Pulse
Pain Reliever
Stefan Friedrichsdorf thinks physicians need to do more to alleviate children’s pain.
Pediatric pain expert Stefan Friedrichsdorf, M.D., decided he needed to do more for hurting children 10 years ago when he was caring for premature infants in a neonatal intensive care unit in Datteln, Germany. Many of his patients had undergone multiple procedures that were extremely painful. “I felt powerless to relieve these little screaming babies from the pain I was inflicting,” he recalls.
That experience prompted him to pursue a fellowship in pediatric pain and palliative care at Children’s Hospital in Westmead in Sydney, Australia, one of the only programs of its kind at the time.
Today, Friedrichsdorf is one of a handful of pediatricians in the world who specialize in pain management. In 2005, he came to Minnesota in order to direct the Pain and Palliative Care Program at Children’s Hospitals and Clinics of Minnesota. The program serves newborns to 17-year-olds.
Pediatric pain is a bigger issue than many physicians might realize. In Minnesota alone, more than 120,000 children and adolescents have pain severe enough to cause them to miss school. This may manifest as acute pain from an injury or following surgery, chronic pain from migraine or tension headaches, or pain associated with conditions such as cancer or muscular dystrophy. If the pain is left untreated, Friedrichsdorf says, children may experience regressive behaviors, have difficulty adjusting socially, or have trouble performing activities of daily living. Helping them manage their pain, he says, starts with understanding the severity of it.
No Pain, Much Gain
To Friedrichsdorf, evaluating pain in kids is “not rocket science.” For kids who are verbal or old enough to express the fact that they’re in pain, measuring it is a matter of using the 0 to 10 pain scale or the FACES pain scale. For kids who are nonverbal, it requires reading clues—how long have they been crying, grimacing, or flinching—or using tools such as the FLACC (Face, Legs, Activity, Cry, Consolability) scale. Mild pain might call for acetaminophen or ibuprofen. Moderate pain might require a weak opioid such as tramadol. And severe pain might require strong opioids.
Getting physicians to prescribe these medications is the bigger challenge. Friedrichsdorf says most physicians have not been trained to administer pain medications to children and hesitate to prescribe them because they are worried that children will become addicted or that the drugs will affect their development. As a result, kids don’t get the pain relief they need. He points out that studies have repeatedly shown that adults in the United States get two to three times more pain medication relative to their body size than children. “The smaller the child is, the less likely it is that he or she will get adequate analgesia,” he says.
When Friedrichsdorf talks to physicians, he tries to dispel their fears about giving children medication for pain. He cites studies that have shown no long-term developmental effects of exposure to pain-relieving medications and others that describe the long-term consequences of exposure to untreated pain (increased morbidity, increased risk of intraventricular hemorrhage, increased mortality). And he emphasizes that there has been no published case of a child becoming addicted to opioids if treated for acute pain.
To help physicians at Children’s better treat children in pain, Friedrichsdorf’s team created a pocket-sized card that lists starting doses of the most common pediatric pain medications per kilogram of bodyweight, along with guidelines about what do to if the drugs are not working or are causing side effects such as excessive sedation or respiratory depression. Physicians can receive a copy of the card by contacting Friedrichsdorf at CIPPC@childrensmn.org.
The Other Side of Pain Control
When a child’s pain is adequately controlled pharmacologically, it paves the way for what Friedrichsdorf considers the other essential ingredients of pain management. “For both adults and children, the state-of-the-art care in the 21st century is that we must—as in we have to, as in there is no other choice—combine fabulous drugs with integrative, complementary, and nonpharmacological treatment modalities,” he says. He explains that research has shown that such approaches stimulate the descending inhibiting pathways and activate the body’s own pain-relief systems. “It could be hypnosis, biofeedback, progressive muscle relaxation, breathing exercises, or imagery, or it could be as simple as hearing a story, playing a video game, or being rocked by a parent,” Friedrichsdorf says, adding that Children’s has staff who can offer these therapies. “Even newborns can learn coping strategies and stimulate the filter that turns the pain down.”
In order to decide which treatments are most helpful, a five-member team at Children’s—including the lead pediatrician, a clinical nurse, a clinical psychologist, a social worker/family therapist, and a specially trained physical therapist—evaluates the patient in the presence of his or her family. Children suffering from acute postoperative pain would likely be given medications; once the pain is under control, they might receive acupuncture or acupressure or learn biofeedback techniques. For a child with complex or chronic pain, the team might add adjuvant analgesia (eg, amitriptyline or gabapentin), and focus on weaning the child off strong pain medications, then move toward managing the pain using integrative therapies, counseling, and physical therapy.
A Slow Start
Whether or not pediatric pain management will catch on elsewhere remains to be seen. The pediatric pain program at Children’s is one of only a few in the United States. Friedrichsdorf says hospitals have been slow to start pediatric pain management programs because reimbursement for such services remains poor. “Insurers pay for procedures like spinal fusion for back pain, which may cost up to $30,000 and has no evidence of its effectiveness, but they rarely reimburse for services at a chronic pain clinic, which may cost only $5,000. That takes a toll.” he says.
He says philanthropy pays for about half the cost of the pain and palliative care program at Children’s; the rest is paid by health insurers. That means, in addition to being medical director of the program, Friedrichsdorf helps with fundraising—a job that is likely to consume more of his time as the economy worsens.
Still, Friedrichsdorf hopes the reimbursement situation will change one day and that more physicians will want to pursue pediatric pain management as a subspecialty. In the meantime, he’s doing what he can to teach physicians about managing children’s pain. This year, Children’s will offer a fellowship in pediatric pain and palliative care; it is the first fellowship of its kind in the country. In addition, Children’s offers an annual weeklong pediatric pain master class for physicians. Friedrichsdorf and his colleague, Kaci Osenga, M.D., also train pediatric residents from the University of Minnesota, and Friedrichsdorf regularly speaks to physicians and medical students around the country, inviting pediatricians to shadow him in order to learn what pediatric pain management entails.
Friedrichsdorf’s take-home message for all physicians is that you don’t have to be an expert to make a difference for young patients. “Take it at face value when a child tells you they are in pain, and then do something about it…. We have kids at this very minute who are literally crying in pain in this country. And we need to make sure we take their pain away. It’s just that simple.”—Jeanne Mettner