Transcription:
Chronic Pain Management in Kids

Trisha Williams (Host): Hi guys. Welcome to our third season of the Advanced Practice Perspectives. I'm Trisha William.

Tobie O'Brien (Host): And I'm Tobie O'Brien. This is a podcast created by Advanced Practice Providers for Advanced practice providers. Our goal is to provide you with education and inspiration. We will be chatting with pediatric experts on timely key topics and give you an inside look at the various advanced practice role at Children's Mercy.

Trisha Williams (Host): We are so glad that you're joining us today. So sit back, tune in, and let's get started. We are so pleased to have Dr. Rae Ann Kingsley with us. She is a doctoral prepared pediatric nurse practitioner in the specialty care clinic focusing on pain management and children at Children's Mercy. Well, welcome to the podcast Rae.

Dr Rae Ann Kingsley: Hi. Thank you all. This is such an honor to be featured here on this podcast. Myself, I've been a pediatric nurse practitioner for 23 years, having graduated from the University of Nebraska Medical Center in 1999 with a dual certification as a primary care nurse practitioner and a clinical nurse specialist. I initially worked as a clinical nurse specialist, concentrating on RN orientation skills development, performance improvement, and I later partnered with the Department of Anesthesia and Hospital Medicine to develop the first NP led sedation program at the Children's Hospital Medical Center in Omaha.

Before I arrived here at Children's Mercy, my husband and three children lived in Connecticut and I worked there within the Department of Anesthesia at Yale University. I was responsible for the day to day inpatient consultation assessment and management of perioperative pain, and acute and chronic medical pain treatment in infants, children and adolescents across all areas of the hospital. I also managed the weekly outpatient chronic pain clinic and was faculty at the school of nursing.

And then nine years ago, we returned to the lovely Midwest and I began here at Children's Mercy. My primary responsibility here has been ambulatory assessment, diagnosis and treatment of a variety of chronic pain conditions. And over time I've had a variety of practice iterations within the inpatient setting as well.

Tobie O'Brien (Host): Well welcome. That is quite the background. So you have really been in sort of pain assessment and management kind of your entire career it sounds like to me.

Dr Rae Ann Kingsley: Yes.

Tobie O'Brien (Host): So had this been a special area of interest for you, or how did you know that's where you would want to land? Or is it just sort of the first place that you decided to work?

Dr Rae Ann Kingsley: When I reflect back, I remember being invited as a very young RN to participate in the trial and evaluation of what was, then in the late eighties and early nineties, a novel pain intervention, that we could, consider using before pediatric IV placement. What we all know now is that's called Emla Cream. and there's been a few different formulations and naming, of that over the years. But I think I really attribute my earliest interest, into that experience and just all of the dynamics that I was involved in, in that trial.

I also really have to attribute my early interest in pain management to really having witnessed lots of skilled nurses and, innovative child life specialists, advocate for patients under their care. And I believe these together set that foundation for my later career specialization. It was then during my time at Yale University. Interest in pain management really permeated into what is now a passion for me.

Trisha Williams (Host): The pain experience for patients, for me it's very difficult. And the reason being is because it's so subjective, right? I'm a very objective thinker. I need data, I need numbers, I need statistical evidence, things to that nature. But pain is so subjective and what was it we called it in nursing school? The fifth vital sign, or something to that nature. Expand a little bit on that if you can, and some factors that contribute to individuals and patients pain experience.

Dr Rae Ann Kingsley: I think that pain is subjective is a very basic conceptual premise, that we all do need to keep in mind. In medicine, in nursing. In healthcare, you're exactly right. we are asking, continually what's the evidence? What's the scientific basis? Where's the numbers, where's the data? What can we measure and objectify? And that makes pain really, really challenging I think. There's lots of factors that we now know can contribute to that pain experience. When we're assessing and evaluating a child's pain, it's best to really consider a biopsychosocial framework.

Often those biological and physical factors come to mind first. Those are those things a little more, objective. Was there a physical injury or tissue damage, tissue damage from just a cut or abrasion or an incision, or even in an injection. Is the patient experiencing exacerbation or an underlying disease process, that has pain as a symptom? Is it just illness? We know that kids, even having routine fevers, they feel miserable, and they get myalgias and, can have pain just with routine childhood illnesses.

We know other biological factors including age, genetics, early pain exposures, early pain experiences and even sleep problems can contribute to that pain experience. If we move into some of those psychological factors, those factors can include their developmental levels or developmental disabilities. Trauma experience is a significant factor, that we know contributes to that overall pain experience. Children with other comorbid, mood disorders, anxiety, depression, even poor self-esteem, and poor emotional regulation can contribute to that pain experience.

Even the, interactions of family.

. And then we can't, overlook any social factors and, we can contemplate how one's cultural beliefs or behaviors, may contribute to that pain experience and some of those expectations that are, shared with them culturally as well as. school absenteeism, bullying, isolation, even the environment that a child may be, raised in all can affect that pain experience.

so really that subjective, is one piece. and it's a really important piece, because pain is really what that child says it is. And it happens when that child says it does. but those biopsychosocial factors are so important into, playing that role in that complete assessment.

Tobie O'Brien (Host): And it sounds just super multifactorial and very complex process

Dr Rae Ann Kingsley: Yes, we often do, say that, pain is complex,

Tobie O'Brien (Host): That was super complex. Well, tell us about what you do in your role, in the pain management center.

Dr Rae Ann Kingsley: So my primary role in, the clinical capacity is really to serve as that primary provider for specialty pain care, for any infant child or adolescent that gets referred to our clinic. There's substantial evidence for the effectiveness of multidisciplinary treatment for chronic pain problems, and I'm really proud to say that we do offer such treatment here at Children's Mercy.

our clinic includes nurses, licensed massage therapists, social work psychologists, and occasionally physical therapists. and as one of those medical providers within that team, At that initial pain evaluation, I spend time with the patient gathering a broad medical, social, and family history in addition to a very pain specific history.

I complete a thorough head to toe initial physical exam. and then an alliance with our psychologist will provide pain education and utilize shared decision making with our patients and families to create an individualized treatment plan. I feel really fortunate in my role, here at Children's Mercy and in the, pain, treatment center to be able to manifest.

So many of the other advanced practice domains and not just that clinical practice, I have the support of my leadership to really consult and collaborate with other specialty. Providers across the enterprise. I've been able to work as a primary investigator on, more than one IRB approved protocol, and also have been the project lead on an interdepartmental QI charter.

While I've been here, I've been able to, present a number of scholarly works, have a couple publications. and I think one of the things that I value most is my opportunity to work as a role model and an informal leader as I advocate for not only my patients, but also my team and all, advanced practice providers here in Children's Mercy.

Trisha Williams (Host): I love the term informal leader because we're all leaders and Toby and I are doing a lot of work on that aspect. So thank you for touching on that. I think that your work that you're doing, for our patients and for, our advanced practice group is phenomenal though. One thing that I really wanna touch on right now, is that, I read where you do some work with our patients with sickle cell disease, because we all know that those patients have extreme pain crises and pain management interventions that need to happen.

are you willing to expand a little bit on that for us today?

Dr Rae Ann Kingsley: absolutely. that has become, one of my practice. and something I do feel very passionate with. I think as all of you are aware, children and adolescents with sickle cell disease experience, unpredictable and extremely painful vaso-occlusive events. and these vary with age and frequency, duration and intensity. But not only does this population have, acute painful events, they also are subject to complications in which chronic pain can become a symptom of that complication. The part that is a little lesser known is that anywhere from nine to 50%, depending on the literature you're looking at, patients with sickle cell disease also experience this phenomena that happens in between and also overlaps with these other pain. Conditions that can be quite debilitating and difficult to manage. That experience is referred to as persistent pain. And my research interest has been in the predictors of chronic pain in youth with chronic health conditions. and this interest has led to the implementation of a routine screen. And early pain management intervention for children at Children's Mercy with sickle cell disease.

I think when I was working on my D N P I identified a gap in the number of youth with sickle cell disease that were being referred to the pain clinic. And the number of patients that I was seeing on the inpatient service that were admitted with these painful events. I also looked at this and began exploring the number of patients that are followed in our comprehensive sickle cell center and realize, There's probably a number of patients that could benefit from an early referral and treatment.

And so I was able to partner with key stakeholders in hematology and pain management and psychology, social work, inpatient nursing and medicine to develop a risk screening tool that, was meant to facilitate early referral to our sickle cell Integr. Persistent Pain program, that has become our, go to, SKIP team.

and we often get referred to as, the SKIP team. We are a multidisciplinary team, that provides comprehensive, physical, behavioral, and emotional assessment. We tried to blend conventional and complementary mortalities of healing to promote physical ability, empower self management, and enhance quality of life.

since the implementation of that screening tool, we have grown our skip program by over 300% in the past five years.

Trisha Williams (Host): Wow.

Dr Rae Ann Kingsley: Very impressive and very exciting

to see that. And, and I continue to see that grow. and we're looking at, what are some of those next steps and how do we continue to, really look those predictors of chronic and persistent pain, in this population.

we do manage persistent pain within the same biopsychosocial model. It's enjoyable to collaborate so closely with the sickle cell team, in discussing disease modifiers and responses as well as, pain treatments and, really have a team approach even though we are in separate clinic spaces.

also it has been really rewarding to. Provide that bridge, for these patients. From their outpatient pain management and their inpatient pain management. and coordinate some of those things that, aren't traditionally thought of in the acute pain setting or the inpatient pain setting. that help with coping. so we do aid in navigating medication treatment, and that may include opioids. We also introduce coping strategies that are beyond medications, and we encourage healthy lifestyle and other ways to aid disease management. and we really over time work to educate patients and our colleagues.

and how do you differentiate between acute pain, chronic pain, and persistent pain?

Tobie O'Brien (Host): I love hearing the collaboration that takes place between. All of the disciplines. And I'm so curious to know, when you talk to these patients , I guess the goal to get people to understand whether it's acute, chronic, persistent, and then to take some ownership of how they plan to manage that.

Will you talk a little bit more about those, strategies that you guys used to, help these patients be able to self-manage that?

speak to the specific, treatments besides medications that

are proposed to the families.

Dr Rae Ann Kingsley: when we discuss different treatment, options, and working with patients and families, we really draw from a combination of. I like to explain it as four treatment domains or four Ps, in no specific order. Those are prevention, physical, pharmaceutical, and psychological. in each of those domains, we can draw from, interventions that have an evidence base in supporting.

That pain experience. If we look at prevention, much of this is demonstrated through education and anticipatory guidance, helping families to differentiate. that pain experience, and begin to identify, how they can differentiate that and categorize that. prevention can also be using topical anesthetics.

it may be planning for a painful procedure and developing a comfort plan. prevention also lies heavily in the importance of healthy lifestyle. Quality sleep. our pain research has shown that poor quality sleep actually can predict pain. so we do a lot of, information and, information gathering, regarding sleep, and some interventions to help with healthy sleep.

past activity, and using assistive devices. There are some, Diagnoses that, it's important that these children have adequate assisted devices that fit them well, and are in good functional use. our physical interventions include treating pain. Really through addressing different mechanisms of origin.

we often will recommend physical or occupational therapy and a graduated approach to a self-directed home activity. and that may be just doing those activities they enjoy and going to the mall or walking to the grocery store, those types of things using 10 units. Therapeutic massage. often, our discussions include acupuncture and chiropractic treatments. We also look, at that pharmaceutical side of things, because it's important to make sure that we're matching the medication. To the type of pain that they're experiencing. So some of that assessment does include that categorization of type of pain that the patient's experiencing. We look at medications, prescribing them in the smallest therapeutic dose for the shortest duration.

A lot of times, I like to say, have that exit plan. At the onset when we begin prescribing a medication, and always consider topical agents for very focal or localized pain. the goal of medications is to make movement more comfortable. It may not always eliminate pain, but it should facilitate that function.

And the final domain is psychological treatment. Whereas this may include formal counseling, it is often simply strategies that empower self management. We always educate patients and families about pain physiology, and introduce ways in which the child can modulate that pain experience through relaxation training, diaphragmatic breathing.

Biofeedback, imagery and self hypnosis and aromatherapy, are just a few of those it gets exciting, diving into some of these interests, in more detail with patients as they start to get exposed to different, treatment domains.

Trisha Williams (Host): That was some very helpful information, I think for all of our listeners. whether they, practice in a private practice or, A subspecialty area. Those four domains that you mentioned I think we can all take away hints on and tips on how to help our patients with pain. It doesn't necessarily need to be a pain clinic referral or pain management specific.

There are things that sounds like that we can do as providers, even at a primary care office to help our patients manage pain. So that's very helpful. Thank you for that.

I wanted to talk a little bit, I work in otolaryngology and so does Toby. So we kind of think about pain, in our clinic and how can we help kids with pain? And kids are terrified of ear exams. They think that they're gonna hurt, they scream, they kick, the parents Take that as a painful procedure because their children are so upset about it and they're like, it really hurts them to look in their ears. And I feel like I do not do a very good job with the saying. I understand they think that it hurts. I always just say I'm not doing anything to hurt them, and I don't feel like that that is appropriate.

So as something as simple as an ear, and the patient perceives that it's pain. Do you have any recommendations to help that or is that too

broad?

Dr Rae Ann Kingsley: when we work in healthcare and one of the things that, fascinates me with pain management is, Pain can occur in any setting of healthcare. , I would even. Venture to, post it that any child that enters the healthcare arena has the potential to experience a painful procedure.

and I think knowing that changing some of the historical model that we have, Changing that model and pairing that with the information that we've learned over time about pain. Preparation is probably key. preparation is, the best defense for addressing medical pain and anxiety.

and it's very difficult in children to separate pain and anxiety. In different procedures. it also is important to incorporate parade. That preparation and various implementation of tools into our workflow, not so that we work harder or such that it takes more time to do things, but how can we work smarter?

and where is that kind of give and take and that balance. It's always important to consider the age and developmental level of the child, and emphasizing their ability to have some choice, power, and control. when children are feeling, out of control, that is oftentimes when. Those feelings become exacerbated and those behaviors can become exacerbated and families naturally or caregivers naturally begin to feed off of their child's responses.

I think it's important that we empower families. Which also includes coaching those caregivers in how they can take an active role in that procedure. oftentimes, we have seen in, pain studies that parents feel very helpless. or that they themselves feel, like they should be the expert, but they haven't felt like they've been given the information where they could, serve in that role of expert for their child. I think the other thing is always to, praise the child and watch our language and how we frame that experience so that it's positive. what research has shown is that what is said after a procedure. She helps form a child's memory of that experience and ultimately influence how they feel about future medical interventions.

so it may not help that procedure that's just been finished. But especially for, immunizations, for ear exams, for those things that happen very routinely in, primary care practices or even kids that have recurrent medical procedures, reframing or framing that experience, to express how brave they were.

pulling something that they did that empowers them to feel that they had that choice and that control. There's a website that I just absolutely love. it is the Meg Foundation for pain.

It has, information, education resources that are all evidence based, is very scientific driven and includes, Modules for children, based upon age of the child. It has modules and information that are targeted towards parents and caregivers, and it also has an excellent, toolkit for providers, that can be printed out, that can be distributed, it can be posted in your office.

even used as kind of a framework, to start to build some of that, change in practice within different practice settings.

Tobie O'Brien (Host): That is great information. And I wrote it down to utilize, We're lucky at Children's Mercy because we do have so many amazing child life therapists that are really important and valuable for us, especially in e and t I'm sure all over the hospital.

They are so valuable in providing that little bridge over. They're sort of our little toolkit, if you will.

Many of our listeners take care of kids and understand that pain is so individual. but do you have any clinical pearls or words of wisdom for us today that would help us better take care of our patients and acknowledge their.

Dr Rae Ann Kingsley: Oh, absolutely. and I think as advanced practice providers, we all really do a wonderful. In taking care of our patients and acknowledging pain. I think as nurses we have a really strong foundation, in holistic care. looking at that patient, as a whole person and as an individual.

I think when looking at pain specifically, I always encourage colleagues to. Assume pain is present in infants and children, even if they may not be able to express that discomfort, or even in an older child that may be stoic and not express that discomfort, but assume pain is present when they are undergoing a procedure that is otherwise accepted as painful. Validate that pain experience. remember all pain is real pain. make sure that when we discuss treatment interventions that we're treating that pain within the context of that presentation. we know that proper treatment requires a multifactorial approach. We know that pain can cause changes in the brain that can make future pain experience worse.

And on the flip side, we know that well managed pain has been associated with faster recovery, fewer complications, and decrease healthcare utilization. And have a clear understanding of treatment goals, partner with the patient in establishing those treatment goals. And that goal of pain treatment is to promote function, and to promote that function in a safe way.

Tobie O'Brien (Host): We end each episode with a question that we pose to our guests. So our question for this season is, in what way do you love to encourage your colleagues?

Dr Rae Ann Kingsley: I think some of my personal philosophy I like to encourage in others, I think it is really important to honor and respect your own emotional, psychological, physical needs. honor and respect where you're at, and don't hesitate to place boundaries. In order to protect those things that are valuable to you, always be your authentic self.

Lean into those imperfections, and don't ever resist feeling joy as deeply as you can.

Trisha Williams (Host): Those are great words of encouragement. Thank you so much Dr. Kingsley for joining us today. We really, truly do appreciate your knowledge and your, wisdom on pain management. So thank you for spending your morning with us.

Dr Rae Ann Kingsley: Thank you guys. This has been a wonderful opportunity and, I am so appreciative, for being invited.

Tobie O'Brien (Host): . Well thank you so much for joining us. Really. It's been an honor to have you on.

Trisha Williams (Host): If you have a topic that you would like to hear about or you're interested in being a guest, you can email us at tdo O'Brien cmh.edu or tWilliams@cmh.edu. Once again, thanks so much for listening to the Advanced Practice Perspectives Podcast.