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Addressing Pain in Children: Strategies for Effective Management · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

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I'm Holly Wehment, and this is Pediatrics Now, cases, updates,
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and discussions for the busy pediatric practitioner.
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Today, we're talking about addressing pain in children.
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This talk has been designated by UT Health San Antonio for one credit of education
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in pain management and the prescription of opioids.
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One of the things that I think is so awesome about this podcast is we can bring
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you talks that you don't have time to attend.
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This talk is from our recent pediatric grand rounds.
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It's called Addressing Pain in Children.
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The speaker is Dr. Melissa Fry-Jones. She's a professor of pediatrics in our
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division of pediatric hematology oncology.
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Pediatrics Now is brought to you by the Department of Pediatrics at UT Health
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San Antonio and University Health's new Women's and Children's Hospital.
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Let's listen in to this talk on addressing pain in children.
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So I have no financial disclosures. I will be discussing off-label use of medications
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because many pain medications,
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especially different types of opioids, are not actually FDA approved for children
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and infants, though we have used them as part of clinical practice for many, many years.
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And so officially it's off-label, but we have plenty of data to support the
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use of these medications.
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So my learning objectives today, I'm going to think a little bit about the complexities
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of pain and pain assessment that varies between this dramatically different
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group of patients we take care of from infants, children's, to adolescents.
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Development plays a huge role in helping us understand pain and pain assessment.
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We're going to explore some of the pharmacologic and non-pharmacologic methods of pain management,
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talk about pain management in some special populations, and then we're going
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to talk a little bit about prescribing opioids in the modern era,
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which includes some of the guidelines that involve pain contracts,
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the prescription monitoring database, and how we now prescribe opioids electronically.
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So, you know, what is pain? I mean, the basic definition, you know,
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it's an unpleasant sensory or emotional experience.
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So just to highlight how complex pain is, who we are, what we're feeling,
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what's going on at the moment it's happening directly impacts how we experience
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this unpleasant sensation.
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And it may be associated with actual or potential tissue damage.
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So, you know, the classic picture of you putting your hand on the stove and
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withdrawing it because the heat or the fire is causing tissue damage.
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Though sometimes the damage isn't as obvious or, you know, the experience is
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described in terms of such damage.
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So as, you know, as people who take care of patients, you know,
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when, when do, when is pain, pain?
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The, the basic tenet among pain practicing physicians is, you know,
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pain is whatever the person experiencing it says it, you know,
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you'll learn that there is no test.
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There's no objective test that I can do. There's no lab work. There's nothing.
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Even sometimes vital signs cannot tell the whole truth about the pain a patient is experiencing.
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And so whatever the patient says is their pain, that is what we are supposed
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to believe and to address them based on their experience since I cannot experience it for them.
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So pain exists if the person experiencing it says it does. and the patient is
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going to be the authority on pain.
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So we'll talk a little bit about some of the different types of pain that patients can experience.
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So we can think about acute pain. So this is, you know, sudden onset,
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should be self-limited over a period of time.
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It usually involves a couple of different types of pathways.
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And so the nociceptive pathway, that's sort of our classic example I just mentioned,
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And, you know, putting your hand on the hot stove and withdrawing it.
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And so that pain sensation is in the nociceptive pathways.
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And so the normal processing of those pathways include both somatic input.
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So from our bones, our joints, our connective tissue, sometimes in people who
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can describe the pain, it's aching or throbbing.
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And usually you can localize the pain.
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Like it's this finger that hurts. But this also nociceptive pain is part of
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how our visceral system, so our organs, our soft tissue, so like our intestines are visceral.
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And when you have diarrhea and have cramping, that's a nociceptive pain process.
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And so visceral pain can sometimes be localized, but it can also be diffuse,
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which can be one of the challenges of localizing those symptoms.
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And then another type of processing of pain is neuropathic.
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And so this is centrally mediated, and this can evolve for a number of reasons.
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One of the classic things that we'll sometimes use as an example is an individual
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who's had an amputation.
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So those nerves have been severed. Therefore, when they fire,
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they are abnormally processing because the localized place that would be injured
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and sending the signal is no longer there, but the nerves are firing. And so...
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That is an example of neuropathic pain. We can have centrally and peripherally mediated.
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Peripherally mediated is a little bit less common in pediatrics,
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though we can see it in our oncology population as a result of medical therapies like in Christine.
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This would be one of the conditions that adults may deal with in the diabetic
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populations who develop diabetic and or vascular peripheral neuropathies.
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These tend to be sharp, shooting, electric sensations.
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So the description of neuropathic pain is often very different than the description of nociceptive pain.
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And it often does not respond great to opioids. And so if the pain you're identifying
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as neuropathic, then choosing an opioid may not be the best choice.
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And then chronic pain. So we have a lot more awareness of chronic pain.
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We're trying to understand more about it. There's definitely lots of gaps in
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our knowledge, and we struggle to know exactly what to do for patients who develop
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chronic pain syndromes.
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But the general definition is that it's a pain sensation. So again,
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a patient expresses feeling something they identify as pain,
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present for at least three to six months.
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And it no longer serves the purpose of pain. It's no longer a warning sign that
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something bad is happening.
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It's just there all the time. And, you know, it can dramatically affect all
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aspects of a patient's life.
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It usually involves, you know, the sensation of the pain, emotion,
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cognition, memory, contact. Sometimes the pain is worse if they're in certain
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situations based on maybe the initial feelings of the pain.
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It could be nociceptive or neuropathic in quality. And it's one of our most
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difficult conditions to treat.
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Okay, so what about pain in children? You know, the classic saying,
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you know, children are not little adults.
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And so, you know, what are the special things that happen in children?
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Well, one is to note that the nociceptive pathways are functional at birth.
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Many, many years ago, there was a belief that babies couldn't feel pain.
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And so, you know, there was not felt to be a need to address that.
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Now we know infants can feel pain, and there are many interventions that are
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taken in our youngest patients to try to alleviate pain when they experience it.
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Pain triggers both physiologic and behavioral responses at all age.
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So no matter whether you're a toddler, a teenager, or an adult,
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you have physical sensations of your pain, but it also affects the way you react and behave.
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There are developmental changes in the pain pathway early in life that can impact
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your response to pain medicines and alter processing of pain later in life.
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Repeated exposure to untreated pain early in life leads to increased anxiety
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and perception of pain can make it more difficult to treat painful events in the future.
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Children require unique coping strategies that are different from those in adults
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because of developmental differences. is.
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Let's think about, you know, like what are some of the types of pain that we
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may encounter as we take care of children?
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Well, one of the first ones we can often think about is trauma.
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So accident, you know, the kid falls on the playground, they're riding a bike and they have an event.
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And then sports, we have many young children who participate in recreational
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and even higher level sports from very early ages.
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And that can result in them having lots of different pain complaints.
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I know there was a sports medicine lecture recently, you know,
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knee pain, all of those type of things.
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Then we have children who develop different types of cancer.
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The diagnosis itself can cause a lot of pain depending upon the location and type of cancer.
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The treatment of the cancer with surgery and medications and therapies that
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can also provoke more pain. We can have surgical pain, you know,
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for the child who has the tonsillectomy, who has the appendectomy.
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There are occasionally surgical procedures that our patients may have to experience
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and would need to have pain treatment. We can think about procedural pain.
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Sometimes this is maybe more minimized or dismissed, like, oh,
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everybody gets immunizations.
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You know, oh, it's just a little poke in the arm and lab draws,
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though those can be very difficult and very distressing for children and actually for many adults.
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This is kind of a side note, but there were some studies during the COVID pandemic
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that there were some adults who did not want to seek out the vaccine because
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of needle phobia, because they were more afraid of the needle.
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And so that is something that developed over time due to exposure to vaccines
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as a child and to adulthood.
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And so there were people who were looking at addressing that.
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So, you know, the fear and pain related to vaccines is real among our patients.
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And then we can have chronic disease-related pain syndrome. So our patients
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who have recurrent pancreatitis, many of our inflammatory bowel disease patients,
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patients who have juvenile arthritis, lupus, any type of chronic arthropathy,
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and then our sickle cell patients.
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And then there are other pains, you know, that we have to deal with,
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you know, the chronic functional abdominal pain, chronic headaches,
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the growing pains that people come in and report for children.
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We have to distinguish, is that, you know, just truly growing pains or is it
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something more pathologic?
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And then dental pain, you know, occasionally have patients come in with swelling,
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a broken tooth, a cavity, those type of things.
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So there are lots of parts of the body that can cause a patient to experience pain.
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So what are some of our issues and challenges in treating pediatric pain right now?
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Well, most research is in cancer pain. We lack a lot of information on prevalence
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and epidemiology data for pain in children.
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We have significantly limited research in neonates. We have limited use of pain guidelines.
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For many years, there were literally no pain guidelines for the general pediatric
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population. There may be some specific ones for certain conditions,
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as I mentioned, cancer or sickle cell.
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There have been some newer guidelines published by the AEP in the past two to
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three years, which are helpful.
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And then effective pain on quality of life is poorly characterized.
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So, you know, due to all the developmental reasons, which make it difficult
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to assess pain in children, it can also be difficult to understand how it impacts them.
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So now we're trying to move on to, so we've talked about pain.
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We don't know a lot about pain, but we are confronted with pain in our patients frequently.
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So how do we assess pain in children? So again, we have to use developmentally
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appropriate pain scales.
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I'm going to present three or four types of pain scales that can be used.
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If you look in the literature, there's bunches of different kinds.
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Some are other iterations of the ones that I'm going to be talking about,
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but these are sort of the gold standard ones that have been used and have the
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most information sort of evaluating them and validating them in our patients. So.
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In younger children, we use the FLAC pain scale, which I'll show you an example of that in a minute.
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For patients who are pre-verbal, so kids under three years of age,
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and then for older nonverbal patients, we certainly have a growing population of patients who,
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for various developmental reasons, are not able to communicate verbally with
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us even on into young adulthood.
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And then patients who are developmentally unable to use what's called the FACI
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scale, which, again, I'll also show you that. You can use the FACES pain scale
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for patients three years and older.
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And typically, the severe pain is defined as 8 to 10 on a 0 to 10 FACES scale.
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And then it's defined as greater than 5 on the FAC scale.
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So for children less than three, this is the FLAC scale.
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So the FLAC is an acronym for Face, Legs, Activity, Cry, Consolability.
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And so there are definitions for what is happening on those five criteria for a young child.
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And so you get points based on which of these things are happening.
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So for scores of zero, which would be no pain, you know, they don't have any
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particular facial expression. They're relaxed.
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They're lying quietly. They're not crying. They're content.
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That makes sense. And then as you move up the scale, they identify physical
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evidence that the child may be in distress or in pain with a grimacing,
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clenched jaw, you know, rigid legs,
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crying, difficult to console and comfort.
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And so this is the traditional scale we use for nonverbal patients.
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So you can apply this also to older patients who are not able to communicate.
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And then for children ages three and older, you can use the facey scale.
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I have here represented the classic Wong-Baker facey scale.
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This has been in use for a very, very long time and was the traditional facey scale.
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There are lots of other iterations of this. There are some scales that have
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actual children's faces on them.
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Some of the newer scales, the zero is a neutral face as opposed to being a smiley face because,
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there's been some understanding that if you're in a hospital and somebody shows
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you this and you're a child, you may pick a two because you're not that happy to be in the hospital.
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And so there are some specifics that have changed what these faces look like over time.
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Now, some of the caveats is that, you know, young children may not be able to
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distinguish between physical or emotional discomfort.
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And so again, sometimes they may pick slightly higher numbers Also,
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there's some developmental things where children do naturally pick higher numbers.
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You know, do you want one cookie or four cookies?
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Those type of things. So when you use this pain scale, you do have to very carefully, you know,
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kind of give them some anchoring for it that, you know, this 10 Hertz worse
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is not because my brother took my cookie because I could look like that and
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cry and be sad if I lost something important to me.
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That's more of an emotional discomfort as opposed to, you know,
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I fell off my bike or fell down the stairs.
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That type of thing should be used when having children use the FACES scale, at least initially.
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As they get older and they understand a little bit more about what these numbers
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are supposed to represent or these FACES are supposed to represent,
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they may not need as much guidance as initially.
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Then frequently in an older patient and in adults, we'll use a verbal analog
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scale. We may not have those faces with us for the patients to look at.
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And so we'll ask them out loud, you know, on zero to 10, you know, where is your pain?
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And, you know, we tend to just give patients that as opposed to,
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you know, providing them with some anchoring statements.
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So it is important to say, you know, zero, I'm comfortable.
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I'm, you know, no pain at all. I'm lying. Some people say I'm laying in a fluffy
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bed versus 10. 10, you can pick any number of different things.
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I had one attending once who was like, 10, you jumped into a pool without water.
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So like trying to give them some dramatic, like this is supposed to be dramatic
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pain, very severe pain that would limit what you could normally do.
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And again, as I mentioned, young children may develop me to pick higher numbers
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if they don't understand the anchors that you're using.
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And then I'm going to talk a little bit about functional pain scales.
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I really like functional pain scales, especially in our patients who have chronic pain.
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There's a general movement that for chronic pain patients,
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the traditional facies and verbal pain scales of zero to 10 really are not helpful
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because these patients live with pain on a daily basis and it may go up and down,
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but it never goes to zero for sure.
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And so that's why we sometimes get patients to start telling you their pain
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is a 15 and a 20 on a zero to 10 scale, because that scale no longer serves
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as a good tool to help understand how their pain is affecting their life for
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our chronic pain patients.
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And so more of the research in chronic pain, again, this is mostly in adults,
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so I think we could use it in our adolescent AYA patients, are in functional pain scales.
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And so this looks at more and has the patient think about more of what can I
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do, what can I not do? What is my pain limiting me from doing?
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What can I normally do that isn't able to accomplish because of my pain?
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And so it shifts it from pain assessment toward patient function and impairment.
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Unfortunately, again, these functional pain skills are not yet validated in
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children, but I find them to be more helpful in our patients with chronic pain syndromes.
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So, you know, what are some of our barriers? What are reasons why children who
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are in pain may not get the treatment that they need?
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Well, I mean, some of it's us, the physicians, nurses, pharmacists,
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you know, we now are fearful.
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We have a lack of experience and discomfort with these meds.
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You know, when I started training, the fifth vital sign of pain had become,
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you know, the thing that was checked off every, you know, every so many hours.
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And there was a lot of advertising and promotion that we need to ask patients about pain.
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We need to address their pain. We need to respond to within 30 minutes.
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We were using a lot more pain medications during that time period.
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But now in light of the opioid epidemic, which I will address later in the presentation,
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you know, we use it less frequently and there's a lot of fear related to it.
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We have more fear of opioid-induced complications because we don't have as much
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experience with the medications than fear of consequences of treating pain.
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Again, the consequences of treating pain, we don't have a lot of data on because
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that's like quality of life and impact in adulthood about not having pain treated as a child.
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Those are things that are more difficult to quantify, and it's easy to quantify
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number of times a patient had respiratory depression.
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And so that's one of the reasons why it can be difficult for us to feel comfortable
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giving these pain medications.
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The family of the patient can be a barrier. The caregiver can have a fear that
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even one dose of these pain medicines could result in an addiction.
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And there's a huge social meaning in our country right now related to opioids
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and narcotics and legal pain medicines and illegal substances. And.
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Weight in some families when we talk about using these medications.
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And then patients, barriers, verbal communication and language.
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If they can't tell you they're hurting, if they can't communicate with you about
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how the medicines make you feel, it can be a real difficulty to determine if
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the doses and medication you're using are effective or if you need to use another one.
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So again, I just want to highlight the effects of uncontrolled pain.
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So when a patient is in pain and they're not appropriately treated,
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they do not receive doses of medicine that will cause some decrease in their pain or some relief.
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We know that we can't erase all pain, but if there's not some lifting of the
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intensity of the pain and patients become agitated, they become depressed,
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there's anxiety, they have loss of appetite and sleep disturbance,
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decreased quality of life, interruption of family life.
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They can develop what's called a pseudo addiction.
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And so this is where they're in so much pain and they're so desperate for relief
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that they may start having behaviors that you would typically see or you would
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typically associate with an individual who had an opioid addiction where they're going,
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I mean, they're in so much pain and no one's treating them.
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So they just keep going to different places and asking until they hopefully
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find someone who may be compassionate enough to actually give them medication
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to provide some relief because they're having so much suffering.
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And so they can develop behaviors that look like addiction, but it's not because
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they're truly opioid addicted. It's because they have pain that is not being addressed.
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And then the other effects of not treating pain is that we put patients at risk
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of developing opioid misuse, which again, I will discuss in some subsequent slides.
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Okay, so what are our pharmacologic strategies of pain management?
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These are usually the things we think of first when we want to treat patients with pain.
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We immediately, we're doctors, we prescribe medication. So if somebody has a
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problem, I'm going to give them medication for it.
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So that's usually our first action that we do in patients who have pain.
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And so there's the Who Pain Ladder, which has been around for a long time,
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that discusses like for mild pain, you can use non-opioids, so NSAIDs, acetaminophen.
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And then as the pain goes up, you should consider adding like weak opioids and
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then strong opioids as your pain gets higher and to continue using some of those
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non-opioid medications. So what about using the pain ladder in children?
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Usually the recommendation for children is to do more of a two-step strategy
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instead of the three-step strategy.
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For mild pain, use things like ibuprofen, endoproxen, acetaminophen.
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And you're going to skip the middle step of using some of the weak opioids because
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the benefits of using a stronger opioid outweigh the benefits of the intermediate
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opioids in the pediatric population.
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So I know for many years people felt comfortable prescribing codeine,
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but 33% of patients do not metabolize codeine to an active analgesic,
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so you're functionally giving them nothing.
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And then there's a certain percentage, probably about 28%, who will under-metabolize
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the active analgesic, and so they're at risk of excessive sedation.
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And so codeine is not recommended for use, and so that leaves us with maybe
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some of the more classic opioids, so moderate to severe pain,
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to treat with hydrocodone initially, and then consider morphine,
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and then the other agents, depending upon the type and severity of pain for the patient.
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So, you know, medical management of severe pain, you know, this is...
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It's specific to, you know, think about.
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So one of the things you have to think about when you're addressing a patient
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with pain is, you know, what is the mechanism of their pain and what is the
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natural history of this patient's pain?
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You know, I stub my toe, it's going to feel bad for a day and then feel better the next day.
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You know, there are other things I can potentially do to treat it.
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But let's say I have a patient with a large abdominal tumor.
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That's not going to go away quickly. They're going to have pain for quite a while.
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And so I need to address their pain and I need to address it in a way that doesn't
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cause them to have these huge shifts and swings of I'm in a lot of pain and then I'm not in pain.
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So, you know, as needed or PRN medications are not appropriate for severe pain.
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You don't want patients to have these swings of pain scores of 10 and then better
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because I got a pain medicine and then not get anything for a while until I go back up to a 10.
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The untreated pain leads to anxiety and even more severe pain experiences in this situation.
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So, you know, scheduling an analgesic in patients with these type of severe
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pain that is not going to get better rapidly.
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And then having some additional medications for increased or breakthrough pain.
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I mean, you do have to, you have to adapt it to the individual child,
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you know, you know, dosing relief versus adverse effects.
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So if the dose is too high and they're too sleepy, then back off on it.
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If the dose is not enough, then go up on it.
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These medications are completely titratable. You just have to be willing to try a lower dose.
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If that's not enough, then go up a little bit and keep adjusting it based on
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the patient's response.
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So when we are looking at patients with severe pain, morphine is still recommended
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as the initial opioid, though I've had several anesthesiologists tell me it's
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kind of a crappy opioid, but it's the one that we've had the most experience
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with, and so it's still the one that we use.
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There's really not a lot of evidence to recommend using, like going straight
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to hydromorphone or one of those other medicines if you have a patient in severe
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pain, morphine is still the gold standard.
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They can be given oral, IV, sub-Q, rectal, transdermal, intranasal.
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So there's lots of ways in which you can administer these pain medications to patients.
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And in general, in most of the pain literature, there is no longer a reason
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to administer intramuscular opioid injections, especially in children.
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Again, we've already talked about how needles and injections are a source of
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pain and distress in patients.
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And so if you're in pain and then you're going to have to have an injection
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that is also anxiety and stress inducing, it's going to raise your experience
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of the pain you're having right now.
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And so the pain literature recommends strongly against giving intramuscular pain med injections.
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And then you're gradually going to increase the dose until it's effective.
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You want to limit the pain between the doses.
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So you don't, again, you don't want to have these wide swings of being at a zero and being at a 10.
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If you find that the medication you're using isn't working and you're having
27:22
lots of adverse effects, then that would be a reason to switch to another pain medicine.
27:26
So if you're on a dose of morphine and the patient has horrible itching and
27:31
nausea and they just feel terrible on it and they're still in pain,
27:35
then that would be a reason to consider switching to hydromorphone.
27:38
Okay, so breakthrough pain. So this happens in patients who are taking scheduled
27:43
pain medicines that their pain will start to increase.
27:46
Sometimes that could be, you know, the end of the dose or the pharmacology of
27:51
these pain medications that we are using. Some medications, you know, last a long time.
27:56
Some last a short period of time. So, you know, if you dose morphine every six
28:00
hours, it's definitely out of your system.
28:03
If you dose IV morphine, you know, it's usually two to four hours of IV morphine
28:10
and then it's mostly out of your system.
28:11
So, you know, if a patient is having pain because you're not giving them their
28:16
IV morphine stuff every six to eight hours, well, that's because you don't have
28:19
a dose interval control.
28:21
Or is it associated with movement or procedure pain? So they only have pain
28:24
whenever they get out of bed.
28:25
Well, then maybe you need to think about having an additional dose of medicines
28:29
available to them to take either before or after they get out of bed.
28:33
Or maybe it's with physical therapy. So they need to have a dose right after
28:36
they do their physical therapy because their pain goes up.
28:38
But you don't need to change their scheduled dose of medicine.
28:42
It's just for when they have increased pain.
28:46
So typically, there's not, again, we lack data. So there's not like data that
28:51
says there's a specific way in which you treat breakthrough pain.
28:55
We usually use either IV or immediate release morphine and you give the rescue
29:02
dose is about 5 to 10% of the total morphine equivalent the patient has during the day.
29:07
You can also consider using patient-controlled analgesia, which is the morphine
29:12
or other pain medication in the pump with the button where the patient can then
29:18
control when they get a dose.
29:19
If they're getting ready to have physical therapy, they can take a dose of their
29:22
pain medicine before they do that as a tool that gives the patient more control.
29:27
So the therapeutic window, so again, this is why we want to have scheduled pain medicines.
29:33
So if we are giving a patient a dose at a regular interval, then we keep the
29:38
dose of drug in this therapeutic window.
29:40
And if our interval is too close together or our dose is too high,
29:44
then we can end up in this toxic area and have side effects.
29:47
And we know we need to drop either the interval of the dose.
29:49
However, if we're not giving the dose frequently enough or we're not giving
29:53
a good enough dose, then we are in the ineffective period, so the patient is
29:57
not having any pain relief.
29:58
So we really want to try to get our dosing so the patient is living in this
30:03
sort of therapeutic window.
30:05
Okay, so we've talked about a little bit about the philosophy of prescribing
30:10
opioids in patients who have pain.
30:12
Then we can talk about some of the adverse effects. So these are the things
30:15
that we're afraid of. These are the things that patients are afraid of.
30:17
So sedation, you know, Excessive sedation can be present without respiratory
30:22
depression. That's a separate process.
30:24
And then there's also the risk of respiratory depression with excessively high doses.
30:30
Now, the respiratory depression is most common in patients who are opioid naive,
30:33
patients who've had previous opioids or are especially on oral opioids at home.
30:39
The risk of respiratory depression with IV doses is significantly lower.
30:42
They can have sedation, but they don't have the same risk of respiratory depression.
30:47
Itching. Itching is a huge side effect. constipation, nausea,
30:51
vomiting, urinary retention, and some patients will experience headaches with their opioids.
30:56
So I highlighted the fact that in 2024, or I mentioned that the AAP has put
31:02
out some pain guidelines.
31:04
And so this is from, this was just recently published.
31:08
They made some assessments. Again, it's just like all other guidelines.
31:13
It goes through how they decided what the data was, you know,
31:17
what are strong, you can see they have strong recommendations versus recommendations.
31:21
But the couple of things, the
31:23
references is on the slide. So you can certainly access this on your own.
31:27
But a couple of things that I was going to highlight is that it's listed in
31:31
several places that there is a strong recommendation to not prescribe codeine
31:36
or tramadol in our patients anymore, either post-surgical,
31:43
when we're treating acute pain in patients who have obesity,
31:46
obstructive sleep apnea.
31:47
There's literally multiple things that say don't use codeine and tramadol,
31:51
don't use codeine and tramadol.
31:52
So if we get anything out of the presentation, hopefully we will stop prescribing
31:56
codeine and tramadol in our pediatric patients.
31:59
There are maybe a handful of AYA patients that I treat specifically with sickle
32:05
cell in a very specific, you know,
32:08
sort of shared decision-making process with them and having tried other pain
32:13
medicines where they may occasionally use some tramadol.
32:16
But again, that's a very different situation than, you know,
32:20
post-tonsillectomy, you know, general pain, those type of things.
32:25
So I'm going to hit a little bit on the medications. I don't want to spend too
32:28
much time on this because you guys can access this through any number of different formularies.
32:33
You can talk to your pharmacist, but just to kind of highlight,
32:37
you know, what are our non-opioid analgesics?
32:40
So, you know, our oral ones, our ibuprofen, naproxen sodium,
32:46
actually, you know, I forgot to add on here, Celecoxib or Celebrex is actually FDA approved for.
32:53
When it goes down to H2, but there is an FDA approval for naproxen and for celecoxib,
32:59
primarily related to our arthropathy and arthritis patients.
33:05
Naproxen does have a liquid formulation, but celecoxib doesn't.
33:09
Aspirin, we don't traditionally use as a analgesic in children.
33:13
It's more often we may see using it in our patients who have inflammatory diseases,
33:18
Kawasaki's, you know, maybe as antiplatelet agent and stroke patients and thing.
33:23
And then acetaminophen, you know, we have a lot of patients who use that.
33:27
We have to be careful though, because there's lots of combination drugs with acetaminophen in it.
33:31
And I know we have to really caution families to not mix too many different
33:35
medications to avoid acetaminophen toxicity.
33:39
And then we do have IV Toradol or Torilac, which is a nice medication to use
33:45
in our hospitalized patients.
33:47
There is an oral form, but it's a tablet and I tend to not like to use it and
33:52
save it for our hospitalized patient.
33:54
But 30 milligrams of Cotorlac is supposed to be comparable to six milligrams of morphine.
33:59
So it can be a profound analgesic in patients if there's not a contraindication.
34:04
So you're not supposed to use it in patients who have renal herpetic dysfunction,
34:08
anybody who has ulcers or patients who are on anticoagulants or have coagulopathies,
34:14
patients at risk of bleeding.
34:15
So there are some patients where it's not safe to use, But in patients,
34:18
it may be a good choice to try ahead of an opioid in a hospitalized patient
34:23
who's experiencing some pain
34:25
if they don't want to have the sedation and itching related to the opioid.
34:30
Then we have our opioid analgesics. So this list hasn't changed a whole lot.
34:35
We don't have like a bunch of new ones out there for us to use.
34:38
It's kind of the same suspects all the time. So we've already mentioned about
34:41
morphine and hydromorphone and fentanyl. So these are the ones that we most
34:46
commonly will think about using, you know, fentanyl.
34:49
We don't use too often as an analgesic.
34:51
We may use it in like the emergency room because there is an intranasal component.
34:56
And so they are looking at using it for more rapid pain relief,
35:00
at least acutely when a patient shows up in severe pain in the ER.
35:03
Typically in inpatient settings, we may be using the IV forms of morphine or hydromorphone.
35:09
Methadone is actually available IV or PO, though we traditionally use it orally.
35:13
It's a synthetic opioid, and it does have activity against both nociceptive
35:18
and neuropathic pain, so it can be very helpful in our chronic pain patients.
35:23
Demerol, I do include it on here because it still shows up at some points in
35:27
time. A lot of the dentists still like to use IM Demerol, so they're not paying
35:33
attention to the current guidelines for office sedation and things like that.
35:37
But in general, Demerol has been removed from all children's hospitals' formularies
35:41
because there's an increased risk of seizures, especially in patients with renal disorders.
35:47
And there can be abnormal metabolism, especially patients with liver issues,
35:52
patients who have seizure disorders who get Demerol, it lowers their seizure
35:55
threshold. So in general, it's not used as an analgesic.
35:59
We will use it occasionally to treat patients who have chills or shakes,
36:07
like I can remember using it in patients who are getting amphotericin and things
36:11
like that to help treat those symptoms.
36:14
And then we have some of our more common oral oxycodone with and without acetaminophen
36:18
and hydrocodone, which unfortunately is only combined with acetaminophen.
36:23
So most patients, and this also can be related to some of the insurance regulations,
36:27
start with hydrocodone.
36:28
And then if they fail that, maybe they can use oxycodone. The benefit between
36:33
the two is oxycodone does have faster onset.
36:35
It kicks in in about 10 minutes.
36:38
Hydrocodone takes about 30 minutes. So that's the main benefit,
36:41
I think, of the oxycodone is that it has quicker onset of action.
36:45
And then I mentioned I put codeine
36:47
here, but I'm reminding you it's not recommended for use in children.
36:51
Okay, and so then just I mentioned methadone. So there are some newer pain medicines
36:55
that are floating around out there.
36:57
If you're in the hospital setting, you may have some patients who are starting
37:01
to get low-dose ketamine, or there's a protocol in the ICU for certain patient
37:05
populations, and then we have one for our sickle cell patients.
37:09
And then again, methadone has an unpredictable half-life, but we do use it often
37:14
in our chronic pain patients, and palliative will often use it in some of our oncology patients.
37:21
So there's also non-classical pain medications. So these are things we don't
37:26
always think about as helping us treat pain, but they definitely do.
37:29
So we have for neuropathic pain, we have amitriptyline, gabapentin, pregabalin.
37:34
Again, this is one of those things not approved in children,
37:36
but we do sometimes use it in our older patients. So this may be good for things
37:41
like phantom limb pain, which I mentioned the classic example of neuropathic pain.
37:45
And then because pain is a total person, total body experience,
37:50
there's such a large emotional component to it as well.
37:53
Many SSRIs can be helpful in managing patients with severe pain syndromes.
37:59
So the fluoxetine, citalopran, and duloxetine are the three that are recommended
38:04
to use as an adjuvant for medical therapy in our patients with pain syndromes.
38:11
Okay, so I wanted to move on from pain syndromes to, or off of pharmacologic
38:18
syndromes to, what can we do?
38:21
These, we always think of this stuff second, and probably we should start thinking
38:25
of some of this stuff first or at the same time that we're thinking of the medications.
38:29
So many pain, especially our patients with chronic pain syndrome,
38:33
they really benefit from these other therapies.
38:37
So you need a multimodal approach. So physical and cognitive therapy using heat,
38:44
the TENS, the transcutaneous nerve stimulation.
38:48
Maybe they need a wheelchair so that they don't have to walk so far,
38:52
which provokes their pain.
38:53
Things like distraction, mindfulness, breathing,
38:57
integrative medicine, vitamins, breathing, yoga, acupuncture,
39:02
acupressure, massage, all of our therapies, physical and occupational therapy,
39:07
music and art therapy, child life, counseling and support groups.
39:10
There are so many different things that can be incorporated into treating pain
39:15
besides just using a medication.
39:18
These interventions are beneficial. We know that things like cognitive behavioral
39:23
therapy and biofeedback and relaxation and hypnosis.
39:28
Some studies have found that they reduce pain intensity for children when these
39:32
are employed, when people have chronic headaches and the benefits are sustainable.
39:36
They've been shown to improve pain and disability also for non-headache pain.
39:41
So it's been shown in patients with sickle cell disease, fibromyalgia,
39:45
recurrent abdominal pain, that these strategies can help reduce pain and improve
39:51
chance of return to normal activities.
39:54
This table you guys can refer to in the presentation.
39:58
This is an example of some development appropriate non-pharmologic pain strategies.
40:02
If you spend any time with our child life staff, you will notice how they use
40:08
many of these things when they're trying to help patients cope with behavior
40:12
or with interventions or procedures or things that are distressing and painful.
40:17
And so, you know, some involve touch and sensory, so music, massage,
40:22
some involve activities, believe it or not, blowing bubbles,
40:25
you know, all of those type of things.
40:27
And then imagery can be very helpful to help patients think about something
40:31
else besides what's happening to them.
40:34
All right. So now I'm going to touch base for a few minutes on some pain management
40:38
and special populations.
40:40
So for procedural pain, so examples, venipunctures, immunizations,
40:44
medication injections, there is a tool.
40:46
And again, you may have noticed the nursing staff and child life have these buzzy tools.
40:52
So what are they? They are vibration. You can also get these little cold wing
40:56
packs attached to them, but it's not necessary.
40:58
And so the cold and vibration distracts all the nerves around where the injection's being given.
41:05
And so you don't feel the injection anymore.
41:07
Studies have found it reduces pain up to 88% and it reduces needle fear.
41:11
I can tell you we have kids who specifically ask for this when they come into
41:15
clinic now, which is very nice because they're less fearful of injections and
41:20
less fearful of venipuctures.
41:22
Cold spray can also help. And then we have the topical M-LUN LMAX,
41:26
which can be used at sites where procedures may happen, such as menopunctures
41:30
or bone marrows, those type of things, which can be important.
41:35
Perioperative pain. So, you know, it's good to be aggressive initially because
41:42
pain is historically undertreated in pain.
41:44
But fortunately for us, you know, most surgical pain gets better in a few days.
41:49
So it doesn't have to, we're not looking at long-term pain meds.
41:52
You can use, again, the lidocrine, Imla cream before the surgical procedure
41:58
for IV starts to help relieve pain and related to that going into the procedure.
42:02
And then for postoperative pain, you know, a PCA is safe to use in children
42:06
over six years of age, and that may be a useful way to allow patients to have
42:11
control and take medicines when they're hurting the most.
42:14
And I'm going to hit a little bit on sickle cell patients. So for our sickle
42:18
cell patients, you know, they have acute and chronic pain, and we try to have
42:22
them have what's called a home pain action plan.
42:25
These are used across the country, and it basically has them escalate their
42:28
pain. It's the WHO pain ladder, but it's written like an asthma action plan.
42:32
For mild pain, they start ibuprofen, then they may start their,
42:36
depending upon how severe their pain is, they may start additional pain medicines,
42:40
and then it gives them instructions on what to do when their pain is really bad.
42:44
And so when a sickle cell patient presents to the ER, the recommendation is
42:48
that they are triaged to level 2 and that they should receive pain meds within 60 minutes of arrival.
42:53
The main issue is that we need to regard the patient or the caregiver as the expert on this disease.
42:58
And if they are in pain, we need to address their pain. We can assess them with a pain scale.
43:04
There are no laboratory or vital signs that will prove or disprove the present of their pain.
43:10
Hydration may be important, but boluses don't change the pain.
43:14
And what's more important than giving them fluids is getting them analgesia, which can be titrated.
43:20
If they've been using their home pain action plan, IV opioids are appropriate.
43:24
There's no reason to give them orals when they've already been taking orals at home.
43:27
But if they are occasionally a young kid who comes in for his first pain crisis
43:32
and he hasn't had any oral opioids, you could certainly try an oral dose and
43:35
see if that's sufficient.
43:37
Other supportive care while they're starting with these pain crises,
43:41
such as heat and massage, those type of things can be helpful.
43:45
And there is a recommendation for patients 12 and older to have individual ED
43:48
pain plans to help the ER manage these patients as they get more complex, as they get older.
43:54
In patient care, we do think most patients who need two to three doses of IV
44:00
opioids need to be admitted.
44:02
And then we continue to schedule IV pain meds while they're admitted.
44:07
Again, we have individualized pain plans for the patients who are 12 and older.
44:11
We always have to remember to include the supportive care because we've already
44:14
talked about all the side effects of opioids.
44:16
So they get constipated, so they need a bowel regimen. There's lots of itching.
44:19
So we have use of Narcan drips and other medicines to try to alleviate these side effects.
44:27
Frequently, there's not another option to treat the severe pain they're in,
44:30
and they do have to tolerate a certain amount of side effects,
44:33
unfortunately, with opioids.
44:36
One of the things that is often highlighted with our sickle cell patients is
44:40
that they are sort of the example used for their presence of implicit bias in pain management.
44:47
I posted up here this, are they going to believe me?
44:50
This is a common theme in discussions and support groups for patients with sickle
44:56
cell disease that they feel like they're going to the hospital,
45:00
they're not going to be believed. The data actually supports that.
45:05
Providers tend to overestimate risk of addiction for patients with sickle cell,
45:09
and then patients consistently report that they're misbelieved,
45:14
mistreated, and dismissed within the healthcare system.
45:16
There was a study that looked at sickle cell pain and femur fractures,
45:19
and the sickle cell patients waited 25% longer than the general patient sample,
45:24
and they waited 50% longer than patients who had femur fractures to get pain medications.
45:29
So there's clearly work that we need to do to treat these patients fairly and,
45:36
again, to believe them when they come in and tell us that they are in pain.
45:42
So chronic pain, this is a issue that I kind of talked about a little bit earlier.
45:50
It really needs multimodal interventions in order for us to address it.
45:54
Lots of gaps in things that we don't know.
45:57
Cancer pain, again, this needs to be individualized for the patient.
46:01
We often involve palliative care for our patients who have severe progressive
46:05
or relapsed or terminal disease.
46:07
We want to try to maximize their time at home, and so we use oral medications if we can.
46:16
And then depending upon the patient's other symptoms, we may need to use other
46:21
types of administration with IV.
46:24
Okay, so I'm going to talk a little bit about opioid crisis.
46:27
Pain contracts, a prescription monitoring for the end of our presentation.
46:32
So, you know, the opioid crisis has been in the news for more than 10 years now.
46:38
This has been a definite impact on children.
46:41
There's a risk of poisoning and overdose for them within their homes.
46:46
Opioid misuse in pregnancy, we could have a whole separate lecture on neonatal
46:49
abstinence syndrome that our NICU was having to deal with.
46:53
It has affected parenting and attachment, maternal deprivation,
46:57
and there may be extended separation from parents.
47:00
So when the adults in their lives have opioid addiction, it directly affects
47:04
our patients that we're taking care of.
47:07
But what does this mean when we're treating children with pain?
47:11
Despite the opioid crisis, we should not be ignoring their pain,
47:15
you know, but we should also think about using other tools that I talked about,
47:21
non-pharmacologic methods, in addition to pain medicines.
47:25
You know, We do need to be thoughtful about how many medications we prescribe
47:29
in terms of number of pills and how often we are giving refills.
47:34
We need to provide good education to the older patients and their parents.
47:39
And it's really important to use the fewest number of analgesics to control
47:42
pain so patients shouldn't be sent home on six different types of pain medicine.
47:47
That increases their risk of misuse.
47:50
In 2016, the CDC presented some guidelines for prescribing chronic opioids.
47:55
This was aimed at primary care physicians and for adults. There were no recommendations
48:01
in these guidelines for children and adolescents because they felt there was
48:05
no data or evidence that they could comment on.
48:08
So these guidelines are for adults.
48:11
And what was the effect of this? Well, unfortunately for our sickle cell patients,
48:15
because they were not included specifically as being separate,
48:19
they included cancer as a different group that didn't apply to these guidelines.
48:22
Our sickle cell patients, unfortunately, were swept up in the group,
48:27
and we found there were a couple groups that found that we had increased hospitalizations
48:31
and patients were receiving fewer pain medicines, which led to their increased
48:35
hospitalizations as a result of these guidelines in 2016.
48:40
So then in 2022, the CDC also said, oops, we made a mistake.
48:45
And they updated the guidelines and said, by the way, these guidelines don't
48:49
apply to sickle cell disease or cancer or patients receiving palliative or end-of-life care.
48:55
So that's still been, it's still taking time for that to trickle down that those
49:01
patients are excluded from some of those opioid prescribing recommendations.
49:05
So what is opioid use disorder? This is when a patient uses an opioid without
49:13
a prescription or differently than the prescription is written for.
49:16
Our adolescents are at risk for OUD.
49:19
It's reported that 1 in 315 youth experience opioid use disorder the following
49:26
year that they receive an opioid prescription. And where are they getting these opioids from?
49:31
About 39% from relatives, 26% from doctors, 12% are being bought.
49:37
Risk factors. So there's a 1.2 to 2 times risk with ADHD and trauma.
49:43
Patients, similar risk for chronic pain. Age and mood disorder has a 3 to 7 times risk.
49:50
And if you have a patient who has previously been diagnosed with a substance
49:53
use disorder, there's a 20 time risk. So these patients are especially vulnerable
49:57
when you're deciding to give them an opioid prescription.
50:00
The good news is that there's a declining overall prevalence of opioid use disorder.
50:06
In 2015, before those 2016 guidelines came out, they reported about 12.5 million.
50:14
This is people 12 and older, so lots of adults are included in this.
50:17
And most recently in 2019, it had fell to 9.7 million. So they do believe those
50:23
2016 guidelines are helping with the adults who were developing opioid use disorder.
50:31
It's estimated that about 3.6% of adolescents will misuse their prescription
50:35
opioids and post-dental visits.
50:38
So dental visits are the leading source of opioids for adolescents.
50:41
So it's when our patients go get their wisdom teeth removed,
50:44
major dental procedures that they get given an opioid, and that's often the
50:48
first place that they're exposed.
50:50
So what can the pediatrician do? You can provide adolescents and caregivers
50:54
with, you know, tailored information about the risk of developing addiction.
50:58
If you're going to prescribe pain medication, start with low doses and increase slowly.
51:03
Counsel patients and caregivers about safe storage and proper disposal of opioids.
51:08
You know, advise them about, you know, dental procedures and what type of pain
51:12
medicine you want from that, since that seems to be a key area where our teenagers
51:16
are exposed to the opioids.
51:18
So pain contracts, these are recommended for patients over the age of 18.
51:23
But I do use them in some of my chronic pain patients, especially in preparation
51:27
for transition to adult.
51:30
It typically includes opioid safety practices, so there may be a good reason
51:34
to use it any number of different patients.
51:36
You're not going to share your prescription. You're only going to take it as prescribed.
51:39
You're not going to ask for prescriptions from other providers.
51:41
You're going to use the same pharmacy, and you need to have clinic visits every
51:45
three months for regular prescriptions.
51:48
And then the last thing I was going to mention was this prescription monitoring database.
51:52
Any of us who have a DEA number and have ability to prescribe controlled substances
51:58
can look up any individual patient.
52:01
And there is a requirement if you prescribe controlled substances to check this
52:05
database in order to see if your patient's getting medicine from other places
52:11
or when their last prescription was filled.
52:13
And it can be useful for our patients who have chronic pain syndromes.
52:18
Again, it's supposed to remind you to limit the number of days of medication
52:23
for acute pain patients.
52:25
Again, not counting chronic pain, cancer, hospice, palliative care,
52:29
and sickle cell patients.
52:32
In the EPIC system, if you prescribe an opioid, this window will pop up.
52:37
Depending upon the age of patient, there may be some other things that pop up, but it's very easy.
52:41
You just click on the review PDMP, and then it will open up the patients.
52:47
This is a little example of what it looks like for a particular patient.
52:51
It'll talk about their overdose score. It'll talk about how much medicines,
52:56
when they've been getting medicines.
52:56
It'll show you the pharmacies where they've been getting their medication.
53:00
And then you can just click that you've reviewed it and you've met any requirements
53:04
for checking the prescription database monitoring program.
53:08
But again, it's easy to do through Epic.
53:11
All right. So in conclusion, the person experiencing the pain is the expert about their pain.
53:18
Pain in children is often undertreated, which can lead to increased anxiety.
53:22
Opioids are important tools in treating pain in children and can be safely prescribed.
53:27
Prescription opioid misuse is declining, but our adolescents are at at-risk populations.
53:32
And safe opioid prescribing practices in adults include prescription database
53:36
review and opioid contracts.
53:38
These tools, although not required, are useful in treating adolescents.
53:41
With chronic pain. So I realize this was a whirlwind of information.
53:46
There are lectures, the AAP has information on any of these specific topics
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as full separate lectures.
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If anyone wants to explore more about integrative medicine or non-pharmacologic
54:00
pain management strategies, then I have some references.
54:05
Thank you, Dr. Fajan, for educating us on management of pain in children.
54:10
There are quite a few questions in the chat box. I'll read the first one.
54:14
Can you comment on IV acetaminophen in pediatrics?
54:20
Yes. So acetaminophen is an analgesic that is available as an oral rectal IV.
54:29
It seems to be a very potent analgesic. Most of the data on IV Tylenol is in a surgical setting.
54:36
So there's some data about giving IV acetaminophen before a surgical procedure
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decreases the amount of opioids needed after the surgical procedure.
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And so I think it is a useful analgesic to use in, again, operative settings,
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hospitalized settings, obviously not something you have access to in the outpatient world.
54:55
I know we have run into some issues with some shortages of it in the hospital.
55:00
So there have been some limitations on how much we can dose it or how frequently we can dose it.
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Typically, we've had some instances we can give a few doses,
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but we can't keep giving it for multiple days.
55:11
Okay, the second question, for our patients with more chronic pain syndrome,
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the normal pain scales are sometimes counterproductive, hard to use,
55:20
distraction when they are constantly being asked to assess their pain.
55:23
I know we have discussed functional pain scale.
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I have found it difficult for our nursing staff to get on board with this because
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they are required to document number of pains in EPIC.
55:32
Any thoughts about this process and how we can work with our other staff to
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move forward more helpful assessment tools for certain patients?
55:42
Yeah, I think that's a great question.
55:45
I know it's been a couple of years ago that the UHS updated some of their like
55:50
opioid and pain medicine prescribing for the adults because I was on that committee
55:55
and I know they added functional pain scales for the adults and they're supposed
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to be, I don't know if the adult side is doing both,
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but we kind of run into this, you know,
56:07
it's competing demands because we're.
56:12
Like we just had our JCO visit and they checked the nurses to see if they were
56:16
documenting pain scores, if they were responding to pain scores.
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And so there's these administrative people who are going to come and check to
56:23
make sure that they were still documenting the numbers. And we can't get away
56:26
from that because that's not in our control.
56:28
But I wonder if we can engage to try to decide if we can update some of the
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pediatric nursing policy to have both documented in certain patients.
56:38
That might be something we can talk to the nursing leadership about.
56:42
I can, I don't remember who led the adult policy, but the updated adult policy
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has functional pain scales in it as preferred.
56:51
Next question is, can you talk about non-opioid options for gastrointestinal pain?
56:56
Oh goodness. So I am probably not going to be able to speak very much on that.
57:01
That might be more for our GI doctors who treat our irritable bowel syndrome.
57:05
I mean, I know that there are newer medications.
57:10
One of them, Bental, there's a couple that I've seen.
57:13
It's not something that I have as much experience with, but maybe one of our
57:17
GI colleagues could provide some insight on that.
57:21
Next question, should we pre-medicate with acetaminophen for routine vaccines?
57:28
And secondly, what is your thoughts on using both alternating acetaminophen
57:33
and ibuprofen for febrile illnesses?
57:35
Oh, those are great questions. So, you know,
57:38
I think there's been some data out there questioning pre-vaccine analgesia and
57:47
response to vaccines and altered immune response to vaccines.
57:51
And I mean, I think...
57:54
I think probably you could use other tools for your vaccine,
57:59
like get a buzzy, you know, use some things.
58:02
Because the reason you're giving the Tylenol beforehand is because you have
58:05
a fear of the needle pain, the injection pain, the infusion pain.
58:09
That's what you're using the acetaminophen for frequently is the pain associated with the vaccines.
58:14
So maybe you could explore non-pharmacologic ways to treat or address injection pain at the time,
58:20
and then only add acetaminophen or ibuprofen after the vaccine's given if the
58:25
patient develops a symptom like a fever or, you know, increased pain and swelling.
58:30
Because I find that it's typically parents are using it because they're more
58:33
worried about the pain the child is going to experience from the injection itself.
58:37
So maybe you could use a non-pharmacologic.
58:39
And then, you know, scheduling acetaminophen and ibuprofen for fever.
58:44
I mean, I think we tell patients to do that.
58:47
My husband's an ID doctor. So he's like, fever's good.
58:51
Fever's your immune system, fighting your infection. Why are we so afraid of fever?
58:54
So, you know, there's that, there's that, there's that, that disconnect because
58:58
our parents are very fearful of fever and they're afraid whether all of their
59:02
fever was 102, you know, versus 99.
59:04
And just, you know, they can, there's a lot of emotion and fever for our parents
59:08
sometimes. And so, I mean, I don't think there's been no data suggests that that's harmful.
59:13
You know, we also have the parents who say Tylenol never works,
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ibuprofen is anything that lowers our fever.
59:18
Certainly if you have a very anxious and distressed patient,
59:22
that may be very appropriate to give them something to do so they feel like
59:25
they're doing something to help their child feel better and to lower their fever
59:29
curve potentially so that they feel less distressed and caring for the child.
59:34
Thank you so much for listening to that fascinating talk. Don't forget to click
59:39
on the link in this podcast for free credit.
59:42
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59:49
Please email me with questions or episode ideas.
59:53
Music.
59:53
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We get some answers from a pediatric psychiatrist. That's coming up next week.
1:00:18
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1:00:43
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1:00:45
I'm Holly Wehment, and I'll see you soon.