Society for Pediatric Pain Medicine
Better Care for Children in Pain

May's Question Submitted By:

Carole Lin, MD
Clinical Assistant Professor
Stanford University

Patient is a 11-year-old child presenting to the operating room for right thoracotomy with pleural fluid drainage and middle lobe mass resection. Past medical history is complicated with current ongoing chemotherapy-induced low platelets (below 40 platelets per microliter), CNS and spinal metastases, scoliosis, and chronic headaches. Port placement and open thoracotomy is planned due to mass size. Chest tube drainage is planned the end.

April's question submitted by:


Caitlin Thompson, PhD
Pediatric Psychology Consultation Program
Kennedy Krieger Institute


Chris Joseph, DPT
Pediatric Chronic Pain and Connective Tissue Disorders Clinic
Kennedy Krieger Institute

A 15-year-old female presents to the multidisciplinary chronic pain clinic for evaluation of widespread body pain, primarily in the back and knees.  Her rheumatological testing and imaging were normal.  During the physical exam, all orthopedic testing indicated no acute injury.  She reports that she has more pain when sitting for a long period of time and after doing a lot of activity. She feels her sleep is nonrestorative and has difficulty initiating sleep. She has little to no pain during an activity she really enjoys, but pays for it the next day.  She scores a 9/9 on the Beighton scale for hypermobility and shows mild proximal weakness in the core and hip extensors.  Her numeric self-rating of pain is 9/10 at the worst, with an average of 6-7/10.  She previously participated in field hockey and volleyball, but discontinued due to pain. She is typically very social but has avoided doing activities with friends because she worries that doing so will lead to increased pain.  Psychologically, she describes anxiety about schoolwork, worries that her pain will not get better, and feelings of hopelessness.  Standardized measures showed clinical elevation of anxiety and depression. 

What course of treatment should be recommended?

March's question is written by:


Clarice Nguyen, MD
Combined Pediatrics and Anesthesiology Resident
Department of Anesthesiology
Department of Pediatrics
Stanford University

AND


Viviana F. Ruiz, MD
Pediatric Anesthesiology Fellow
Lucile Packard Children's Hospital
Stanford University

An 11-year-old female with a history of precursor B cell acute lymphoblastic leukemia (ALL) is admitted to your pediatric hospital after she was found to have a medullary relapse. The patient has already undergone two rounds of chemotherapy and is now undergoing Chimeric Antigen Receptor (CAR) T-cell therapy.  The patient also has a history of chronic peripheral neuropathy and low back pain and is on scheduled hydromorphone. Four days after starting CAR T-cell therapy the patient develops flu-like symptoms, including fever, headache, and severe muscle and joint pain. Blood cultures have been negative to date. You are consulted to help manage the patient’s acute on chronic pain during CAR T-Cell treatment. Which of the following would BEST address this patient’s current pain symptoms?