  I think that's probably one of the first thing to consider.
• 0:56
  The suffering, although it is most salient in the immediate moment, it
• 1:00
  isn't just what's seen in office, that we know has a longer term impact.
• 1:05
  So, long-term impacts suggestive of babies, for example, who've spent
• 1:10
  a long time in the NICU, have had painful procedures, there's actually
• 1:14
  some really fascinating data about decreased brain volumes in those babies,
• 1:18
  increased startle and pain responses.
• 1:20
  And so, again, really the idea that not managing it in the moment,
• 1:24
  is not benign and that we ought to do well to prevent increased
• 1:27
  impact over the long term as well.
• 1:29
  Host: Dr.
• 1:30
  Deacy, that's really interesting.
• 1:31
  So if I heard you correctly, what you're saying is even infants when
• 1:34
  they undergo something painful or emotional, even though they may not be
• 1:38
  very conscious of it in that moment, it has consequences down the line?
• 1:42
  Dr. Amanda Deacy:
• 1:42
  Absolutely.
• 1:43
  So, what the data have told us, like I said, there are actually some fascinating
• 1:47
  MRI studies that look at decreased brain volumes in babies who have spent time in
• 1:52
  the NICU, who routinely underwent painful procedures, usually, not well-managed.
• 1:57
  And there's been functional changes in those babies at toddler age, and we think
• 2:02
  that the mechanism is really hyperalgesia or nerve hypersensitivity that is
• 2:08
  triggered by unmitigated pain in infancy.
• 2:11
  And so, over time, obviously, you have the hyperalgesia, but you also
• 2:15
  then have pre-procedural anxiety, a more general fear of the doctor, and
• 2:20
  ultimately, and in worst case scenarios, healthcare avoidance altogether
• 2:24
  Host: That really is some amazing news for me.
• 2:27
  And I guess the more I think about it, Dr.
• 2:28
  Deacy, it makes sense.
• 2:30
  And so, thank you for bringing that up.
• 2:31
  That was very interesting.
• 2:33
  So then, with that situation going on, and I would assume the effect
• 2:36
  can even be the same for toddlers and stuff, what do we do in a primary
• 2:41
  care setting to avoid all that?
• 2:43
  What are some of the simple evidence-based ways, by the way, that you like
• 2:47
  to handle this pain and stress?
• 2:49
  Dr. Amanda Deacy:
• 2:49
  Yeah.
• 2:50
  So, the good news is despite those, you know, potentially dire outcomes
• 2:53
  that I just talked about, the good news is that there is current
• 2:56
  evidence that supports four primary strategies for pain management
• 3:00
  related to routine needle procedures.
• 3:02
  So, these are not even the NICU babies, although we ought to pay
• 3:05
  particular attention to those.
• 3:06
  But this is a well-developed healthy child too.
• 3:09
  There are really four strategies that have a longstanding evidence base that
• 3:14
  suggests that layering not only one of the strategies being beneficial, but
• 3:18
  actually layering them, using more than one at a time, produces incremental
• 3:22
  benefit for both pain and anxiety.
• 3:24
  And so, just very briefly, these four strategies include some sort of topical
• 3:29
  anesthetic, so some sort of numbing cream.
• 3:32
  The great news is that these can now be applied at home.
• 3:34
  These are available over the counter.
• 3:36
  It's a 4% lidocaine cream.
• 3:39
  The second of those four is something we call comfort positioning.
• 3:42
  So, this is not the same as holding babies or toddlers down on their backs.
• 3:47
  So, comfort positioning.
• 3:49
  Number three is distraction.
• 3:51
  And the fourth is either sucrose or breastfeeding during
• 3:55
  painful needle procedures.
• 3:57
  Host: With these four techniques and stuff that are evidence-based,
• 4:01
  are they widely used?
• 4:02
  I mean, are these things that most of your primary care pediatricians know about?
• 4:07
  Dr. Amanda Deacy:
• 4:07
  So, in my experience, I think while the evidence is longstanding/ I
• 4:12
  think the transition from research evidence to practice has been slow.
• 4:17
  And so, really, what I've adopted, as really one of my primary
• 4:20
  goals for my practice is to close that research practice gap.
• 4:24
  So, I do spend a lot of time providing education, doing
• 4:28
  trainings related to these.
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  Because despite the fact that the literature has been there, really,
• 4:33
  the uptake has lagged a bit behind.
• 4:35
  And so, really, that's why I feel so passionately about this, is making
• 4:38
  sure that every child—I always joke, you know, my children have a pain
• 4:42
  psychologist for a mother, but my children shouldn't be the only ones
• 4:45
  who have access to this evidence base.
• 4:47
  And so, really, it's become my mission to get these in the hands of all
• 4:50
  primary care pediatric practices.
• 4:53
  Host: I love it.
• 4:53
  Dr.
• 4:54
  Deacy, I think that's so important.
• 4:55
  The time from research to clinical application of just about anything is so
• 4:59
  long that by the time we start clinically recognizing it and doing it, researchers
• 5:03
  have known about it for 20 years.
• 5:05
  Dr. Amanda Deacy:
• 5:05
  Exactly.
• 5:05
  And that is indeed the case for pain prevention and pain management around
• 5:09
  painful procedures for children.
• 5:10
  You bet.
• 5:11
  Host: So, how do early experiences with pain in healthcare settings affect a
• 5:16
  child's long-term trust in medical care?
• 5:19
  I got to believe there has to be some trust issue there if their
• 5:22
  experience isn't great, right?
• 5:24
  Dr. Amanda Deacy:
• 5:24
  Well, I think just the thing to remind the audience of is that even healthy children,
• 5:28
  again, they receive 15 to 20-plus doses of various vaccines by age 10.
• 5:34
  Those babies, like I mentioned in the NICU, who spend an average length
• 5:37
  of time, they can undergo 4,800 painful procedures, again, most
• 5:41
  without adequate pain management.
• 5:43
  So, what we see is that there are higher pain ratings during venipuncture, for
• 5:49
  example, by school age in some of these babies when pain is not well treated.
• 5:53
  Like I said, just pre-procedural anxiety or a general fear of going to the doctor.
• 5:58
  The American Academy of Pediatrics actually put out an interesting
• 6:01
  paper not too long ago on the contributors to vaccine hesitancy.
• 6:05
  And among those contributors, parents reported that the pain of vaccines was
• 6:10
  among the top most discussed parental reasons for delaying or avoiding
• 6:14
  vaccinations for their children.
• 6:15
  So, the implication is certainly community-wide, but also for an individual
• 6:21
  child or family, medical non-adherence or avoidance of healthcare altogether.
• 6:26
  So, I think that takes me back to your initial question, which is, is this
• 6:29
  shift of thinking that I might suggest?
• 6:31
  And that is, again, moving the idea from it being just this very brief
• 6:35
  moment in your office to actually being a brief moment that potentially
• 6:40
  has long, long-lasting impacts for the health not only of an individual
• 6:44
  child, but our community at large.
• 6:46
  Host: So, how do you feel about the trends you see on social media where
• 6:49
  parents are filming their kids having a bad experience getting a vaccine and not
• 6:54
  really doing much about it and posting it?
• 6:56
  Dr. Amanda Deacy:
• 6:56
  Yes.
• 6:56
  Well, you know, I have a lot of empathy.
• 6:58
  I will say, I think that many of us grew up in the era of just dealing with it.
• 7:03
  It was considered just a part of childhood and that kids cry, and we just
• 7:07
  sort of need to get over it, really.
• 7:09
  But again, I think we can't expect parents or pediatricians, for that matter,
• 7:14
  to do better until they know better.
• 7:15
  And so, again, it goes back to really what I feel so passionately about.
• 7:19
  I think parents want to do well by their children.
• 7:22
  We have to just make sure they're equipped with the appropriate skills to do so.
• 7:26
  Comfort positioning is really something that parents can participate
• 7:29
  in, too, and we have the hope that they will during children's visits.
• 7:32
  So, encouraging parents to be part of the care team during those painful procedures,
• 7:37
  giving them a job, can also really help.
• 7:40
  Host: I wanted to go back to two of the strategies and talk
• 7:44
  a little bit more about them.
• 7:44
  And one of them was the positioning, the comfort positioning.
• 7:48
  Are there certain positions that children just do well with, babies,
• 7:53
  toddlers, that you can discuss?
• 7:56
  Dr. Amanda Deacy:
• 7:56
  Absolutely.
• 7:57
  So, most babies, we ought to recommend—again, this is for routine,
• 8:02
  non-emergent, expected needle procedures.
• 8:05
  We want to hold a baby just like we would be holding them to sing to
• 8:09
  them, to feed them, to talk to them.
• 8:11
  And so, a traditional football hold, for example, or even over
• 8:16
  chest-to-chest, we talk about that a lot.
• 8:19
  We talk about kids just being able to sit upright.
• 8:23
  So, we know there's some fascinating physiologic data about what happens
• 8:27
  to kids' vital signs when we lie them flat on their backs, as well
• 8:31
  as their emotional responses.
• 8:33
  There's sort of a fear response that happens, sort of this fight or flight that
• 8:37
  is initiated by lying kids on their backs.
• 8:39
  And then, additionally, when we hold them down, that reaction is only compounded.
• 8:43
  So, to the extent that you can hold infants in a comfortable position, put
• 8:48
  toddlers either, again, chest-to-chest or creating tummy-to-tummy, like I said, is
• 8:54
  really going to be the most comfortable and safe position for toddlers.
• 8:57
  And of course, this will require nursing education as well, because we want to
• 9:01
  ensure that our nurses are kept safe.
• 9:04
  There are ways to do that, that also mitigate needle sticks.
• 9:08
  Host: The comfort position reminds me or it brings to mind the idea of
• 9:12
  time, because I know that when I was training—and I'd like to get your
• 9:17
  opinion on this—when I was training, the pediatricians back then, now
• 9:21
  this is late '80s, early '90s, they were like, "Get in and get out.
• 9:25
  Get that kid down, do the procedure you got to do and move on out," meaning
• 9:29
  they felt the faster you were, the better it was overall for the child.
• 9:34
  What do you think about that?
• 9:35
  Has that changed?
• 9:36
  Dr. Amanda Deacy:
• 9:36
  Well, I do have an opinion on that, and it's actually twofold.
• 9:39
  I think one is there is this myth and the data have really borne this out, the idea
• 9:44
  that if we were to do what the evidence suggests, that is implementing these four
• 9:47
  strategies, that it has a detrimental effect on workflow and visit time.
• 9:53
  And actually, that has not turned out to be the case.
• 9:56
  Now, certainly, upfront when families or care teams are initially using
• 10:00
  these things, it may take a bit longer.
• 10:02
  But again, we're taking the marathon view here.
• 10:05
  And the idea is that over time, these visits actually go better and smoother.
• 10:10
  Because kids feel safe, they feel secure, and they know their pain will be treated.
• 10:15
  The other thing is just this idea, again, that yes, while you could do it quickly
• 10:20
  and painfully, they have to come back.
• 10:23
  And so, over time, that stress reaction, that fear reaction just
• 10:28
  gets bigger and bigger, and the interventions take longer and longer.
• 10:32
  So again, this is really all about making an investment in protecting our
• 10:37
  kids' nerves, literally their nerves, so their neural function, their neural pain
• 10:41
  perception, and their emotional health.
• 10:43
  We make an upfront investment so that down the road they are less vulnerable
• 10:49
  to the development of chronic pain conditions certainly, but that also just
• 10:53
  emotionally they are set up for success.
• 10:56
  They are healthy and well-functioning adults who do
• 10:58
  not avoid routine healthcare.
• 11:00
  Host: Yeah.
• 11:00
  That's a great, great point.
• 11:03
  You know, Dr.
• 11:03
  Deacy, when I, again, being a young medical student many, many
• 11:06
  years ago and, you know, being taught to kind of do it quick, do
• 11:10
  a procedure fast, I didn't like it.
• 11:12
  It wasn't good for me.
• 11:14
  You know, I didn't want to go back in and do the procedure, you know?
• 11:17
  Dr. Amanda Deacy:
• 11:17
  Exactly.
• 11:17
  And I'm so glad you brought that up.
• 11:19
  And, you know, and it's difficult because as a medical staff member myself, I
• 11:23
  realize that I'm having to encourage my peers as well to make a practice change.
• 11:28
  And that's not always an easy position to be in.
• 11:31
  And yet, just like the outcomes are improved for parents and children,
• 11:36
  staff actually prefer this too.
• 11:38
  The data have been clear.
• 11:39
  Providers and nurses don't go into pediatrics certainly because they
• 11:42
  enjoy hurting children, right?
• 11:43
  It's the opposite of that.
• 11:45
  And so, when we can equip staff members, their own distress goes down as well,
• 11:50
  and they see these things working, and they ultimately have confidence
• 11:53
  that they are providing best practice.
• 11:56
  Host: Now, one of the other strategies you mentioned was distraction.
• 11:59
  So, any great tips there?
• 12:02
  Dr. Amanda Deacy:
• 12:02
  There's a couple of things.
• 12:03
  One is you are your patient's own best distraction device, meaning talking to
• 12:09
  them, telling a story, engaging in a silly game, singing, commenting on their shoes,
• 12:15
  noticing the animal on their T-shirt.
• 12:18
  All of those things can serve as a cognitive distraction and
• 12:22
  get kids' brains refocused on something other than the pain.
• 12:25
  There's some fascinating cognitive data about the fact that there is
• 12:28
  only so much sensory information that can be sent to the brain at one time.
• 12:33
  So, if we interrupt that, I'm sure your audience is familiar with
• 12:36
  the gate control theory of pain.
• 12:38
  If we close the pain gate, in other words with some other
• 12:41
  form of sensory input, that is distraction, pain sensation is less.
• 12:46
  And so, it can be as simple as, again, singing, talking, telling stories, but
• 12:50
  also our exam rooms are full of games and puzzles and flashing lights and,
• 12:55
  you know, you probably have seen kids in practices showing up with their mom
• 12:59
  or dad's cell phone or their own iPad.
• 13:01
  So, that's really a positive application of a video screen to
• 13:06
  distract them away from the poke.
• 13:08
  Host: What are some of the common misconceptions you see that clinicians
• 13:13
  have around pain and distress?
• 13:17
  Dr. Amanda Deacy:
• 13:17
  Yeah.
• 13:17
  So, I'd say three of them come to mind.
• 13:19
  One of them is that kids' pain doesn't matter because they forget it anyway.
• 13:23
  That has been a myth or a misconception for some time.
• 13:26
  And again, the science just really does not bear that out.
• 13:30
  While they may cognitively not remember it, their bodies remember it.
• 13:35
  And also, the emotional distress is obviously something that we've all seen.
• 13:38
  So, that's one of the biggest.
• 13:40
  Kids' pain does in fact matter, and the implications can be quite big.
• 13:44
  The second misconception I'd say is that there's nothing we can do about it.
• 13:48
  They just have to get through it just like we did.
• 13:49
  We know that's not true.
• 13:51
  This data has been around for, like you mentioned, 20 plus years.
• 13:55
  And they've been tested in various situations with both typically
• 13:59
  developing kiddos and those that are not typically developing.
• 14:03
  So, it really spans both developmental status as well as age, and they
• 14:08
  have great positive impact.
• 14:10
  And the other myth is one I've already mentioned, which is that doing best
• 14:13
  practice pain management in primary care slows down the work of medical providers.
• 14:18
  And as I said, that actually has not been borne out.
• 14:21
  Host: Yeah.
• 14:21
  I think that's a big myth.
• 14:22
  You still see that a lot today
• 14:24
  Dr. Amanda Deacy:
• 14:24
  Yes.
• 14:25
  You know, and I think one of the things is, that even just as far as education,
• 14:29
  like I mentioned, the topical lidocaine cream is now available over-the-counter.
• 14:33
  So even if you're not waiting in your own waiting rooms or your own
• 14:37
  exam rooms for this cream to take effect, families can put it on
• 14:41
  before they come to the appointment.
• 14:42
  And so, in that case, they come prepped and ready for their vaccines.
• 14:47
  Host: Yeah.
• 14:47
  I want to mention, so one of the things you said about not remembering pain,
• 14:50
  which we know they do in different ways.
• 14:53
  Because, you know, they may not remember, and this is just my take on it, Dr.
• 14:56
  Deacy, you're the expert.
• 14:57
  But a young child may not remember a bad pain experience in a
• 15:01
  doctor's office, like a memory.
• 15:03
  Like, you know, "On this day in 1990 whatever," they don't remember it
• 15:07
  like that, but they do remember it maybe as an adult because they have
• 15:10
  some fear of needle for some reason.
• 15:11
  They don't even know why.
• 15:12
  Dr. Amanda Deacy:
• 15:12
  Well, exactly, and you took the words right out of my mouth.
• 15:15
  Actually, one in four adults is afraid of needles.
• 15:18
  And so, while those infants may not remember, their parents
• 15:22
  certainly do, and their parents were distressed when that was happening.
• 15:26
  And we also know that the way parents talk to their kids about painful
• 15:29
  experiences also has a lasting impact on the kid's perception of
• 15:33
  pain during subsequent procedures.
• 15:36
  So, that parent was there that day, and they were distraught
• 15:39
  about how upset their baby was.
• 15:41
  And the parent might be the one in four.
• 15:43
  And so, it's a complicated mix potentially.
• 15:46
  Host: Maybe the parent already kind of didn't like needles.
• 15:48
  Now, they definitely don't.
• 15:49
  Dr. Amanda Deacy:
• 15:49
  Exactly.
• 15:50
  And so, now you have an adult who says, "Gosh, maybe we can
• 15:53
  wait on the 10-year vaccines."
• 15:55
  Host: Yeah, maybe we don't need that.
• 15:57
  We don't need that follow-up one.
• 15:58
  Dr. Amanda Deacy:
• 15:58
  Right.
• 15:59
  And it so becomes very uncomfortable not only for the
• 16:01
  parent but also for the child.
• 16:03
  And then you're having to manage behavior on top of it.
• 16:05
  And it just becomes sometimes too much for families who don't feel
• 16:09
  like they have the requisite skill.
• 16:11
  Host: Dr.
• 16:11
  Deacy, this has been fascinating information.
• 16:13
  So happy you came on.
• 16:15
  What's one small change that you think a pediatrician could make tomorrow
• 16:21
  to improve a child's experience?
• 16:24
  Dr. Amanda Deacy:
• 16:24
  So, I think a pediatrician tomorrow.
• 16:26
  Now again, this assumes some bit of education, but I would
• 16:29
  say stop holding kids down.
• 16:31
  Engage parents during the visits by including them and creating a
• 16:35
  comfortable position for their child's vaccines and stop holding them down.
• 16:39
  That would be my first recommendation.
• 16:41
  One step beyond that, I know you asked for one, but I would encourage
• 16:45
  your patient's parents to go to our Comfort Promise webpage, or
• 16:48
  to the Meg Foundation's website.
• 16:50
  There is a ton of information in both of those places, and some very specific
• 16:55
  guidance for parents on creating their very own what's called a comfort kit.
• 17:00
  And it has specific instructions for ensuring that those four
• 17:04
  evidence-based elements I talked about get included in your child's kit.
• 17:09
  Host: Fantastic.
• 17:10
  Thank you again, Dr.
• 17:11
  Deacy, for coming on.
• 17:12
  As a reminder to our audience, claim your CME credits after listening to this
• 17:16
  episode by visiting cmkc.link/cmepodcast
• 17:22
  and clicking the Claim CME button.
• 17:25
  If you enjoyed this podcast, please share it and check out the entire podcast
• 17:29
  library of topics of interest to you.
• 17:31
  This has been Pediatrics in Practice, a CME podcast.
• 17:34
  I'm Dr.
• 17:35
  Mike.
• 17:36
  Thanks for listening.