Pedia Pain Focus

In these trying times, it is not uncommon to observe more emotional distresses, anxiety, depression, and grief from the inability to go out and engage with people. Given that, how can working with children around their pain be further improved? Not only in helping them in dealing with their physiological pain but also their psychological needs and distress?

Sam Huestis PhD is a Pediatric Pain Psychologist specializing in chronic pediatric pain management, Cognitive Behavioral Therapy (CBT), Acceptance and Commitment Therapy (ACT), Biofeedback, Family Therapy, Group Therapy, and clinical research, in pediatrics. She is a Clinical Assistant Professor of Anesthesiology & Pain Medicine Stanford University School of Medicine / Stanford Children's Health.

Having worked with and observed children, backed up with salient research, we will address the impact of Covid-19 pandemic on pediatric pain management and the different ways to improve it. Her great passion working with children and their psychology acts as a huge mirror that will get parents, physicians, health care providers, and hopefully even insurance companies to rethink the importance and impact of managing children's pain.

We are all struggling from this pandemic and hoping to get by. Listen to this episode to be further equipped in handling the children and teen pain management challenges.

Takeaways in This Episode

• How Dr. Samantha Huestis began to love pediatrics and psychology
• Children's resilience as observed in the hospitals
• How COVID impacted children's recovery
• The importance of following a routine with the new normal virtual learning
• Some positive traits observed in people's behavior during this pandemic
• Cognitive Behavioral Therapy or CBT
• Acceptance and Commitment Therapy or ACT
• Group therapy for children
• Acquiring therapeutic shared narratives and pain narratives
• The use of metaphors in encouraging children to speak up
• Working with children and parent's goals
• Working with insurance companies

Links

• Samantha Huestis - https://profiles.stanford.edu/samantha-huestis

• LinkedIn @samanthaehuestisphd
• Proactive Pain Solutions
• Managing Chronic Pediatric Pain PDF
• WebMAP Mobile App by Tonya Palermo - https://apps.apple.com/us/app/webmap-mobile/id1296377145
• The Comfortability: The Teen and Parent Pain Coping Workshop - https://www.thecomfortability.com/
• Stanford Free Coping Websites - http://med.stanford.edu/content/dam/sm/elspap/documents/WEBSITES.pdf
• Chip - http://publichealth.lacounty.gov/plan/chip.htm
• The Creative Healing - http://creativehealingproject.com/

Dr Whitaker is a pediatric anesthesiologist at the University of Vermont Children's Hospital and an Assistant Professor of Anesthesiology, Neurological Sciences, & Pediatrics at The University of Vermont College of Medicine. His clinical interests lie in the anesthetic care of neonates and in spinal anesthesia for neonates, infants, and children. His research is focused on developing optimal anesthesia care for neonates and infants and his current research interests include developing novel ways to monitor pediatric regional anesthesia.

Today he shares how he got started with this practice, the groundwork established by his mentors, and the recent findings and developments in this field. We also talk about the general reception of spinal analgesia from parents, doctors, and other stakeholders.

This episode is very practical and eye opening. If you're being asked about it or are thinking of how to start incorporating spinal analgesia in your clinical practice or you're still on the fence, this episode is definitely for you!

Takeaways In This Episode:

• How Dr. Emmett Whitaker got interested and started the practice of spinal anesthetics
• The importance of having a surgeon champion and the stakeholders being really engaged partners for a successful implementation of a new initiative/program
• When is it appropriate to do spinal anesthesia analgesia for children
• The benefits of pediatric spinal anesthesia
• Parents' reception of pediatric spinal anesthesia
• Anesthesiologists' and surgeons reception of pediatric spinal anesthesia
• How can an institution get started with pediatric spinal anesthesia program
• Skill set required to perform this procedure
• The typical workflow for pediatric spinal anesthesia
• Dr. Emmett Whitaker's final thoughts on pediatric spinal anesthesia

Links

Emmett Whitaker, MD

Contact Dr. Whitaker

Ensuring Opioid Safety for Children and Teens

Opioid Stewardship: Responsible Pediatric Pain Care!

Proactive Pain Solutions Physicians Academy

We may think we really know the pain we or our patients have, but the pain experience is complex and its treatment can be just as complex, not to mention risky.

Understand and relieve children's pain effectively and safely in today's episode as we speak with Dr. Rita Agarwal, a Pediatric Anesthesiologist with an expertise with pediatric acute pain management, regional anesthesia, ambulatory anesthesia and opioid safety.

She shares her in-depth knowledge about pain, the right treatment options and specifically how to navigate treatment when opioids medications are used. She stresses on how and when it is safe and appropriate to use opioids for pediatric pain; including the right prescriptions, usage, storage and disposal of this (and other)substance.

Lastly, she notes that we must develop sensitivity when we speak with people using opioid treatment as it may carry stigma and negative connotations especially with the opioid epidemic in our society and especially because we're dealing with pediatrics. We must evaluate and include multidisciplinary treatment options, AND educate our patients and families about safe and appropriate use, storage and disposal of their medication EACH TIME!

So the next time you treat a child's pain, as Dr Agarwal said, don't ever downplay the role of multimodal treatments, but provide them the necessary education in the use of medications, especially something with a higher risk profile like the opioids.

Takeaways In This Episode

• When is it appropriate to prescribe opioids for pediatric pain.
• Knowing Opioids; proper prescription, usage, storage, and disposal.
• Understanding pain; and knowing the appropriate treatment options for specific pain diagnoses.
• Reducing risk of opioid addiction and misuse.
• Why it's imperative to counsel families to keep these medications locked up,away from other members of the family, or potential visitors, even for short courses of opioid analgesics.
• What should be included in the discussion adn how a clinician can achieve that efficiently in their practice.
• How well intentioned friends or family members become the main source of opioid diversion and misuse.
• Various avenues for Safe disposal methods available in the community
• Relying on experts for the right treatment plans, when in doubt or feel pushed beyond your comfort.

Links

• About Dr. Rita Agarwal
• Society for Pediatric Pain Medicine
• AAP Safe Medication Storage/Disposal Poster

• AAP Safe Disposal of Unused Medications

• DEA National Take Back Days

• CDC Guidelines for Prescribing Opioids

• FDA Guidelines on Safe Disposal of Medications

• DEA Drug Disposal Information

• Proactive Pain Solutions

With 5 million middle & high school teens in US reporting misuse/abuse of opioids, it is imperative to understand and address the contributing factors. In conversation with Dr. Benjamin Lee MD, MPH, we examine appropriate, effective, pain management, balanced with appropriate risk mitigation when it comes to pediatric pain.

Dr. Lee is a board-certified pediatric anesthesiologist, pediatric pain and palliative care physician. He's the Division Chief of Pain Medicine at Texas Children's Hospital and Associate Professor of Anesthesiology at Baylor College of Medicine. A strong advocate for children's responsible pediatric pain management, he has done extensive work in the area of opioid stewardship.

Takeaways in This Episode

• The informal conversations with colleagues and nurses that marked his research path involving opioid safety.
• Finding from examining prescribing behaviors of clinicians, and what parents did with the leftover medications.
• Common types of prescription errors and what can be done to fix them.
• Scope of opioid prescriptions and the opioid epidemic.
• When it is or isn't appropriate to prescribe opioids for children's pain.
• What opioid stewardship in your clinical practice means.
• Unique challenges related to COVID-19 pandemic around opioid prescriptions and monitoring, role of Prescription Drug Monitoring Programs (PDMPs), and telemedicine in opioid safety.
• 7 Fundamental actions of an opioid stewardship program.
• Dr. Lee's "take home message" for safe and effective pediatric pain management practices.

Links

Dr. Benjamin Lee MD, MPH

Connect with Dr. Benjamin Lee, MD MPH

National Quality Forum Opioid Stewardship Program Playbook

Opioid Stewardship Fundamentals PDF

Society for Pediatric Pain Medicine

Proactive Pain Solutions

Training in 3 different countries' medical systems and practicing across international borders, Dr. Deepa Kattail has a unique perspective on pediatric pain care and healthcare practices overall. She's a pediatric anesthesiologist, pain physician, fellowship director, assistant professor at McMaster University in Ontario, Canada and chairs the Communications Committee in the Society for Pediatric Pain Medicine (SPPM). Her unique experiences in various healthcare settings and her experiences and insights are a great resources for any clinician, but especially a pediatric pain professional.

Takeaways in This Episode

• Unique aspects of training programs and healthcare practices in India, United States and Canada.
• Influence of strong mentors on her choice of career and how she would practice.
• What characteristics of her mentors and seniors influenced her own clinical and teaching practices.
• Essential ingredients of an expert and the role of confidence.
• What areas in medicine need to have more recognition as major contributions to the evolution of healthcare and in alignment with societal norms.
• Transitional challenges in early career as a pediatric anesthesiologist and pain physician.
• The type of training and essential elements in education of a pediatric pain physician (or anyone engaged in care of pediatric pain patients!).
• Aspects of pediatric pain medicine that are enjoyable vs. challenging.
• Key differences in the healthcare practices for pain management in USA and Canada
• Role of a society and professional community in pediatric pain medicine.
• Her advice to a new pediatric pain medicine professional.

Links

Deepa Kattail MD, MHS, FAAP

Twitter

Email Dr. Deepa Kattail

Society for Pediatric Pain Medicine

Proactive Pain Solutions Physicians Academy

In this episode, Dr Rachel Zoffness, PhD discusses the role of scientifically supported, non-stigmatizing and interdisciplinary education in advancing the quality of pediatric pain medicine, for HCPs and patients.

Dr. Zoffness is a health and pain psychologist on faculty at UCSF School of Medicine, runs educational program for the trainees at UCSF and a pain workshop for HCPs. She's is the author of the Chronic Pain & Illness Workbook for Teens and has a successful clinical practice in pediatric pain medicine. She's a self proclaimed "nerd" with a passion for science and education, who wanted to live at the intersection of medicine and psychology, patient care and education. She also brings a unique perspective due to her personal experience with chronic pain.

Takeaways in This Episode

• Her controversial approach to treating her patient's pain helping him get from being bedridden to the captaincy of his ultimate frisbee team.

• Current gaps in pediatric pain management and how these contribute to the mismanagement of children's pain.

• Why "training the trainer" is a imperative and how our current training system stacks up in that regard.

• The bio-psychosocial framework of pediatric pain.

• Where she (and other pediatric pain clinicians) experience resistance (Hint: It's more widespread than you think!)

• Barriers to adequate education in pain medicine.

• Pain as a ubiquitous experience and what YOU can do to eliminate the barriers to appropriate education.

• How you can give back the power and hope that pain takes away from your patients and families.

• How to create multidisciplinary teams, and what to do if you don't have a multidisciplinary pain management team.

• What you can do to remove the stigma from referral to pain psychology.

• How to navigate the lack of time and still give your patients and families the needed education in addition to the treatment plans.

• A kid-friendly 3 minute, "pain dial" metaphor explanation of pain for any child or family that you can adopt and implement right away.

• Addressing the question "why do I need to see a psychologist if I'm feeling the pain in my body?".

• What you can do to pivot and innovate during the COVID19 pandemic.

Links

Rachel Zoffness, PhD

Chronic Pain and Illness Workbook for Teens

CBT for Chronic Pain in Children and Adolescents

Pain Survival Guide

Pain: The Science of Suffering

The Comfort Ability

Lorimer Moseley TEDx Talk

WebMAP App

Join me in this episode as we uncover the influence of memory and language in children's pain management with Dr. Melanie Noel, PhD!

Dr. Melanie Noel is an Assistant Professor of Clinical Psychology at the University of Calgary, a Full Member of the Alberta Children's Hospital Research Institute (Behaviour and the Developing Brain Theme), and an Associate Member of the Mathison Centre for Mental Health Research and Education.

Her expertise is in the area of children's memories of pain and co-occurring mental health issues and pediatric chronic pain. She has published conceptual psychological models of children's pain memory development, co-occurring PTSD & chronic pain, and fear-avoidance.

Find out how words and memory impact children's pain experiences, and its prognosis. Moreover, learn what we can do as parents, adults and clinicians to help them manage, cope, and alleviate it, in order to optimize future health outcomes and prevent chronic pain!

Takeaways in This Episode

• Determinants of a child's pain experience
• The role of language, choice of words and narratives in pain management
• Parent's narrative and role in influencing their children's pain experience and its prognosis
• Dr. Melanie Noel's significant findings and how it influences children's pain and its outcomes
• A 3-step approach to Re-framing a child's memory of painful experience
• Boosting a child's confidence and their ability to manage their pain
• Dr. Melanie Noel's current research and projects, and her plans for the future

Links

Connect with Dr. Melanie Noel

Twitter

Email Dr. Melanie Noel

Additional resources for Dr. Melanie Noel

Role of Epigenetics in Chronic Post-Surgical Pain

Storytelling in Pediatric Pain Medicine

Storytelling in Pediatric Pain Medicine Part 2

Proactive Pain Solutions Physicians Academy

Some children recover quickly from surgery while others may develop long lasting pain and disability. Research shows there are many factors that may play a role in how a child recovers from surgery, genetic or heritable factors being among those. Besides the gene structure, the response of these genes to other environmental and psychosocial factors may play a big role in the generation and propagation of pain. My guest's research examines what those factors are and how they may be affecting the behavior of the genes responsible for her patients' pain experiences. Find out what she discovered.

Takeaways in This Episode

• How she became interested in this research and created her Pediatric Pain PAL lab.
• What constitutes Chronic Post-surgical Pain (CPSP), how common is it among children (and adults) and why that might be relevant to us.
• Psychosocial and perioperative factors that predict CPSP
• Why the findings from Systematic reviews may be limited in their findings about ability to predict or impact CPSP.
• Can you modify the genetic factors involved in pain experience after surgery and how.
• Things that healthcare professionals do to change the response of the genes associated with pain, before during and after surgery.
• CPSP related expenses, cost-effectiveness of genetic testing and when it should be considered.
• Applicability of the epigenetics in chronic pain conditions

Links

Vidya Chidambaran, MD

Peds pain PAL

Publications

Epigenetics in Migraine

The clinical presentation of EDS is quite varied, widespread and complex. Patients often have a widespread pain presentation or these are your "pain everywhere" patients. This is even more challenging when it comes to pediatric patients. In this part 2 of Caring for EDS, I speak with Dr Pradeep Chopra, a renowned expert in this condition, and explore the assessment and management techniques, the cautions, and how to improve the outcomes.

Takeaways in This Episode

• Clinical picture of EDS patients and what a typical patient may look like.
• The unique aspect of growing pains in children with EDS and how to address it.
• Unique aspect of sleep disturbance for EDS patients and how it's different from other pain patients.
• The appropriate age when patients can be diagnosed with EDS and what should be done in the interim.
• Different diagnostics used for EDS
• Role of genetic testing and what you should know before ordering genetic testing.
• Therapeutic options for EDS - what medicines offer best options and how.
• Low Dose Naltrexone for pain management
• Why opioids can be much more harmful for these patients and what one must be aware of when using them.
• What you should know about the type of activity, exercise and physical or occupational therapy for EDS patients.
• What role do interventional pain management techniques play in their pain management.

Links

Pedia Pain Focus episode 23

Ehlers Danlos Syndrome Society

Chronic Pain Partners

Beighton Score

Low Dose Naltrexone Research Trust

The clinical presentation of EDS is as varied, widespread and as complex. They may often present as pain "everywhere". This is even more challenging when it comes to pediatric patients. In this 2 part series on EDS, I speak with a renowned pain physician expert in this condition and explore the clinical features, assessment, diagnostic and therapeutic dilemmas and how to address them.

Takeaways in This Episode

• What makes this condition and these patient so complex.
• Reasons these patients may respond differently than other pain patients even with similar pain symptoms and similar medications and what you can watch for or do differently as a clinician.
• Major differentiating feature(s) of EDS amongst children.
• The double whammy of EDS patients.
• The particular disadvantage of EDS patients as it relates to their GI symptoms.
• Why it choosing brand name medications may be better for your EDS patients.
• How to work through the complexities of multiple medications often needed for these patients and how to effectively determine whether they are effective.
• Role of pharmacogenomics for EDS patients.
• "One principle" in the treatment of EDS patients.
• How to effectively assess and manage a patient presenting with "pain everywhere".

Links

Pradeep Chopra MD

Ehlers Danlos Syndrome