VOLUME 29, ISSUE 2

A RESIDENT’S OPINION TO PEDIATRIC PAIN MANAGEMENT

Priscilla J. Garcia, MD, MHA
Pediatrics Editor

A crying child can be hungry, sleepy or even frightened. However, pain is seldom at the top of every parents’ mind when children cry. For pediatric anesthesiologists, all influences need to be considered: “Can analgesics help this child? or “Can Princess Elsa’s singing from Frozen’s theme song ease a child’s apprehension?”

Henry Huang, MD
Baylor College of Medicine

The definition of pain varies, but the easiest interpretation is “a causality from noxious stimulation.” This distress in the pediatric population is often manifested as an agitated child. For me, my initial exposure to pediatric pain was unorthodox. As a general surgery resident, I scrubbed in cases of pectus excavatum repair where I traumatically inserted metal rods into patients’ thorax. I became keenly aware of the extensive analgesic management that our anesthesiologists concocted during the perioperative and postoperative environment. I discovered that my passion to patient care leaned more towards a holistic approach in the perioperative setting. I left my surgical residency program and became a research associate at Texas Children’s Hospital in Houston. I was involved in projects comparing analgesic management of pectus excavatum repairs; in addition, I sought further research projects in pain management such as using supraclavicular nerve blocks for closed reduction/percutaneous pinning of type II supracondylar fractures. After beginning my anesthesiology residency, I was trained to help a child’s pain not only with intravenous opioids and non-opioid adjuncts, but also with my interventional skills. I became proficient at administering miniscule amounts of intravenous fentanyl for a newborn requiring PICC line access. For infants with bilateral inguinal hernias, I utilized single shot caudal epidural injections for both surgical and post-op analgesia. On the pain team, I would fine-tune regimens of benzodiazepines and long acting narcotics to recurrent acute pain crisis after a 15-year-old’s idiopathic scoliosis repair. For patients on chronic multimodal analgesics for cancer pain, I often counselled the parents’ psychological distress in addition to meticulously adjusting the children’s pain regimens. Even as a trainee, I had a front role seat to experience the expansive ability of a pain specialist to ease the distress of a child and the patient’s family.

Pediatric pain management is not for every pediatric anesthesiologist. However, I believe pediatric anesthesia and pain management offers physicians a more encompassing role to a child’s hospital course. I urge all anesthesiology residents to have more exposure to pediatric pain management and consider pediatric pain fellowship a crucial advanced training.

Currently, there is a need for more pediatric pain specialists; however pediatric pain training is variable and in flux. For example, in Texas there are five adult pain programs1and three pediatric anesthesia programs2, but no programs in Texas offer an official pediatric pain fellowship. Thus, programs that offer ACGME accreditation must combine pediatric pain training with adult pain fellowships. Most of us are familiar with ACGME certified pain programs for adults. These programs are listed on the ACGME website and the application process is through a common electronic application like the residency application.3 Unfortunately, identifying a pediatric pain program is laborious, and different programs offer varying types of training. Three pediatric pain fellowships offer a combined six-month pediatric pain with six-month adult pain experience so the trainee is eligible to sit for the adult Pain boards.4 Alternatively, two programs offer a full one-year pediatric pain fellowship without adult Pain board eligibility.5 (Stanford’s Lucile Packard Children’s Hospital and Seattle Children’s Hospital). Newer arrangements at some programs include a two-year pain fellowship with one year of adult and one year of pediatric pain training. However, contacting the program directors and coordinators seems to be how most people find out which programs suit their individual needs as these programs continuously change what they offer.

If someone is interested in obtaining training in this growing field, the Society for Pediatric Pain Management (an organization under the Society for Pediatric Anesthesia) may be helpful.
5,6

Index:

  1. Adult Pain Fellowships in Texas
    • MD Anderson/University of Texas Health Science Center at Houston
    • Scott and White Memorial Hospital
    • Texas Tech University (Lubbock)
    • University of Texas Medical Branch Hospitals
    • University of Texas Southwestern Medical School
  2. Pediatric Anesthesiology Fellowship in Texas
  3. Programs that currently offer an ABA and ACGME approved fellowship in pediatric pain medicine, where those completing pediatric pain fellowship (6 months of pediatric pain rotation and 6 months of adult pain rotation) are eligible for adult Pain board
    • Boston Children’s Hospital/Beth Israel Deaconess Medical Center/Brigham and Women’s Hospital
    • Children’s Hospital Pain Center/Medical College of Wisconsin Pain Treatment Center/Zablocki VA Pain Clinic/Integrated Pain Mental Health Clinic at the MCW Pain Center/Inpatient Acute and Chronic Pain Services Clinic at Froedtert Hospital
    • Cincinnati Children’s Hospital Medical Center/University of Cincinnati Medical Center
  4. Programs that offer year-long pediatric pediatric pain medicine without board eligibility (may be transitioning to the two-year adult-pediatric pain model)
    • Lucile Packard Children’s Hospital/Stanford University
    • Seattle Children’s Hospital/University of Washington medical Center/Harborview Medical Center/Veterans’ Affairs Puget Sound Health Care System/Seattle Cancer Care Alliance
  5. Web Address for the Society for Pediatric Pain Management
    www.pedspainmedicine.org
  6. The most established programs that offer training in pediatric pain include:
    • Boston Children’s Hospital/Beth Israel Deaconess Medical Center/Brigham and Women’s Hospital
    • Children’s Hospitals and Clinics of Minnesota – pediatric rehabilitation medicine.
    • Cincinnati Children’s Hospital Medical Center/University of Cincinnati Medical Center
    • Children’s Hospital Pain Center/Medical College of Wisconsin Pain Treatment Center/Zablocki VA Pain Clinic/Integrated Pain Mental Health Clinic at the MCW Pain Center/Inpatient Acute and Chronic Pain Services Clinic at Froedtert Hospital
    • Lucile Packard Children’s Hospital/Stanford University
    • Seattle Children’s Hospital/University of Washington medical Center/Harborview Medical Center/Veterans’ Affairs Puget Sound Health Care System/Seattle Cancer Care Alliance

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