Learning Objectives. What are children most afraid of when coming to see a doctor?

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1 Don t have enough staff for Pain Control? Funny, how there is always enough to restrain a child 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 Identify myths and misconceptions around needle pain prevention [ attitude ] Appreciate high incidence and importance of preventing needle pain [ knowledge ] Evaluate the four non-negotiable components of needle pain management and design implementation plan for your own clinical environment [ skill ] What are children most afraid of when coming to see a doctor? Friedrichsdorf S, Eull D, Weidner C: Children Are Actually Afraid of Needle Pokes. And their Parents, too. Journal of Things We Already Knew. 2016:(1)1:1-518

2 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. Needle Pain: A Call for Action Needle procedures (incl. vaccine injections) performed in childhood are a substantial source of distress By age 2: vaccine injections in US Children get behind in vaccination schedule Needle fear was the primary reason for immunization noncompliance for 7% and 8% of parents and children, respectively Taddio A, Ipp M, Thivakaran S, Jamal A, Parikh C, Smart S, Sovran J, Stephens D, Katz J. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine 2012;30(32):

3 Procedural Pain: A Call for Action It is estimated that up to 25% of adults have a fear of needles (with most fears developing in childhood) 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: Untreated needle pain can have long-term consequences including 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 evidencebased clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E preprocedural anxiety hyperalgesia needle fears avoidance of health care (including nonadherence with vaccination schedules Procedural pain: A Call for Action Exposure to neonatal pain in preemies related to higher pain selfratings during venipuncture at school age Valeri, B.O., et al., Neonatal Invasive Procedures Predict Pain Intensity at School Age in Children Born Very Preterm. Clin J Pain, 2015 Pain ratings at 4-6 months routine vaccination higher for circumcised versus uncircumcised boys: Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet. 1997;349(9052): 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 : 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 What do we need to do? Hey, it is not rocket surgery Joey Tribbiani, Friends

4 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:. Hospital Pediatrics (1): Essential Components of Needle Pain Prevention Non-Negotiable Topical Anesthesia 0-12 months: Sucrose Positioning Distraction (Integrative nonpharmacological therapies) Develop Plan B (or deferral process) Child life, psychology Nitrous gas sedation Consider moderate-deep sedation, if excellent analgesia cannot be achieved other approaches 4 steps to make needles less painful 1. Numb the skin 2. Sugar water or breastfeeding for babies 3. Comfort positioning 4. Distraction Watch videos at childrensmn.org/comfortpromise.

5 Non-negotiable Components of Needle Pain Prevention in Children Topical Local Anesthetics To reduce pain at 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 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 emla ametop_pc-cp-eng.php insufficient evidence for or against use of skin-cooling techniques (vapocoolants, ice, cool/cold packs) to reduce pain at time of injection Success of venipuncture or venous cannulation in children 388 children (255 with EMLA, 133 without). Procedures were successful at first attempt in: Schreiber S, Ronfani L, Chiaffoni GP, et al. Does EMLA cream application interfere with the success of venipuncture or venous cannulation? A prospective multicenter observational study. Eur J Pediatr. Feb 2013;172(2): % percent of in the EMLA group 76.7 % in the no EMLA group

6 EMLA and Neonates In neonates, EMLA reduces 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 Single 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 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): Application of Cream Consider Cellophane (transparent film dressing [e.g. Tegaderm] might hurt at time of removal) Needle pokes without the pain? J-Tip in the Emergency Room (CBS 4 Morning News)

7 J-Tip (Lidocaine) J-tip: single-use, disposable, carbondioxide-powered, needle-less lidocaine injector Adults: More pain than s.c. lidocaine Cooper JA, Bromley LM, Baranowski AP, Barker SG: Evaluation of a needle-free injection system for local anaesthesia prior to venous cannulation. Anaesthesia (3): Non-negotiable Components of Needle Pain Prevention 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 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):

8 Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube Integrative Therapies for Neonates Morphine does NOT provide adequate analgesia for acute procedural pain among preterm neonates Carbajal R, Lenclen R, Jugie M, Paupe A, Barton BA, Anand KJ. Morphine does not provide adequate analgesia for acute procedural pain among preterm neonates. Pediatrics Jun;115(6): Combination of sucrose and radiant warmth effective analgesic in newborns; reduces pain better than sucrose alone Gray L, Garza E, Zageris D, Heilman KJ, Porges SW. Sucrose and warmth for analgesia in healthy newborns: an RCT. Pediatrics. Mar 2015;135(3):e Providing natural warmth [Infant Warmer System] to newborn infants during painful procedure decreases crying and grimacing on par with the "gold" standard treatments of sucrose or pacifier. Gray, L., C. W. Lang, et al. (2012). "Warmth is analgesic in healthy newborns." Pain 153(5): Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube

9 Non-negotiable Components of Needle Pain Prevention in Children 3. Positioning not optimal... Non-negotiable Components of Needle Pain Prevention in Children Pediatric Analgesia in 1985 Papoose Boards

10 M0155b 3/15 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 evidencebased clinical practice guideline. CMAJ : Canadian Medical Association journal 2010 Dec 14;182(18):E When feasible, offer choice to child (parent s lap?) Parents not partners in crime Comfort positions for needle procedures Babies (0-12 months) Held by parent Swaddled or skin to skin Pacifier with sugar water or breastfeeding Distraction: favorite toy, blanket or music Toddlers and preschoolers (1-5 years) Held by parent, sitting upright is best Distraction: bubbles, books, toys or music School age (6-12 years) Held by parents or close by, upright is best Distraction: interactive toys, books or electronics Child may choose to watch or lay down Teens (13-18 years) Parents available Sitting upright is best Distraction: interactive toys, books or electronics Teen may choose to watch or lay down childrensmn.org Swaddling, facilitated tucking, kangaroo care Skin-to-skin care for procedural pain in neonates

11 Harrison, DM. Be Sweet to Babies (August, 2014). Retrieved from YouTube Non-negotiable Components of Needle Pain Prevention in Children With quote from our phlebotomist 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 Strong evidence that distraction and hypnosis effective in reducing 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

12 Integrative Therapies for Needle Procedures To reduce pain at time of injection among children four years of age and older, offer to rub or stroke 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 behaviors (e.g., nonprocedural talk, suggestions on how to cope, humor) 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 Distraction Reduction of fear and anxiety Determine if child wishes to watch or be distracted Young children: books, bubbles and pinwheels Coaching roles for parents Older children: video games and biofeedback

13 Do you remember Marius...? How about a Plan B? 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): What s Plan B? If adequate procedural analgesia not feasible with the 4 Non-Negotiables alone, refer patient to: (1) Child Life (should t have been involved by now?) (2) Needle Phobia: psychology (CBT) (2) 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 (3) Moderate/deep sedation (e.g. ketamine, propofol) Note: A sedative alone (such as a benzodiazepine) can never be a substitute for procedural analgesia.

14 Thanks to Patricia D. Scherrer MD Children's Hospitals and Clinics of Minnesota IV Access Under Nitrous Gas 22 months-old, Lidocaine 4% cream in place, needed IV for radiologic procedure, history of challenging IV access in the past handout_images/3p_babiesto1yr_e.pdf 3p_kidsandteens_e.pdf Conclusions Needle Pain Prevention Treatment protocol for painful procedures is expected standard of care in 21st century: Non-negotiable: positioning, topical anesthesia, integrative therapies, sucrose plus/minus sedation

15 Just say stop! 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) Stefan J. Friedrichsdorf, MD, FAAP Medical Director, Department of Pain Medicine, Palliative Care & Integrative Medicine Associate Professor of Pediatrics, University of Minnesota Medical School Blog: Children's Hospitals and Clinics of Minnesota 2525 Chicago Ave S Minneapolis, MN USA phone fax stefan.friedrichsdorf@childrensmn.org