Society for Pediatric Pain Medicine
Better Care for Children in Pain

Correct Answer: B. Pain unpleasantness


Virtual reality (VR), a multimodal system that transports users into a fully immersive virtual world, has been explored as a complementary pain management strategy for many years. Until now, the primary use of VR in both pediatric and adult care has been distraction-based therapy during acutely painful procedures.^1–5 However, given the risks associated with opioid exposure in children, including after surgery,⁶ VR is now being explored as a method of helping to decrease postoperative pain and anxiety after surgery.^7–9


A pilot study done at Cincinnati Children’s Hospital Medical Center explored the use of a single, guided relaxation-based VR session (VR-GR) in children and adolescents following surgery.^8,10 Over a 9-month period, a total of 51 children and adolescents followed by the Acute Pain Service participated in a single, 10-minute session using the “Mindful Aurora” application (Invincikids, Palo Alto, CA). Baseline measurements of pain intensity, pain unpleasantness, and anxiety were taken for each patient and compared to these same values immediately following the experience as well as 15 and 30 minutes following session completion. The VR-GR session was associated with transient reductions in pain intensity, pain unpleasantness, and anxiety. Patient and family satisfaction with the experience was high. Future study is being done to assess the efficacy of VR in decreasing pain, anxiety, opioid, and benzodiazepine consumption via a randomized controlled trial allowing for further exploration of this alternative, non-pharmacological intervention.


References:


1. Malloy KM, Milling LS. The effectiveness of virtual reality distraction for pain reduction: A systematic review. Clin Psychol Rev. 2010;30(8):1011-1018. doi:10.1016/j.cpr.2010.07.001


2. Indovina P, Barone D, Gallo L, Chirico A, De Pietro G, Giordano A. Virtual Reality as a Distraction Intervention to Relieve Pain and Distress During Medical Procedures: A Comprehensive Literature Review. Clin J Pain. 2018;34(9):858-877. doi:10.1097/AJP.0000000000000599


3. Mallari B, Spaeth EK, Goh H, Boyd BS. Virtual reality as an analgesic for acute and chronic pain in adults: a systematic review and meta-analysis. J Pain Res. 2019;Volume 12:2053-2085. doi:10.2147/JPR.S200498


4. Garrett B, Taverner T, Masinde W, Gromala D, Shaw C, Negraeff M. A Rapid Evidence Assessment of Immersive Virtual Reality as an Adjunct Therapy in Acute Pain Management in Clinical Practice. Clin J Pain. 2014;30(12):1089-1098. doi:10.1097/AJP.0000000000000064


5. Li A, Montaño Z, Chen VJ, Gold JI. Virtual reality and pain management: current trends and future directions. Pain Manag. 2011;1(2):147-157. doi:10.2217/pmt.10.15


6. Harbaugh CM, Lee JS, Hu HM, et al. Persistent Opioid Use Among Pediatric Patients After Surgery. Pediatrics. 2018;141(1):e20172439. doi:10.1542/peds.2017-2439


7. Olbrecht VA, Williams SE, O’Conor KT, et al. Guided relaxation-based virtual reality versus distraction-based virtual reality or passive control for postoperative pain management in children and adolescents undergoing Nuss repair of pectus excavatum: protocol for a prospective, randomised, controlled trial (FOREVR Peds trial). BMJ Open. 2020;10(12):e040295. doi:10.1136/bmjopen-2020-040295


8. Olbrecht VA, O’Conor KT, Williams SE, et al. Guided Relaxation-Based Virtual Reality for Acute Postoperative Pain and Anxiety: A Pilot Study in a Pediatric Population. J Med Internet Res. Published online May 4, 2021. doi:10.2196/26328


9. Olbrecht VA, O’Conor KT, Williams SE, et al. Transient Reductions in Postoperative Pain and Anxiety using Virtual Reality in Children. Pain Med Malden Mass. Published online June 27, 2021:pnab209. doi:10.1093/pm/pnab209


10. O’Conor KT, Olbrecht VA. Using Guided-Relaxation Based Virtual Reality to Manage Post-Surgical Pain and Anxiety in Children. Society for Pediatric Pain Medicine Newsletter. https://pedspainmedicine.org/wp-content/uploads/newsletters/2021/summer/VR/guided%20relax.html. Published Summer 2021. Accessed September 20, 2021.

Correct Answer: A. One night


Sleep is a highly complex process that is essential for recuperation, memory, emotional modulation, performance and learning.1 Disturbances in sleep have been shown to impact all areas of functioning as well as acute and chronic pain in children.2 The directionality between sleep and pain, where poor sleep results in increased pain or increased pain results in poor sleep, have been highly debated. In adult populations, more recent evidence has showed a stronger effect of poor sleep resulting in worsening pain as opposed to the bidirectional relationship that was previously thought.1 A single night of sleep deprivation in patients with arthritis resulted in increased self-reported pain.3 Further, experimental studies in healthy volunteers showed that two nights of poor sleep resulted in spontaneous bodily pain after partial sleep deprivation.3


The pediatric literature is less clear. In the acute pain setting, evidence seems to indicate that poor sleep was associated with greater next day pain.4 In youth with sickle cell disease, pain and sleep seemed to be bidirectional.5 Comorbidities and socioeconomic factors also affect sleep in children.6,7 Although further studies are needed to establish the sleep-pain relationship, poor sleep in children with pain should be addressed and improved.


References:


1. Babiloni AH, De Koninck BP, Beetz G, De Beaumont L, Martel MO, Lavigne GJ. Sleep and pain: recent insights, mechanisms, and future directions in the investigation of this relationship. Journal of Neural Transmission. 2020;127:647-660.


2. Valrie CR, Bromberg MG, Palermo T, Schanberg LE. A Systematic Review of Sleep in Pediatric Pain Populations. J Dev Behav Pediatr. 2013;34(2):120-8.


3. Finan, PH, Goodin BR, Smith MT. The association of sleep and pain: an update and a path forward. J Pain. 2013;14(12): 1539-1552.


4. Rabbitts JA, Zhou C, Narayanan A, Palermo TM. Longitudinal and Temporal Associations Between Daily Pain and Sleep Patterns After major Pediatric Surgery. J Pain. 2017;18(6):656-663.


5. Fisher K, Laikin AM, Howard Sharp KM, Criddle CA, Palermo TM, Karlson CW. Temporal relationship between daily pain and actigraphy sleep patterns in pediatric sickle cell disease. J Behav Med. 2018;41(3):416-422.


6. Allen JM, Graef DM, Ehrentraut JH, Tynes BL, Crabtree VM. Sleep and Pain in Pediatric Illness: A Conceptual Review. CNS Neurosci Ther. 2016;22(11):880-893.


7. Evans S, Taub R, Tsao JCI, Meldrum M, Zeltzer LK. Sociodemographic factors in a pediatric chronic pain clinic: The roles of age, sex and minority status in pain and health characteristics. J Pain Manag. 2010;3(3):273-281.

Correct answer: (C) Improves local vasodilation and oxygen delivery


Pharmacotherapy for Sickle Cell Disease vaso-occlusive crisis targets peripheral and central nociceptive and inflammatory-mediated pathways. The 2020 American Society of Hematology (ASH) guidelines for the management of acute and chronic pain in Sickle Cell Disease (SCD) provided updated recommendations for multimodal treatment modalities with the introduction of regional anesthesia to this pathway. Regional anesthesia blunts autonomic nociception and the inflammatory response for surgical stimulants, while promoting local vasodilation to improve tissue oxygenation. These characteristics are beneficial for SCD patients with vaso-occlusive crisis (VOC). Two pediatric prospective observational reports demonstrated decreased opioid consumption, improved oxygenation and activity rehabilitation following the thoracic epidural analgesia for severe sickle cell mediated acute chest syndrome. However, there is no literature replicating this with peripheral nerve blockade and SCD-VOC. The up-regulation of interleukins (ILs), cytokines and endothelial adhesion molecules details the pathophysiology of the microvascular occlusion characteristic of VOC. Furthermore, there are no regional anesthesia studies investigating the up-regulation or down-regulation of inflammatory markers specific to SCD-VOC. Albeit, several surgical case reports have demonstrated the reduction in the inflammatory response following regional anesthesia; suggesting this effect may be seen in patients with SCD-VOC after receiving regional anesthesia as well. Further investigation into the pathophysiology of regional anesthesia for SCD-VOC is prudent.


References:


1. Tighe PJ, Elliott CE, Lucas SD, et al. Noninvasive tissue oxygen saturation determined by near-infrared spectroscopy following peripheral nerve block. Acta Anaesthesiol Scand 2011:55(10):1239-1246.


2. Weber G, Liao S, Burns MA. Sciatic (Popliteal Fossa) Catheter for Pediatric Pain Management of Sickle Cell Crisis: A Case Report. A A Case Rep 2017:9(10):297-299.


3. Wyatt KE, Pranav H, Henry T, et al. Pericapsular nerve group blockade for sickle cell disease vaso-occlusive crisis. J Clin Anesth 2020:66:109932.


4. Yaster M, Tobin JR, Billett C, et al. Epidural analgesia in the management of severe vaso-occlusive sickle cell crisis. Pediatrics 1994:93(2):310-315.


5. New T, Venable C, Fraser L, et al. Management of refractory pain in hospitalized adolescents with sickle cell disease: changing from intravenous opioids to continuous infusion epidural analgesia. Journal of pediatric hematology/oncology 2014:36(6):e398-402.


6. Brandow AM, Carroll CP, Creary S, et al. American Society of Hematology 2020 guidelines for sickle cell disease: management of acute and chronic pain. Blood Adv 2020:4(12):2656-2701.


7. Wyatt KE, Liu CJ. Regional Anesthesia for Sickle Cell Disease Vaso-occlusive Crisis. SPPM Newsletter Fall 2020.

Correct Answer is C. A case series of 8 patients showed significant reduction in pain scores after receiving propofol in patients who failed a combination of triptans, opioids, NSAIDs, or steroids


RATIONALE:


Migraine headaches can cause severe, disabling pain, leading many patients to present to the Emergency Room (ER) in search of pain relief. Migraines are common in children with prevalence of 5% by age 10 and this increases further during adolescence. The use of propofol for refractory migraines is currently being investigated. A retrospective study on children with migraines showed propofol to be an effective abortive treatment. (1). In another study, even though propofol was not superior to standard therapy, it resulted in fewer rebound headaches and shorter length of stay. (2) A RCT in adults concluded that propofol can be used for management of acute migraines with decreased rates of recurrence in the propofol group compared to the Sumatriptan group. (3) A case series of 8 patients showed significant reduction in pain scores after receiving propofol in patients who failed a combination of triptans, opioids, NSAIDs, or steroids. (4) Propofol works by increasing GABA-mediated inhibitory tone in the CNS. Propofol decreases the rate of dissociation of the GABA from the receptor, thereby increasing the duration of the GABA-activated opening of the chloride channel with resulting hyperpolarization of cell membranes.


Migraines result from a combination of lifestyle, environmental, and genetic factors. The risk of suffering from migraines is about 50% higher among those who have a first degree relative with migraines. Certain disorders that affect children have been associated with migraines and may represent manifestations of migraine genes in their early years. Ability to diagnose and treat migraines in a timely manner may decrease disability, minimizing days away from school and the negative impact on social life. Preventive treatment includes lifestyle modifications, cognitive behavior therapy and medications. The Pediatric Migraine Disability Assessment (PedMIDAS) is a useful tool in assessing the degree of disability and the response to treatment.


REFERENCES:


1. Gelfand A., Pediatric and adolescent headache. Continuum (MINNEAP MINN), 2018; 24(4): 1108-1136


2. Sheridan D.C., Spiro D. M., Nguyen T., Koch T.K., Mackler G.D., Low dose Propofol for the abortive treatment of pediatric migraine in the emergency department. Pediatric Emergency Care, 2012; 28(12): 1293-1296


3. Sheridan D.C., Hansen M.L., Lin A.L., Fu R., Meckler G.D., Low dose Propofol for pediatric migraine: A prospective, randomized controlled Trial. Journal of Emergency Medicine. 2018; 54(5):600-606


4. Moshtaghion H., Heiranizadeh N., Rahimdel A., Esmaeili A., Hashemian H., Hekmatimoghaddam S., The efficacy of Propofol vs. subcutaneous Sumatriptan for treatment of acute migraine headaches in the emergency department: A double-blinded clinical trial. Pain practice, 15(8), 701-705.