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. Ali's answers to my questions below: Working Group and Technical Group Members There were many stakeholders involved in the creation of this standard (emergency medicine, anesthesia, psychologists, and chronic pain physicians, nurses, physical therapists, pharmacists, child life, patients, and families. Working with such a multi-disciplinary group, was there any insight provided by a non-physician member that you found particularly enlightening? Make Pain Matter The framework  includes six main points: People-centred care and building trust Policies for pediatric pain management Culture of patient safety and incident reporting Pain education curriculum Variety of validated pain assessment tools Goals and objectives for QI around pediatric pain management. Can you give some examples at your own institution of these practices in action? There are many challenges healthcare is currently facing. How do you convince organizational leaders that pediatric pain management should be a priority? Make Pain Understood This section emphasizes education around health inequities and mentions specific groups such as Indigenous, people of colour, immigrants, non-English/French speaking families, patients who represent all aspects of the gender spectrum, patients with disabilities (include neurodiverse and/or developmental disabilities, and nonverbal). The standard uses the term “evidence-informed” rather than “evidence-based.” Can you tell us the difference between these two terms and why you chose to use one over the other? Make Pain Visible Pain assessment includes both qualitative and quantitative pain measures. Often in pediatrics, we get reports of pain from both the child and the family. Previous research has demonstrated that sometimes, the correlation between the pain that the child reports compared to what the caregiver does not fully align [10]. Do you have any tips for how to navigate this situation? Do you find these scales clinically useful, or should we just simply be asking, “is your pain better, worse, or the same?” Make Pain Better This section emphasizes partnership with the child and family in developing an individualized care plan that everyone is held accountable to. You refer to something called a “best possible medication history (BPMH).”Can you tell us what this means? This standard includes some useful charts that give specific strategies for physical, psychosocial, pharmacologic strategies for acute pain and chronic pain management. Psychosocial strategies may be a challenge to implement. Who is responsible for instituting these strategies (child life, psychiatry, psychology)? Do all children need it? Practical Application I presented four clinical scenarios for Dr. Ali to demonstrate what these themes look like in practice. Child who is needle phobic and needs some blood drawn. Child with appendicitis. Infant who needs a full septic work up (lumbar puncture, blood draw, urine) Child with arm fracture that needs reduction Strategies for Implementation What strategies is the work group using to see that these standards are not just implemented in Canada but around the world? The SGEM will be back next episode doing a structured critical appraisal of a recent publication. Trying to cut the knowledge translation window down from over ten years to less than one year using the power of social media. So, patients get the best care, based on the best evidence.   Remember to be skeptical of anything you learn, even if you heard it on the Skeptics’ Guide to Emergency Medicine. References: Cavalieri TA. Management of pain in older adults. J Am Osteopath Assoc. 2005;105(3 Suppl 1):S12-17. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergency department analgesia. JAMA. 1993;269(12):1537-1539. Simon LJ, Bizamcer AN, Lidz CW, Stefan S, Pletcher MJ. Disparities in opioid prescribing for patients with psychiatric diagnoses presenting with pain to the emergency department. Emerg Med J. 2012;29(3):201-204. Brown JC, Klein EJ, Lewis CW, Johnston BD, Cummings P. Emergency department analgesia for fracture pain. Ann Emerg Med. 2003;42(2):197-205. Selbst SM, Clark M. Analgesic use in the emergency department. Ann Emerg Med. 1990;19(9):1010-1013. Groenewald CB, Wright DR, Palermo TM. Health care expenditures associated with pediatric pain-related conditions in the United States. Pain. 2015;156(5):951-957. Trottier ED, Ali S, Doré-Bergeron MJ, Chauvin-Kimoff L. Best practices in pain assessment and management for children. Paediatr Child Health. 2022;27(7):429-448. Pate JT, Blount RL, Cohen LL, Smith AJ. Childhood medical experience and temperament as predictors of adult functioning in medical situations. Children’s Health Care. 1996;25(4):281-298. Taddio A, Ipp M, Thivakaran S, et al. Survey of the prevalence of immunization non-compliance due to needle fears in children and adults. Vaccine. 2012;30(32):4807-4812.Groenewald CB, Wright DR, Palermo TM. Health care expenditures associated with pediatric pain-related conditions in the United States. Pain. 2015;156(5):951-957.Míguez-Navarro MC, Escobar-Castellanos M, Guerrero-Márquez G, Rivas-García A, Pascual-García P, Clinical Working Group of Analgesia and Sedation of the Spanish Society for Pediatric Emergencies (SEUP). Pain prevalence among children visiting pediatric emergency departments. Pediatr Emerg Care. 2022;38(5):228-234. Escobar-Castellanos M, Míguez-Navarro MC, García-Mancebo J, et al. How much do parents know about pain in their children? Pediatr Emerg Care. 2023;39(1):40-44.