Learning Objectives. From Myth to Multimodal Analgesia: Treating Pain in Children

Transcription

1 Pain Workshop / Manejo del dolor en niños con traducción (English and Spanish / Inglés y Españo) Stefan Friedrichsdorf (USA); Ross Drake (New Zealand); Alison Twycross (UK); Mercedes Bernada (Uruguay) From Myth to Multimodal Analgesia: Treating Pain in Children Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota, Minneapolis/St. Paul, MN Associate Professor of Pediatrics, University of Minnesota Medical School stefan.friedrichsdorf@childrensmn.org Learning Objectives Evaluate assumptions about opioid use in children [ Attitude ] Discuss how multiple agents, interventions, rehabilitation, psychological & integrative therapies act synergistically for more effective pediatric pain control with fewer side effects than a single analgesic or modality - and improves patient experience [ Knowledge ] Practice morphine prescription in case example [ Skill ]

2 So, how do we treat the individual pain patient in front of us? Hmhh... Spoiler Alert: Crystal-clear answer on 3rd last slide! Pediatric Pain - Status Quo Under treatment of pain in children Parents expect pain to be relieved Forgeron PA, Finley GA, Arnaout M. Pediatric pain prevalence and parents' attitudes at a cancer hospital in Jordan. J Pain Symptom Manage. 2006; 31(5): Priorities of parents of hospitalized children "Taking care of pain" rated as second highest priority (1st: getting right diagnosis) Ammentorp J, Mainz J, Sabroe S. Parents priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med 2005;159: Parents greatest distress: failing to protect their child from pain Tiedeman, M. (1997). Anxiety responses of parents during and after the hospitalisation of their 5 - to -11 year old children. Journal of Pediatric Nursing, 12(2), Melnyk BM. Intervention studies involving parents of hospitalized young children: an analysis of the past and future recommendations. J Pediatr Nurs Feb;15(1):4-13. Assumption: everything possible is done Anand s neonatal surgery studies Pediatric Pain - Status Quo USA: adults receive more than two - three times as many analgesic doses as children (with identical diagnoses) (1) Eland JM, Anderson JE: The experience of pain in children. In: Jacox A (ed). Pain: a source book for nurses and other health care professionals. Boston: Little Brown & C0; 1977: (2) Beyer JE, DeGood DE, Ashley LC, Russell GA. Patterns of postoperative analgesic use with adults and children following cardiac surgery. Pain Sep;17(1): (3) Schechter NL, Allen DA, Hanson K. Status of pediatric pain control: a comparison of hospital analgesic usage in children and adults. Pediatrics Jan;77(1):11-5. The younger children are, the less likely they receive appropriate analgesia Broome ME, Richtsmeier A, Maikler V, Alexander M. Pediatric pain practices: a national survey of health professionals. J Pain Symptom Manage May;11(5): ; Nikanne E, Kokki H, Tuovinen K. Postoperative pain after adenoidectomy in children. Br J Anaesth Jun;82(6): Compared to adults, pediatric patients receive fewer and/or incorrectly dosed analgesics in daily routine Ellis, J. A., O Connor, B. V., Cappelli, M., Goodman, J., Blouin, R., & Reid, C. W. (2002). Pain in hospitalized pediatric patients: How are we doing? Clinical Journal of Pain, 18,

3 Inappropriate Analgesia: Why Bother...? Children with persistent pain suffer more physical symptoms in adult life, more anxiety and more depression 1946 Medical Research Council and 1958 National Child Development Study Inadequate analgesia for initial procedures in children diminishes effect of adequate analgesia in subsequent procedures Weisman SJ, Bernstein B, Schechter NL: Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med :147-9 NICU: increased morbidity & mortality Anand KJ, Barton BA, McIntosh N, Lagercrantz H, Pelausa E, Young TE, et al. Analgesia and sedation in preterm neonates who require ventilatory support: results from the NOPAIN trial. Neonatal Outcome and Prolonged Analgesia in Neonates. Arch Pediatr Adolesc Med Apr;153(4):331-8 Higher morphine doses = less PTSD in months after major trauma Stoddard FJ, Jr., Sorrentino EA, Ceranoglu TA, Saxe G, Murphy JM, Drake JE, et al. Preliminary evidence for the effects of morphine on posttraumatic stress disorder symptoms in one- to four-year-olds with burns. J Burn Care Res Sep-Oct;30(5): Up to 25% of adults have fear of needles with most fears developing in childhood: avoidance of health care (including nonadherence with vaccination schedules Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management duringchildhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S ) Myths and Barriers to Using Opioids Case Scenario: You are taking care of a child in a hospital with severe acute somatic nociceptive pain. It crosses your mind to administer a strong opioid such as morphine, fentanyl, or hydromorphone. What would be the most common concerns you might hear from your colleagues or parents arguing against opioid use in this child? Common Opioid Assumptions Addiction chronic relapsing condition characterized by persistent, compulsive dependence on a behavior or substance despite adverse consequences Tolerance addiction Pseudo-addiction Over Sedation / Respiratory Depression Ileus / Constipation Medication Too strong Masking symptoms Abdominal Pain Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of patients with abdominal pain? JAMA 2006: 296: Opioids after major cranial surgery in children do NOT result in altered mental status nor respiratory depression Maxwell LG. PAIN MANAGEMENT FOLLOWING MAJOR INTRACRANIAL SURGERY IN PEDIATRIC PATIENTS: A PROSPECTIVE COHORT STUDY IN THREE ACADEMIC CHILDREN S HOSPITALS Pediatric Critical Care Medicine: May Volume 15 - Issue 4_suppl - p 77. Abstracts of the 7th World Congress on Pediatric Critical Care As always... Think first!(e.g. compartment syndrome?)... analgesia second...

4 How Do We Manage Acute Pain in Children? WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses (2012) Data suggests that applying the World Health Organization (WHO) principles of pain management result in good pain relief for a large majority of children with cancer. In addition there is emerging evidence, that these principles are equally effective in acute pediatric pain management for non-malignant conditions Available online at: whqlibdoc.who.int/publications/ 2012/ _Guidelines.pdf WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses (2012) Dosing at regular intervals ( By the Clock ) Adapting treatment to the individual child ( With the Child ) Using the appropriate route of administration ( By the appropriate route) Using a two-step strategy ( By the Analgesic Ladder )

5 WHO Principle 1: Dosing at Regular Intervals PRN (pro re data = as needed ) PRN = Patient Receives Nothing When pain is constantly present, analgesics should be administered, while monitoring side-effects, at regular intervals By the clock and NOT as an as needed (or pro re nata PRN ) basis Regular scheduling ensures a steady blood level, reducing the peaks and troughs of PRN ( as needed ) dosing PRN (as needed) only: May take several hours & higher opioid doses to relieve pain Results in cycle of undermedication and pain, alternating with periods of overmedication and drug toxicity American Pain Society: Principles of Analgesic Use in the Treatment of Acute Pain and Cancer Pain WHO Principle 2: Adapting Treatment to the Individual Child Treatment should be tailored to the individual child and opioid analgesics should be titrated on an individual basis At analgesic dosing: no sedation expected The effective dose is what relieves the pain Different children may respond differently to same dose Effective dose must be adjusted to child s needs Dose of strong opioids: only the sky is the limit Assess response frequently Pain Scales Look for opioid-induced side effects and toxicity Regular (!) Pain Assessment One-dimensional selfreport scores Multi-dimensional rating scores

6 What are we measuring...? (1) Nociceptive Pain: arises from the activation of peripheral nerve endings (nociceptors) that respond to noxious stimulation Somatic (for example, muscles, joints) Chronic somatic pain typically well localized & often results from degenerative processes (such as arthritis) Visceral (internal organs) (2) Neuropathic Pain: resulting from injury to, or dysfunction of, the somatosensory system. Central pain: caused by a lesion or disease of the central somatosensory nervous system (3) Psycho-social-spiritualemotional Pain / Total Pain (4) Chronic Pain Pain beyond expected time of healing Pain in children with impaired communication Non-communicating Children s Pain Checklist - Revised (NCCPC-R); postoperative Version (NCCPC-PV) Breau LM, McGrath PJ, Camfield CS, Finley GA. Psychometric properties of the non-communicating children's pain checklist-revised. Pain 2002;99(1-2): Pediatric Pain Profile (PPP) Hunt A, Goldman A, Seers K, Crichton N, Mastroyannopoulou K, Moffat V, Oulton K, Brady M. Clinical validation of the paediatric pain profile. Dev Med Child Neurol 2004;46(1):9-18. r-flacc Malviya S, Voepel-Lewis T, Burke C, Merkel S, Tait AR. The revised FLACC observational pain tool: improved reliability and validity for pain assessment in children with cognitive impairment. Paediatr Anaesth 2006;16(3): WHO Principle 3: Route of Administration i.v. / s.c. nebulization? i.m. Analgesic Medications oral intranasal (MAD device) sublingual transmucosal transdermal suppository

7 WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses (2012) Dosing at regular intervals ( By the Clock ) Adapting treatment to the individual child ( With the Child ) Using the appropriate route of administration ( By the appropriate route) Using a two-step strategy ( By the Analgesic Ladder ) WHO Principle 4: Using a Two-Step Strategy WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses (2012) WHO Step 1 Mild Pain Ibuprofen and/or Acetaminophen (Paracetamol) Other NSAIDs? Cox-2 Inhibitor? Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus 2nd Neuron Aδ or C fiber Acetaminophen (Paracetamol) Injury NSAIDs

8 Citius, Altius, Fortius...? Ibuprofen salts: fast-acting formulations Moore, R.A., et al., Faster, higher, stronger? Evidence for formulation and efficacy for ibuprofen in acute pain. Pain, (1): p e.g. Advil Film-Coated Tablets: 266 mg ibuprofen sodium (= 200 mg of standard ibuprofen) Produced significantly better analgesia over 6h, fewer remedications than standard formulations 200-mg fast-acting ibuprofen (NNT 2.1; 95% confidence interval ) was as effective as 400 mg standard ibuprofen (NNT 2.4; 95% CI ), with faster onset of analgesia. More rapid absorption, faster initial pain reduction, good overall analgesia in more patients at the same dose, and probably longerlasting analgesia, but with no higher rate of patients reporting adverse events. However, earlier onset preferred in other pain condition, such as chronic nociceptive or neuropathic pain? Peloso, P.M., Faster, higher, stronger: to the gold medal podium? Pain, (1): p WHO Principle 1: Using a Two-Step Strategy WHO Step 1 Mild Pain WHO Step 2 Moderate to Severe Pain Morphine Ibuprofen and/or Acetaminophen (Paracetamol) Other NSAIDs? Cox-2 Inhibitor? or fentanyl, hydromorphone, oxycodone, methadone Multimodal (Opioid-sparing) Analgesia Non-Opioids Acetaminophen / Paracetamol NSAIDs Integrative Therapies Such as: Massage Distraction Deep Breathing Biofeedback Aromatherapy Hypnosis Opioids Tramadol ( weak ) Morphine ( strong ) 4 WHO- Principles By the clock

9 Integrative Pain Management State of the art pain management in the 21st century demands that pharmacological management must be combined with supportive and integrative, nonpharmacological therapies to manage a child's pain. Physical methods (e.g. cuddle/hug, massage, comfort positioning, heat, cold, TENS) Cognitive behavioral techniques (e.g. guided imagery, hypnosis, abdominal breathing, distraction, biofeedback) Acupuncture, acupressure, aromatherapy Integrative Pain & Symptom Management A Pediatrician s Top 10 Apps for Distraction & Pain Management NoNeedlessPain.org Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus Periaqueductal grey (endorphins) Integrative (non-pharmacological) therapies Descending Inhibition + 2nd Neuron Descending pathways that modulate transmission of nociceptive signals originate in periaqueductal gray, locus coeruleus, anterior cingulate gyrus, amygdala & hypothalamus: are relayed through brainstem nuclei in the PEG and medulla to spinal cord. Inhibitory transmitters involved in these pathways incl. norepinephrine, 5-hydroxytryptamine, dopamine, & endogenous opioids. Aδ or C fiber Opioids Acetaminophen (Paracetamol) Injury NSAIDs

10 How does this stuff work...? The periaqueductal gray and descending pain modulation: Hemington KS, Coulombe MA. The periaqueductal gray and descending pain modulation: Why should we study them and what role do they play in chronic pain? Journal of neurophysiology. Feb :jn Distraction significantly increased activation of cingulo-frontal cortex including orbitofrontal & perigenual anterior cingulate cortex (ACC), as well as periaquaeductal gray (PAG) & the posterior thalamus. Active distraction techniques, such as imagery, appear to modulate endorphine release in the midbrain, including the periaqueductal grey and thereby increase activity of descending inhibiting pathways thereby decreasing nociception from the dorsal horn resulting in gate pain modulation during distraction. Valet M, Sprenger T, Boecker H, et al. Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain--an fmri analysis. Pain. Jun 2004;109(3): ; Tracey I, Ploghaus A, Gati JS, et al. Imaging attentional modulation of pain in the periaqueductal gray in humans. The Journal of neuroscience : the official journal of the Society for Neuroscience. Apr ;22(7): ; Derbyshire SW, Osborn J. Modeling pain circuits: how imaging may modify perception. Neuroimaging clinics of North America. Nov 2007;17(4): , ix.; Bingel U, Wanigasekera V, Wiech K, et al. The effect of treatment expectation on drug efficacy: imaging the analgesic benefit of the opioid remifentanil. Sci Transl Med. Feb ;3(70):70ra14 Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus CORTEX: -Stress - Anxiety - Catastrophizing - Depression - perceived injustice - disturbed Sleep OFF 2nd Neuron Periaqueductal grey (endorphins) Integrative (non-pharmacological) therapies ON Opioids Acetaminophen (Paracetamol) Aδ or C fiber Injury NSAIDs Multimodal (Opioid-sparing) Analgesia Non-Opioids Acetaminophen / Paracetamol NSAIDs Integrative Therapies Such as: Massage Distraction Deep Breathing Biofeedback Aromatherapy Hypnosis Opioids Tramadol ( weak ) Morphine ( strong ) 4 WHO- Principles By the clock Rehabilitation Exercise Physical Therapy Sleep Hygiene Occupational Therapy Speech Therapy Psychology CBT Regional Anesthesia Neuraxial infusion Peripheral/Plexus Nerve block Neurolytic block Intrathecal port/pump Intraventricular opioids? Percutaneous cervical cordotomy?

11 Regional anesthesia approaches to pain management in PC Regional anesthesia: pediatric knowledge limited to case reports and case series: Rork, J.F., C.B. Berde, and R.D. Goldstein, Regional anesthesia approaches to pain management in pediatric palliative care: a review of current knowledge. J Pain Symptom Manage, (6): p Neurolytic Sympathectomy: Amr YM, Makharita MY. Neurolytic sympathectomy in the management of cancer pain-time effect: a prospective, randomized multicenter study. J Pain Symptom Manage. Nov 2014;48(5): e942. central neuraxial infusions peripheral nerve and plexus blocks or infusions neurolytic blocks implanted intrathecal ports & pumps for baclofen, opioids, local anesthetics, and other adjuvants RCT (n=109) inoperable abdominal or pelvic cancer: better pain control, less opioid consumption, and better quality of life Multimodal (Opioid-sparing) Analgesia Friedrichsdorf S: 8th Annual Pediatric Pain Master Class, Minneapolis, MN, June 20-26, 2015 Non-Opioids Acetaminophen / Paracetamol NSAIDs Integrative Therapies Such as: Massage Distraction Deep Breathing Biofeedback Aromatherapy Hypnosis Opioids Such as: Tramadol ( weak ) Morphine ( strong ) 4 WHO- Principles By the clock Psychology CBT Rehabilitation Exercise Physical Therapy Sleep Hygiene Occupational Therapy Child Life Regional Anesthesia Neuraxial infusion Peripheral/Plexus Nerve block Neurolytic block Intrathecal port/pump Intraventricular opioids? Percutaneous cervical cordotomy? Adjuvants Such as: Alpha-Agonist Gabapentinoids TCA/Antidepressants NMDA-Antagonists Na-channel blockers Antispasmodics Benzodiazepines Corticosteroids Muscle relaxants Radiopharmaceuticals Bisphosphonates Multimodal Analgesia No Needless Pain

12 So, how do we treat the individual pain patient in front of us? Crystal clear answer: Σωκράτη Sōkrátēs; 470/ BC Small Group work, please Case Example 1: Andrea 10-year-old girl in severe acute (!) pain (e.g. metastasized osteosarcoma, sickle cell crisis); weight: 20 kg PCA pump currently not available Choice of opioid? Immediate release morphine...unless...

13 Case Example Morphine Route of administration? Per kg dosing: Maximum 50 kg (!) Lean weight for obese children Please write the order (small group work) Case Example Morphine (Immediate Release) Scheduled (round-the-clock) dose IV: 0.1 mg x 20 kg = 2 mg Q4h (= 12 mg/day) PO: 0.3 mg x 20 kg = 6 mg Q4h (= 36 mg/day) Breakthrough (rescue) dose = 1/10-1/6 of daily dose (Q1-2h) IV: (1.2-2 mg) 1.2 mg Q1h PRN PO: (3.6-6 mg) 3.6 mg Q1h PRN if pain score >...?.../10 and no signs of over sedation Case Example Morphine 0300 hrs: Pain Score 10/10 -> 2 mg IV [or 6 mg PO] 0400 hrs: Pain Score 8/10) -> 1.2 mg IV [or 3.6 mg PO] 0500 hrs: Pain Score 7/10 -> 1.2 mg IV [or 3.6 mg PO] 0600 hrs: Pain Score 6/10 -> 1.2 mg IV [or 3.6 mg PO] 0700 hrs: Pain Score 5/10...??? Do I need to increase the dose? Crystal clear answer:...it depends...!

14 Opioid Dose Escalation for Acute (!) Pain How to increase the dose? 50 per cent rule!...however, depends on clinical scenario... 2 mg IV Q4h -> 3 mg IV Q4h 1.2 mg IV Q1 (-2)h PRN -> 1.8 mg IV Q1 (-2)h PRN or...add breakthrough dose to regular dose...? [not initial hours] Case Example 2: Sean 10-year-old boy in severe acute (!) pain (e.g. metastasized osteosarcoma, sickle cell crisis); weight: 20 kg PCA pump now available Question: PCA bolus only or continuous infusion plus PCA bolus? Meta-Analysis: Addition of continuous (or background) infusion to the demand (or PCA bolus) dose for IV-PCA is NOT associated with a higher incidence of respiratory events than PCA bolus alone in pediatric patients (in contrast to adults). George JA, Lin EE, Hanna MN, Murphy JD, Kumar K, Ko PS, et al. The effect of intravenous opioid patient-controlled analgesia with and without background infusion on respiratory depression: a meta-analysis. J Opioid Manag Jan-Feb;6(1): PCA with a CADD can be used to manage pain in the home setting. Dose adjustments and opioid switches were performed with no adverse incidents. Mherekumombe MF, Collins JJ. Patient-controlled analgesia for children at home. J Pain Symptom Manage. May 2015;49(5): PCA-Pumps in Infants, Children and Teenagers WHO Principle 1: Dosing at Regular Intervals Rule of thumb: Management of acute medium-severe (!) pain in children with PCA pumps: USUALLY start continuous infusion PLUS on-demand PCA bolus. However, PCA only: Part of multimodal postoperative analgesia (e.g. nerve block, scheduled acetaminophen / NSAIDs, dexmedetomidine etc...) Incidence pain only Weaning opioid / rotating to oral administration Unclear pain pathophysiology... Other...?

15 Please write PCA Order Morphine (and Plan B: Fentanyl and Plan C: Hydromorphone) Patient (or nurse-) controlled analgesia: PCA (1) Continuous Infusion (2) PCA- Dose (3) Lock-Out Time (4) Maximum number of boluses per hour Continuous Infusion / PCA Dose (1) Background (continuous) infusion i.v./s.c.: Morphine: mcg x 20 kg = mg/hr Fentanyl: mcg x 20 kg = mcg/hr Hydromorphone: 2-5 mcg x 20 kg = mcg (2) PCA- Dose Same as above / hourly dose (e.g 0.4 mg morphine) Unless there is a good reason not to... PCA Order Set (3) Lockout time: (5) - 10 minutes (4) Maximum number of boluses per hour: 4 (-6)...however, depends on the clinical scenario Loading dose?...depends... (hourly dose x ) Lower starting dose?...depends...age... if multimodal analgesia... How to increase the dose? 50 per cent rule

16 Finally Andrea & Sean would like to thank you for your excellent pain management Example for 50% titration orders: Patient (or nurse-) controlled analgesia: PCA Background infusion i.v./s.c.: 0.4 mg/hr Bolus i.v./s.c.: 0.4 mg (max 6 per hour); Lockout time: 5 (-10) minutes Example for 50% titration orders: ÆIf receiving > boluses/hour for > consecutive hours AND if unrelieved pain AND no over sedation or dose limiting side effects, increase PCA by 50% as follows: Æ Step 1: Continuous infusion 0.6 mg/hr, PCA dose 0.6 mg, max. 6 boluses/hr Æ Step 2: (if á again) Continuous infusion 0.9 mg/hr, PCA dose 0.9 mg, max. 6 boluses/hr Æ Step 3: (if á again) Continuous infusion 1.35 mg/hr, PCA dose 1.35 mg, max. 6 boluses/hr Conclusions Withholding evidence-based analgesia from hospitalized children in pain suffering from serious hematologic/oncologic diseases not only unethical, but causes immediate and long-term harm Potential risks in safety of analgesics are real, but manageable; cannot justify denying administration of pain medications to pediatric patients Opioids (outside end-of-life) usually short term only - contraindicated for chronic pain Use multimodal (opioid-sparing) analgesia: Multiple agents, interventions, rehabilitation, psychological and integrative therapies act synergistically for more effective pediatric pain control with fewer side effects than single analgesic or modality

17 With profound gratitude to our interdisciplinary Pain, Palliative & Integrative Medicine team Physician Kris Catrine, MD Kaci Osenga, MD Kathleen Farah, MD Stefan Friedrichsdorf, MD Matt Armfield, MD, Pain Fellow Meghan Young, MD, Palliative Care Fellow Nurse Practitioner Barb Symalla, RN, CNS Nancy Jaworski, RN, CNS Kathy Popp, RN, CNS Sarah Thu, RN, CNS Anna Hoffman, RN, CNS Maura Fitzgerald, RN, CNP Jennifer Worley, RN, CNS Psychology Kavita Desai, PhD Jade Raffety, PhD Jennifer Waters, PhD Physical Therapy Andrew Warmuth, DPT Eva Frank, PT Research / Quality Improvement / Lean Andrea Postier Donna Eull, RN Christian Weidner, BS Lexie Goertzen Laurie Foster Jule Yang Palliative Nursing Sarah Hasse, RN Michael McLoone Social Work Martha Schermer, LiCSW Cyndee Daughtree Jessica Convey Chaplain: Hal Weiden Child Life: Margaret Monsoon Music Therapy: Mark Burnet Clinic nurse: Blanche Amar Massage Candace Linaris Jill Maltrud Laura Beck Admin Assistants Katie McQuire Cheryl Puumala Clinic staff Brock Hebert Allison McQuade Manager Tracey Crocoll Liz Leighton, RN Further Links The New York Times (Dec 16, 2015) essay by Dr. Stefan Friedrichsdorf When a Baby Dies opinionator.blogs.nytimes.com/2015/12/16/when-a-baby-dies/?_r=1 Video: Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic Tour Children s Comfort Promise: Doing everything possible to treat and prevent pain. Eliminating Needle Pain in children (Feb 2015) Staff video: Short Movie: Meet the Interdisciplinary Chronic Pain Clinic Team at Children s Minnesota: LittleStars TV Video: Tour of the Kiran Stordalen and Horst Rechelbacher Pediatric Pain, Palliative and Integrative Medicine Clinic at Children's Hospitals and Clinics of Minnesota and an overview of the three programs that are offered at Children's under this clinic. Short Movie: LittleStarsFilm 'Kali's Story - Beyond the NICU': This amazing pediatric palliative care short movie (7 min) features 8-year-old Kali's journey at Children's Hospitals and Clinics of Minnesota from NICU to today, receiving care by the Pain & Palliative & Integrative Medicine program while inpatient, in the clinic, and at home (Jan 22, 2015) Further Training: CIPPC@ChildrensMN.org 10th Annual Pediatric Pain Master Class Minneapolis, Minnesota, USA June 17-23, 2017 Education in Palliative & End-of-life Care [EPEC]: Become an EPEC-Pediatrics Trainer Montréal, Québec, Canada April 29-30, 2017 (Professional Development Workshop: 04/28/17) Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Associate Professor of Pediatrics, University of Minnesota Medical School Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S Minneapolis, MN USA phone fax stefan.friedrichsdorf@childrensmn.org Blog: