Treating children with chronic pain


-Good morning thank you for joining us in our webinar presentation today as we talk about treating chronic pain in children. My name is Shalini Shah I’m director of pediatric pain services here at UC Irvine health and it is my pleasure to talk to you today about what pain means in children, how we assess it, what we do at UC Irvine to treat pain in children, and what are some things that you can do as a parent at home for your child in pain. Welcome to our parents and welcome to our medical colleagues to join us today let’s start by discussing imagine what pain feels like in children well it can look like a variety of things and some children it can be a daily headache it just doesn’t go away sometimes I think of the image of the child who fell on the playground and they have a little scrape or a sprain as a result sometimes I think of the child who has a persistent tummy ache every night after dinner but just won’t go away and despite that the fact that this looks relatively benign the feeling that the children have inside can be much more some children describe it as an electrical sensation strolled of electricity in the body sometimes it can be described as a burning sensation like walking on hot coals some very rare cases even the most benign stimulus the smallest stimulus of a feathers touching the skin or bed sheets at night can cause incredible amount of pain I’ll give you an example I had a patient her name was jenny well she was an energetic 13 year old girl a very talented ballerina and when she came to her pediatrician she was complaining of heel pain she said she probably fell in ballet class nothing out of the ordinary nothing that’s unusual for her she went to her pediatrician the pediatrician to the appropriate workup she was diagnosed with a heel sprain and was treated appropriately here is a picture of her leg wrapped an ace bandage is healing well but what happened over the next two years was very interesting the pain started to come back even after the original heel sprain had healed the pain grows gradually increased she went back to her pediatrician the work was negative the MRI was negative for any edema the x-rays were negative for any fractures she even a blood tests which were negative for infection so her pediatrician referred her to the orthopedic surgeon who then referred to the neurologist to the rheumatologist she had gone from Doctor to doctor to doctor for multiple opinions and in the meantime the pain just kept getting worse and this is an example of how she presented when she first came to our clinic she had an intense amount of pain and this is what had happened because the paint had gone so long untreated now thankfully this is a very rare case most children do not progress to this stage but what I want to hone in on is that here left untreated even the most simple stimulus of a feather touching the skin is exquisitely painful so the question then becomes how did the brain perceive this so wrong well conventionally pain is protective mechanism when we put our hand on the stove the signal from the stove goes to our hand goes to our spinal cord up to the brain and tells us you got to remove that hand from the stove it protects us it’s a variety of pain signaling pathways that help us process pain but what we have actually learned over the last three and four decades is that it’s not just about pain signaling that determines how much we feel pain but it’s this conceptual framework of how old the child is what’s going on at home underlying anxiety or depression the expectations of the child how high functioning the child is that determines what kind of pain they’re going to perceive so let’s take a step back and talk about what types of pain we see and treat commonly gratefully most of the types of pain that we treat in children are benign which means that there’s no structural changes or body tissue injury in most cases for our athletic children our divers, our gymnasts, our baseball players they you should complain a back pain or limb pain and that goes along because of the repetitive injury that they have sometimes we see headache this can be the migrant type of headache or just that chronic daily headache that never goes away in some other cases we see abdominal pain in fact one of the most common complaints of children when they go to a gastroenterologist is abdominal pain and they’ve gone through the multiple workup of CAT-scans, endoscopies, colonoscopies and nothing is wrong thankfully nothing is wrong but the impact that this has on the child is enormous because when the child is sick they don’t go to school and when they don’t go to school they don’t perform they are held back they don’t graduate on time and essentially what we have is that the child is now no longer able to fulfill their full potential in life so now let’s go back to Jenny. What Jenny was suffering from is something what we call complex regional pain syndrome or CRPS it’s a nerve type of pain syndrome that’s associated with color changes and temperature changes but what I want to let you know on when the pain is left untreated the pain is no longer just a symptom of the disease but it becomes a disease in and of itself and here’s that picture again where that smallest stimulus causes intense amount of pain when the pain goes untreated but thankfully it’s a responds very well to therapy so this is Jenny just four weeks after therapy this is no magical treatment this is just medications and physical therapy and this is her at eight weeks of therapy back to ballet class and this is her at 12 weeks at three months she came into the office and she came in her ballet outfit to surprise me she’s back on point for any of your ballerinas out there she’s back on point and she’s doing extremely well so now I want to move on to how we treat pain in children. Historically we used to have a belief that children especially infants do not feel pain and if they did well they don’t create a memory of pain and if we treat pain hey we may create addicts in our children by giving them pain killing medications so overall we had a belief that preventing pain in children had no long-term benefit and it really just took too much time and effort over the last thirty and forty years significant amount of research has been done which demonstrated that just like any other chronic illness like hypertension like diabetes pain itself has a chronic effect so from the physiological standpoint the children are always revved up their heart rate is elevated the respiratory rate is elevated they have high blood pressure they’re constantly functioning at this fight or flight response system metabolically hormones are secreted the children don’t heal their wounds appropriately they don’t want to eat they don’t want to sleep because of the pain and then when they finally do fall asleep they can’t stay asleep because of the pain they don’t want to function they don’t want to go to school and they’re chronically irritable and can you imagine the toll that this takes not only on the child but as on the family as well so what we have essentially is a cycle of pain pain brings on decreased activity which brings on decrease school performance because the children don’t want to get up and go to school and now they’re being held back and because of that now they’re not sleeping well and when they’re not sleeping well they feel socially isolated because here they are they’re not in school they’re not going to baseball camp they’re not in basketball camp they’re not playing with the children on the playground so they feel isolated from their own friends and that begins some anxiety and depression and what you have is this downward spiral of negative consequences so when is it time to see a pediatric pain specialist well as a mom you can ask yourself when are we beyond something just being wrong and as a pediatrician you can ask yourself how do you know when it’s time to refer well as a pediatric pain specialist we have the tools necessary to assess children appropriate to their level of functioning for example toddlers and preschool children are not able to localize pain which means they cannot tell your mommy it’s my arm that’s hurting or it’s my leg that hurts they’re not able to localize pain so we have to rely on a faces scale in which they’re able to point to the diagram that most corresponds to them at that moment the older children they’re able to communicate a little bit more effectively in regards to their pain they can use abstract terms burning stabbing stinging squeezing type of pain descriptions they respond very well to direct questioning and we also use faces scales and body outlines and visual analogue scales and that’s something that means on a scale of 1 to 10 how severe is your pain because conceptually they’re able to understand that now the bottom line is pain exists wherever it is and exists whenever the patient says it does and that’s what I want to really let our community physicians know is that as a parent we shouldn’t be so dismissive or as a practitioner we shouldn’t be so dismissive of our complaints in our children of pain so what is our approach well at UC Irvine we have a center for comprehensive pain management and what we do is we take a multidisciplinary approach to the child that means we take a 360 degree evaluation of the child from the medical doctors perspective from the psychologists perspective hey is there any anxiety is there any depression how are they functioning in school we also a physical therapist it evaluates the child and that person is looking for mobility functioning and strength and for example when I see the child in initial consultation I sit down with the family it’s about 30 minutes to an hour interview and we sit down and we talk together we talk about the pain we talked about how it started but we also talked about the other impact on the family how is the child going to school are they doing well in school were they previously an A student and now they’re functioning at a B and C level are they sleeping all right what’s going on at home are mom and dad going through a divorce is one child getting a lot more attention than this child and that’s why the pain is coming on the psychological cycle psychologists will also do some educational and personality testing so we really get to understand who this child is and what we have found is that there’s significant amount of core morbidity with children in pain and with psychiatric diagnosis and what that means is that we often find children who have pain also have psychiatric diagnoses it’s not that one leads to the other but they frequently co-occur bottom line is that we have commitment to a therapeutic alliance okay we see your children at UC Irvine we also discuss the case with all of your physicians we speak with your pediatrician we speak with your rheumatologist your orthopedic surgeon your neurologist your physical therapist and we come and make a complete goal for the child parents you can do the same thing at home you shouldn’t get to the point where you feel that the pain has taken over the mind the body and the spirit of the child you should not feel that this has unraveled the family life and just breaking up the family I’ll give you an example for me when we were living in Boston I had a daughter she was or have a daughter at that time she was a year old and she suffered a burn injury to both of her legs it was very unfortunate from a babysitter accident and we used to go to the burn hospital from daily burn dressing changes and if anyone knows anything about burns after a burn the skin is very raw the nerve endings are exposed and doing burn dressing changes exquisitely painful so I am thinking to myself how is my daughter going to handle this I’m revved up I started to unravel Here I am as a pediatric pain specialist and I’m falling apart what I realized that if I brought a low anxiety state to the scenario and I call myself down I did my breathing techniques my child did well she handled it like a champ and that’s what I want to let you know as mom and dads out there that you can do the same thing at home I was able to distract my daughter I was able to bring her to our happy place and sing songs she didn’t even know what was going on so you know the bottom line is is that the children must learn to function in spite of pain just because there is pain doesn’t mean that there is something wrong with the body you have to keep moving you have to keep functioning as pediatricians in the office you may want to obtain a history in a very low anxiety very calm environment you want to use some of those tools and assessment strategies that we talked about using the phase of skill the younger children remembering that they cannot localize pain you might want to be able to talk about abstract term squeezing burning those type of things with the older children overall the top 10 reasons to refer to a pediatric pain lists are when the pain persists it’s been longer than three months and the pain has not been relieved when there are changes in sensory or motor functioning in the child that previously weren’t there when the child has been stored on prescription painkillers you want to see a specialist who manages pain consistently when the child is starting to withdraw from activities they’re not going on the baseball team or they’re not playing in the swimming pool with the other kids there’s behavioral changes have started to set up there’s anxiety some depression that you see some mood changes school performance starts to decline not only they’re not going to school but when they do go to school they’re not staying for the entire school period they’re leaving early they have tardies they’re late to school they used to be an A student and not anymore sleep disturbances they’re not able to fall asleep and if they are they’re not able to stay asleep you go from Doctor to doctor to doctor to treat the pain and still the pain persists even when the original injury is healed and that’s the case in Jenny remember the ankle had healed the sprain had been relieved but the pain persisted and when you refer when you think about it the earlier we are in preventing pain and children the better off the results are the long-term outcomes so goals of management in pain management yes I want to decrease pain and suffering in children but that’s not the only goal I want these children to function I want them to get up and go back to sports that they enjoyed I want the family to be united again often this can take a toll on the family just like any chronic illness we want the family to be united and not be chronically stressed about this I want the children to promote coping mechanisms hey I don’t really need to rely on medications or physical therapy or things like that I can do this myself when the pain becomes too much I’m going to relax I’m going to breathe through it and I can do it and I want to decrease patients raised from long-term complications and what I really want you to let you know is that success is on your side thankfully most pain syndromes and children are benign and most relief over time and weird working within a few weeks to a few months so success is on your side bottom line is is that you are the key as parents you’re with your child day in and day out and from one mother to another I want to let you know I have been there too and you can do this you have the tools to assess your children appropriately and you have the tools to make it better so thank you for joining us today it was my pleasure to speak about pain in children and now I’m happy to take any questions you may have through Twitter and through Facebook all right so let’s see okay some of the questions that have come in all right how long will my child continue to be in pain will this continue on to her adulthood well that’s a very good question as we just described thankfully most pain syndromes in children do resolve in fact 90-95% of pain syndromes in children do resolve so with the right therapy with the right eyes on the child with the right medications and physical therapy I’m happy to report that most of the pain syndromes will resolve how does treatment with the pediatric pain specialist differ than the pediatrician that’s a very very good question the pediatrician is a vital part of your child’s health they manage the child as a whole they are the home for the child they manage all the developmental milestones as well as the common ailments you may see ear aches and toothaches and and respiratory infections and things like that but when it comes to specialized things such as pain medicines such as neurological issues you want to really refer to people who have an eye for dealing with these type of syndromes on a daily basis so as a pediatric pain specialist my eyes are on dealing with the pain effectively and making sure that the all the other things that we talked about sleep school eating things like that personality all improve as well all right these are great questions okay I’m a doctor in the community how can I have my patients seen by you okay very good question you are here at some contact information for our clinic at UC Irvine but to ensure a smooth referral process what I would like for you to do is collect all the progress notes that you have on the child including the initial consultation and the exams that you may have ordered or test results and make a nice packet and fax it to our office or give us a ring at 949 UCI pain and we’d be happy to start the referral process for you okay can I use my pain doctor to treat my daughter’s pain that’s a very interesting question i get that quite a bit a lot of adults that i see have pain and their children consequently have pain as well and you should they say hey a pain doctors a pain doctor right can I just go to my normal pain doctor the answer is no you can but you really want someone again who focuses on pediatrics and like we talked about it’s not just the pain that we’re trying to treat but it’s the global health of the child the functioning the school performance and we take that all into consideration when we treat the child we’re not just treating the pain okay my child has missed a lot of school due to his pain are there any resources you can recommend to help that is a fabulous question a fabulous question because as we talked about most of the children are not in school or some children are missing school because of their pain so what we do with our team is speak with the school directly we get on the phone and we talked about how much school is missed and what plans we can put into place with the school district to help the child a catch up and be give the child more allotment for test taking for homework assignments things like that so we help you with the entire process like I said we’re in this for the child to improve and to live his or her full potential so whatever we can do please do not hesitate to ask us okay these are wonderful questions keep them coming in no questions of bad questions okay let’s see why are antidepressants and seizure medications commonly used in the treatment of pain well that’s a good question so what we have learned over the last 60 to 70 years in in regards to pain research is that pain travels in the same tracks with anxiety depression and that when we’re able to treat the anxiety depression we did a better job at treating the pain and it’s not to say that you treat one and the other one will be relieved but pain is easier to treat when we attack the anxiety depression first that’s why we typically use antidepressants for a treatment of pain that’s a very good question okay my child is currently on prescription painkillers is it safe so like we talked about prescription painkillers do have an addiction potential and we call the medical community a dependence physical dependence and over time what we have noticed is when the child comes in with a five out of ten pain they’re on chronic prescription pain killing medications sometimes that the pain progresses it progresses to a 6 out of 10 to seven and 10 despite being on pain-killing medications so a the pain can get worse with these types of medications and be there is an addictive potential so it opens up the closet to alcohol abuse in the future tobacco abuse in the future and again not living to your full potential so as much as we can we try to get the children off the pain killing medications we have a variety of other things that we can offer children and they do remarkably well so even in the absence of pain killing medications your children do but do well these are wonderful okay how can a pediatrician like myself provide the best pain care to their patients very good question like I talked about you want to evaluate the child in a low anxiety environment you want to keep the room dimly lit and don’t use the word pain the more you focus on the pain the more their system gets wrapped up use other words when when this happens to you what do you feel use worse that they may relate to owie or booboo or things like that you don’t want to use the word pain okay when you talk about treating pain in children the other thing you want to do is distract the child so while you’re talking to mom or why you’re doing your physical exam you really want to use a lot of distracted distraction techniques candy lollipops games things like that so the child is not focused on pain because you also want to evaluate their functioning so distraction is good to evaluate functioning as well okay what other questions do we have these are wonderful questions can you describe me why we use nerve blocks to treat pain okay that’s a very good questions not all children when they have pain or not all adults when we have pain will need nerve blocks there are a variety of ways that we can variety methods that we have to treat pain sometimes it’s medications sometimes it’s physical therapy sometimes it’s just time and the pain goes away in some cases where there is a distinct nerve injury or a nerve pain syndrome it may be beneficial to block the nerve with the combination of medications and and that will help a take come off medications and be give you some persistent long lasting relief to decrease inflammation very good questions and I think we have them all so thank you very much it was truly my pleasure to speak with you today it’s obviously my passion to talk about pain and children how we can treat it effectively in a very meaningful way and I really appreciate your response on Twitter and on Facebook with wonderful questions you have and at any point please feel free to contact me thank you very much

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