Dr. Rob Steele (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm your host, Dr. Rob Steele, Executive Vice President and Chief Strategy and Innovation Officer at Children's Mercy, Kansas City. Before we introduce our guest, I wanted to remind you to claim your CME credits after listening to today's episode. You can do so by visiting cmkc.link/cmepodcast and click the Claim CME button.

Today, we are joined by Dr. Amanda Deacy to discuss how to help kids with immunizations as well as some other pain control conversations. Dr. Amanda Deacy is a pediatric psychologist with more than 15 years of experience with acute and chronic pediatric pain. She is a pediatric psychologist at Children's Mercy Kansas City and an Associate Professor of Pediatrics in the University of Missouri Kansas City School of Medicine. She's also the Clinical Director of the Abdominal Pain Program and Medical Director for School Health Initiatives.

Her experience with standardization and implementation of pediatric pain interventions spans primary to tertiary settings. Currently, as a Comfort Promise champion and quality improvement lead in gastroenterology, Dr. Deacy is leading work to improve documentation and uptake of evidence-based interventions for needle procedures within GI that can serve as a local model for rollout across other ambulatory clinics in the organization.

Dr. Deacy has previously presented at the QI, CE workshops, spoken for local news media outlets, published peer-reviewed papers on the topic of QI methodology to implement and maintain use of evidence-based tools for pain prevention during painful procedures. With that, I don't know this podcast is a step down for you, Dr. Deacy, and I apologize. You're well accomplished and now you've kind of taken a step back with having to talk with me, but thank you for joining us today.

Dr. Amanda Deacy: I am incredibly happy to be here. This really is a passion area for me. So, I will take any venue to be able to talk about this and how important it is.

Host: Very good. Well, you're kind. Well, I have to say, in preparation for this, there's a couple of things. One is I learned a new word, trypanophobia, the fear of needles. We're going to get into that a little bit. So, I learned something there. But also, you seem to be living my best life having just gotten back from the South of France, spending a reasonable amount of time, polishing off your French that you've learned. Is that all correct?

Dr. Amanda Deacy: That is all correct. I had the good fortune of spending almost two weeks with my extended family in France. I hadn't been since high school, so it was wonderful.

Host: That's fantastic. I'm probably about two and a half years into learning Italian, and that is exactly what I want to do on the Italian side. So, maybe we'll have to compare notes at some point.

Dr. Amanda Deacy: We will.

Host: Very good. Well, let's jump into it. First of all, maybe for our listeners, many of whom are primary care pediatricians, maybe you can give a flavor of what the Comfort Promise is.

Dr. Amanda Deacy: Sure. The Comfort Promise really is a bundle of pain prevention elements that has a large evidence base. I think that's an important piece of context to say, you know, while the Comfort Promise, that label is relatively new, the evidence for this has been around for 20 plus years. So, part of why I'm so passionate about this is really bridging that research practice gap and getting those elements into everyday practice.

So, like I was saying, the Comfort Promise itself is really just a bundling of those elements in a way that allows them to be more easily disseminated and packaged in primary and tertiary care settings. So typically, we talk about the four elements as including some sort of topical anesthetic. Usually, that's in the form of lidocaine. We talk about comfort positioning as the second of those elements, distraction as the third. And then, for our little ones, those babies 18 months and younger, either sucrose or breastfeeding. And those are really the four elements that have really withstood the test of time in the literature as being the primary things that we know both to decrease pain perception, but also distress that accompanies it.

Host: Yeah, fantastic. So, those are the things that we should be doing that are evidence-based. Let's talk about what happens when those things don't occur. So, maybe the mismanagement of pain or lack of attention to pain control. What are some of the consequences of that?

Dr. Amanda Deacy: Most of the time, I think people think about that one moment in time where there's lots of crying, lots of distress, and most of us maybe think about that being the end of whatever the consequences are, that really difficult few moments in the office. Unfortunately, that's actually not the case, and we know that the long-term consequences are many.

One is that pre-procedural anxiety. So, should a child have a bad experience one time, it increases the likelihood that any subsequent procedure is going to be difficult. The other thing is we know at a physiologic level, repeated, painful procedures that go unmitigated really can lead to what we call hyperalgesia or visceral hypersensitivity, making a kiddo more prone to either chronic pain conditions or just, in the moment, higher sensory perception of pain.

Needle fear, you mentioned. Needle fear is a known outcome. In the biggest sense, avoidance of healthcare becomes a really big issue, including non-adherence to vaccination schedules. So, especially for our most chronically ill kids, this can really balloon, if not managed well, into a lifelong struggle with getting care that they need, because needle procedures are just part of their everyday lives.

Host: Just to pull on that string just a little bit, because we're going to jump into immunizations and, of course, a lot of the immunizations are given to children that are pre-verbal. You've mentioned sort of the longer term sequelae of that pain Maybe give little bit of understanding for those children that are pre-verbal that are still getting, say, immunizations or any other painful procedures. Do you see the same outcomes? Do you see the same challenges if those are mismanaged?

Dr. Amanda Deacy: Absolutely. In fact, one of the largest populations on which we have this data is our NICU babies. So, those babies, as your audience well knows are more likely very early in life to undergo lots and lots of painful procedures. And despite being pre-verbal, their nervous systems are equally reactive to the failure to manage pain and probably even more so. And so, I think in particular, starting early is so, so important. And so I think that's where things like education on breastfeeding, sucrose, swaddling, that's part of that comfort position, especially important for even those pre-verbal young, young babies.

Host: Yeah, very good. What about the surrounding environment? Those painful procedures, they involve parents, they involve the providers. So, are there outcomes that have been looked at from that perspective as well, not just the child who's experiencing it?

Dr. Amanda Deacy: Indeed. In fact, I think important to know is that one in four adults is afraid of needles. So, those are the parents, those are the nurses, those are the physicians even sometimes that are with these kids. So, absolutely, parents and providers are affected. We know that parent and provider distress is important. When we've evaluated and surveyed nurses, for example, they say one of the worst parts of their jobs is giving vaccinations because it is stressful. Now, they do it, and they do it well, and they move through their day as if nothing terrible has happened. And yet, that distress doesn't necessarily leave them.

So, the other really cool part of the literature that has really developed over the last decade is we know that the way that parents in particular, but it stands to reason providers also, the way that we talk to our kids about painful experiences, we also know has a lasting impact on their perception of pain during subsequent procedures. So, I think that's really important. So, it's not just that the way we talk to kids changes the way they think about it, it actually changes the way they perceive pain. We need parents and providers to be educated themselves, in terms of how to talk to kids about these procedures, but also how to manage their own distress surrounding them so as to not further heighten the anxiety and distress of an already stressful situation.

Host: Yeah. So, that's really great advice. You know, I think about, in practice, you get used to-- I mean, I did get used to these babies coming in, getting their immunizations. The fact that the parents may have some level of anxiety about needles in and of themselves or just simply the procedure themselves, to be honest, you don't really think about that in the moment. So, I think that's a really important point. You mentioned how we talk to those patients. I imagine there's things that you should say. There's things that you shouldn't say. So, could you give us an idea particularly on the what not to say?

Dr. Amanda Deacy: Sure. I'll start by saying what not to do, but it's part of how we use language is not to surprise kids with needle procedures. So, I think, instinctively, sometimes parents in a very well intentioned way will avoid letting kids know about an upcoming procedure because they think it increases their anxiety. And while true in the moment, over the long term, what it doesn't do is allow kids time to plan, prepare, and recover. And so, first off is really using words, using language to inform kids so that they're aware of what's about to happen. As far as during the actual procedure itself, you're absolutely right that the data has been very clear on this. We tend to, and again instinctively so, we use things like reassurance. We use things like apologizing. We focus on it won't hurt that much, right? So, we focus on pain itself. Those are things we want to actually avoid.

Again, reassurance seems like, "How, could that be harmful?" It implies that there's something for kids to be worried about. So, alternatively, we really want any adult, any caregiver in the room to use information-giving. So, providing very neutrally information step by step about what's happening. Secondly, using language to distract. "What'd you bring with you today? Cool tennis shoes. What are you going to do after this?" So, using verbal interaction just as a form of distraction.

And then, third is really praising and describing what you're seeing in kids that they're doing well to cope. "Wow, I see you taking really big, deep breaths. That's so helpful." "Look at you looking at your mom across the room. That's so great." So, using our words instead to praise, describe, provide information and distract. That's really where we want the language to be focused during these painful interactions.

Host: Great advice. Is there any nuance to that? A lot of what I'm hearing you say is in that, I'll say kindergarten, as I'm thinking about immunizations, the kindergarten immunizations, certainly, even in those toddlers that may be getting immunizations too. What about the teenagers? Because of course, there are a number of shots that we give right around 10, 11 years of age, and then again at 15, 16. So, are there any other nuances with respect to the adolescents?

Dr. Amanda Deacy: Absolutely. I think what is sort of a running theme through any age is really the idea of choice. And so, particularly in adolescence, they're not going to be sitting on our laps. We're not going to be commenting on their T-shirts probably in the same way, but nonetheless, letting them use their phones, asking if there's a video they want to watch, asking them where they would like to sit in the room, which arm they would like to use. So, the idea of giving adolescents choice is really important.

We had something incredibly cool happen in our COVID mass vaccination clinics that specifically involved teenagers. Just if I can take a quick second to highlight, we were using a modified bundle of the Comfort Promise for those given the rapidity with which we needed to kind of move kids through. When our teenagers were coming back for their second dose of their vaccine, we got some really great candid photos of these teenagers standing in line with three things. They were standing in line with their phones, they were standing in line with their vaccine cards, and they were standing in line with this little piece of yellow plastic called a shot blocker.

And what that tells us is that those are things they held on to for two plus weeks, that little yellow piece of plastic, along with their card and their phones, and that's what they returned with. So even the teenagers, the teenagers we think this doesn't matter for, they don't care about managing pain, they held on to that little shot blocker, which is a form of sensory distraction. They held on to that and brought it back with them. So, let's not forget those adolescents, because they're telling us with their behavior that this stuff does matter to them.

Host: Yeah, really great example. So, I've got teenagers myself and we experienced that very thing. They held onto their shot blocker, which is this little plastic thing that's got kind of some sort of sharp plastic prongs that you put up against your arm, but it's got a little hole or a little area that you can actually give the immunization. I'm telling you, they loved it. You're exactly right, they held on to it.

Dr. Amanda Deacy: We were so impressed and intrigued.

Host: It was impressive to see them take charge of that. Are there any other sources that you might suggest for parents, particularly around needles, immunizations, those type of things?

Dr. Amanda Deacy: Sure. So, we, over the last probably half decade or so, have really curated a robust set of resources for parents on our own Children's Mercy website, so the Making Needle Procedures More Comfortable for Patients page. Also, you can search it via Comfort Promise. That is chock-full of resources. It's divided by age. So, the resources are bundled. Click on the tab that is consistent with your child's age, and it will just open an entire section on ways to get prepared, creating a comfort kit, how to talk to your child at those various developmental levels. So, that's one that I really encourage families to take a look at.

Another resource that I really like for families is a place called the Meg Foundation. Meg Foundation is a non-profit that was started by a pediatric psychologist named in honor of her friend Meg, who lived a life far too short, but had undergone multiple, multiple painful procedures. And so, the Meg Foundation is in honor of Meg and in honor of the evidence for pain mitigation in our youth.

And then, last but not least, I also really love that It Doesn't Have To Hurt Campaign. This is out of Canada, which is actually a movement really, the use of social media to educate parents to advocate for their own children with their children's healthcare providers about, again, the evidence base, putting it right in the hands of the parents who are taking kids to these doctor's appointments.

Host: Very good and great, resources that we can put actually on the website. So, we'll put links to that as part of this podcast. Dr. Deacy, thank you so much for joining us today. Before I let you go, I have to know, and I'm not going to put you on the spot to say something in French, for example, but as a foodie, tell me how great the food was in South of France. I mean, did you gain 15 pounds? Because I'm going to be disappointed if that's not the case.

Dr. Amanda Deacy: Not 15, but I did a good job. I did a good job with the pastries, I'll just say.

Host: Very good. That's great. Well, thanks again, Dr. Deacy, for joining us. As a reminder, claim your CME credit for listening to today's show. Visit cmkc.link/cmepodcast and click the Claim CME button. This has been another episode of Pediatrics in Practice, a CME podcast. I'm Dr. Rob Steele. See you next time.