At BMC, we recognize that pain can affect all areas of a child or adolescent's life, which can lead to decreased physical activity, social isolation, and can fuel the cycle of chronic pain. Pain impacts relationships, school experience, and family life.
In this podcast, Dr. Caitlin Neri, from The Pediatric Pain Clinic at Boston Medical Center, discusses pain management in children and how at BMC, they can help manage acute, complex, and chronic pain in children from infancy to age 22. Our team of experts work closely with each patient's primary care physician, striving to help children regain normal lives and participate in typical age-appropriate activities.
Caitlin Neri, MD, MPH
Dr. Neri is a pediatric specialist at BMC. She has a specialized focus in pediatric hematology, and is the Medical Director for the pediatric pain clinic. The pediatric pain clinic treats an array of painful conditions in children, including chronic musculoskeletal pain, pain related to sickle cell disease, chronic headache and abdominal pain.
Learn more about Caitlin Neri, MD, MPH
Melanie Cole (Host): When a child or adolescent is in pain, it can affect all areas of their life which can lead to decreased physical activity, feelings of social isolation, and can fuel that cycle of chronic pain. For the parents, it can be an unbearable feeling watching your child in pain. My guest today is Dr. Caitlin Neri. She’s a pediatric specialist at Boston Medical Center and the Medical Director for the Pediatric Pain Clinic. Welcome to the show Dr. Neri. What are some of the most common causes of pediatric pain that you see?
Dr. Caitlin Neri, MD, MPH (Guest): Well thanks so much for having me. We see a wide variety of painful conditions in children. Some of the most common ones are chronic abdominal pain and chronic headaches. We also see a bit amount of musculoskeletal pain from a variety of causes, occasional chest pain or limb pain from certain conditions that can cause those types of things. But really, any type of pain that is distressing to the child or family or has gone on for longer than what most people would expect as a reasonable time; then we are happy to see them in our interdisciplinary pain clinic.
Melanie: So, that was going to be my next question. When do things like headaches, I mean chest pain is a different thing. Because that could be really scary. But headaches can happen pretty regularly in kids with the stress in school and the activities and all these things, the fact that they may not be getting enough sleep. When does something like a headache require a visit to a pain specialist?
Dr. Neri: Well, typically children have been seen by their pediatrician. Often a number of things have been tried. Sometimes they have also seen child neurology. Sometimes multiple specialists. But really, if the headaches are going – are happening several times a week or sometimes everyday and are really interfering with the child’s life and the normal family life, interfering with school and social relationships; then we want you to come see us. Because it usually requires a more in-depth or comprehensive solution that really needs to be delivered in an interdisciplinary program, such as ours.
Melanie: How do you even measure chronic pain in children? Because it is really a subjective thing, right? I mean you have to ask this child how much pain they are in and then try and diagnose the situation.
Dr. Neri: Yes. That’s exactly right. I think pain is whatever the patient says it is. That is sort of the mantra of measuring pain in anybody. There are certain scales and things that are used for acute pain, most people are familiar with the sort of 1-10 scale with 10 being the worst pain ever and zero is no pain at all and what number is your pain. That’s make a lot of sense for acute pain in the hospital or after surgery; that is often the way that we manage or measure pain and kind of tailor our interventions to treat pain using that sort of scale. Chronic pain is quite different. Where the numerical scale is not that helpful, and we tend to define it as pain that continues beyond what you would expect despite recommended medical interventions and pain that interferes with normal age appropriate daily life.
My role as the pediatrician on the team is to review the medical workup to date and do - I always tell the kids I do the doctor stuff, the physical exams, prescribe any medications that might be indicated and kind of oversee the overall health of the child while they are under the care of our interdisciplinary program.
But when pain been going on for a long time; it typically can’t be fixed by the medical piece alone. And that’s because as you mentioned, the stress and anxiety related to missed work, can sort of lead to school avoidance and anxiety can sometimes fuel that pain and so, that’s one of the reasons that we have a psychologist on our team. The other reason is that the patient’s perception of pain is controlled by the brain and you can actually use that connection to treat pain in kids and there’s very good evidence for the efficacy of mind-body strategies to manage pain in children and adults.
Fortunately, on our team, we have Dr. Laura Goldstein, who is a pediatric pain psychologist and has special training in effective mind-body strategies to manage pain in children. And so, we are able to use those strategies as well in our pain clinic. We also recognize the usefulness of integrative therapies, things like acupuncture, massage, and aroma therapy to manage pain in children and we have been able to make those available in our pediatric pain clinic. Sometimes physical therapy can be quite useful, particularly for musculoskeletal pain and also for headaches when neck tension and things like that can contribute to the headaches and so we have a physical therapist on our team.
And then we also have a social worker because nobody really ever tells parents how to best approach pain when it becomes chronic in their children and it really is important to have our social worker work with the parents and other caregivers about how to best support this child as they recover from chronic pain. For example, sometimes well-meaning parents tend to attend to the pain, focus on the pain, ask a lot of questions. How’s your pain? How’s your pain? How’s your pain? And that’s actually – can be detrimental in terms of recovery from chronic pain. It can be more helpful if we can redirect parents to focus on what’s going right, encourage the kids to practice their mind-body strategies, encourage – cheer them on when they stay in school, despite perhaps having a bit of pain that day. Because those things really help in recovery.
Melanie: So, based on everything you have said and the nonpharmacologic therapies and the integrative services; what about medicational intervention? When does that become necessary and I mean are parents really opposed to this? Is this a scary thing because we hear about the opioid addiction? How does that all work Dr. Neri?
Dr. Neri: Yeah, well opioids can be indicated for acute pain in children, things like postoperative pain or severe pain from a sickle cell crisis for example. For those things, absolutely strong pain medicine such as opioids are required. But in chronic pain, there is almost no role for opioids, but in general, when pain has become chronic; like chronic headaches, chronic abdominal pain, musculoskeletal pain that has gone on for a long time; there is really no role for opioid medications. There is sometimes role for other medications like nonsteroidal anti-inflammatories, things like Motrin and Naproxen; those things can be helpful. There are sometimes roles for other agents that can be helpful in headaches, tricyclic antidepressants such as amitriptyline and nortriptyline. There are other medications like gabapentin and medications that can used in neuropathic pain that we sometimes use in our chronic pain patients. And then there are some medicines for abdominal pain that can be helpful, and we utilize those as well. But there is really not any role for opioid medications in our chronic pain population here in pediatrics.
Melanie: Well, I’m glad you mentioned things like nonsteroidal anti-inflammatories, Motrin; I mean kids get they have pain as you say. Is there – what do parents ask you about giving their children Motrin if they have got a headache or how often they are allowed to do that? Do you try and put a bit of a limit on it and say well we would like to work on this non-medicationally if possible and then if it is really severe then you could go ahead and use Motrin?
Dr. Neri: Yeah, exactly. You are exactly right. And actually, sometimes when people over use nonsteroidals like Motrin, it can contribute to things like headaches or abdominal pain. There is such a thing as an NSAID overuse headache that we sometimes see or the GI upset that can come from too much of those NSAIDs, but so my kind of rule of thumb is it’s fine to use for when things are bad, but no more than twice per week and it’s always if you are treating your child’s pain, you can certainly use medications in collaboration with the other tools that we are going to teach you here in pain clinic including relaxation, and breathing exercises, aromatherapy; we send people home with these little devices where they can utilize that in their homes. And so, we really want them to have more than one thing to be able to try and people are really very open to it, is what I have found. They recognize that their child needs more than simply one medication, but they hadn’t been given the tools yet to try those other things at home.
Melanie: What an interesting field and pain management is certainly growing around the country. Wrap it up for us Dr. Neri, with your best advice for parents listening about the way they should approach a child in pain, when to see a pain specialist such as yourself and what you want them to know about when children have chronic pain.
Dr. Neri: Sure. I think the most appropriate first step is always to see your child’s pediatrician and there are often simple things that the pediatrician can do to help your child recover from pain. But I think when it gets to the point where it is interfering with schooling, it’s interfering with parents and their work, because of so much missed work due to pain, when there have been many doctors visits or appointments and really things aren’t getting better; then I would look into an interdisciplinary comprehensive pain program such as ours and there are several, many around the country actually and more are popping up. But you really need to look for things outside of medications, but in a coordinated team approach. So, I don’t think it’s that helpful for parents to go place to place and all different providers without kind of a coordinated team approach. I think the team approach is really essential. And so, I would encourage families to seek that out when pain has gone on for a long time or is really distressing.
Melanie: Thank you so much Dr. Neri, for all the great information. This is Boston Med Talks with Boston Medical Center. For more information on the pain clinic, the pediatric pain clinic at Boston Medical Center you can go to www.bmc.org, that’s www.bmc.org. This is Melanie Cole. Thanks so much for listening.