SGEM Xtra: Hurts so Good…but does it Have to? A Pain Management Standard for Children

Date: 15 June 2023 Guest Skeptic: Dr. Samina Ali is a pediatric emergency medicine physician, clinician scientist, and Professor of Pediatrics and Emergency Medicine at the University of Alberta in Edmonton. Her research focuses on improving assessment and treatment of pain in children. She is an executive member of Pediatric Emergency Research Canada (PERC), pain content advisor for TREKK and faculty member of BEEM. Dr. Samina Ali Background: Pain, a common acute and chronic complaint that we see a lot in the emergency department. Whether it is a broken bone, a laceration, abdominal pain, sickle cell vaso-occlusive pain episode, emergency department physicians are familiar with patients experiencing pain, but do we always do a good job at addressing it? The answer is no, especially in vulnerable groups like the seniors [1], certain ethnicities [2], patients with mental health issues [3], and pediatric patients [4,5]. While addressing pain, we sometimes must perform medical procedures which lead to…more pain. This issue is magnified in children where even placement of an IV can be traumatic and painful for a child who does not understand why they’re getting poked. The emergency department can be a painful place to be… We have covered pediatric pain management on the SGEM multiple times. Peds EM superhero, Dr. Anthony Crocco from McMaster University, did one of his rants on pediatric pain. SGEM#78: Sunny Days (Pediatric Pain Control) SGEM#123: Intranasal Fentanyl – Oh What a Feeling SGEM#242: Pain, Pain, Go Away – IN Ketamine vs. IN Fentanyl for Pediatric Pain Management SGEM#378: Keepin’ It REaL when Treating Pediatric Migraine Patients SGEM Xtra: RANThony#3 - Paediatric Pain It is estimated that 1 in 5 children develop chronic pain before childhood. Pediatric pain is one of the costliest chronic conditions, even more so than asthma and obesity [6]. When admitted, children experience an average of 6.3 painful procedures per day and this goes up to 12 in the ICUs! Although evidence-based best practices for addressing pain in children have been published all over the world, we still often fall short. Some of the most serious consequences of untreated pain in children occur much later than the procedure itself. For example, a child who is scared to get an IV: One might think we can hold the child down, bundle them up, and just quickly get it over with, as they need their antibiotics/iv fluids. On that day, we might hear crying and stress from the child, but they will likely settle down and we have successfully delivered out treatment. But there are consequences to this. Poor pain management contributes to avoiding medical care in the future and even vaccine hesitancy [8,9]. This same child, if unvaccinated, may present with serious vaccine-preventable illnesses, require more time and resources for every fever. There is also psychological trauma for the patient, their families, and the healthcare workers who care for them.  Sometimes, healthcare workers think that treating children’s procedural pain takes up precious ED time, like waiting for a topical anesthetic to work. In fact, using pain relief for procedural pain leads to less repeat procedures, better ED flow and shorter lengths of stay. Importantly, children who experience chronic pain are more likely to have mental illness, opioid use, and socioeconomic disparities in adulthood. Canada creates 15% of the world’s pediatric pain research, so it made sense that we would be the first country in the world to create a national standard.  This new standard is divided up into four main themes. Make pain matter: creating a framework to provide better pain care and employing continuous Quality Improvement (QI) Make pain understood: education and knowledge sharing Make pain visible: pain assessment Make pain better: individualized care plans & multi-modal pain strategies Tune into the podcast to hear Dr.