Painless in Seattle – 10th International Symposium on Pediatric Pain

By Kathryn Russell, NZPS Pain in Childhood SIG Chair
Consultant Clinical Psychologist – Paediatric Consult Liaison team, Whirinaki, Counties Manukau Health.

A tourist asks a local Seattleite child: “I’ve been here an entire week and it’s done nothing but rain. When do you have summer here?” The kid says, “How do I know? I’m only 6.”

I attended the 10^th International Symposium on Pediatric Pain with the support of the NZ Pain Society and Counties Manukau Health. Fortunately the sun arrived with me, and I enjoyed a brilliant pre-conference day exploring the sights and sounds of Seattle. It is fitting that my interest in procedural pain could be nurtured in a city with a giant hypodermic needle as its symbol.

One of the best aspects of attending the conference was meeting and talking with some of the leaders in the field, having plenty of time to ask questions and catch up in the breaks. I went to the conference with questions about sucrose: to use or not to use for infants?; does it just mask pain?; or does it reduce distress through another mechanism?. The consensus of those I canvased, including Dr Suellen Walker and Dr Stefan Friedrichsdorf, was that we should continue to use sucrose for mild infant procedural pain when nothing else is available, and also continue to look for better options. One of the researchers from the Oxford group that published the article about sucrose not inhibiting the nociceptive response[i] was circumspect about the lack of knowledge about how sucrose creates a calming response and felt that fMRI might provide more information in the future. It is worth mentioning that the initial article was widely criticized with six Lancet replies. Research into improving the effectiveness of sucrose for infant procedural “pain” relief continues with radiant warmth appearing to be a new area of interest.[ii]

In our conference pack the Pain in Child Health research programme[iii] presented us with Canadian statistics: 1 in 5 Canadian children have chronic pain, 1 in 20 children are disabled by their pain, 2/3 of children with chronic pain become adults with pain, and children in hospitals average six painful procedures every day. They have developed a nine institution research group with three main funders including the Canadian Institute of Health Research, and have links to research networks in 14 counties (not currently NZ). They have 700+ publications and 218 current trainees in this network. If you would like more information please see the Youtube video: Changing the way we care for children in pain: Pain in Child Health Program.

The conference itself started with an education day covering acute neonatal pain and its long term effects. This topic highlighted the enormous complexities of neonatal pain research. During the mornings sessions it was clear that there were problems with a lack of good research focusing on analgesic medications for children[iv]. However there was good news about absence of long term negative outcomes of opioid use for preterm babies (babies who had similar procedures with or without opioid pain relief did not differ in IQ at age 8-9 years)[v]. In the afternoon sessions the importance of the multidisciplinary team (MDT) for chronic pain was touted, however access remains an issue everywhere: for example, in Japan there were 4200 pain specialists in 2006 but no pain services with an MDT[vi]. Cognitive Behaviour Therapy (CBT) and other psychological therapies in the pain context were reviewed, with a new focus towards online programmes[vii]. Professor Christopher Eccleston discussed how worry contributes to a misdirected problem solving pattern in chronic pain[viii]. Later in the day, key psychological components for chronic pain treatment were reviewed: psychoeducational; motivational interviewing; active coping (comfort boosting) including confidence building activities, distractions, and keeping a routine (school, sleep, activity); CBT skills; bio-behavioural strategies including diaphragmatic breathing, guided imagery, relaxation, mindfulness, and biofeedback; parent training (context of developmental transitions, promoting positive adaptation, involvement of family in all aspects); and school advocacy.

For a bit of psychological pain humour look up the vimeo video “It’s not about the nail”.

The main conference was three and a half days and I struggled with the universal problem of which concurrent session to attend. I did not attend any of the neuroimaging sessions, but there were a lot of them so fMRI must be the way of the future.   I went to several workshops on procedural pain. One summed it up nicely in the title “30+ years of research and practice guidelines and still they get held down.” This talk focused on the challenges of knowledge translation and drove home how difficult it is to encourage institutional shifts in practices, especially when facing beliefs from medical staff that experiencing pain may be beneficial for children[ix]. Even some of the hospitals with major (and expensive) quality programmes, like no needless pain and the comfort promise (see childrensMN.org/comfortpromise), have significant challenges in achieving consistency[x]. At the conference it was announced that World Health Organisation Strategic Advisory Group of Experts on immunization committee (WHO SAGE committee) has produced guidelines on “pain during the immunisation event”. They recommended infants be immunised with close physical contact to their parents, breastfeeding during the immunisations, or use of oral rotavirus vaccine (which is in a sucrose base) prior to the injected vaccines. Distraction was recommended for older children. These were seen as scientifically based recommendations that could be applied in low to middle income countries [xi]^,[xii]. Given that WHO regulates most of the vaccination programmes in low to middle income countries there was a suggestion that these guidelines would be followed more uniformly than might be done in higher income countries where practices may be more varied. For me the thought that the pain related to a simple needle procedure was being considered by WHO as a topic worthy of such investigation was very encouraging.

The two career award talks were absorbing. Dr Charles Berde (Distinguished Career Award) did try and fit his extensive life work into his presentation which was a little overwhelming; his research into a new local anaesthetic agent lasting days (made from algae) is interesting[xiii], as was the story of drug development without pharmaceutical company buy-in. Dr Jennifer Stinson (Early Career Award) outlined some of her research into new mobile and electronic health technologies like Pain Squad for cancer pain[xiv]. These technologies are expensive to develop and research, but some may be adaptable to different cultures, medical conditions and settings.

Several other sessions at the conference also pointed to new technological approaches for research, pain assessment, and pain management – in the form of apps. Many are in early stages of evaluation. It was pointed out that there are lots of apps available that have no medical/psychological input let alone any evaluation[xv]. However it is likely that this will be a growth area in the next few years. One example amongst many was healing buddies comfort kit for acute and procedural pain[xvi]. There is also an emerging trend to try and directly inform the public with you tube videos like “The Power of a Parent’s Touch”, “Be Sweet to Babies”, “Understanding pain – and what’s to be done about it in less than 10 minutes”, and “It doesn’t have to hurt”. A workshop about this kind of approach did suggest it was to evaluate the effectiveness of social media – though if you count hits it was an effective way of disseminating information. The ‘It Doesn’t Have to Hurt’ video  had 111,000 views by April 2015 from over 120 countries, but survey response rates at the end of these videos were pitiful (about 1%)[xvii]. There is a new IT world and working out how to navigate, moderate and evaluate information on social media is something many health professionals may not be comfortable with.

My prize for the most humorous presenter went to Brian Anderson who represented New Zealand very well in his Plenary Session on what he called a boring topic (Acetaminophen and NSAIDs in Infants and Children). He kept our attention focused on the different methods of quantifying analgesic effects and explained the concentration-response relationship and the challenges clinicians and scientists face when trying to work out what we should be aiming at[xviii].

My pick for the most useful workshop was an excellent session on neuro-irritability and pain, with a good overview and good practical tips: Look for causes of pain, use parent/caregiver knowledge, use environmental soothing[xix] but also cut feeds dramatically and don’t wait too long to start gabapentin. The slides from this workshop are available on http://noneedlesspain.org/.

It seems that the poster sessions were the place to be and it was a stroke of genius linking them to a drinks and nibbles reception. I am still working my way through all the photos and handouts. It was encouraging to see a study of the use of breastfeeding and comfort positions for Kenyan neonates during needle procedures; this poster was also presented in the poster prize oral sessions[xx]. British Columbia Children’s Hospital had posters evaluating educational pamphlets (from evidence based recommendations and from patient feedback), webinars and parent training groups for chronic pain. These approaches where all valued by parents of teens with chronic pain. There are 60 other posters worthy of mention.

During this conference I took solace in the fact that pain creates clinical and research challenges everywhere. There are significant differences in what is available in different countries. Overall the conference quite nicely summed up recent advancements in the field of paediatric pain but left me pondering the following….

In the last NZ census there were 847,740 people aged 15 or under in NZ. If the Canadian statistics are roughly transferable to NZ then there would be 169,548 children in NZ with chronic pain. Of those 42,387 would be disabled by their pain. That means about 1% of New Zealand’s total population is made up of children disabled by chronic pain …… Surely not – my maths must be wrong.

References:

[i] Slater, R., Cornelissen, L., Fabrizi, L., Patten, D., Yoxen, J., Worley, A., & Fitzgerald, M. (2010). Oral sucrose as an analgesic drug for procedural pain in newborn infants: a randomised controlled trial. The Lancet, 376(9748), 1225-1232.

[ii] Bergamo, C. (2015). Sucrose and Warmth for Analgesia in Healthy Newborns: An RCT. Journal of Emergency Medicine, 49(1), 123.

[iii] von Baeyer, C. L., Stevens, B. J., Chambers, C. T., Craig, K. D., Finley, G. A., Grunau, R. E., & McGrath, P. J. (2014). Training highly qualified health research personnel: The Pain in Child Health consortium. Pain Research & Management: The Journal of the Canadian Pain Society, 19(5), 267.

[iv] Berde, C. B., Walco, G. A., Krane, E. J., Anand, K. J. S., Aranda, J. V., Craig, K. D., … & Zempsky, W. T. (2012). Pediatric analgesic clinical trial designs, measures, and extrapolation: report of an FDA scientific workshop. Pediatrics, peds-2010.

[v] Walker, S. M. (2014). Neonatal pain. Pediatric Anesthesia, 24(1), 39-48.

[vi] Kitahara, M., Kojima, K. K., & Ohmura, A. (2006). Efficacy of interdisciplinary treatment for chronic nonmalignant pain patients in Japan. The Clinical journal of pain, 22(7), 647-655.

[vii] Palermo, T. M., Wilson, A. C., Peters, M., Lewandowski, A., & Somhegyi, H. (2009). Randomized controlled trial of an Internet-delivered family cognitive–behavioral therapy intervention for children and adolescents with chronic pain. Pain, 146(1), 205-213.

[viii] Eccleston, C., & Crombez, G. (2007). Worry and chronic pain: a misdirected problem solving model. Pain, 132(3), 233-236.

[ix] Taddio, A., Chambers, C. T., Halperin, S. A., Ipp, M., Lockett, D., Rieder, M. J., & Shah, V. (2009). Inadequate pain management during routine childhood immunizations: the nerve of it. Clinical Therapeutics, 31, S152-S167.

[x] Friedrichsdorf, S. J., Postier, A., Eull, D., Weidner, C., Foster, L., Gilbert, M., & Campbell, F. (2015). Pain Outcomes in a US Children’s Hospital: A Prospective Cross-Sectional Survey. Hospital pediatrics, 5(1), 18-26.

[xi]http://www.who.int/immunization/sage/meetings/2015/april/1_SAGE_latest_pain_guidelines_March_24_Final.pdf

[xii] http://www.who.int/wer/2015/wer9022/en/

[xiii] Berde, C. (2015). Developing Better Local Anesthetics. Anesthesia & Analgesia, 120(4), 718-720.

[xiv] Jibb, L. A., Stevens, B. J., Nathan, P. C., Seto, E., Cafazzo, J. A., & Stinson, J. N. (2014). A smartphone-based pain management app for adolescents with cancer: establishing system requirements and a pain care algorithm based on literature review, interviews, and consensus. JMIR research protocols, 3(1).

[xv] Lalloo, C., Jibb, L. A., Rivera, J., Agarwal, A., & Stinson, J. N. (2015). “There’sa Pain App for That”: Review of Patient-targeted Smartphone Applications for Pain Management. The Clinical journal of pain, 31(6), 557-563.

[xvi] Smith, K., Iversen, C., Kossowsky, J., O’Dell, S., Gambhir, R., & Coakley, R. (2015). Apple apps for the management of pediatric pain and pain-related stress. Clinical Practice in Pediatric Psychology, 3(2), 93.

[xvii] Chambers, C. (2014, August). It Doesn’t Have to Hurt: Development and Preliminary Evaluation of a YouTube Video for Parents with Information about How to Help Children with Shots and Needles. In Medicine 2.0 Conference. JMIR Publications Inc., Toronto, Canada.

[xviii] Hannam, J., & Anderson, B. J. (2011). Explaining the acetaminophen–ibuprofen analgesic interaction using a response surface model. Pediatric Anesthesia, 21(12), 1234-1240.

[xix] Hauer, J. M. (2013). Caring for Children who Have Severe Neurological Impairment: A Life with Grace. JHU Press.

[xx] Stevens, B., Gastaldo, D., & Gisore, P. (2014). Procedural pain in neonatal units in Kenya. Archives of Disease in Childhood-Fetal and Neonatal Edition, 99(6), F464-F467.