Four steps to eliminate or reduce pain in children caused by needles (part 1)

Written by Friedrichsdorf SJ

Dr Stefan Friedrichsdorf speaks to Jade Parker, Commissioning Editor: Stefan J Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children’s Hospitals and Clinics of Minnesota, Minneapolis/St Paul, MN, USA, home to one of the largest and most comprehensive programs of its kind in the country. The interdisciplinary pain team is devoted to prevent and treat acute, procedural, neuropathic, psycho-social-spiritual, visceral, and chronic/complex pain for all inpatients and outpatients in close collaboration with all pediatric subspecialties at Children’s Minnesota. The palliative care team also provides holistic care for pediatric patients with life-threatening diseases and adds an extra layer of support to the care of children with serious illness and their families. Integrative medicine provides and teaches integrative (‘non-pharmacological’) therapies, such as massage, acupuncture/acupressure, biofeedback, aromatherapy and self-hypnosis, to provide care that promotes optimal health and supports the highest level of functioning in all individual children’s activities. Children’s Minnesota became the first children’s hospital to system-wide implement a “Children’s Comfort Promise: We promise to do everything to prevent and treat pain,” resulting in decrease or elimination of needle pain caused by vaccinations, blood draws, intravenous access, and injections in more than 200,000 children annually.
Q Children’s Minnesota’s Department of Pain Medicine, Palliative Care & Integrative Medicine is one of the largest programs of its kind the USA & won the American Pain Society Clinical Centers of Excellence Award in 2013. It recently became the first children’s hospital, which after internal roll-out at four pilot organizations, received the prestigious ChildKind certification. ChildKind is a global initiative aimed at reducing pain & unnecessary suffering in children by offering a special designation to those facilities that have demonstrated an institutional commitment to pain relief & by providing the technical support to achieve that goal. In your opinion what is it about the center that makes it stand out so distinctly?

According to the 2010 Declaration from Montréal, access to pain management is a fundamental human right and it represents a human right violation not to treat pain [1]. We have learned in our field and here at Children’s Minnesota that providing excellent pain prevention and treatment in babies, toddlers, school kids and teenagers is so much more than just prescribing medication. Thanks to our organization’s leadership and interdisciplinary pediatric care team members, we developed a very unique program at our institution. Now, we are able to utilize multimodal analgesia – that is, many different modalities concurrently, to achieve optimal pain control with the least amount of side effects in children.

At Children’s Minnesota, we are using advanced pharmacology, aiming to use the right amount of the right medication via the best route of administration. This may mean using simple analgesia and/or adjuvants and/or opioids, which not infrequently means rotating from one opioid to another. We have also found that advanced pain control commonly includes the integration of rehabilitation, physical therapy and exercise, occupational therapy, child life, psychology, including cognitive behavioral therapy and, most importantly, active integrative ‘non-pharmacological’ modalities. We are proud to have one of the largest integrative medicine programs in the USA and as such we teach children and their caregivers both inpatient and in our clinic many modalities including deep breathing, progressive muscle relaxation, self-hypnosis and biofeedback. In addition, we offer aromatherapy, massage, acupuncture and acupressure [2]. All in all, this whole package has shown that we can provide much better pain control, and when we started regular audits, we were able to demonstrate how we successfully implemented a system-wide change toward better analgesia and higher patient satisfaction.

In 2013, when we received the Center of Excellence Award from the American Pain Society, I believe the panel recognized that, on the one hand, we are a rather active pain service, which takes care of not only children with acute pain but also with procedural, chronic, psychosocial–spiritual and neuropathic pain. As part of the above-mentioned multimodal analgesia, we are also utilizing pharmacological modalities and anesthetic interventions including neuroaxial anesthesia such as epidural or paravertebral analgesia and nerve blocks, as well as using an interdisciplinary pain clinic model.

Additionally, our advocacy and training was recognized. By running the international pediatric pain master class [3], the largest pediatric pain course of its kind annually in Minneapolis and after having trained more than 500 physicians and nurse practitioners from more than 30 countries, we have shown that we are not only interested in providing excellent pain care here in our area but that we are also very interested in teaching and providing this knowledge nationally and internationally. In addition, we have trained more the 450 professional ‘Trainers’ through the comprehensive Education in Palliative and End-of-Life Care (EPEC) – Pediatrics curriculum, made possible by a US$1.6 million grant by the NIH/National Cancer Institute [4].

Children’s Minnesota recently received the prestigious ChildKind designation [5] certifying that we were able to demonstrate an institutional commitment to pain relief and provide the technical support to achieve that goal. Our pain service is fully integrated within the hospital, and all employees including nurses, social workers, clinicians, physicians, physiotherapists, among others, have access to modalities to provide best pain prevention and treatment. Importantly, our hospital leadership has made this a priority in patient care and made it part of the institution’s strategic goals.

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