The following is a summary of a topical session from the 42nd Annual Scientific Meeting of the Australian Pain Society, which took place from April 10-13 in Hobart, Tasmania. The session—focusing on the promotion of coping in children from ‘everyday’ to persistent pains—featured clinicians and researchers discussing their work and experiences on this topic. Read on for a summary of the topical session.
Teaching children about ‘everyday’ pain
Dr Sarah Wallwork, a physiotherapist from the University of South Australia, opened the topical session by discussing her research into ‘everyday’ pain—from minor bumps, scratches, or bruises—in children between the ages of two and seven years. Wallwork’s interest in this area developed from the desire to talk to her own children about pain and injury in a helpful way.
Children can learn about pain from a variety of sources, from their own personal experiences, to observing how other people (parents, siblings, and peers) react when they themselves are in pain or to the pain of others, to the wider cultural or environmental context in which pain occurs.
The audience was introduced to Bandura’s social learning theory, which considers how cognitive and environmental factors interact to influence learning and behaviour. However, learning can also come from a variety of sources, such as getting feedback or observing responses to direct personal experiences and observing the behaviours of others. These sources combine to allow individuals to develop and reinforce hypotheses about which behaviours bring about particular responses, which in turn guide future actions when similar situations occur.
Wallwork went on to explain how she views ‘everyday’ pain experiences as an opportunity for learning. When we talk to children about pain and injury, we try to promote recovery, building resilience for the future, and guiding them about helpful levels of protection for future injuries. ‘Everyday’ pain experiences occur frequently and provide an opportunity for children to experience things for themselves while also observing how others react and respond.
But what do parents currently do around children when they experience an ‘everyday’ pain event? The small pool of research in preschool aged children has identified common parent or carer responses (such as hugging or reassurance), gendered differences in children’s responses (boys displaying less protective behaviour; girls displaying greater distress), and age differences (where help-seeking behaviours decline as children age).
Wallwork then posed the question, “How can we best foster the development of adaptive pain beliefs and behaviours in children?” The previously discussed research tells us what parents and carers are doing. But what else could they be doing?
To answer this question, Wallwork and colleagues undertook a Delphi survey of 18 international experts from several different disciplines: parents, pain specialists, psychologists, and more. Survey respondents were asked to provide key messages and communication strategies for children aged two to seven years to promote pain-related recovery and resilience. Twelve key themes were identified; a selection were presented in the topical session.
One strategy the experts strongly agreed on was the need to educate children from a very early age about how pain works. This can include talking to children about how pain acts as a warning system to protect us from harm, or that many factors—including our emotions—contribute to how we respond to painful situations.
Providing reassurance that the pain will end was another suggested strategy. Wallwork explained the somewhat controversial nature to this suggestion, as reassuring children during acute procedures such as injections or vaccinations can increase pain and distress. Wallwork referred to the Canadian initiative It Doesn’t Have to Hurt, which recommends minimising reassurance for this exact reason. However, further research is required to determine the effects of reassurance in response to ‘everyday’ pain, as contextual influences may play a role here.
Another important strategy identified from the Delphi survey was that differences in how information about pain is communicated should be based on the developmental abilities and cognitive level, not age. Similarly, the strategies should not differ based on the gender of the child. Rather, they should be tailored to the individual child—it’s not a one size fits all approach.
Wallwork concluded her presentation by reinforcing the need to educate children about pain from an early age to improve resilience for future pain events as they grow and develop.
Managing procedural pain
Dr Dianne Crellin, a paediatric emergency nurse practitioner and researcher from the Royal Children’s Hospital in Victoria, continued the session with a presentation on practical evidence-based options for procedural pain management in children.
Crellin started her presentation by reinforcing the consensus that Nike’s “Just do it” approach should only be applied to exercise, not pain management. This view is informed by the swathe of research reporting the associations between unrelieved pain in children (of all ages, not just neonates) and negative outcomes in the future, including delayed post-natal growth and neurocognitive development.
This research cannot be ignored when considering the number of procedures neonates and children experience when receiving routine vaccinations, when presenting to an emergency department, or during a hospital admission. Therefore, it is critical to ensure pain is appropriately managed when neonates and children are undergoing medical procedures.
Proper procedural pain management has two key components: pre-emptive management (how much pain is likely to be generated during the procedure) and targeted management (titrating specific management approaches to the needs of the individual).
Clinicians and adult patients report nasogastric tube insertion as one of the most painful and distressing procedures going around. Pain and distress scores from paediatric studies confirm this is also the case in a younger cohort. But according to Crellin, the pain management approach for nasogastric tube insertion has not changed for 30 years, unlike other painful and distressing procedures. Crellin urged attendees to consider this fact when pre-empting how much pain and distress children may experience before undertaking this procedure before moving on to discuss the targeted management component.
There are several methods researchers and clinicians use to assess pain and distress: carer and clinician assessment, observational scales, and physiological measures. One of the most challenging aspects in using any of these methods during a procedure is being able to differentiate between pain, fear, and anxiety—because none of these tools are very good at it.
Crellin then walked attendees through the various options for managing pain and distress in children and how appropriate each option is for nasogastric tube insertion. Each approach is supported by varying levels of evidence and has benefits and drawbacks—so ultimately the recommendation is to use a range of strategies.
For example, non-pharmacological distraction-based therapies such as virtual reality and hypnosis have proven to be effective in the limited literature available. However, these approaches require the appropriate resources and leadership to be used effectively.
The use of sweet solutions (e.g., sucrose or glucose) is effective in neonates and infants, but less effective in older children. Similarly, although local anaesthetics like lignocaine are effective in adults, the two studies examining it in children haven’t seen similar benefits. Here Crellin posed the question about whether the lack of benefits in children was due to the difficulty in differentiating between pain and distress.
One approach which appears very beneficial is the use of nitrous oxide. Although there are yet to be any studies looking at the use of nitrous oxide in nasogastric tube insertion, it has revolutionised the management of other painful procedures due to its analgesic and sedative properties, its relative safety, and the quick acting onset and offset. So, it seems like nitrous oxide might be an ideal option for nasogastric tube insertion. One challenging aspect in testing this theory will be needing to use a mask to deliver the treatment.
Crellin concluded her talk by proposing a slight variation to the Nike motto: “It might take longer but we have an obligation to manage procedural distress, so just do it.”
Getting comfortable with the Comfort Ability Program
In the final part of the session, Anna Hilyard, pain physiotherapist at the Perth Children’s Hospital, and Tegan Starr, registered psychologist and health psychology registrar at the Women’s and Children’s Hospital in Adelaide, discussed their experiences with Comfort Ability, a brief cognitive behavioural therapy (CBT) intervention originally developed by Dr Rachel Coakley at the Boston Children’s Hospital.
Hilyard and the team in Perth were keen to explore the feasibility of introducing Comfort Ability for a variety of reasons. They felt they were spending a lot of time preparing families for their more intensive CBT intervention and wondered whether Comfort Ability could improve the efficiency of this process. They were also curious to see if Comfort Ability would be suitable for patients requiring a lower level of care or who were otherwise unsuitable for the more intensive intervention.
The four key elements to the Comfort Ability program are psychoeducation, pain neuroscience education, hands-on skills training, and social support. These elements are delivered within a CBT framework using a range of strategies including thought restructuring, activity pacing, and communication skills restructuring.
In-person and virtual versions of the Comfort Ability program were implemented by Hilyard and colleagues in mid-2021, and after six months they were keen to see how things were working with respect to the program’s data collection system and to determine changes using the Pain Stages of Change Questionnaire to determine how many patients would be required for a larger study.
Of the 23 families included in the program since its initiation, only nine young people and eleven parents had data pre- and post-intervention. This figure is much lower than the follow-up rates for the intensive CBT program. Of the 11 parents, six parents improved their stage of change category from the pre- to post-intervention measurement, indicating they were more ready to adopt a pain self-management model. Hilyard is encouraged by these findings, despite the small numbers.
In contrast, none of the young people improved the state of change category following the Comfort Ability Intervention. Hilyard wasn’t surprised by this finding, as parents are more open to change than children. Despite this, all six adolescents reported positive feedback to the program. Clinicians also reported positive feedback, feeling it appropriately prepared families for a transition into the more intense model.
Overall, Hilyard felt the program was useful for introducing families to a biopsychosocial treatment model but noted the need to ensure there was sufficient time beforehand to help families to engage with the clinicians and service processes such as data collection.
Starr was then welcomed to talk about how the Women’s & Children’s Hospital team had experienced the Comfort Ability program. The program has been running for slightly longer in Adelaide compared to Perth, and the team had persisted with only face-to-face sessions, even throughout the COVID pandemic.
There have been seven Comfort Ability groups who have completed the program in Adelaide to date. Starr reports there have been massive improvements and benefits to their models of care since implementing the program. Particularly, many families benefit from the Comfort Ability program so much they can be discharged to community supports after the program, rather than requiring additional individual appointments with the chronic pain service.
Both adolescents and parents report benefits after completing the program, according to the early data coming from the feasibility program being undertaken in Adelaide. Adolescent participants report improvements in sleep, while parents report decreases in pain catastrophising.
One initially unexpected finding is the increase in adolescent anxiety after completing the program. However, Starr feels this may be the result of participants learning more about what anxiety is during the program—and therefore may be more able to identify this in themselves.
Starr concluded the session with a brief demonstration of one of the guided relaxation strategies used in the program, giving attendees the opportunity to take a moment to themselves. This provided attendees with a great insight into the content of the program and how it can help adolescents think about their pain differently.
Lincoln Tracy is a postdoctoral research fellow in the School of Public Health and Preventive Medicine at Monash University and freelance writer from Melbourne, Australia. He is a member of the Australian Pain Society and enthusiastic conference attendee. You can follow him on Twitter (@lincolntracy) or check out some of his other writing on his website.
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Simons LE, Sieberg CB, Conroy C, et al. Children With Chronic Pain: Response Trajectories After Intensive Pain Rehabilitation Treatment. J Pain. 2018;19(2):207-218. doi:10.1016/j.jpain.2017.10.005