Integrative Care for Pediatric Patients with Pain

Abstract

Objectives:

Although pediatric patients with chronic pain often turn to complementary therapies, little is known about patients who seek academic integrative pediatric care.

Design:

The study design comprised abstraction of intake forms and physician records from new patients whose primary concern was pain.

Setting/location:

The study setting was an academic pediatric clinic between January 2010 and December 2011.

Subjects:

Of the 110 new patients, 49 (45%) had a primary concern about headache (20), abdominal pain (18), or musculoskeletal pain (11).

Results:

The average age was 13±4 years, and 37% were male. Patients reported an average pain level of 6±3 on a 10-point scale, and most reported more than one kind of pain; parents had an average of 7±3 health concerns per child, including fatigue (47%), mood or anxiety (45%), constipation/diarrhea (41%), and/or sleep problems (35%). Most patients (57%) were referred by specialists; 71% were taking prescription medications; and 53% were taking one or more dietary supplements at intake. Of those tested, most (61%) had suboptimal vitamin D levels. All families wanted additional counseling about diet (76%), exercise (66%), sleep (58%), and/or stress management (81%). In addition to encouraging continued medical care (100%) and referral to other medical specialists (16%), frequent advice included continuing or initiating dietary supplements such as vitamins/minerals (80%), omega-3 fatty acids (67%), and probiotics (31%). Stress-reducing recommendations included biofeedback (33%), gratitude journals (16%), and yoga/t'ai chi (8%). Other referrals included acupuncture (24%) and massage (20%).

Discussion:

Patients who have chronic pain and who present to an integrative clinic frequently have complex conditions and care. They are interested in promoting a healthy lifestyle, reducing stress, and using selected complementary therapies.

Conclusion:

Patients with chronic pain who seek integrative care may benefit from the kind of coordinated, integrated, comprehensive care provided in a medical home.

Introduction

C hronic pain is a large and growing problem. According to a 2011 report from the Institute of Medicine, nearly 115 million Americans suffer from chronic pain, with costs as high as $635 billion per year.^1,2 These staggering figures do not include chronic pain experienced by children. The National Pain Foundation estimates that persistent or recurrent pain in children and adolescents affects nearly 40% of children at least once weekly.³ For the most common pediatric pain problems, prevalence ranges from 8% to 83% for headache (HA), 4%–53% for abdominal pain (ABD), and 4%–40% for chronic musculoskeletal pain (MS).^4

–8

Untreated pain impairs quality of life and may lead families to seek complementary therapies.^4,9,10 Children are at an increased risk for undertreatment of pain due to developmental factors that complicate its timely recognition, misconceptions about children's ability to feel pain, lack of translational research, and lack of standardized treatment guidelines.³ Left untreated, pain in children often results in significant impairment in quality of life including mood, sleep, relationships, academic performance, and social development, and may predispose to the development of pain later in life.³ Families of pediatric patients with pain suffer increased emotional and financial stress secondary to health care expenses and lost wages to care for a sick child. Approximately 12% of nonclinical populations seek complementary therapies for their children, with higher rates in clinical populations.^11,12 Although several surveys have assessed the use of complementary therapies among patients with specific types of pain who seek care from gastroenterologists, hematologist-oncologists, neurologists, and rheumatologists,^4,9,10 little is known about the kinds of pain and its treatment among children and adolescents seeking care from an integrative pediatrician.

Since 2005, one of the authors (KK) has conducted a Pediatric Second Opinion and Integrative Medicine Clinic (PSOIMC). Integrative Medicine is patient-centered care building on patients' goals and strengths to achieve optimal health using a comprehensive approach to lifestyle, complementary, and conventional therapies. Based on collaborations with the Pediatric Working Group of the Consortium of Academic Health Centers for Integrative Medicine, since late 2009, the PSOIMC has used a standard intake form.

This study was conducted to (1) describe the demographics, comorbid health concerns, and therapies used by patients with chronic or recurrent pain presenting for care at the PSOIMC; (2) assess caregiver and patient health goals and interest in health-promoting strategies such as optimizing nutrition, activity, sleep, and stress management; (3) describe the types of complementary and alternative medicine (CAM) and conventional therapies recommended at initial evaluation to improve quality of care and to inform others caring for similar patients.

Materials and Methods

This was a retrospective cohort study; the basic methods have been described previously.^13,14 Briefly, subjects were included if they visited the PSOIMC between January 2010 and December 2011 and their parents indicated a concern about pain or noted a history of pain within the past week on the clinic's standard intake form. The PSOIMC meets weekly in the pediatric specialty clinic area of the Brenner Children's Hospital. All patients were seen by the same PSOCIM board-certified pediatrician (KK). In addition to the pediatrician and clinic nurse, the clinic also has an on-site nutritionist and social worker (shared with other specialties), and institutional availability of multiple pediatric specialists, psychologists, psychiatrists, and licensed massage therapists. Acupuncture services are available in the community.

Data were abstracted from the intake form that parents completed prior to the initial physician evaluation. Parents were asked to describe current therapies and interest in discussing lifestyle factors such as diet, activity/exercise, sleep, and stress management. There were also questions about household psychosocial factors that may impact pain including family history of mental health problems or substance abuse in the household. The intake form and educational materials are available on the clinic's website (www.wakehealth.edu/cim). In addition to the intake form, notes from referring physicians, PSOIMC chart notes, including notes to the referring physician and other consultants, and laboratory tests were also reviewed.

Charts were independently reviewed by 2 reviewers for accuracy. All questions were resolved by the treating clinician. Data were abstracted into a spreadsheet and analyzed using simple descriptive statistics (Microsoft Excel, 2010). Patients were divided into three groups by their primary pain concern at the time of the initial visit: HA, ABD, or MS.

The study was approved by the Wake Forest School of Medicine Institutional Review Board.

Results

Demographic and health characteristics

Of the 110 new patients seen between January 2010 and December 2011, 49 (45%) had a primary concern about pain, with average pain scores of 5.9±2.7 out of a maximum of 10 over the previous 7 days. Of the 49 patients with pain, 41% primarily reported HA, 37% ABD, and 22% MS (Table 1). Patients' average age was 13±4 years and 37% were male. Perceived health status was generally excellent or good except among those with MS pain, of whom 73% reported only fair or poor health. Most patients (57%) were referred by specialists, particularly those whose primary concern was ABD (72%) or HA (65%).

Table 1.

Patient Description

Factor
Number (%) or mean±standard deviation	Headache 20 (41%)	Abdominal pain 18 (37%)	Musculoskeletal pain 11 (22%)	Total 49 (100%)
Age in years (mean±SD)	13.2±4	12.4±5	13.4±4	13±4
Gender N (%) male	5 (25%)	10 (56%)	3 (27%)	18 (37%)
Referred by specialist (%)	65%	72%	18%	57%
Pain score (range 0,10)	5.6±2.5	6.5±2.7	6.5±2.5	5.9±2.7
Pain concerns
Headache	100%	33%	73%	69%
Abdominal pain	25%	100%	55%	59%
Musculoskeletal (back, joint)	15%	28%	100%	39%
Health status (% fair or poor)	15%	33%	73%	35%
Other health concerns (selected)
Fatigue	35%	39%	82%	47%
Mood/anxiety	45%	33%	64%	45%
Constipation/diarrhea	10%	61%	64%	41%
Insomnia/sleep problems	30%	33%	45%	33%
Behavior/emotional issues	30%	22%	45%	31%
Total mean number concerns/patient	5.8±3	6.3±3	8.6±4	6.6±3
Stress level (0,10)	5.6±3	4.4±2	6.5±2	5.4±3
Vitamin D<30 ng/mL among those tested	58%	67%	57%	61%

Statistical comparisons between groups were not conducted because this was a descriptive study without a priori hypotheses and small sample sizes preclude meaningful comparisons. Data for different groups are provided separately for reader interest and to generate hypotheses for future studies.

SD, standard deviation.

In addition to their primary concern about pain, parents reported an average of 6.6 health concerns per child, most commonly other kinds of pain. For example, of those with a primary concern about HA, 73% also reported MS pain, and of those who primarily reported ABD pain, 55% also reported MS pain. Other common concerns included fatigue (47%), mood or anxiety (45%), constipation/diarrhea (41%), and insomnia or other sleep problems (35%).

Medications and other therapies

Most patients (71%) used one or more prescription medications (Table 2). However, only 10% overall reported regular use of nonsteroidal anti-inflammatory drugs for pain, and no patients reported using prescription narcotic analgesics within the past month. The most commonly used prescriptions varied somewhat by the type of pain problem, with 65% of patients with HA having a prescription for psychotropic medications such as selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors, while 50% of those with ABD had prescriptions for proton pump inhibitors or H2 receptor antagonist blockers (H2 blockers). Other commonly used prescription medications included antihistamines (27%), oral contraceptives (26%), and tricyclic antidepressants (22%).

Table 2.

Treatments at Intake

Type of treatment, therapy, or licensed clinician	Headache 20 (41%)	Abdominal pain 18 (37%)	Musculoskeletal pain 11 (22%)	Total 49 (100%)
Medications N (%) with:	15 (75%)	14 (78%)	6 (55%)	35 (71%)
Any acetaminophen products	0%	0%	0%	0%
Any opioid analgesic medications	0%	0%	0%	0%
Ibuprofen and other nonsteroidal anti-inflammatory products	10%	6%	18%	10%
Any CNS/psychiatric medication (e.g., anticonvulsant, anxiolytic, antidepressant, etc.)	70%	39%	45%	53%
Any specific migraine medication (e.g., triptans, etc.)	10%	6%	0%	6%
Any GI medications (e.g., anti-emetic, H2 blockers, proton pump inhibitors, laxatives, motility agents, etc.)	45%	78%	18%	51%
Any allergy/asthma medications (e.g., antihistamines, inhaled corticosteroids, etc.)	35%	39%	27%	35%
Any hormonal contraceptive therapies	33%	25%	13%	26%
Other medications (includes acne medications, antibiotics, steroids, etc.)	35%	39%	27%	35%
Dietary supplements (any)	7 (35%)	9 (50%)	3 (27%)	19 (39%)
Vitamins, minerals, or combinations	40%	33%	55%	41%
Melatonin	25%	11%	18%	18%
Omega-3 fatty acids	15%	0%	27%	12%
Probiotics	10%	17%	0%	10%
Other including chamomile, peppermint, other herbs, tryptophan, 5-HTP, or combinations	0%	6%	0%	2%
Non-MD licensed therapists	12 (60%)	7 (39%)	8 (73%)	27 (55%)
Acupuncturist	15%	0%	0%	6%
Chiropractor	10%	11%	36%	16%
Massage therapist	20%	6%	18%	14%
Mental health professional	50%	11%	55%	37%
Nutritionist or dietitian	0%	17%	0%	6%
Physical therapist	10%	28%	9%	16%
Yoga or t'ai chi instructor	0%	6%	0%	2%

CNS, central nervous system; GI, gastrointestinal.

Most patients (53%) also used dietary supplements at intake. Of the 35 (71%) patients reporting the use of prescription medications, 12 (34%) also reported concurrent use of one or more dietary supplements. Overall, the most commonly used dietary supplement at intake was a multivitamin (41%); in addition, 27% of those with musculoskeletal pain reported using fish oil (or other omega-3 fatty acid supplement), and 25% of patients with HA reported using melatonin to help them sleep.

In addition to seeing pediatric specialists and taking medications and supplements, the patients received a variety of professional care. For example, 50% or more of the patients with HA and ABD had received care from a mental health professional, 36% of those with MS had seen a chiropractor, and more than 25% of those with ABD had received physical therapy. Other professionally provided complementary therapies such as acupuncture and yoga were used by fewer than 20% of patients (Table 2).

Interest in health promotion, including stress management

Regardless of the type of pain, most parents were interested in advice about how to improve their child's diet/nutrition (76%), activity/exercise (66%), and/or sleep (58%). When rating the child's stress on a 0–10 scale with 0 being no stress and 10 being extreme stress, parents rated children's stress level at an average of 5.4±3 (Table 3). Although they used a variety of stress-management practices such as listening to music (69%), watching TV (63%), bathing (39%), spending time in nature (33%), going to bed (33%), talking with family or friends (31%), deep breathing (27%), prayer (24%), and/or exercise (22%), fewer than 10% had tried meditation, guided imagery, visualization, hypnosis, biofeedback, or yoga to help manage stress. Most parents (81%) were interested in their child learning additional stress-management techniques.

Table 3.

Recommendations from Pediatric Second Opinion and Integrative Medicine Clinic

Type of treatment, therapy, or licensed clinician	Headache 20 (41%)	Abdominal pain 18 (37%)	Musculoskeletal pain 11 (22%)	Total 49 (100%)
Professional care
Continue current professional care	100%	100%	100%	100%
Refer to new pediatric specialist	15%	11%	27%	16%
Refer to new mental health professional	0%	0%	18%	4%
Refer to licensed massage therapist	25%	11%	27%	20%
Refer to licensed acupuncturist	35%	22%	9%	24%
Medications and supplements
Continue current prescription medications	94%	95%	100%	96%
New prescription medication(s)	0%	0%	0%	0%
Vitamins/minerals or combinations (e.g., vitamin D, iron, etc.)	90%	72%	73%	80%
Omega-3 fatty acids	75%	50%	82%	67%
Probiotics	25%	56%	0%	31%
Melatonin	15%	11%	27%	16%
5-HTP/tryptophan	15%	11%	9%	12%
Health-promotion counseling
Nutrition, activity, and/ or sleep	100%	100%	100%	100%
Stress management, new strategies	45%	56%	45%	49%

Psychosocial risk factors and laboratory studies

Family history was often (48%) positive for mental health problems, such as depression or anxiety. Nearly 1 in 4 (23%) reported a positive family history or screen for household substance abuse. Of note, many of these families had previously been referred for mental health care and declined referral to a mental health professional.

Because vitamin D insufficiency is linked to fatigue and MS pain, levels are often checked in patients with these symptoms, particularly between October and April and in patients with darkly pigmented skin, obesity, and those who avoid the sun or use sunscreen regularly since these are risk factors for deficiency.^15,16 Of the 28 patients who had laboratory testing for 25-hydroxyvitamin D, 61% had suboptimal levels (<30 ng/mL).

Recommendations

All families were encouraged to continue care with their primary and specialist physicians and mental health counselors. Medications were rarely discontinued except when families reported they had already stopped taking them or were planning to do so because of lack of effectiveness or intolerable side-effects. In addition, 16% of all pain patients received referrals to other medical specialists, 18% of those with MS pain received new referrals to mental health professionals, 27% were referred to massage therapists, and 35% of patients with HA were referred to licensed acupuncturists. Primary physicians and referring specialists were notified about all treatment recommendations (Table 3).

All parents interested in lifestyle advice received counseling on healthy diet, exercise, and sleep hygiene. The use of dietary supplements was discussed with interested parents and those whose children had a documented deficiency. Specific recommendations included continuing or initiating vitamins or minerals (such as vitamin D or iron to correct low ferritin levels) (80%) and omega-3 fatty acids (67%). Probiotics were recommended to 56% of those with abdominal pain. Tryptophan and melatonin were recommended for some of those whose concerns included sleep problems. New stress management strategies were recommended to 49% of patients, including brief training in biofeedback (33%) and gratitude journals (16%). Yoga or t'ai chi were recommended for 18% of those with MS pain.

Discussion

Although previous studies have described CAM use in pediatric pain patients seeing particular types of specialist physicians,^{4,9,10,17

–21} this is the first to describe pediatric pain patients coming to an integrative pediatric clinic in an academic health center. The data of this study suggest that chronic or recurrent pain is common among pediatric patients seeking integrative care (45% of all new patients seen in this clinic). As in earlier studies of complementary medicine use among patients seeking tertiary care, those in the authors' clinic used conventional care and medications, and had high rates of comorbidity. Unlike studies of adult patients with pain, none of the patients presenting to the authors' clinic reported using opioid medications, so none reported side-effects from these medications.²² Furthermore, none reported substance abuse by the patient, although there were high rates of comorbid anxiety, mood, and behavior problems and many positive family histories for mental health and substance abuse problems; this combination of factors leads to concern that if their pain is not well managed, pediatric pain patients may be at risk for developing addiction problems like those seen in adult pain clinics.²³

Nearly all parents expressed interest in obtaining healthy lifestyle advice. For example, families were often interested in advice to improve sleep. Insomnia was a commonly reported problem that is a frequent comorbidity with chronic pain as well as mood problems, which were a common comorbidity in this sample.^24

–28 Chronic pain and sleep may affect one another in a bidirectional manner producing a cyclical pattern that may intensify pain and further disrupt sleep.²⁶

These patients were also reported to have moderate–high average stress levels, and despite using a variety of stress management strategies, were interested in learning and using additional strategies including biofeedback, gratitude journals (noting what they are grateful for each day), yoga, t'ai chi, and more time spent outside in nature. The innovative parents of one patient who had chronic musculoskeletal pain, fatigue, and mood problems reported at a subsequent visit a significant reduction in her symptoms after getting her pet ducks and giving her the “chore” of walking them to the stream and back each day; as the ducks imprinted on her and she got more outdoor exercise, her mood lifted and pain diminished enough that she was able to gradually return to more daily activities. Although “duck therapy” has not undergone rigorous randomized trials, the notion of spending time walking pets (a fun, healthy behavior) may be more acceptable to teens than prescriptions for physical therapy (the sick role).

The complexity and multifaceted therapies used by patients in this study are similar to those described for children with complex medical conditions such as asthma, cerebral palsy, or cancer.^29

–34 Furthermore, although the Pediatric Second Opinion and Integrative Medicine Clinic is advertised as a consultation service, in fact it provides some components characteristic of a medical home in terms of a comprehensive approach to both physical and mental health concerns and coordinating care among multiple providers.^35
–37

Although the data in this study build on earlier research and offer important clues for clinical care and future research, it was based on a small sample of patients seen at one academic medical center in the southeastern United States and may not reflect the broader population of pediatric patients seeking integrative care in regions reporting higher use of complementary therapies. It was a retrospective, observational descriptive study, relying on parental report, which may not be a good proxy for adolescent experience.^38,39 Furthermore, because it was a retrospective study of a clinical population and not a prospective research project on pain, not every patient underwent the same laboratory testing. There were no a priori hypotheses about differences between patients with different kinds of pain and there was substantial overlap in the groups; hypotheses about differences between patients with different kinds of primary pain complaint and which patients might benefit the most from different interventions need to be addressed in larger comparison studies.

Conclusions

Despite these limitations, these results may offer useful insights for clinical care and future research. First, pediatric patients with chronic pain who present to an integrative medical clinic have a high rate of comorbidity and multiple therapies, and like others with complex medical conditions, may be best served in a medical home providing coordinated, comprehensive care.^37,40,41 Second, families report concerns about nutrition, which appear to be supported by epidemiologic studies and our laboratory testing,^16,42 suggesting that screening and replenishment of deficiencies might be useful routinely in these children. Furthermore, families are interested in learning additional stress management strategies; while many families accept referrals for professional mental health care, simple remedies like gratitude journals, walking in nature, caring for pets, and biofeedback are acceptable as well.

Additional research is needed to determine which pediatric pain patients benefit most from health promotion and stress management counseling and other therapies such as dietary supplements, massage, and acupuncture. Future research can also determine the extent to which optimally managing chronic pain in children and adolescents minimizes later risks of opioid-related side-effects and substance abuse. Building on this work, future studies that compare the cost and impact of integrative therapies in the context of a medical home with fragmented, pharmaceutically based care may offer insight into optimal strategies to serve families and children with diverse types of chronic and recurrent pain.

Footnotes

Acknowledgments

The authors are grateful to Ben Banasiewicz, Paula Stant, and Denise Lanning for assistance with retrieving and reviewing patients' charts and to all the families who trust us with their care.

Disclosure Statement

Neither author (Young and Kemper) has any commercial associations that might create a conflict of interest in connection with this article.

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