The Pain Management Clinic at St. Louis Children's Hospital (SLCH) provides evaluation, treatment, education and support for pediatric patients experiencing either acute or chronic pain. It is the only clinic in the region offering these specialized services through providers with particular training in helping children deal with pain.
In this segment, Jacob Aubuchon, MD, Washington University pediatric anesthesiologist and director of the Pain Management Clinic at St. Louis Children's Hospital, discusses chronic pain in children and when a pediatrician should refer to a pain specialist.
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Chronic Pain in Children
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Learn more about Jacob Aubuchon, MD
Jacob Aubuchon, MD
Jacob Aubuchon, MD, is a Washington University pediatric anesthesiologist and director of the Pain Management Clinic at St. Louis Children’s Hospital.Learn more about Jacob Aubuchon, MD
Transcription:
Chronic Pain in Children
Melanie Cole (Host): Pain can affect anyone at any age. Even children and teenagers can feel chronic pain caused by neurological or musculoskeletal disorders. Pediatric Pain Management doesn’t receive as much attention as therapies for adults but left untreated childhood chronic pain could lead to life-long problems. My guest today is Dr. Jacob Aubuchon. He’s a Washington University Pediatric Anesthesiologist and the Director of Pain Management at St. Louis Children’s Hospital. Welcome to the show, Dr. Aubuchon. What is considered chronic pain in children?
Dr. Jacob Aubuchon (Guest): For chronic pain, in general, whether it’s adult or childhood pain we think of longstanding pain, or chronic pain as anything that’s persisting over three months. Normally when we sprain our ankle, or we break a bone, that pain is self-limited. We expect that it’s going to resolve in a number of weeks or months and we’ll be back to our normal activity after treatment or after rest, whereas with chronic pain, or persistent long-standing pain, it usually keeps going. The treatment is different, of course, once we have developed long-standing pain and it hasn’t resolved after what we would expect to be a normal course.
Melanie: So what about the significance of this problem? Are you seeing many children with chronic pain?
Dr. Aubuchon: I think that’s one of the misconceptions in the community. We all know that as we get older and arthritis sets in for older adults that we expect to have some amount of pain, so I think the chronic pain in the adult world is pretty well understood. Pediatric pain, I think most providers in the community don’t realize that 2 out of every 10 children will have the long-standing pain of some sort extending outside that three-month span.
Melanie: One of the difficult things I think with children especially, Dr. Aubuchon, is conceptualizing this pain and vocalizing – really with adults we can say, “It hurts here,” or “it hurts there,” or “It hurts on a scale of ten,” but sometimes with children it’s a little bit different. How do you assess their level of pain?
Dr. Aubuchon: Yeah, that’s a great question and something that we continue to struggle with throughout pediatric pain from both a postoperative standpoint, but also when we see patients in our chronic pain clinic. There are validated scales, scales that we can use depending on the child’s age and their developmental status, for example. If it’s a two-year-old that we’re trying to assess pain in we’re going to use mainly observation, so are they consolable? What are their extremities doing? Are they rigid or constantly crying? You can imagine, though that with those type of scales, it’s still highly subjective and anybody that’s had a toddler, or children, or been around children, if they don’t get their way, often times they could have what looked to be a really high pain score.
More important in a chronic pain standpoint, ways to assess I think are better at looking at all of those areas of life that are affected by pain. For example, decreased sleep, withdrawing from social interaction even in young children, not interacting with their family. For school-aged children, withdrawal from school, unable to get to school, or if they have to leave early frequently. I think those are better measures and at least more consistent in my mind of ways to see how pain is affecting their lives other than these very subjective pain scales and scores.
Melanie: If we’re talking about musculoskeletal pain, Dr. Aubuchon, what about things like juvenile arthritis, are there tests to see which joints are affected or how much pain is going on in each particular joint?
Dr. Aubuchon: Sure, and one thing I should mention when referring or considering a workup for pain, we’re going to use other specialties to help us out with this. For example, arthritis and even juvenile arthritis, so children -- we’re going to ask help from our rheumatology colleagues. From our chronic pain clinic standpoint what we're trying to do is once we’ve established a diagnosis, or even if there’s still not a firm diagnosis in place, we’re not going to wait to try and help the child in pain, we’re going to treat them in ways that we know are effective despite having a diagnosis may be managed by another specialty or if the diagnosis still hasn’t been confirmed.
Melanie: And when would you advise Pediatricians to refer to a specialist such as yourself, or when can the general pediatrician handle this kind of pain on their own?
Dr. Aubuchon: I think, at first, if – and this will go both ways – if there’s no red flags – now, I’ll get to the red flags in minutes – I think the pediatrician will be fine managing pain, as long as they start with the – for musculoskeletal pain, what’s shown to be most effective, for example, is physical therapy. There’s plenty of very experienced physical therapists in the community that work with children, so for back pain or even joint pain, that’s a good place to start. The red flags that I would be concerned for are the ones that I previously mentioned -- withdraw from school, maybe they’ve missed ten days of school in the last month, or even more concerning if they haven’t been to school in six months, which is actually fairly common when they have severe pain, not able to sleep at night, and also withdrawing from social interactions and things that they used to love to do, but have not been able to do them due to severe pain. Those are the red flags that would say, “Okay, we need to call the pain management center and see if the can get seen sooner than later.”
Melanie: So if a child doesn’t respond to the simple first-line treatments you’ve discussed, how is the condition treated at the pain management clinic. Speak about the interdisciplinary clinic and the nature of it that you deal with.
Dr. Aubuchon: Sure. The fortunate thing – we do have a Pediatric Pain Clinic in St. Louis – maybe the unfortunate thing for the small communities around St. Louis is there’s only about 40 centers across the country, and the importance of pediatric pain is that we need this interdisciplinary approach. It’s not just a focus on one area. It’s not that they come to see our pain clinic and we prescribe medicine, and we send them on their way. No, it’s built into our clinic. We have both the medical provider, we have nurse practitioners, but also importantly we have physical therapists and also a pain psychologist that’s very experienced to work on every area of the child’s life. When a patient’s referred and we evaluate them for the first time, they will see all three disciplines, psychology, physical therapy, and myself.
We’ve really come up with a multidisciplinary approach to improve their pain. When children have significant pain like I mentioned it affects every aspect of their life. Just focusing on one area will likely not get the most bang for our buck, but if we focus on both their school attendance, maybe even parental counseling on how they can go about dealing with their child’s pain on a daily basis but also working on increasing their physical function through physical therapy has been shown to be the most beneficial for longstanding pain in pediatrics. There is still a role for medications and medical management, but we definitely don’t focus on the opiate-type pain medicines for long-standing pain because they’re just not indicated for long-standing pain.
Melanie: And what about some non-medicational treatments? Speak just a little bit more about some of those.
Dr. Aubuchon: Sure, so from the psychology realm, when thinking about biofeedback, especially for headaches in pediatric patients, but also cognitive behavioral therapy for headaches or any type of pain, what our psychologist is working with them in regards to that is just coming up with a daily strategy and coming up with appropriate expectations for how to get through the day of the child, and how to get back to school, and sleep counseling because all of this stuff is very important.
Other non-medication strategies, like I mentioned, physical therapy, working on a gradual pacing plan of increasing daily physical function, exercise in order to build up stamina so they can get through school or get back to their normal activities if they were involved in sports or other extracurricular activities that they’ve been withdrawn from, giving them a plan and placing them back into those activities.
Melanie: So wrap it up for us, Dr. Aubuchon, really give your best advice to pediatricians about when they should refer and dealing with children’s chronic pain and then tell us about your team. Why is St. Louis Children’s Hospital, so great to work with?
Dr. Aubuchon: Yeah, so one is -- those things that concern me are the child is just getting ready to fall off this normal developmental trajectory. Whatever area of pain, whether it’s a headache, abdominal pain, or musculoskeletal pain, if they have withdrawn from school or if they previously were involved in something they love to do or even hanging out with their family and now they’re unable to do it, that’s a time to refer to us so we can intervene early through psychology, physical therapy, and some medical therapies.
I think the reason St. Louis Children’s Hospital is so effective at helping these children in pain is, one, is our own interdisciplinary approach, but also because we work so well with all the other disciplines. We commonly refer back and forth between rheumatology, plastic surgery, multiple surgical disciplines, and genetics. I think we just have a very collegial atmosphere that really we just want to strive to improve the child’s life as efficiently as possible.
Melanie: Thank you, so much, for being with us today, Dr. Aubuchon. That’s great information. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that's 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks, so much, for listening.
Chronic Pain in Children
Melanie Cole (Host): Pain can affect anyone at any age. Even children and teenagers can feel chronic pain caused by neurological or musculoskeletal disorders. Pediatric Pain Management doesn’t receive as much attention as therapies for adults but left untreated childhood chronic pain could lead to life-long problems. My guest today is Dr. Jacob Aubuchon. He’s a Washington University Pediatric Anesthesiologist and the Director of Pain Management at St. Louis Children’s Hospital. Welcome to the show, Dr. Aubuchon. What is considered chronic pain in children?
Dr. Jacob Aubuchon (Guest): For chronic pain, in general, whether it’s adult or childhood pain we think of longstanding pain, or chronic pain as anything that’s persisting over three months. Normally when we sprain our ankle, or we break a bone, that pain is self-limited. We expect that it’s going to resolve in a number of weeks or months and we’ll be back to our normal activity after treatment or after rest, whereas with chronic pain, or persistent long-standing pain, it usually keeps going. The treatment is different, of course, once we have developed long-standing pain and it hasn’t resolved after what we would expect to be a normal course.
Melanie: So what about the significance of this problem? Are you seeing many children with chronic pain?
Dr. Aubuchon: I think that’s one of the misconceptions in the community. We all know that as we get older and arthritis sets in for older adults that we expect to have some amount of pain, so I think the chronic pain in the adult world is pretty well understood. Pediatric pain, I think most providers in the community don’t realize that 2 out of every 10 children will have the long-standing pain of some sort extending outside that three-month span.
Melanie: One of the difficult things I think with children especially, Dr. Aubuchon, is conceptualizing this pain and vocalizing – really with adults we can say, “It hurts here,” or “it hurts there,” or “It hurts on a scale of ten,” but sometimes with children it’s a little bit different. How do you assess their level of pain?
Dr. Aubuchon: Yeah, that’s a great question and something that we continue to struggle with throughout pediatric pain from both a postoperative standpoint, but also when we see patients in our chronic pain clinic. There are validated scales, scales that we can use depending on the child’s age and their developmental status, for example. If it’s a two-year-old that we’re trying to assess pain in we’re going to use mainly observation, so are they consolable? What are their extremities doing? Are they rigid or constantly crying? You can imagine, though that with those type of scales, it’s still highly subjective and anybody that’s had a toddler, or children, or been around children, if they don’t get their way, often times they could have what looked to be a really high pain score.
More important in a chronic pain standpoint, ways to assess I think are better at looking at all of those areas of life that are affected by pain. For example, decreased sleep, withdrawing from social interaction even in young children, not interacting with their family. For school-aged children, withdrawal from school, unable to get to school, or if they have to leave early frequently. I think those are better measures and at least more consistent in my mind of ways to see how pain is affecting their lives other than these very subjective pain scales and scores.
Melanie: If we’re talking about musculoskeletal pain, Dr. Aubuchon, what about things like juvenile arthritis, are there tests to see which joints are affected or how much pain is going on in each particular joint?
Dr. Aubuchon: Sure, and one thing I should mention when referring or considering a workup for pain, we’re going to use other specialties to help us out with this. For example, arthritis and even juvenile arthritis, so children -- we’re going to ask help from our rheumatology colleagues. From our chronic pain clinic standpoint what we're trying to do is once we’ve established a diagnosis, or even if there’s still not a firm diagnosis in place, we’re not going to wait to try and help the child in pain, we’re going to treat them in ways that we know are effective despite having a diagnosis may be managed by another specialty or if the diagnosis still hasn’t been confirmed.
Melanie: And when would you advise Pediatricians to refer to a specialist such as yourself, or when can the general pediatrician handle this kind of pain on their own?
Dr. Aubuchon: I think, at first, if – and this will go both ways – if there’s no red flags – now, I’ll get to the red flags in minutes – I think the pediatrician will be fine managing pain, as long as they start with the – for musculoskeletal pain, what’s shown to be most effective, for example, is physical therapy. There’s plenty of very experienced physical therapists in the community that work with children, so for back pain or even joint pain, that’s a good place to start. The red flags that I would be concerned for are the ones that I previously mentioned -- withdraw from school, maybe they’ve missed ten days of school in the last month, or even more concerning if they haven’t been to school in six months, which is actually fairly common when they have severe pain, not able to sleep at night, and also withdrawing from social interactions and things that they used to love to do, but have not been able to do them due to severe pain. Those are the red flags that would say, “Okay, we need to call the pain management center and see if the can get seen sooner than later.”
Melanie: So if a child doesn’t respond to the simple first-line treatments you’ve discussed, how is the condition treated at the pain management clinic. Speak about the interdisciplinary clinic and the nature of it that you deal with.
Dr. Aubuchon: Sure. The fortunate thing – we do have a Pediatric Pain Clinic in St. Louis – maybe the unfortunate thing for the small communities around St. Louis is there’s only about 40 centers across the country, and the importance of pediatric pain is that we need this interdisciplinary approach. It’s not just a focus on one area. It’s not that they come to see our pain clinic and we prescribe medicine, and we send them on their way. No, it’s built into our clinic. We have both the medical provider, we have nurse practitioners, but also importantly we have physical therapists and also a pain psychologist that’s very experienced to work on every area of the child’s life. When a patient’s referred and we evaluate them for the first time, they will see all three disciplines, psychology, physical therapy, and myself.
We’ve really come up with a multidisciplinary approach to improve their pain. When children have significant pain like I mentioned it affects every aspect of their life. Just focusing on one area will likely not get the most bang for our buck, but if we focus on both their school attendance, maybe even parental counseling on how they can go about dealing with their child’s pain on a daily basis but also working on increasing their physical function through physical therapy has been shown to be the most beneficial for longstanding pain in pediatrics. There is still a role for medications and medical management, but we definitely don’t focus on the opiate-type pain medicines for long-standing pain because they’re just not indicated for long-standing pain.
Melanie: And what about some non-medicational treatments? Speak just a little bit more about some of those.
Dr. Aubuchon: Sure, so from the psychology realm, when thinking about biofeedback, especially for headaches in pediatric patients, but also cognitive behavioral therapy for headaches or any type of pain, what our psychologist is working with them in regards to that is just coming up with a daily strategy and coming up with appropriate expectations for how to get through the day of the child, and how to get back to school, and sleep counseling because all of this stuff is very important.
Other non-medication strategies, like I mentioned, physical therapy, working on a gradual pacing plan of increasing daily physical function, exercise in order to build up stamina so they can get through school or get back to their normal activities if they were involved in sports or other extracurricular activities that they’ve been withdrawn from, giving them a plan and placing them back into those activities.
Melanie: So wrap it up for us, Dr. Aubuchon, really give your best advice to pediatricians about when they should refer and dealing with children’s chronic pain and then tell us about your team. Why is St. Louis Children’s Hospital, so great to work with?
Dr. Aubuchon: Yeah, so one is -- those things that concern me are the child is just getting ready to fall off this normal developmental trajectory. Whatever area of pain, whether it’s a headache, abdominal pain, or musculoskeletal pain, if they have withdrawn from school or if they previously were involved in something they love to do or even hanging out with their family and now they’re unable to do it, that’s a time to refer to us so we can intervene early through psychology, physical therapy, and some medical therapies.
I think the reason St. Louis Children’s Hospital is so effective at helping these children in pain is, one, is our own interdisciplinary approach, but also because we work so well with all the other disciplines. We commonly refer back and forth between rheumatology, plastic surgery, multiple surgical disciplines, and genetics. I think we just have a very collegial atmosphere that really we just want to strive to improve the child’s life as efficiently as possible.
Melanie: Thank you, so much, for being with us today, Dr. Aubuchon. That’s great information. A physician can refer a patient by calling Children’s Direct Physician Access Line at 1-800-678-HELP, that's 1-800-678-4357. You’re listening to Radio Rounds with St. Louis Children’s Hospital. For more information on resources available at St. Louis Children’s Hospital, you can go to StLouisChildrens.org, that’s StLouisChildrens.org. This is Melanie Cole. Thanks, so much, for listening.