@NoNeedlessPain. Multimodal strategies for body, mind, and spirit: Advanced prevention and treatment of pain in children.

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1 Multimodal strategies for body, mind, and spirit: Advanced prevention and treatment of 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 Minneapolis / St. Paul, Minnesota, USA Follow Stefan J. Friedrichsdorf, MD, FAAP (USA)

2 US ELECTION NOVEMBER 10, 2016 Queen Offers to Restore British Rule Over United States BY ANDY BOROWITZ This two-hundred-and-forty-year experiment in self-rule began with the best of intentions, but I think we can all agree that it didn t end well, she said. Let s get started (My daughter s prenatal ultrasound) Pediatric Pain - Status Quo Pain in children s hospitals is common, under recognized and under treated 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. Hospital Pediatrics (1):18-26 Kozlowski LJ, Kost-Byerly S, Colantuoni E, et al. Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Manag Nurs. 2014;15(1): Taylor EM, et al. Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manage ;1: Canada: 3,822 pediatric inpatients (32 units): Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, et al. Pain assessment and intensity in hospitalized children in Canada. J Pain 2012 Sep;13(9): ; 33% moderate to severe pain 88% acute, 12% chronic pain USA 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. Hospital Pediatrics (1): % of all children surveyed experienced moderate, 30% severe pain in previous 24 hours 12% reported having pain routinely before admission None of the 15 children with 1 severe pain score documented received consultation from Pain & Palliative Care

3 5-year old Marius: Procedural Pain Management Redningskvinder Channel Tv3 - (Episode 7, Season 4.) 2014 Don't have enough staff for pediatric pain control...? Funny, how there is always enough staff to restrain a child. Pediatric Analgesia in 1985 Papoose Boards

4 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): 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, Pediatric Pain - Status Quo Pain in children s hospitals is common, under recognized and under treated 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. Hospital Pediatrics (1):18-26 Kozlowski LJ, Kost-Byerly S, Colantuoni E, et al. Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Manag Nurs. 2014;15(1): Taylor EM, et al. Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manage ;1: Canada: 3,822 pediatric inpatients (32 units): Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, et al. Pain assessment and intensity in hospitalized children in Canada. J Pain 2012 Sep;13(9): ; 33% moderate to severe pain 88% acute, 12% chronic pain USA 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. Hospital Pediatrics (1): % of all children surveyed experienced moderate, 30% severe pain in previous 24 hours 12% reported having pain routinely before admission None of the 15 children with 1 severe pain score documented received consultation from Pain & Palliative Care

5 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 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 ) Declaration of Montreal (2010) Access to pain management is a fundamental human right Human right violation not to treat So, how do we treat the individual pain patient in front of us? Hmhh... Spoiler Alert: Crystal-clear answer on 3rd last slide!

6 Multimodal Analgesia No Needless Pain: The Children s Comfort Promise 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 Case Example: Chronic-on-acute pain Roman (11-years old) Nov March 2015 Single left-ventricle, status post 3 palliative surgeries Protein-loosing enteropathy (PLE) Significant constant wandering pain everywhere (pain score VAS 8-10/10), plus chronic headache plus recurrent severe abdominal pain Missed > 40 days of school Deconditioned

7 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 Integrative modalities Integrative modalities effective in management of pediatric pain Hunt, K.; Ernst, E. The evidence-base for complementary medicine in children: A critical overview of systematic reviews. Arch Dis Child 2011, 96, ; Friedrichsdorf, S.; Kuttner, L.; Westendorp, K.; McCarty, R. Integrative pediatric palliative care. In Integrative pediatrics, Culbert, T.; Olness, K., Eds. Oxford University Press: pp ; Evans, S.; Tsao, J.C.; Zeltzer, L.K. Complementary and alternative medicine for acute procedural pain in children. Alternative therapies in health and medicine 2008, 14, include hypnosis Kuttner, L.; Friedrichsdorf, S.J. Hypnosis and palliative care. In Therapeutic hypnosis with children and adolescents., 2nd ed.; Crown House Publishing Limited: Bethel, 2013; pp ; Richardson, J.; Smith, J.E.; McCall, G.; Pilkington, K. Hypnosis for procedure-related pain and distress in pediatric cancer patients: A systematic review of effectiveness and methodology related to hypnosis interventions. J Pain Symptom Manage 2006, 31, acupuncture Vas, J.; Santos-Rey, K.; Navarro- Pablo, R.; Modesto, M.; Aguilar, I.; Campos, M.A.; Aguilar-Velasco, J.F.; Romero, M.; Parraga, P.; Hervas, V., et al. Acupuncture for fibromyalgia in primary care: A randomised controlled trial. Acupunct Med massage Verkamp, E.K.; Flowers, S.R.; Lynch-Jordan, A.M.; Taylor, J.; Ting, T.V.; Kashikar-Zuck, S. A survey of conventional and complementary therapies used by youth with juvenile-onset fibromyalgia. Pain Manag Nurs 2013, 14, e biofeedback Blume, H.K.; Brockman, L.N.; Breuner, C.C. Biofeedback therapy for pediatric headache: Factors associated with response. Headache 2012, 52, guided imagery Dobson, C.E.; Byrne, M.W. Original research: Using guided imagery to manage pain in young children with sickle cell disease. The American journal of nursing 2014, 114, 26-36; test 37, 47. yoga Bussing, A.; Ostermann, T.; Ludtke, R.; Michalsen, A. Effects of yoga interventions on pain and pain-associated disability: A meta-analysis. The journal of pain : official journal of the American Pain Society 2012, 13, 1-9.; Evans, S.; Moieni, M.; Taub, R.; Subramanian, S.K.; Tsao, J.C.; Sternlieb, B.; Zeltzer, L.K. Iyengar yoga for young adults with rheumatoid arthritis: Results from a mixed-methods pilot study. J Pain Symptom Manage 2010, 39, 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

8 Nociceptive Pathways & Primary Sites of Action of Analgesics Aδ or C fiber Injury Nociceptive Pathways & Primary Sites of Action of Analgesics Thalamus 2nd Neuron Aδ or C fiber Acetaminophen (Paracetamol) Injury NSAIDs 6-year-old Cassandra with severe pain due to chest tube insertion Fentanyl PCA the pump and blowing bubbles going to bubble land

9 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 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

10 Nociceptive Pathways & Primary Sites of Action of Analgesics CORTEX: Thalamus -Stress - Anxiety - Catastrophizing - Depression - perceived injustice - disturbed Sleep OFF 2nd Neuron Periaqueductal grey (endorphins) Integrative (non-pharmacological) therapies ON Aδ or C fiber Opioids Acetaminophen (Paracetamol) Injury NSAIDs Brain Regions that Modulate Pain and Emotion Somatosensory Cortex Insular Cortex Isnard J, Magnin M, Jung J, Mauguiere F, Garcia-Larrea L. Does the insula tell our brain that we are in pain? Pain Apr; 152(4): Both Pain Thalamus Prefrontal Cortex Hippocampus Anterior Cingulate Cortex Apkarian AV, et al. Eur J Pain. 2005;9: ; Casey KL, Tran TD. Cortical mechanisms mediating acute and chronic pain in humans. In: Cervero F, Jensen TS, eds. Handbook of Clin Neurology. 2006: ; Charney DS, Nestler EJ, Bunney BS, et al, eds. Neurobiology of Mental Illness. 2nd ed. 2004; Schweinhardt P, et al. Curr Opin Neurology. 2006;19: Amygdala Slide with Permission: Barry Cole, Bob Dworkin, Roy Freeman, Charles Argoff, Howard Fields Healing Environment" Pain, Palliative & Integrative Medicine Clinic $ 3.1 Mio: funded completely by Philanthropy

11 Integrative Pain & Symptom Management A Pediatrician s Top 10 Apps for Distraction & Pain Management NoNeedlessPain.org Stinson, J.N., et al., Construct validity and reliability of a real-time multidimensional smartphone app to assess pain in children and adolescents with cancer. Pain, (12): p Aromatherapy Diluted in carrier oils and applied topically Placed on a cotton ball and inhaled Used with a variety of diffusion devices Added to steaming water and inhaled Select oils are available orally

12 Aromatherapy Lavender (Lavandula angustifolia) Lemon (Citrus limon) Peppermint (Mentha piperita) Spearmint (Mentha spicata) Sweet orange (sweet orange) 1. Fitzgerald M, Culbert T, Finkelstein M, et al. The effect of gender and ethnicity on children's attitudes and preferences for essential oils: a pilot study. Explore (NY) 2007;3: Fitzgerald M, Culbert T, Finkelstein M, Green M, Liu M. The effect of gender and ethnicity on children's attitudes and preferences for essential oils: a follow up study. Explore (NY) 2010;6:172. Let s have a closer look at this hypnotherapy What is Self-Hypnosis? Altered state of consciousness Increased attention leads to an openness to suggestion Therapist guides the child s stream of consciousness Goal: gives the child a sense of mastery and control of symptoms Adjunct

13 Misconceptions Being asleep or unconscious Loss of Control Address child s and parents fears / concerns! Magic or put under a spell Revelation of secrets Not being de-hypnotised Phenomena of Hypnosis Relaxation Increased Suggestibility Dissociation Anesthesia Ideomotor responses Post-hypnotic suggestion Self-hypnosis When is Hypnosis Indicated? Child is responsive to hypnotic induction A problem is treatable using hypnosis The parents are agreeable to treatment No harm is anticipated using hypnosis Competent Therapist Good rapport between child and therapist Child is motivated to solve the problem

14 When is Hypnosis Contraindicated? Used for fun or entertainment Risking aggravation of emotional problems Hypnotherapy based on misdiagnosis Medical diagnosis and treatment takes precedence Child who is actively psychotic Another form of treatment is indicated Do You Want to Go to Your Favorite Place? A simple child That lightly draws its breath And feels its life in every limb What should it know of death William Wordsworth We are Seven

15 Pediatric Hypnosis Workshops Minneapolis, MN Pediatric Clinical Hypnosis Training Introductory - Intermediate - Advanced Levels National Pediatric Hypnosis Training Institute (formerly associated with the SDBP) Multimodal (Opioid-sparing) Analgesia Friedrichsdorf S: 9th Annual Pediatric Pain Master Class, Minneapolis, MN, June 11-17, 2016 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 OT Spirituality 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 Do you remember Marius...? How about a Plan B?

16 LET Anesthesia Sitting upright Distraction Topical 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): STEP 1: Topical Local Anesthetics

17 STEP 2: Sucrose / Breastfeeding STEP 3: Positioning STEP 4: Distraction

18 69 Picker Systemwide: Pain controlled all the time 64.0% Roll-out 63.7% 63.6% Locations surveyed: Surgery, NICU, SCN, ICC, ED & Med/Surg, Critical Care 62.0% 60.0% 58.0% 56.0% 56.9% 59.9% Q Q Q Q Q % 55.2% Usually/Always 91.8% 91.7% 90.7% 93.6% 93.9% The Magic Glove

19 The Magic Glove Leora Kuttner, PhD: YouTube Roman - 3 1/2 months later So, how do we treat the individual pain patient in front of us? Crystal clear answer: Σωκράτη Sōkrátēs; 470/ BC

20 Pain Chronic Pain Psychological pain Mental Health Anxiety Nociceptive Pain Deconditined Neuropathic Pain Depression Social Pain Poor sleep hygiene School absenteeism Spiritual Pain Visceral Pain Racial Disparity Delirium Total Pain Withdrawal Withholding evidence-based analgesia to children in pain is not only unethical, but causes immediate and long-term harm Effective & safe integrative modalities can be easily taught and integrated into clinical practice Distraction, massage, aromatherapy, biofeedback, selfhypnosis appear to be highly effective in therapy of acute and chronic pain Conclusions 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

21 Further Links The New York Times (June 28, 2016) Why Aren t We Managing Children s Pain? Covering Dr. Stefan Friedrichsdorf 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) Recommended Reading Further Training 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) Contact: CIPPC@ChildrensMN.org 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: