Dr. Mike Smith (Host): Welcome to Pediatrics in Practice, a CME podcast. I'm Dr. Mike. And with me is Dr. Amanda Deacy, Clinical Director of the Abdominal Pain Program and pediatric psychologist at Children's Mercy. And today, we're going to be talking about pediatric pain management in primary care, exploring how clinicians can better recognize, prevent, and treat pain and distress in everyday visits and procedures. Dr. Deacy, welcome to the show.

Dr. Amanda Deacy: Thanks so much for having me.

Host: How should pediatricians think about both pain and emotional distress during routine primary care visits?

Dr. Amanda Deacy: Well, the first thing I'd encourage pediatricians to consider, which may be a big shift, is that not addressing pain and emotional distress during primary care visits is not benign. I think that's probably one of the first thing to consider. The suffering, although it is most salient in the immediate moment, it isn't just what's seen in office, that we know has a longer term impact.

So, long-term impacts suggestive of babies, for example, who've spent a long time in the NICU, have had painful procedures, there's actually some really fascinating data about decreased brain volumes in those babies, increased startle and pain responses. And so, again, really the idea that not managing it in the moment, is not benign and that we ought to do well to prevent increased impact over the long term as well.

Host: Dr. Deacy, that's really interesting. So if I heard you correctly, what you're saying is even infants when they undergo something painful or emotional, even though they may not be very conscious of it in that moment, it has consequences down the line?

Dr. Amanda Deacy: Absolutely. So, what the data have told us, like I said, there are actually some fascinating MRI studies that look at decreased brain volumes in babies who have spent time in the NICU, who routinely underwent painful procedures, usually, not well-managed. And there's been functional changes in those babies at toddler age, and we think that the mechanism is really hyperalgesia or nerve hypersensitivity that is triggered by unmitigated pain in infancy.

And so, over time, obviously, you have the hyperalgesia, but you also then have pre-procedural anxiety, a more general fear of the doctor, and ultimately, and in worst case scenarios, healthcare avoidance altogether

Host: That really is some amazing news for me. And I guess the more I think about it, Dr. Deacy, it makes sense. And so, thank you for bringing that up. That was very interesting. So then, with that situation going on, and I would assume the effect can even be the same for toddlers and stuff, what do we do in a primary care setting to avoid all that? What are some of the simple evidence-based ways, by the way, that you like to handle this pain and stress?

Dr. Amanda Deacy: Yeah. So, the good news is despite those, you know, potentially dire outcomes that I just talked about, the good news is that there is current evidence that supports four primary strategies for pain management related to routine needle procedures. So, these are not even the NICU babies, although we ought to pay particular attention to those. But this is a well-developed healthy child too. There are really four strategies that have a longstanding evidence base that suggests that layering not only one of the strategies being beneficial, but actually layering them, using more than one at a time, produces incremental benefit for both pain and anxiety.

And so, just very briefly, these four strategies include some sort of topical anesthetic, so some sort of numbing cream. The great news is that these can now be applied at home. These are available over the counter. It's a 4% lidocaine cream. The second of those four is something we call comfort positioning. So, this is not the same as holding babies or toddlers down on their backs. So, comfort positioning. Number three is distraction. And the fourth is either sucrose or breastfeeding during painful needle procedures.

Host: With these four techniques and stuff that are evidence-based, are they widely used? I mean, are these things that most of your primary care pediatricians know about?

Dr. Amanda Deacy: So, in my experience, I think while the evidence is longstanding/ I think the transition from research evidence to practice has been slow. And so, really, what I've adopted, as really one of my primary goals for my practice is to close that research practice gap. So, I do spend a lot of time providing education, doing trainings related to these. Because despite the fact that the literature has been there, really, the uptake has lagged a bit behind.

And so, really, that's why I feel so passionately about this, is making sure that every child—I always joke, you know, my children have a pain psychologist for a mother, but my children shouldn't be the only ones who have access to this evidence base. And so, really, it's become my mission to get these in the hands of all primary care pediatric practices.

Host: I love it. Dr. Deacy, I think that's so important. The time from research to clinical application of just about anything is so long that by the time we start clinically recognizing it and doing it, researchers have known about it for 20 years.

Dr. Amanda Deacy: Exactly. And that is indeed the case for pain prevention and pain management around painful procedures for children. You bet.

Host: So, how do early experiences with pain in healthcare settings affect a child's long-term trust in medical care? I got to believe there has to be some trust issue there if their experience isn't great, right?

Dr. Amanda Deacy: Well, I think just the thing to remind the audience of is that even healthy children, again, they receive 15 to 20-plus doses of various vaccines by age 10. Those babies, like I mentioned in the NICU, who spend an average length of time, they can undergo 4,800 painful procedures, again, most without adequate pain management.

So, what we see is that there are higher pain ratings during venipuncture, for example, by school age in some of these babies when pain is not well treated. Like I said, just pre-procedural anxiety or a general fear of going to the doctor. The American Academy of Pediatrics actually put out an interesting paper not too long ago on the contributors to vaccine hesitancy.

And among those contributors, parents reported that the pain of vaccines was among the top most discussed parental reasons for delaying or avoiding vaccinations for their children. So, the implication is certainly community-wide, but also for an individual child or family, medical non-adherence or avoidance of healthcare altogether.

So, I think that takes me back to your initial question, which is, is this shift of thinking that I might suggest? And that is, again, moving the idea from it being just this very brief moment in your office to actually being a brief moment that potentially has long, long-lasting impacts for the health not only of an individual child, but our community at large.

Host: So, how do you feel about the trends you see on social media where parents are filming their kids having a bad experience getting a vaccine and not really doing much about it and posting it?

Dr. Amanda Deacy: Yes. Well, you know, I have a lot of empathy. I will say, I think that many of us grew up in the era of just dealing with it. It was considered just a part of childhood and that kids cry, and we just sort of need to get over it, really. But again, I think we can't expect parents or pediatricians, for that matter, to do better until they know better.

And so, again, it goes back to really what I feel so passionately about. I think parents want to do well by their children. We have to just make sure they're equipped with the appropriate skills to do so.

Comfort positioning is really something that parents can participate in, too, and we have the hope that they will during children's visits. So, encouraging parents to be part of the care team during those painful procedures, giving them a job, can also really help.

Host: I wanted to go back to two of the strategies and talk a little bit more about them. And one of them was the positioning, the comfort positioning. Are there certain positions that children just do well with, babies, toddlers, that you can discuss?

Dr. Amanda Deacy: Absolutely. So, most babies, we ought to recommend—again, this is for routine, non-emergent, expected needle procedures. We want to hold a baby just like we would be holding them to sing to them, to feed them, to talk to them. And so, a traditional football hold, for example, or even over chest-to-chest, we talk about that a lot. We talk about kids just being able to sit upright. So, we know there's some fascinating physiologic data about what happens to kids' vital signs when we lie them flat on their backs, as well as their emotional responses. There's sort of a fear response that happens, sort of this fight or flight that is initiated by lying kids on their backs. And then, additionally, when we hold them down, that reaction is only compounded. So, to the extent that you can hold infants in a comfortable position, put toddlers either, again, chest-to-chest or creating tummy-to-tummy, like I said, is really going to be the most comfortable and safe position for toddlers. And of course, this will require nursing education as well, because we want to ensure that our nurses are kept safe. There are ways to do that, that also mitigate needle sticks.

Host: The comfort position reminds me or it brings to mind the idea of time, because I know that when I was training—and I'd like to get your opinion on this—when I was training, the pediatricians back then, now this is late '80s, early '90s, they were like, "Get in and get out. Get that kid down, do the procedure you got to do and move on out," meaning they felt the faster you were, the better it was overall for the child. What do you think about that? Has that changed?

Dr. Amanda Deacy: Well, I do have an opinion on that, and it's actually twofold. I think one is there is this myth and the data have really borne this out, the idea that if we were to do what the evidence suggests, that is implementing these four strategies, that it has a detrimental effect on workflow and visit time. And actually, that has not turned out to be the case. Now, certainly, upfront when families or care teams are initially using these things, it may take a bit longer. But again, we're taking the marathon view here. And the idea is that over time, these visits actually go better and smoother. Because kids feel safe, they feel secure, and they know their pain will be treated.

The other thing is just this idea, again, that yes, while you could do it quickly and painfully, they have to come back. And so, over time, that stress reaction, that fear reaction just gets bigger and bigger, and the interventions take longer and longer. So again, this is really all about making an investment in protecting our kids' nerves, literally their nerves, so their neural function, their neural pain perception, and their emotional health. We make an upfront investment so that down the road they are less vulnerable to the development of chronic pain conditions certainly, but that also just emotionally they are set up for success. They are healthy and well-functioning adults who do not avoid routine healthcare.

Host: Yeah. That's a great, great point. You know, Dr. Deacy, when I, again, being a young medical student many, many years ago and, you know, being taught to kind of do it quick, do a procedure fast, I didn't like it. It wasn't good for me. You know, I didn't want to go back in and do the procedure, you know?

Dr. Amanda Deacy: Exactly. And I'm so glad you brought that up. And, you know, and it's difficult because as a medical staff member myself, I realize that I'm having to encourage my peers as well to make a practice change. And that's not always an easy position to be in. And yet, just like the outcomes are improved for parents and children, staff actually prefer this too.

The data have been clear. Providers and nurses don't go into pediatrics certainly because they enjoy hurting children, right? It's the opposite of that. And so, when we can equip staff members, their own distress goes down as well, and they see these things working, and they ultimately have confidence that they are providing best practice.

Host: Now, one of the other strategies you mentioned was distraction. So, any great tips there?

Dr. Amanda Deacy: There's a couple of things. One is you are your patient's own best distraction device, meaning talking to them, telling a story, engaging in a silly game, singing, commenting on their shoes, noticing the animal on their T-shirt. All of those things can serve as a cognitive distraction and get kids' brains refocused on something other than the pain.

There's some fascinating cognitive data about the fact that there is only so much sensory information that can be sent to the brain at one time. So, if we interrupt that, I'm sure your audience is familiar with the gate control theory of pain. If we close the pain gate, in other words with some other form of sensory input, that is distraction, pain sensation is less.

And so, it can be as simple as, again, singing, talking, telling stories, but also our exam rooms are full of games and puzzles and flashing lights and, you know, you probably have seen kids in practices showing up with their mom or dad's cell phone or their own iPad. So, that's really a positive application of a video screen to distract them away from the poke.

Host: What are some of the common misconceptions you see that clinicians have around pain and distress?

Dr. Amanda Deacy: Yeah. So, I'd say three of them come to mind. One of them is that kids' pain doesn't matter because they forget it anyway. That has been a myth or a misconception for some time. And again, the science just really does not bear that out. While they may cognitively not remember it, their bodies remember it. And also, the emotional distress is obviously something that we've all seen. So, that's one of the biggest. Kids' pain does in fact matter, and the implications can be quite big.

The second misconception I'd say is that there's nothing we can do about it. They just have to get through it just like we did. We know that's not true. This data has been around for, like you mentioned, 20 plus years. And they've been tested in various situations with both typically developing kiddos and those that are not typically developing. So, it really spans both developmental status as well as age, and they have great positive impact.

And the other myth is one I've already mentioned, which is that doing best practice pain management in primary care slows down the work of medical providers. And as I said, that actually has not been borne out.

Host: Yeah. I think that's a big myth. You still see that a lot today

Dr. Amanda Deacy: Yes. You know, and I think one of the things is, that even just as far as education, like I mentioned, the topical lidocaine cream is now available over-the-counter. So even if you're not waiting in your own waiting rooms or your own exam rooms for this cream to take effect, families can put it on before they come to the appointment. And so, in that case, they come prepped and ready for their vaccines.

Host: Yeah. I want to mention, so one of the things you said about not remembering pain, which we know they do in different ways. Because, you know, they may not remember, and this is just my take on it, Dr. Deacy, you're the expert. But a young child may not remember a bad pain experience in a doctor's office, like a memory. Like, you know, "On this day in 1990 whatever," they don't remember it like that, but they do remember it maybe as an adult because they have some fear of needle for some reason. They don't even know why.

Dr. Amanda Deacy: Well, exactly, and you took the words right out of my mouth. Actually, one in four adults is afraid of needles. And so, while those infants may not remember, their parents certainly do, and their parents were distressed when that was happening. And we also know that the way parents talk to their kids about painful experiences also has a lasting impact on the kid's perception of pain during subsequent procedures.

So, that parent was there that day, and they were distraught about how upset their baby was. And the parent might be the one in four. And so, it's a complicated mix potentially.

Host: Maybe the parent already kind of didn't like needles. Now, they definitely don't.

Dr. Amanda Deacy: Exactly. And so, now you have an adult who says, "Gosh, maybe we can wait on the 10-year vaccines."

Host: Yeah, maybe we don't need that. We don't need that follow-up one.

Dr. Amanda Deacy: Right. And it so becomes very uncomfortable not only for the parent but also for the child. And then you're having to manage behavior on top of it. And it just becomes sometimes too much for families who don't feel like they have the requisite skill.

Host: Dr. Deacy, this has been fascinating information. So happy you came on. What's one small change that you think a pediatrician could make tomorrow to improve a child's experience?

Dr. Amanda Deacy: So, I think a pediatrician tomorrow. Now again, this assumes some bit of education, but I would say stop holding kids down. Engage parents during the visits by including them and creating a comfortable position for their child's vaccines and stop holding them down. That would be my first recommendation.

One step beyond that, I know you asked for one, but I would encourage your patient's parents to go to our Comfort Promise webpage, or to the Meg Foundation's website. There is a ton of information in both of those places, and some very specific guidance for parents on creating their very own what's called a comfort kit. And it has specific instructions for ensuring that those four evidence-based elements I talked about get included in your child's kit.

Host: Fantastic. Thank you again, Dr. Deacy, for coming on. As a reminder to our audience, claim your CME credits after listening to this episode by visiting cmkc.link/cmepodcast and clicking the Claim CME button. If you enjoyed this podcast, please share it and check out the entire podcast library of topics of interest to you. This has been Pediatrics in Practice, a CME podcast. I'm Dr. Mike. Thanks for listening.