Society for Pediatric Pain Medicine
Better Care for Children in Pain

Correct Answer: B. From a friend or relative


Examining data from almost 10 million Americans who misused prescription pain relievers in 2017 the Substance Abuse and Mental Health Services Administration reported that over half bought or took the medication from a friend or relative, over one third obtained the medication from a single prescriber, and 6.5% bought the medication from a drug dealer or stranger (1).


These findings point to a strong need not just for responsible opioid prescribing but also the appropriate disposal of leftover opioids remaining in homes when the medication is no longer needed to treat pain. Hospitals can facilitate drug disposal by sponsoring prescription drug take-back days and providing onsite drug lock boxes. In addition, families can be instructed regarding safe home disposal methods. Drug disposal products can be provided when prescription opioids are dispensed to encourage home disposal. Some commercial products act as chemical adsorbents or deterrents while others act by sequestering medicine in a gel matrix (2). However, provision of a disposal product may not significantly increase rates of opioid disposal (3) unless accompanied by active patient and family education (4, 5).


References:


1. https://www.samhsa.gov/data/release/2018-national-survey-drug-use-and-health-nsduh-releases


2. https://sfenvironment.org/sites/default/files/fliers/files/overviewmedicinedisposalproducts_21april2017.pdf


3. Bicket MC, Fu D, Swarthout MD, White E, Nesbit SA, Monitto CL. Effect of Drug Disposal Kits and Fact Sheets on Elimination of Leftover Prescription Opioids: The DISPOSE Multi-Arm Randomized Controlled Trial. Pain Med. 2021 Apr 20;22(4):961-969.


4. Voepel-Lewis T, Farley FA, Grant J, Tait AR, Boyd CJ, McCabe SE, Weber M, Harbagh CM, Zikmund-Fisher BJ. Behavioral Intervention and Disposal of Leftover Opioids: A Randomized Trial. Pediatrics. 2020 Jan;145(1):e20191431.


5. Lawrence AE, Carsel AJ, Leonhart KL, Richards HW, Harbaugh CM, Waljee JF, McLeod DJ, Walz PC, Minneci PC, Deans KJ, Cooper JN. Effect of Drug Disposal Bag Provision on Proper Disposal of Unused Opioids by Families of Pediatric Surgical Patients: A Randomized Clinical Trial. JAMA Pediatr. 2019 Aug 1;173(8):e191695.

Correct Answer - B. Regional anesthesia reduces late postoperative apnea events as compared to general anesthesia


Spinal anesthesia in neonates and infants has been well studied and shown to be an effective, safe method of anesthesia for procedures <1-2 hours in duration. Multiple studies have demonstrated a low complication rate with spinal anesthesia.


The General Anesthesia compared to Spinal Anesthesia (GAS) study was a multi-nation, multi-institution prospective randomized trial published in 2015. This study randomized 722 infants >26 weeks post menstrual age up to 60 weeks post menstrual age undergoing either unilateral or bilateral inguinal herniorrhaphy into a regional anesthesia (RA) arm and a general anesthesia (GA) arm. The RA arm received one of the following options: spinal alone, spinal with caudal, spinal with ilioinguinal or caudal alone. No sedation or GA was given in the RA arm. The GA arm received sevoflurane for induction and maintenance of general anesthesia supplemented with either caudal block or ilioinguinal block. No opioids or nitrous oxide was allowed intraoperatively. The primary outcome was observed apnea within 12 hours of surgery or until discharge. Apnea was defined as a pause in breathing for more than 15 seconds or more than 10 seconds with an associated desaturation to <80% or bradycardia of a 20% decrease from baseline. Early apnea was defined as apnea occurring within the first 30 minutes postoperatively. Late apnea is defined as occurring between 30 min and 12 hours postoperatively.


The overall rate of at least one postoperative apneic episode in the study was 3%. Ten occurred in the RA arm and 15 in the GA arm. While there was no statistical significance of late apneas between the two study arms, RA did reduce the risk of early postoperative apnea, the degree of post operative desaturation, and the level of needed intervention required for treatment of apnea. This would imply that RA led to less frequent and less clinically significant apneas. Early apneas were also found to be a predictor of late apneas, although more than half of the infants with late apneas had no documented early apnea.


Hemodynamically, patients randomized to the RA arm were also found to have the following advantages: a greater minimum systolic blood pressure (70.7 vs 54.8), less likely to need an intervention for hypotension (7 vs 19%), higher minimum intraoperative heart rate (133.9 vs 127.6 beats per min), and a higher documented temperature (36.1°C vs 36.0°C) . Anesthesia time was shorter in the RA arm (51 vs 66min). In 20% of patients in the RA arm, there was a need for general anesthesia or other sedatives, therefore a backup plan is imperative.


Discussion with the parents regarding risks of a spinal anesthetic versus a general anesthetic should highlight the above advantages: a lower rate of early apneas (but no difference in overall apnea rate), shorter duration of anesthesia, improved blood pressure, and overall low complication rate. This is assuming the anesthesiologist is comfortable with the procedure and possess the knowledge and skill level to perform a spinal anesthetic in this patient population.


References:


1. Jones LJ, Craven PD, Lakkundi A, Foster JP, Badawi N. Regional (spinal, epidural, caudal) versus general anesthesia in preterm infants undergoing inguinal herniorrhaphy in early infancy. Cochrane Database Syst Rev 2015 Jun 9;2015(6): CD003669


2. Dohms K, Hein M, Rossaint R, Coburn M, Stoppe C, Barbara Ehret C, Berger T, Schalte G. Inguinal hernia repair in preterm neonates: evidence that spinal or general anaesthesia is the better option regarding intraoperative and postoperative complications? A systemic review and meta-analysis. BMJ Open 2019 Oct 8;9(10):e028728


3. Andrew J. Davidson, Neil S. Morton, Sarah J. Arnup, Jurgen C. de Graaff, Nicola Disma, Davinia E. Withington, Geoff Frawley, Rodney W. Hunt, Pollyanna Hardy, Magda Khotcholava, Britta S. von Ungern Sternberg, Niall Wilton, Pietro Tuo, Ida Salvo, Gillian Ormond, Robyn Stargatt, Bruno Guido Locatelli, Mary Ellen McCann; Apnea after Awake Regional and General Anesthesia in Infants: The General Anesthesia Compared to Spinal Anesthesia Study—Comparing Apnea and Neurodevelopmental Outcomes, a Randomized Controlled Trial. Anesthesiology 2015; 123:38–54

CORRECT ANSWER: B. Ask your physician for a referral to a pediatric chronic pain program to explore multidisciplinary based approach to management.


Gabapentin is a medication that is commonly used for the treatment of chronic and acute pain. It’s exact mechanism of action in relieving pain is not known, although gabapentin and pregabalin are hypothesized to work via modulation of voltage-gated calcium channels¹. It may be effective in some patients and is often used for neuropathic pain but may take up to 4 weeks for effect. It has some side effects, including mood dysregulation, sedation, and irritability that require close monitoring when initially prescribed. ^2,3. If a child is not getting relief from gabapentin or having side effects that are difficult to manage, parents should be encouraged to talk to their physician about changing medications or adjusting the dose. There are other medications that may work better with less side effects. However, many parents navigating these changes often worry that they or their child will get labeled as difficult, doctor shopping, or drug seeking. This is particularly true for families that live in rural areas or locations with limited access to specialist healthcare. In a survey by the US Pain Foundation less than 50% of patients are cared for by a pain specialist and almost 40% of families have tried unsuccessfully to see a pain specialist.⁴


The use of long-term opioids in patients with chronic pain is controversial.^5,6,7,8 Previously patients including children with chronic non-cancer pain were sometimes prescribed opioids and were getting relief from stable doses of opioids. However, with the increasing evidence regarding the lack of long-term efficacy, and potential harm from opioid use and with the 2016 CDC Guideline regarding prescribing opioids for chronic pain many practitioners are choosing to, or being forced by institutional policies to summarily stop prescribing opioids, in some cases without adequate appropriate alternative multimodal therapy. Families should first discuss these options with their health professional. Multimodal and multidisciplinary techniques to pain management in children have been shown to be the most effective approach.


If a patient’s pain is chronic and complex in nature, the family should ask for a referral to a multidisciplinary pediatric chronic pain program. Since many programs are offering telehealth visits this may be more possible or practical now for families with children living in remote areas. Most specialists in pediatric pain will manage patients with a multidisciplinary approach that includes pain psychology, physical therapy, occupational therapy, and may include psychiatry, and/or interventional procedures such as trials of nerve blocks. While in-person visits are still ideal, a lot of care including PT/OT/complementary therapy, biofeedback, mindfulness, relaxation therapy and hypnosis can be offered in a virtual setting.


Pediatric Chronic pain specialists and clinics can be found here https://pedspainmedicine.org/patients-and-families-useful-links/ or http://childpain.org/wp-content/uploads/2020/03/PedPainClinicList_2020-v2.pdf


References:


1. Mathew, E., Kim, E. & Goldschneider, K. R. Pharmacological Treatment of Chronic Non-Cancer Pain in Pediatric Patients. Pediatric Drugs 16, 457–471 (2014).


2. Li G, Li P. (2020, Summer) The use of membrane stabilizers in acute and chronic pain. SPPM Newsletter. Retrieved from https://pedspainmedicine.org/wp- content/uploads/newsletters/2020/summer/nonopioid/Membrane%20Stabilizers%20.html


3. Trends in Gabapentin and Pregabalin Prescribing in a Tertiary Pediatric Medical Center. Donado C, Nedeljkovic K, Wangnamthip S, Solodiuk JC, Bourgeois FT, Berde CB.Hosp Pediatr. 2021 Aug;11(8):909-914. doi: 10.1542/hpeds.2020-003582. Epub 2021 Jul 13.PMID: 34257145


4. US Pain Foundation. 2021 Pediatric Pain Survey, US Pain Foundation, 2021, https://uspainfoundation.org/wp-content/uploads/2021/06/2021-Pediatric-Pain-Survey-SMALL.pdf.


5. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain—United States, 2016 JAMA. doi:10.1001/jama.2016.1464.


6. The Potential Impact on Children of the CDC Guideline for Prescribing Opioids for Chronic Pain: Above All, Do No Harm. Schechter NL, et al. JAMA Pediatr. 2016. PMID: 26977702


7. European* clinical practice recommendations on opioids for chronic noncancer pain - Part 1: Role of opioids in the management of chronic noncancer pain. Häuser W, Morlion B, Vowles KE, Bannister K, Buchser E, Casale R, Chenot JF, Chumbley G, Drewes AM, Dom G, Jutila L, O'Brien T, Pogatzki-Zahn E, Rakusa M, Suarez-Serrano C, Tölle T, Krčevski Škvarč N. Eur J Pain. 2021 May;25(5):949-968. doi: 10.1002/ejp.1736. Epub 2021 Mar 2.PMID: 33655607


8. Guidelines on the management of chronic pain in children. Geneva: World Health Organization; 2020. Licence: CC BY-NC-SA 3.0 IGO.

Picture from A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format


Correct Answer: E. All of the above statements are true.


LI-4 is a very commonly used acupuncture point used in the treatment of pain and anxiety. It is located on the dorsum of the hand, at the most prominent point of the thenar muscle, on the radial side of the midpoint of the second metacarpal. Because it is an easy point to locate, acupressure at this point can be easily performed and taught to patients, parents, or other medical providers. There are many studies demonstrating its effectiveness in the treatment of anxiety and headache when used in combination with other points^2,3,4,5. In medical acupuncture, it is known to be particularly useful in the treatment of a variety of head and face disorders¹ including toothache^6,7, jaw pain/spasms^8,9, rhinitis, nasal congestion, changes in taste10, and ear pain/tinnitus. It can also be used to relieve dysmenorrhea ^1,11,12. ---------------------------------------------------------------------------------------------- References:


1 A Manual of ACUPUNCTURE by Peter Deadman and Mazin Al-Khafaji, with Kevin Baker. The Journal of Chinese Medicine, 2nd edition, 2007. Digital format


2 Amini Rarani S, Rajai N, Sharififar S. Effects of acupressure at the P6 and LI4 points on the anxiety level of soldiers in the Iranian military. BMJ Mil Health. 2021 Jun;167(3):177-181. doi: 10.1136/jramc-2019-001332. Epub 2020 Feb 2. PMID: 32015185.


3 Coeytaux RR, Befus D. Role of Acupuncture in the Treatment or Prevention of Migraine, Tension-Type Headache, or Chronic Headache Disorders. Headache. 2016 Jul;56(7):1238-40. doi: 10.1111/head.12857. Epub 2016 Jul 13. PMID: 27411557.


4 Doll E, Threlkeld B, Graff D, Clemons R, Mittel O, Sowell MK, McDonald M. Acupuncture in Adult and Pediatric Headache: A Narrative Review. Neuropediatrics. 2019 Dec;50(6):346-352. doi: 10.1055/s-0039-1695785. Epub 2019 Aug 29. PMID: 31466110.


5 Linde K, Allais G, Brinkhaus B, Fei Y, Mehring M, Shin BC, Vickers A, White AR. Acupuncture for the prevention of tension-type headache. Cochrane Database Syst Rev. 2016 Apr 19;4:CD007587. doi: 10.1002/14651858.CD007587.pub2. PMID: 27092807; PMCID: PMC4955729.


6 Grillo CM, Wada RS, da Luz Rosário de Sousa M. Acupuncture in the management of acute dental pain. J Acupunct Meridian Stud. 2014 Apr;7(2):65-70. doi: 10.1016/j.jams.2013.03.005. Epub 2013 Apr 11. PMID: 24745864.


7 Devanand Gupta, Deepak Ranjan Dalai, Swapnadeep, Parul Mehta, B Niranjanaprasad Indra, Saurabh Rastogi, Ankita Jain, Mudita Chaturvedi, Saumya Sharma, Sanjeev Singh, Shruti Gill, Nisha Singh, Rajendra Kumar Gupta. Acupuncture (針灸 Zhēn Jiǔ) – An Emerging Adjunct in Routine Oral Care. Journal of Traditional and Complementary Medicine. 2014;4(4). 218-223. ISSN 2225-4110. doi.org/10.4103/2225-4110.139113.


8 Shen YF, Younger J, Goddard G, Mackey S. Randomized clinical trial of acupuncture for myofascial pain of the jaw muscles. J Orofac Pain. 2009 Fall;23(4):353-9. PMID: 19888488; PMCID: PMC2894813.


9 Lu DP, Lu GP, Lu PM. Clinical effectiveness of acupuncture for mandibular subluxation and dislocation. Acupunct Electrother Res. 2010;35(3-4):187-92. doi: 10.3727/036012910803860896. PMID: 21319604.


10 Djaali W, Simadibrata CL, Nareswari I. Acupuncture Therapy in Post-Radiation Head-and-Neck Cancer with Dysgeusia. Med Acupunct. 2020 Jun 1;32(3):157-162. doi: 10.1089/acu.2020.1410. Epub 2020 Jun 16. PMID: 32595823; PMCID: PMC7310235


11 Huang T, Yang L, Jia S, Mu X, Wu M, Ye H, Liu W, Cheng X. Capillary blood flow in patients with dysmenorrhea treated with acupuncture. J Tradit Chin Med. 2013 Dec;33(6):757-60. doi: 10.1016/s0254-6272(14)60008-x. PMID: 24660607.


12 Bazarganipour F, Taghavi SA, Allan H, Beheshti F, Khalili A, Miri F, Rezaei M, Mojgori M, Imaninasab F, Irani F, Salari S. The effect of applying pressure to the LIV3 and LI4 on the symptoms of premenstrual syndrome: A randomized clinical trial. Complement Ther Med. 2017 Apr;31:65-70. doi: 10.1016/j.ctim.2017.02.003. Epub 2017 Feb 21. PMID: 28434473.