At the new Walnut Creek Clinic in the East Bay of the San Francisco Bay area, kids get a "Comfort Promise."
The clinic extends the work of the Stad Center for Pediatric Pain, Palliative & Integrative Medicine beyond the locations in University of California San Francisco Benioff Children's Hospitals in San Francisco and Oakland.
At Walnut Creek, clinical acupuncturists, massage therapists, and specialists in hypnosis complement advanced medical care with integrative techniques.
The "Comfort Promise" program, which is being rolled out at that clinic and other UCSF pediatric clinics through the end of 2024, is the clinicians' pledge to do everything in their power to make tests, infusions, and vaccinations "practically pain free."
Needle sticks, for example, can be a common source of pain and anxiety for kids. Techniques to minimize pain vary by age. Among the ways the clinicians minimize needle pain for a child 6- to 12-years-old are:
Stefan Friedrichsdorf, MD, chief of the UCSF division of pediatric pain, palliative & integrative medicine, said in a statement: "For kids with chronic pain, complex pain medications can cause more harm than benefit. Our goal is to combine exercise and physical therapy with integrative medicine and skills-based psychotherapy to help them become pain free in their everyday life."
Bundling appointments for early impact
At Lurie Children's Hospital of Chicago, the chronic pain treatment program bundles visits with experts in several disciplines, include social workers, psychologists, and physical therapists, in addition to the medical team, so that patients can complete a first round of visits with multiple specialists in a short period, as opposed to several months.
Natalie Weatherred, APRN-NP, CPNP-PC, a pediatric nurse practitioner in anesthesiology and the pain clinic coordinator, said in an interview that the up-front visits involve between four and eight follow-up sessions in a short period with everybody in the multidisciplinary team "to really help jump-start their pain treatment."
She pointed out that many families come from distant parts of the state or beyond so the bundled appointments are also important for easing burden on families.
Sarah Duggan, APRN-NP, CPNP-PC, also a pediatric nurse practitioner in anesthesiology at Lurie's, pointed out that patients at their clinic often have other chronic conditions as well, such as such as postural orthostatic tachycardia syndrome so the care integration is particularly important.
"We can get them the appropriate care that they need and the resources they need, much sooner than we would have been able to do 5 or 10 years ago," Ms. Duggan said.
Virtual reality distraction instead of sedation
Henry Huang, MD, anesthesiologist and pain physician at Texas Children's Hospital, Houston, said a special team there collaborates with the Chariot Program at Stanford (Calif.) University and incorporates virtual reality to distract children from pain and anxiety and harness their imaginations during induction for anesthesia, intravenous placement, and vaccinations.
"At our institution we've been recruiting patients to do a proof of concept to do virtual reality distraction for pain procedures, such as nerve blocks or steroid injections," Dr. Huang said.
Traditionally, kids would have received oral or intravenous sedation to help them cope with the fear and pain.
"We've been successful in several cases without relying on any sedation," he said. "The next target is to expand that to the chronic pain population."
The distraction techniques are promising for a wide range of ages, he said, and the programming is tailored to the child's ability to interact with the technology.
He said he is also part of a group promoting use of ultrasound instead of x-rays to guide injections to the spine and chest to reduce children's exposure to radiation. His group is helping teach these methods to other clinicians nationally.
Dr. Huang said the most important development in chronic pediatric pain has been the growth of rehab centers that include the medical team, and practitioners from psychology as well as occupational and physical therapy.
"More and more hospitals are recognizing the importance of these pain rehab centers," he said.
The problem, Dr. Huang said, is that these programs have always been resource intensive and involve highly specialized clinicians. The cost and the limited number of specialists make it difficult for widespread rollout.
"That's always been the challenge from the pediatric pain world," he said.
Recognizing the complexity of kids' chronic pain
Angela Garcia, MD, a consulting physician for pediatric rehabilitation medicine at UPMC Children's Hospital of Pittsburgh said recognizing the validity and complexity of pediatric pain has led to multidisciplinary approaches and specialty clinics for chronic pain instead of primarily pharmaceutical solutions.
Techniques such as biofeedback and acupuncture are becoming more mainstream in pediatric chronic care, she said.
At the UPMC clinic, children and their families talk with a care team about their values and what they want to accomplish in managing the child's pain. They ask what the pain is preventing the child from doing.
"Their goals really are our goals," she said.
She said she also refers almost all patients to one of the center's pain psychologists.
"Pain is biopsychosocial," she said. "We want to make sure we're addressing how to cope with pain."
Dr. Garcia said she hopes nutritional therapy is one of the next approaches the clinic will incorporate, particularly surrounding how dietary changes can reduce inflammation "and heal the body from the inside out."
She said the hospital is also looking at developing an inpatient pain program for kids whose functioning has changed so drastically that they need more intensive therapies.
Whatever the treatment approach, she said, addressing the pain early is critical.
"There is an increased risk of a child with chronic pain becoming an adult with chronic pain," Dr. Garcia pointed out, "and that can lead to a decrease in the ability to participate in society."
Ms. Weatherred, Ms. Duggan, Dr. Huang, and Dr. Garcia reported no relevant financial relationships.
This article originally appeared on MDedge.com, part of the Medscape Professional Network.
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