It s Just a Poke, Right? Procedural Pain Management in Pediatrics. Learning Objectives. Procedural Pain in Children

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1 It s Just a Poke, Right? Procedural Pain Management in Pediatrics 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 Learning Objectives Appreciate incidence of procedural pain in children Review the evidence for importance of managing procedural pain Describe importance of the non-negotiable components of state-of-the Art procedural pain management: topical anesthesia, positioning, and distraction (& sucrose if <12 months) Procedural Pain in Children What argument might colleagues voice against procedural pain strategies (such as topical anesthesia, positioning, integrative modalities such as bubble blowing) for all children?

2 Procedural Pain: A call for action What are children most afraid of coming to our clinical service? Needle procedures (incl. vaccine injections) performed in childhood are a substantial source of distress It is estimated that up to 25% of adults have a fear of needles Guideline statement: management of procedure-related pain in children and adolescents.j Paediatr Child Health 2006;42(Suppl 1):S1-29. with most fears developing in childhood Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;41: with most fears developing in childhood Hamilton JG. Needle phobia: a neglected diagnosis. J Fam Pract 1995;41: Pain Controlled ( ) Pain outcomes in a US children s hospital: a prospective cross-sectional survey In past 24 hrs, what was cause of worst pain? 40% Needle poke 34% Trauma/injury/other medical 10 % Surgery 8% Procedure 4% Acute illness/infection 3% Treatment for known disease Friedrichsdorf SJ, Postier AC, Eull D, Foster L, Weidner C, Campbell F: Pain outcomes in a US children s hospital: a prospective cross-sectional survey (submitted: Hospital Medicine)

3 Procedural Pain: A call for action Untreated pain can have long-term consequences including preprocedural anxiety hyperalgesia needle fears 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 ) Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E Procedural Pain: A call for action Procedural Pain in the Neonate Critically ill infant may experience >480 painful procedures during NICU stay Barker DP (1995) Arch Dis Child Fetal Neonatal Ed 72:F47-8; Johnston CC (1997) Clin J Pain 13: Exposure to severe pain on NICU, without adequate treatment, has negative long-term consequences á morbity (hypoxia, coagulopathy, respiratory inccordination, increased intracranial pressure) á risk of IVH á mortality Anand KJS (1999) Arch Pediatr Adolesc Med 153:331-8 Procedural pain: A call for action Pain ratings at 4-6 months routine vaccination higher for circumcised versus uncircumcised boys Taddio A (1994) Lancet, 344:291-2 Preterm infants: Poorer cognition and motor function associated with higher number of skin-breaking procedures Grunau RE, Whitfield MF, Petrie-Thomas J, Synnes AR, Cepeda IL, Keidar A, et al. Neonatal pain, parenting stress and interaction, in relation to cognitive and motor development at 8 and 18 months in preterm infants. Pain May;143(1-2): 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): 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. Memory of previous painful experience has great influence on pain experience during subsequent procedures Versloot J, Veerkamp JSJ, Hoogstraten J: Children s self-reported pain at the dentist. Pain :389-94

4 Procedural pain: A call for action Inadequate analgesia for initial procedures in young children (8 years or younger) diminishes the 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 Children (5-10 yrs) perceive their parents as worried, when they reassure (e.g. it s okay ) - whereas distraction is associated with increased child coping McMurtry CM, Chambers CT, McGrath PJ, Asp E. When "don't worry" communicates fear: Children's perceptions of parental reassurance and distraction during a painful medical procedure. Pain Jul;150(1):52-8. Systematic review: Cross-cultural comparison - Pediatric medical procedures children belonging to cultural minority and in need of health care are a vulnerable population Kristjansdottir O, Unruh AM, McAlpine L, McGrath PJ. A systematic review of cross-cultural comparison studies of child, parent, and health professional outcomes associated with pediatric medical procedures. The journal of pain : official journal of the American Pain Society Mar;13(3): It is not rocket surgery Joey Tribbiani Friends Children s Comfort Promise

5 Essential Components of Procedural Pain Management Non-Negotiable Topical Anesthesia 0-12 months: Sucrose Positioning Distraction (Integrative (non-pharmacological) therapies) Other Considerations Possibly other pharmacological approaches Consider appropriate sedation, if excellent analgesia cannot be achieved Non-negotiable Components of Procedural Pain Management in Children Topical Local Anesthetics " To reduce pain at the time of injection, encourage parents to use topical anesthetics during vaccination of children (grade A recommendation, based on level I evidence). Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E " Topical anesthetics are considered safe for children of all ages. However, administration of excessive doses and/or prolonged application times can lead to serious adverse effects, including irregular heartbeat, seizures and difficulty breathing medeff/advisories-avis/public/_2009/emla ametop_pc-cp-eng.php " For children undergoing vaccination, there is insufficient evidence for or against the use of skin-cooling techniques (vapocoolants, ice, cool/cold packs) to reduce pain at the time of injection (grade I recommendation, based on conflicting level I evidence).

6 EMLA versus LMX EMLA Cream (lidocaine 2.5% and prilocaine 2.5%) vs Ela-Max LMX 4% Lidocaine Topical Anesthetic Cream (1) Koh JL, Harrison D, Myers R, Dembinski R, Turner H, McGraw T: A randomized, double-blind comparison study of EMLA and ELA-Max for topical anesthesia in children undergoing intravenous insertion. Paediatr Anaesth (12):977-82; (2) Eichenfield LF, Funk A, Fallon-Friedlander S, Cunningham BB: A clinical study to evaluate the efficacy of ELA-Max (4% liposomal lidocaine) as compared with eutectic mixture of local anesthetics cream for pain reduction of venipuncture in children. Pediatrics (6): Ela-Max LMX: 30 minutes application as effective as 60 minutes EMLA application for preventing pain during IV insertion in Children Analgesia duration: EMLA 1-2 hours vs. LMX 1 hour Skin time: EMLA 4 hours vs. LMX 2 hours EMLA and Neonates In neonates, EMLA reduces the behavioral pain response to venipuncture but not heel lance Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G: A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics (2):E1 Effective for neonates > 34 weeks gestation for lumbar puncture Kaur G, Gupta P, Kumar A: A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003, 157(11): Single doses have not been associated with methemoglobinemia Taddio A, Ohlsson A, Einarson TR, Stevens B, Koren G: A systematic review of lidocaine-prilocaine cream (EMLA) in the treatment of acute pain in neonates. Pediatrics (2):E1 Application of Cream Cellophane (no Tegaderm : hurts at time of removal)

7 Needle pokes without the pain? J-Tip in the Emergency Room (CBS 4 Morning News) J-Tip (Lidocaine) J-tip: single-use, disposable, carbondioxide-powered, needleless lidocaine injector Adults: More pain than s.c. lidocaine Cooper JA, Bromley LM, Baranowski AP, Barker SG: Evaluation of a needlefree injection system for local anaesthesia prior to venous cannulation. Anaesthesia (3): Needle pokes without the pain? J-Tips at Children s of MN

8 LET Anesthesia 3mL LET-gel: Lidocaine 4%- Epinephrine 0.18% -Tetracaine 0.5% Singer AJ, Stark MJ. Pretreatment of lacerations with lidocaine, epinephrine, and tetracaine at triage: a randomized double-blind trial. Acad Emerg Med Jul;7(7): Sitting upright Distraction Topical Anesthesia Non-negotiable Components of Procedural Pain Management in Children Sucrose for Children 0-12 months Reduces pain (PIPP, VAS) and cry during painful procedure, such as venipuncture Stevens B, Cochrane Database of Systematic Reviews 2004, Issue 3 Role of endogenous opioids - naloxone blunts effect Effective dose (24%): ml (= g) Administration 2 minutes prior to mild - moderately painful procedure Duration ~ 4 min Does not prevent development of hyperalgesia Taddio A, Shah V, Atenafu E, Katz J. Influence of repeated painful procedures and sucrose analgesia on the development of hyperalgesia in newborn infants. Pain Jul;144(1-2):43-8. Breastfeeding Effective in term infants (superior to sweetening agents) (1) Shah PS, Cochrane Database of Systematic Reviews 2006, Issue 3 (2) Gray L, Miller LW, Philipp BL, Blass EM. Breastfeeding is analgesic in healthy newborns. Pediatrics Apr;109(4): (3) Weissman A, Aranovitch M, Blazer S, Zimmer EZ. Heel-lancing in newborns: behavioral and spectral analysis assessment of pain control methods. Pediatrics Nov;124(5):e Ineffective in preterm infants? Holsti L, Oberlander TF, Brant R. Does breastfeeding reduce acute procedural pain in preterm infants in the neonatal intensive care unit? A randomized clinical trial. Pain Nov;152(11):

9 Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube Integrative Therapies for Neonates Neonates Nonpharmacologic, supportive measures: Breastfeeding (Shah PS, Cochrane Database of Systematic Reviews 2006, Issue 3) Sucrose (Stevens B, Cochrane Database of Systematic Reviews 2004, Issue 3 Nesting/Swaddling Kangaroo care (Gray, Pediatrics 2000; Johnston APAM 2003) Dimming light & noise Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidencebased clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E Premature wks: For heelstick - Kangaroo care more effective than oral glucose, which is more effective than placebo Freire NB, Garcia JB, Lamy ZC. Evaluation of analgesic effect of skin-to-skin contact compared to oral glucose in preterm neonates. Pain. 2008; 139(1): Epub 2008 Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube

10 Non-negotiable Components of Procedural Pain Management in Children Non-negotiable Components of Procedural Pain Management in Children 3/4 Positioning Pediatric Positioning in 1985

11 Positioning To reduce pain at the time of injection, do not place children in a supine position during vaccination (grade E recommendation, based on level I evidence). Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E When feasible, offer choice to child (parent s lap?) Comfort Positions Children s of Central California 2014 Swaddling, facilitated tucking, kangaroo care Skin-to-skin care for procedural pain in neonates

12 Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube Non-negotiable Components of Procedural Pain Management in Children Integrative Therapies for Needle Procedures Cochrane Review 2013: 39 trials, 3394 children 2-19 years - needleprocedures (immunizations and injections). Uman LS, Birnie KA, Noel M, Parker JA, Chambers CT, McGrath PJ, Kisely SR. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database of Systematic Reviews 2013, Issue 10 There is strong evidence that distraction and hypnosis are effective in reducing the pain and distress that children and adolescents experience during needle procedures Promising but limited/no evidence for preparation and information or both, combined CBT, parent coaching plus distraction, suggestion, or virtual reality

13 Integrative Therapies for Needle Procedures To reduce pain at the time of injection among children four years of age and older, offer to rub or stroke the skin near injection site with moderate intensity before and during vaccination (grade B recommendation, based on level II-1 evidence) Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, et al. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E Parent coaching: Certain types of parental behaviours (e.g., nonprocedural talk, suggestions on how to cope, humour) have been related to decreases in children s distress and pain, whereas others (e.g., reassurance, apologies) have been related to increases in children s distress and pain. Taddio A, Chambers CT, Halperin SA, et al. Inadequate pain management during childhood immunizations: the nerve of it. Clin Ther 2009;31(Suppl 2):S ) Distraction Hypnosis in Pediatric Practice: Imaginative Medicine in Action By Laurence Sugarman, MD A documentary for child health professionals

14 Distraction Reduction of fear and anxiety Determine if the child wishes to watch or be distracted Young children: books, bubbles and pinwheels Coaching roles for parents Older children: video games and biofeedback How many mistakes can you spot? New York Time 7/2/14: The Price of Prevention: Vaccine Cost Are Soaring Non-negotiable Components of Procedural Pain Management in Children Other Considerations (5) (Intranasal) Systemic Analgesia (6) Sedation

15 Intranasal Opioid Application Nasal mucosa richly vascularized Fenestrated epithelium drains by way of the facial and sphenopalatine veins Avoiding first pass metabolism Hydromorphone: ER trauma patients - plasma concentration similar to those after IV administration Wermeling DP, Clinch T, Rudy AC, Dreitlein D, Suner S, Lacouture PG. A multicenter, open-label, exploratory dose-ranging trial of intranasal hydromorphone for managing acute pain from traumatic injury. J Pain Jan;11(1): Intranasal Opioid Application Drops or spray diluted in normal saline 0.9% Pharmacokinetic profile similar to i.v. in children Mucosal Atomization Device (MAD) Intranasal Opioid Application Drops or spray diluted in normal saline 0.9% Pharmacokinetic profile similar to i.v. in children RCT 24 children (4-8 years) Burn dressing changes Control: oral morphine Titrated until pain free intranasal dose slightly higher (1.4 mcg/kg + 15mcg Q5min) pain relief comparable safety profile acceptable, no serious adverse events Borland ML, Bergesio R, Pascoe EM, Turner S, Woodger S. Intranasal fentanyl is an equivalent analgesic to oral morphine in paediatric burns patients for dressing changes: a randomised double blind crossover study. Burns Nov;31(7):831-7.

16 Intranasal Opioid Application RCT 32 children (4-8 years) Postoperative analgesia Control: i.v. fentanyl Titrated until pain free intranasal dose slightly higher (1.4 mcg/kg) pain relief comparable safety profile acceptable, no serious adverse events Manjushree R, Lahiri A, Ghosh BR, Laha A, Handa K. Intranasal fentanyl provides adequate postoperative analgesia in pediatric patients. Can J Anaesth Feb; 49(2): Case report Acute pain ER 48 children (3-12 years) Dose applied every 5 minutes as required Median dose: 1.5 mcg/kg good pain control no side effects Borland ML, Jacobs I, Geelhoed G. Intranasal fentanyl reduces acute pain in children in the emergency department: a safety and efficacy study. Emerg Med (Fremantle) Sep;14(3): Sedation If good procedural analgesia not feasible with the 4 Non-Negotiables, consider: (1) Mild sedation: Nitrous gas Zier, J. L. and M. Liu (2011). "Safety of high-concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases." Pediatric emergency care 27(12): or (2) Moderate/deep sedation (e.g. ketamine, propofol) Note: A sedative alone (such as a benzodiazepine) can never be a substitute for procedural analgesia. Thanks to Patricia D. Scherrer MD, Medical Director, Sedation Services Children's Hospitals and Clinics of Minnesota IV Access Under Nitrous Gas 22 months-old, LMX in place, needed IV for radiologic procedure, history of challenging IV access in the past

17 Conclusions Procedural Pain Treatment protocol for painful procedures is expected standard of care in 21st century: Non-negotiable: positioning, topical anesthesia, integrative therapies, sucrose plus/minus sedation; systemic anesthesia Children s Comfort Promise We will do everything possible to prevent and treat pain

18 Further Training Education in Palliative & End-of-life Care [EPEC]: Become an EPEC-Pediatrics Trainer Chicago, IL, Oct 16-17, 2014 Center to Advance Palliative Care (CAPC) - Pediatric Palliative Care Leadership Center (PCLC) Training Oct 22-24, th Annual Pediatric Pain Master Class Minneapolis, MN June 20-26, 2015 Stefan J. Friedrichsdorf, MD, FAAP Associate Professor of Pediatrics, University of Minnesota Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S Minneapolis, MN USA phone fax Blog:

I do intend to discuss unapproved or investigative use of commercial products or devices (= off-label).

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