Food Habits,Stressors,and Use of Complementary Medicine Therapies Among Pediatric Patients Who Attend an Integrative Medicine Pediatric Pain Clinic

Abstract

Purpose:

Chronic pain is a growing problem among children and adolescents, and is more prevalent in low-income families. This observational study was conducted to describe the demographics and various descriptors, complementary medicine therapy (CMT) use, and lifestyle factors (i.e., food habits and supplement use) of pediatric patients with chronic pain.

Methods:

Boston Medical Center's Interdisciplinary Pediatric Pain Clinic provides patient education and unique treatment plans, tailored with medical and nonpharmacologic interventions for managing complex and chronic pain. Patient data were obtained through electronic medical chart review and self-reported surveys, and were completed by participants and parents at enrollment.

Results:

Of the 83 participants, the average age was 15.4 ± 4.3, and 80% were female. Referrals to the clinic were due to abdominal pain (52%), headache (23%), and musculoskeletal or other pain (25%). Thirty-one percent were on food assistance programs, with only 24% of patients currently using CMTs and 85% using pain medications. More than half of all participants (63%) missed up to 5 days of school in the past year, while 26% missed more than 6 days. School or academics (77%) were the most frequently self-reported stressor, followed by social/peer issues (39%), bullying (18%), and parental stress (18%). A very small proportion of patients had sufficient intake of dairy (12%), water (23%), vegetables (1%), and fruits (22%).

Conclusion:

Chronic pain can significantly affect lifestyle factors, stress, and child development. Patients evaluated at the clinic had poor diets and report having stressors regarding school, social/peer issues, parental stress, and bullying.

Introduction

Chronic pain is a growing problem among children and adolescents with prevalence rates varying significantly for certain pain types, including abdominal pain (4%–53%), headache (1%–69%), and musculoskeletal pain (4%–40%).¹ It was estimated by the American Pain Foundation (2008) that chronic pain affects ∼15%–20% of children and adolescents in the United States, and is more prevalent among those living in poverty with low parent education, females, and those using public health insurance.^2
–4 However, little is known about how children with chronic pain from low-income families experience daily stressors, engage in lifestyle factors such as a healthy diet, and use nonpharmacologic treatments to cope with pain. This observational study adds new evidence on the prevalence of stressors, daily food habits, and school attendance in a low-income pediatric population from a safety net hospital.

Chronic pain can have a major impact on a child's stress level, mood, sleep, nutrition, and social or family relationships.² Through high rates of medical utilization and low rates of school attendance, it can be a great financial burden and emotional toll for some families.² Children and adolescents presenting with chronic pain are also at a greater risk for undertreatment, which may result in unnecessary hospitalization and/or emergency room (ER) use.² When left untreated, these consequences may continue on into adulthood with 17% of adults with chronic pain disclosing childhood and/or adolescent chronic pain.^5,6

Due to the multifaceted nature of chronic pain, there is evidence exploring interdisciplinary treatment approaches that include pharmacologic therapies, psychologic treatments, lifestyle changes, and/or complementary medicine therapies (CMTs).^7

–10 Many pediatric pain clinics utilize these approaches and several studies have indicated that interdisciplinary pediatric pain programs are effective in improving pain-related disabilities, school attendance, pain levels, and psychologic distress.^7
–9,11 In addition, several studies have found these interdisciplinary programs to have a greater economic impact in comparison with going to a single provider or pharmacologic treatments.^7,10,12

However, children may face barriers in receiving treatment for chronic pain. This could be due to the limited access to treatment, lack of transportation, insurance coverage, delays with the referral process, and safety concerns about the acceptability of these treatments by families and children.^13
–15 In addition, low socioeconomic status (SES) populations often lack access to resources that can support their health such as nonpharmacologic treatments; therefore, the supportive evidence hopes to change the perception of nonpharmacologic treatments among patients and health care professionals, advocate for policy changes regarding insurance coverage and disparities, and support future research on the benefits and impact of nonpharmacologic treatments.¹⁰

Current literature on this topic focuses on children around the United States within pediatric pain clinics from both low-income families and general populations.^13,16 Previous studies have reported CMT use within other multidisciplinary pediatric pain clinics, headache clinics, gastroenterology clinics, and rheumatology clinics.¹⁷ CMT use has also been reported among pediatric patients with cancer and asthma.¹⁸ Furthermore, studies done internationally have reported on the prevalence of bullying and peer issues within this pediatric pain population.^19,20 However, studies in the United States on this topic are scarce. Instead, studies conducted in the United States have focused on exploring the relationship between chronic pain and academic stressors or school attendance.^11,21 Also, research reporting on specific food habits within a pediatric chronic pain population is scarce.

The purpose of this study is trifold. (1) To describe the baseline demographics, primary pain type, and main stressors identified within low-income pediatric patients with chronic pain in Boston Medical Center's (BMC) Interdisciplinary Pediatric Pain Clinic; (2) to explore past and current CMT use of participants within the clinic; and (3) to report lifestyle factors, such as food habits and dietary supplements utilized by participants. This study is part of a series of studies, and in this article, the authors are reporting the baseline data for a pre/post observational cohort study.

Methods

Setting

This study was held at BMC, which is the largest safety-net hospital in New England committed to providing care to low-income, racial, and ethnic minorities facing health disparities in Boston. The data for this study were collected through self-reported methods and chart review from the patients within BMC's Interdisciplinary Pediatric Pain Clinic.

Participant recruitment

Participants were individuals, ages 5–22 years, who were receiving care at BMC's Interdisciplinary Pediatric Pain Clinic for chronic pain. The total enrollment pool was 121 children; however, trained research assistants (RAs) contacted 89 parents and children to ask if they would participate in the study. Overall, 83 children enrolled in the study, while 5 families were not interested. One child came to BMC's Interdisciplinary Pediatric Pain Clinic, younger than 18 years, without a parent, and was unable to be assented into the study. For patients who declined, this study did not interfere with their care in the clinic. Participants could be referred to the clinic by clinicians from various specialties such as gastroenterology, primary care, hematology, rheumatology, and neurology within BMC or from the Boston area.

Inclusion criteria included children ages 5–22 years who were seen and evaluated in the BMC pain clinic. Non-English-speaking patients were also included, and received assistance from interpreters. Children who were referred to the pediatric pain clinic, but were never seen or evaluated in a pain clinic, were excluded from this study. For children younger than 18 years, parents or guardians provided informed consent for their child to join the study, and their children provided assent. Informed consent was also obtained from participants older than 18 years by trained RAs.

Interdisciplinary pediatric pain clinic description

BMC's Interdisciplinary Pediatric Pain Clinic is a weekly clinic that provides medical and psychologic services, patient education, and support for managing chronic, recurrent, and complex pain. The clinic was launched in February 2015 and consists of a pediatric hematologist and oncologist (MD), a licensed psychologist (PsyD), a nurse educator (RN, MSN, PNP), a licensed clinical social worker (LICSW), a physical therapist (DPT), an acupuncturist (EdD, LicAc), a certified clinical aromatherapist (CNM), a registered dietician (RD, LDN), a certified massage therapist (LMT), and a karate instructor. All practitioners had training and/or experience working with children.

Upon arrival to the Interdisciplinary Pediatric Pain Clinic, parents and children were approached by RAs for informed consent/assent. Once the patients were enrolled in the study, they were asked to fill out an intake form that was designed by this study team. Traditionally, participants completed the initial intake form before the pediatrician and team performed an initial assessment. Of the 83 participants, 78 completed the initial intake form before meeting the team, while 5 participants completed the intake form after meeting the team. When patients arrived, vitals (including blood pressure, height, weight, and pulse) were taken by a medical assistant; however, these data were not collected for research purposes. The allopathic team, which comprises the pediatrician, psychologist, nurse, and social worker, would then formulate an integrative treatment plan with medical and behavioral interventions and recommendations. This could include plans to partake in physical therapy, acupuncture, massage therapy, chiropractic, reiki therapy, aromatherapy, nutrition consults, karate, and mind–body therapies. Following the evaluation, the participant would have one-on-one time with the licensed psychologist for additional psychologic evaluations and family assessment. After the first visit, follow-up pain clinic appointments for therapies (including acupuncture, massage, aromatherapy, medical appointments, and mind–body therapy appointments with a psychologist) were booked, and participants would follow up with the research team in 3 months.

Outcomes

Self-reported outcomes

After informed consent was obtained, an intake form collected information, including age (in years), sex (female or male), race (African American, white, Asian, or other), ethnicity (Hispanic), and primary type of insurance (dichotomized into private or public).

Regarding food assistance programs, participants were asked “Do you receive benefits from any food assistance programs, such as Supplemental Nutrition Assistance Program (SNAP; food stamps) or Women, Infants, & Children (WIC)?” and had to indicate “yes” or “no.”

The form also included information on the presence of sleeping problems (yes or no), and if they had a mental health history (yes or no). If they answered “yes” regarding mental health history, they were given an option to choose one or more from the following: attention-deficit/hyperactivity disorder (ADHD), depression, autism spectrum diagnosis, anxiety, behavior problems, trauma exposure, drug/alcohol use, or other.

For pain medication use, parents were asked: “How often does your child typically take pain medicine?” and were given the following options: “Several times a day,” “About once a day,” “About once a week,” “Every couple of weeks,” “Infrequently,” or “Never.”

Participants were asked what their three biggest stressors were in life from the following choices: social/peer issues, bullying, school/academics, parental stress, parental conflict (between parent and child), parent conflict (between parent and other family members), parent/family member's health, parental separation/divorce, parental finances, stable housing, food concerns, new sibling, death of family member/friend, and other. If “other” was selected, they could fill in a stressor they were experiencing that was not listed.

Participants were asked how they typically cope with pain and to check all that apply from the following: “gets upset or angry,” “complains about pain,” “withdraws from others,” “asks for help,” “takes medication,” “asks to go to the doctor/ER,” “rubs painful area,” “puts heat/ice on area,” “sleeps,” “stretches,” “distracts him/herself or does something he/she owns,” “watches television/plays on computer,” “deep breathing/meditation,” “prayer,” or “nothing.” In addition, participants were able to write any other coping mechanism that they used.

For past and current use of nonpharmacologic therapies, participants were asked to indicate if they have tried or are currently using one of the following therapies: physical therapy, chiropractic, acupuncture, massage, aromatherapy, mind–body strategies (i.e., yoga, meditation, hypnosis, or biofeedback), reiki or healing touch, or other. “Current” use of therapy was defined as the month before the initial assessment.

Questions from the National Health and Nutrition Examination Survey (NHANES) 1999–2000 study were adapted and modified to identify participants' food habits, including their daily intake of dairy, water (open-ended), vegetable, fruit, fast food, snacks between meals, and sugar-sweetened beverages.²²

To measure dairy intake, participants were asked “How often does your child drink a glass of milk, eat dairy products like cheese, or eat foods with added calcium?” and were given the following options: “Never,” “1 to 2 times a day,” “3 to 5 times a day,” “Once a week,” or “Several times a week.” They were also asked to write how many cups of water they drink in a day.

In addition, they were asked to indicate how many servings of vegetables and fruits they eat during a typical day, given the following options for each question: “0 servings,” “1 serving,” “2 servings,” “3 servings,” “4 servings,” or “5 or more servings.” One serving of vegetables was defined as 1 cup of raw leafy vegetables, 1/2 cup of other vegetables cooked or raw, or 3/4 cup of 100% vegetable juice. One serving of fruit was defined as one medium apple, 1/2 cup of chopped fruit, or 3/4 cup of 100% fruit juice.

Participants were asked to indicate how often they eat fast foods (i.e., hamburgers, tacos, fried chicken, hot dogs, French fries, and milkshakes) and were given the following options: “Once a day,” “Four or more times per week,” “Two to three times per week,” “Two to four times per month,” or “Never.” They were also asked how often they eat snack foods (i.e., chips, pretzels, crackers) between meals and drink regular soda (not diet) or sugary drinks (i.e., fruit punch). Options were the following for each: “Three or more times per day,” “Once or twice per day,” “Few times per week,” or “Never eat typical snack.”

The intake form also asked participants to identify if they regularly use any of the following vitamins or other supplements: multivitamin, calcium, vitamin D, fish oil, vitamin B, melatonin, probiotics, magnesium, or other. If they selected “other,” they were invited to write in an option that was not listed.

Chart review

During the initial evaluation with the team, the pediatrician would categorize primary types of pain (i.e., abdominal, headache, musculoskeletal, and other), and record information on number of days missed school in the past 30 days and gastrointestinal diagnoses. RAs retrieved these data through chart review of their electronic medical records.

Statistical analysis

Descriptive statistics were used to analyze survey data and chart review information. Means, standard deviations, frequencies, and percentages were calculated for participant's demographics and description information. Frequencies and percentages were calculated for coping mechanisms, days of school missed, and nonpharmacologic therapies.

Information regarding food habits and supplements was categorized, and frequencies and percentages were calculated. Fisher's exact test was used to assess the associations between specific food habits and supplement use, which accounted for small numbers (<5) in table cells. All quantitative analyses were performed using SAS 9.3 software (SAS Institute, Inc., Cary, NC), and p-values were compared to a significance value (alpha) of 0.05. This study was approved by the Institutional Review Board of Boston University School of Medicine.

Results

Demographics

Baseline demographics and other descriptors stratified by age group are presented in Table 1. These age groups comprised school-age children (5–12 years old), adolescents (13–18 years old), and young adults (19–22 years old). A total of 83 participants were enrolled with 53% of the population as adolescents, 24% as young adults, and 23% as school-age children. Overall, the mean age was 15.4 years, and 80% identified as female. Forty-two percent identified as white, 25% as African American, and 33% as other. Thirty percent of the participants identified as Hispanic, and 61% had Medicaid as their primary insurance. Furthermore, 31% of participants were receiving benefits from food assistance programs, such as SNAP or WIC.

Table 1.

Description and Demographics at Baseline by Age Group^*

	Total, 83 (100%)	Age 5–12, 19 (23%)	Age 13–18, 44 (53%)	Age 19–22, 20 (24%)
Intake form
Age in years	15.38 ± 4.27	9.16 ± 2.17	15.75 ± 1.59	20.50 ± 1.36
Female	66 (80%)	13 (68%)	33 (75%)	20 (100%)
Race
White	35 (42%)	6 (32%)	20 (45%)	9 (45%)
African American	21 (25%)	8 (42%)	8 (18%)	5 (25%)
Other	27 (33%)	5 (26%)	16 (36%)	6 (30%)
Hispanic	25 (30%)	5 (26%)	14 (32%)	6 (30%)
Insurance
Public	51 (61%)	15 (79%)	26 (59%)	10 (50%)
Private	32 (39%)	4 (21%)	18 (41%)	10 (50%)
Food assistance programs	26 (31%)	8 (42%)	15 (34%)	3 (15%)
Sleeping problem	55 (66%)	9 (47%)	31 (70%)	15 (75%)
Mental health history
Mental health^a	39 (47%)	6 (32%)	19 (43%)	14 (70%)
ADHD/behavior problems	15 (18%)	4 (21%)	8 (18%)	3 (15%)
Other^b	5 (6%)	0	3 (7%)	2 (10%)
Pain medicine use	71 (85%)	17 (89%)	38 (86%)	16 (80%)
Chart review
Primary type of pain
Abdominal	43 (52%)	13 (68%)	19 (43%)	11 (55%)
Dyspepsia	4 (9%)	0	1 (5%)	3 (27%)
Abdominal pain	39 (91%)	12 (92%)	16 (84%)	0
Irritable bowel syndrome	1 (2%)	0	0	1 (9%)
Chronic abdominal pain	6 (14%)	1 (8%)	3 (16%)	2 (18%)
Celiac disease	0	0	0	0
Lactose intolerance	1 (2%)	1 (8%)	0	0
Constipation	22 (51%)	10 (77%)	8 (42%)	4 (36%)
Helicobacter pylori/parasite infection	2 (5%)	0	1 (5%)	1 (9%)
Gastroenteritis	0	0	0	0
Other^c	16 (37%)	2 (15%)	9 (47%)	5 (45%)
Headache	19 (23%)	2 (11%)	12 (27%)	5 (25%)
Musculoskeletal and other^d	21 (25%)	4 (21%)	13 (30%)	4 (20%)
Days of missed school in past year (n = 82)
N/A	9 (11%)	2 (11%)	3 (7%)	4 (20%)
0–5	52 (63%)	15 (79%)	28 (65%)	9 (45%)
6+	21 (26%)	2 (11%)	12 (28%)	7 (25%)
Stressors
Stressors (selected)
School/academics	64 (77%)	11 (58%)	36 (82%)	17 (85%)
Social/peer issues	32 (39%)	11 (58%)	14 (32%)	7 (35%)
Parental stress	15 (18%)	1 (5%)	9 (20%)	5 (25%)
Bullying	15 (18%)	6 (32%)	8 (18%)	1 (5%)

Includes depression (n = 17), anxiety (n = 35), and trauma exposure (n = 13).

Includes autism spectrum diagnosis (n = 2), drug/alcohol use (n = 1), post-traumatic stress disorder (n = 1), and auditory/visual hallucinations (n = 1).

Includes Crohn's disease (n = 1), epigastric pain (n = 3), gastroesophagel reflux (n = 6), diarrhea (n = 4), vomiting (n = 3), heartburn (n = 1), eosinophilic gastroenteropathy (n = 1), and migraines (n = 1).

Other includes sickle cell disease (n = 2), chest pain (n = 2), epidermolysis bullosa, diabetic peripheral neuropathy.

Percentages in all columns are based on the column total (column %).

ADHD, attention-deficit/hyperactivity disorder.

Reasons for referral to BMC's Interdisciplinary Pediatric Pain Clinic included abdominal pain (52%), headache (23%), and musculoskeletal or other pain (25%). All participants with primarily abdominal pain visited the gastroenterology (GI) clinic at BMC before visiting the pain clinic. Participants were assessed by a GI specialist and could have had more than one GI diagnosis.

A majority of participants reported having sleeping problems (66%), while 47% were prediagnosed with mental health concerns, including depression, anxiety, and trauma exposure. Eighteen percent of participants were also prediagnosed with ADHD or behavioral problems. Six percent of participants reported other mental health concerns, including autism spectrum diagnosis, drug/alcohol use, post-traumatic stress disorder, and auditory/visual hallucinations. Eighty-five percent of all participants were using pain medicines with opioid use being very rare and nonsteroidal anti-inflammatory drugs being very common. A few patients were also using neuropathic agents. Furthermore, more than half of all participants (63%) missed up to 5 days of school in the past year, while 26% of participants missed more than 6 days of school.

In addition, the most prevalent stressors participants reported by age group are outlined in Table 1. Overall, school or academics (77%) were the most frequently self-reported stressor, followed by social or peer issues (39%). Fifty-eight percent of school-age children reported school/academics as a main stressor compared with adolescents (82%) and young adults (85%). More than half of school-age children reported social or peer issues (58%) in comparison with adolescents (32%) and young adults (35%). Twenty percent of adolescents, 25% of young adults, and 5% of school-age children self-reported parental stress as a main stressor. Overall, bullying was reported by 18% of participants. It was reported by 32% of school-age children compared with adolescents (18%) and young adults (5%).

Coping mechanisms

Table 2 outlines the various coping mechanisms participants typically used by age group. Overall, 98% of participants utilized various mind–body coping mechanisms such as exercise (92%), meditation (33%), stretching (29%), and prayer (27%). Ninety-six percent of participants adopted self-care strategies, including rubbing the painful area (75%), sleeping (58%), watching television (57%), distracting themselves with something they enjoy (57%), and using ice or heat on the painful area (43%). In addition, 94% of participants coped with their pain by expressing their emotions. Majority of participants (87%) indicated complaining about their pain, while 59% and 51% of participants would get upset and withdraw from others, respectively. Coping strategies that utilize medical treatment and assistance were used by 90% of all participants. Medication use was utilized by 73%, while 60% would ask for help and 42% would ask to go to the doctor or emergency room.

Table 2.

Coping Mechanisms at Baseline by Age Group^*

	Total, 83 (100%)	Age 5–12, 19 (23%)	Age 13–18, 44 (53%)	Age 19–22, 20 (24%)
Resources/medical treatment	75 (90%)	17 (89%)	43 (98%)	14 (74%)
Asks for help	50 (60%)	14 (74%)	27 (61%)	8 (42%)
Asks to go to doctor/ER	35 (42%)	7 (37%)	21 (48%)	7 (35%)
Takes medication	61 (73%)	12 (63%)	36 (82%)	13 (65%)
Uses mind–body approach	81 (98%)	19 (100%)	43 (98%)	18 (95%)
Stretches	24 (29%)	6 (32%)	10 (23%)	8 (40%)
Meditation	27 (33%)	9 (47%)	10 (23%)	8 (40%)
Prayer	22 (27%)	6 (32%)	10 (23%)	6 (30%)
Adopts self-care	80 (96%)	18 (95%)	43 (98%)	18 (95%)
Puts heat/ice on area	36 (43%)	7 (37%)	20 (45%)	9 (45%)
Distracts with enjoyment	47 (57%)	10 (53%)	28 (64%)	9 (45%)
Rubs painful area	62 (75%)	15 (79%)	32 (73%)	15 (75%)
Sleeps	48 (58%)	7 (37%)	27 (61%)	14 (70%)
Watches TV	47 (57%)	11 (58%)	27 (61%)	9 (45%)
Expressed through emotions	78 (94%)	18 (95%)	44 (100%)	15 (79%)
Gets upset/angry	49 (59%)	11 (58%)	26 (59%)	12 (60%)
Complains	72 (87%)	17 (89%)	41 (93%)	14 (70%)
Withdraws from others	42 (51%)	8 (42%)	25 (57%)	9 (45%)
Other
Other^a	20 (24%)	6 (32%)	13 (30%)	1 (5%)
Nothing	1 (1%)	0	1 (2%)	0

Other includes self-isolation (n = 1), communication with parent (n = 3), screaming (n = 1), sitting quietly (n = 1), crying (n = 2), pillow hugging (n = 1), avoids eating (n = 1), laying down (n = 3), listen to music (n = 2), reading (n = 1), massage and acupuncture (n = 1), lidocaine patches (n = 1), and research pain options (n = 1).

Percentages in all columns are based on the column total (column %).

Current and past use of nonpharmacologic therapies

Table 3 outlines nonpharmacologic therapies participants have ever used in the past or are currently using within the last 30 days before the initial visit. Overall, about half (52%) of total participants have ever used nonpharmacologic therapies, while 24% are currently using them. Regarding ever use, 41% of total participants used manual therapies, which included physical therapy (27%), massage therapy (16%), and chiropractic therapy (7%). Eighteen percent of participants ever used mind–body therapies, which included yoga, meditation, hypnosis, and biofeedback, while 11% of participants ever used acupuncture. Other therapies, which include dance, art/music therapy, cupping, deep breathing/rhythmic music, going to the gymnasium, reiki therapy, and aromatherapy, were ever used by 12% of all participants.

Table 3.

Current and Past Use of Nonpharmacologic Therapies at Baseline

	Ever use, 43 (52%)	Current use, ^a 20 (24%)
Manual	34 (41%)	16 (19%)
Physical therapy	22 (27%)	10 (12%)
Massage therapy	13 (16%)	8 (10%)
Chiropractic therapy	6 (7%)	2 (2%)
Mind–body therapy^b	15 (18%)	11 (13%)
Acupuncture	9 (11%)	6 (7%)
Other^c,d	10 (12%)	4 (5%)

Current use defined within the last 30 days.

Includes yoga, meditation, hypnosis, biofeedback.

Other ever use = dance (n = 1), art/music therapy (n = 1), cupping (n = 1), deep breathing/rhythmic music (n = 1), gymnasium (n = 1), reiki therapy (n = 4), and aromatherapy (n = 1).

Other current use = reiki therapy (n = 2) and aromatherapy (n = 3).

Manual therapies (19%) were the most frequently used therapies in the past 30 days with 12% using physical therapy, 10% using massage therapy, and 2% using chiropractic therapy. Mind–body therapies were currently used by 13% of participants, while acupuncture was currently used by 7% of participants. Other therapies, which included reiki therapy and aromatherapy, were currently used by 5% of all participants.

Food habits and dietary supplement use

Table 4 describes food habits and dietary supplement use of participants by age group. Recommendations were based on the Recommended Daily Allowance's suggestions. The daily national recommendation for dairy intake is three cups per day. Only 12% of participants were meeting this recommendation, as 88% were having less than three cups of dairy per day. Twenty-three percent of participants met the recommendation for eight cups of water per day, while only 1% of participants consumed the recommended amount of four servings of vegetables per day. Also, 12% of participants met the recommendation of three servings of fruit per day. Regarding intake of fast food, a majority of participants (74%) consumed fast food several times per month, 18% at least more than four times a week, while only 8% never consumed it. About half of the participants (51%) eat less than three snacks a week, 29% have one to two snacks per day, and 20% have three or more snacks per day. Twenty-four percent of participants consumed sugary beverages at least once or twice a day, while 40% consumed it several times a week, and 36% never consumed sugary beverages.

Table 4.

Food Habits and Dietary Supplement Use at Baseline by Age Group

	Total, ^a 83 (100%)	Age 5–12, 19 (23%)	Age 13–18, 44 (53%)	Age 19–22, 20 (24%)
Food habits
Intake of dairy products
Recommended: three cups/day
Less than three cups	73 (88%)	15 (79%)	40 (91%)	18 (90%)
At least three cups	10 (12%)	4 (21%)	4 (9%)	2 (10%)
Cups of water/day
Recommended: eight cups
Less than eight	64 (77%)	14 (74%)	38 (86%)	12 (60%)
At least eight	19 (23%)	5 (26%)	6 (14%)	8 (40%)
Servings of vegetables/day
Recommended: four servings (two cups)
Less than four	82 (99%)	19 (100%)	44 (100%)	19 (95%)
At least four	1 (1%)	0	0	1 (5%)
Servings of fruit/day
Recommended: three servings (1.5 cups)
Less than three	65 (78%)	14 (74%)	36 (82%)	15 (75%)
At least three	18 (22%)	5 (26%)	8 (18%)	5 (25%)
Intake of fast food
At least 4+/week	15 (18%)	3 (16%)	8 (18%)	4 (20%)
Several times/month	61 (74%)	15 (79%)	34 (77%)	12 (60%)
Never	7 (8%)	1 (5%)	2 (5%)	4 (20%)
Snacks between meals^b
3+/Day	17 (20%)	3 (16%)	10 (23%)	4 (20%)
1–2/Day	24 (29%)	5 (26%)	14 (32%)	5 (25%)
<3/Week	42 (51%)	11 (58%)	20 (45%)	11 (55%)
Sugar-sweetened beverages
At least 1–2/day	20 (24%)	4 (21%)	10 (23%)	6 (30%)
Several times/week	33 (40%)	7 (37%)	21 (48%)	5 (25%)
Never	30 (36%)	8 (42%)	13 (29%)	9 (45%)
Dietary supplements
Patients taking at least one vitamin/mineral or nonvitamin/mineral	43 (52%)	11 (58%)	21 (48%)	11 (55%)
Taking at least one vitamin/mineral^c	34 (41%)	7 (37%)	18 (41%)	9 (45%)
Multivitamin	16 (47%)	6 (86%)	9 (50%)	1 (11%)
Calcium	5 (15%)	0	3 (17%)	2 (22%)
Vitamin D	16 (47%)	2 (29%)	10 (56%)	4 (44%)
B vitamins	7 (21%)	0	3 (17%)	4 (44%)
Magnesium	3 (9%)	0	0	3 (33%)
Taking at least one nonvitamin/mineral^d	19 (23%)	5 (26%)	10 (23%)	4 (20%)
Fish oil	6 (32%)	1 (20%)	3 (30%)	2 (50%)
Melatonin	12 (63%)	3 (60%)	6 (60%)	3 (75%)
Probiotics	7 (37%)	2 (40%)	2 (20%)	3 (75%)

Percentages in all columns are based on the column total (column %).

Includes chips, pretzels, crackers, and so on.

Includes multivitamins, calcium, vitamin D, B vitamins, and magnesium.

Includes fish oil, melatonin, and probiotics.

Fifty-two percent of participants were taking at least one vitamin, mineral, or nonvitamin. Of the 34 participants taking at least 1 vitamin, multivitamins (47%) and vitamin D (47%) were the most commonly used, while magnesium was the least commonly used (9%). Of the 19 participants taking at least 1 nonvitamin, melatonin (63%) was the most commonly used, followed by probiotics (37%) and fish oil (32%).

Further analyses were completed to assess the associations between certain food habits and supplement use. Among the 73 participants who did not meet the dairy recommendations, only 19% of participants were taking vitamin D supplements and 7% were taking calcium supplements. In addition, only 18% of participants who did not meet the dairy recommendation were taking multivitamins. Among the 65 participants who did not meeting their daily fruit recommendations, only 13% were taking multivitamins. Furthermore, among the 82 participants who did not meeting the daily vegetable recommendations, only 6% were taking calcium supplements and 19% were taking multivitamins. No significant associations were found between any of these food habits and supplement use (p > 0.05).

Discussion

This study is one of the first studies to report on food habits and to examine the prevalence of stressors within a low-income, pediatric chronic pain population in the United States. Thirty-one percent of participants were facing food insecurity with a large proportion of patients not taking the daily recommendations of dairy, water, vegetables, and fruits. A majority of participants self-reported school or academics as a main stressor, followed by social/peer issues, bullying, and parental stress. A majority of participants missed up to 5 days of school in the past year and only 24% of participants were currently using CMTs at baseline, while 53% have used them in the past.

While there is limited research on specific food habits within pediatric chronic pain populations, other studies have explored diet among adult chronic pain populations. In a small 2014 study on adults with chronic pain who were receiving long-term opioid therapy in an outpatient pain rehabilitation program, it was determined that obesity, poor nutrition, and poor eating habits were highly prevalent.²³ Even though research reporting on eating behaviors and food habits among pediatric pain populations is scarce, Young and Kemper noted that parents are interested in learning how to improve their child's diet.¹⁶ More research is needed to study the connection of food habits and chronic pain in a rigorous clinical study to assess if there are biologic mechanisms in place.

This study is the first to report on the use of food assistance programs within a pediatric chronic pain population. In this study, one-third of participants were using food assistance programs, and a large majority had poor diets characterized by high rates of fast-food consumption, high rates of sugar-sweetened beverage consumption, and low fruit, vegetable, water, and dairy intake. As evidenced earlier, many participants who are not meeting their recommended intakes of fruits, vegetables, and dairy were also not taking vitamin or mineral supplements to offset the potential deficiency. Although participants were characterized as having poor nutrition, the temporality of the association between chronic pain and poor nutrition is unclear. It is unknown if food insecurity leads to poor-quality diets and ultimately may contribute, in part, to their chronic pain, or if participants eat poor-quality diets due to their chronic pain.

The participants in this study population represent a low-SES group of individuals receiving care at a safety net hospital with more than 50% using public insurance. Previous studies have shown mixed results regarding insurance status of patients referred to pediatric chronic pain programs.^13,24 In a 2017 study with a Los Angeles-based specialized pediatric pain clinic, it was determined that 72% of their patients referred to the clinic were enrolled in governmental insurance plans, which was significantly correlated with delayed referral to the clinic.¹³ In comparison, 39% of patients in a primarily anesthesiology-based, pediatric pain clinic study in Indiana were enrolled in public insurance plans.²⁴

Data from the 2012 National Health Interview Survey (NHIS) indicated that 21.3% of children with chronic pain conditions used CMT in the past year.¹⁷ Similarly, 24% of participants were currently using CMT at baseline. Manual therapies (i.e., chiropractic and osteopathic manipulations, massage therapy, CranioSacral therapy, movement or exercise techniques) were the most prevalent, followed by biology-based therapies and mind–body therapies.¹⁷ This was compared with the proportion of participants who were currently using CMT in this study, with manual therapies being most common, followed by mind–body therapies. However, these results compared with the nationally representative sample results were lower than rates found in other urban, multidisciplinary pain clinics and pediatric headache patients.^16,25,26 Using data from the 2007 NHIS survey, Bethell et al. reported that 29.6% of youth with headache used one or more CMTs in the past year, and CMT users were significantly (p < 0.05) more likely to come from homes with higher income and having private health insurance.²⁷ Other studies conducted within the general pediatric populations have determined that CMT use is more prevalent among families of higher income and higher parental education.^17,28 Furthermore, CMTs, including acupuncture, chiropractic therapies, massages, and naturopathy services, are often 60%–70% less likely to be reimbursed by insurance.²⁹ Due to the lack of insurance coverage and reimbursement, it is possible that low-income populations have trouble accessing CMT for pain.²⁹ However, more research is needed to understand if low-income, pediatric populations face barriers in accessing CMT and receiving care.

Furthermore, this was one of the first studies to examine the prevalence of stress and bullying within a low-income, pediatric chronic pain population in the United States. Previous research has found that being exposed to bullying was associated with an increased risk of recurrent pain (odds ratio = 3.39, 95% confidence interval: 1.62–7.09) in general pediatric populations, and children with chronic abdominal pain experienced higher levels of victimization compared with their peers.^19,30 Comparatively, in this study, bullying was one of the top four stressors that participants reported. Prior research has shown that peer relationships can be problematic for children with chronic pain, as they engage in fewer peer activities, have only a few friends, and were viewed as being more isolated.^20,31 These findings support this because in addition to bullying, social and peer issues were also one of the top four stressors indicated and were reported by 39% of total participants. However, future studies should target economically diverse groups and the relationship between social functioning and chronic pain.

Rates for missed school days found in this study were better than results found in other studies with children with chronic pain or chronic diseases. One study conducted in an interdisciplinary pediatric pain program with U.S. adolescents ages 12–18 years found its participants missed an average of 11 days of school per month.¹¹ Another international study done in a German tertiary pediatric pain clinic found 66% of their participants missed up to 5 days of school, while 24% missed more than 6 days of school in the past month.²¹ For this study participants, school attendance was not critically influenced by their chronic pain. However, school and academics were the top stressors participants reported. These results may indicate the dire emotional and mental impact chronic pain can have on school functioning for participants in this study.

Participants in this study used a large variety of coping mechanisms. Eighty-seven percent used complaining, rubbing painful areas (75%), and taking medication (73%) as the top three strategies for coping. Other studies have examined the different coping profiles among children with pain. Previous studies have shown that accommodative coping and self-reliant copers (i.e., acceptance, self-encouragement, and positive reappraisal of stressors) were associated with lower levels of pain symptoms, depressive and anxiety symptoms, and better adaptation, compared with avoidant copers (i.e., self-isolation and avoids social support).^32

–35 As social/peer issues were one of the top stressors reported, and 51% of participants withdrew from others as a coping mechanism, it may be beneficial to increase participant's knowledge on using accommodative coping strategies. Additional research is necessary to examine the how economically diverse children cope with their pain and their coping typologies, as they have different daily stressors and levels of access to conventional medicine and CMT.

In this study, a majority of the participants were referred primarily for abdominal pain (52%, n = 43), whereas the primary pain site in other studies was often headache or musculoskeletal pain.^16,17,36 Furthermore, in this study, 85% of participants were taking at least one pain medication. In another study, it was found that only about half of the general pediatric clinic patients were taking pain medications.¹⁸ This is also comparable with 70% of those in a chronic musculoskeletal pain pediatric population and 71% in an interdisciplinary pediatric pain population.^16,37 Although speculative, the slightly higher rates of medication use and lower rates of CMT use may be due to the low-income population in this study compared with previous studies.^16,18,37

Strengths to this study include enrolling both English- and non-English-speaking participants and families into the clinic to utilize their data for this study. Spanish and Portuguese interpreters were provided for nine non-English-speaking children to aid in answering these surveys and understanding evaluations in clinic. Second, there was a high recruitment retention rate (93%).

Due to the observational study design, the temporality between chronic pain and other factors is unclear. It is not evident, for example, if a poor diet contributed to chronic pain or if chronic pain resulted in a poor diet, making it difficult to make inferences about certain characteristics. When collecting data for missed school days, these data were self-reported and not verified with the participants' schools; therefore, there is a potential risk for under- or overestimation for school attendance. There is also potential for parental bias related to food choices and CMT use especially for younger children. Most parents make food coices for their kids, which can vary for families dependent on food assistance programs such as SNAP and WIC. Their limited funds will not be spent on fresh food because those foods tend to be more expensivce and have a shorter shelf life. Also, the authors did not collect blood levels of nutrients to determine if any participants were nutrient deficient. It can only be concluded that a majority of participants do not meet the necessary guidelines for dairy, vegetable, fruit, and water intake. Furthermore, results of this study may not generalize to other populations with different demographics and access to health care and diverse food, since this study was done in a public safety net hospital. Another limitation within this study is that there were no data on where CMT services were provided outside of this Interdisiciplinary Pediatric Pain Clinic. These were self-reported data and were not verified with clinic/study staff. This may skew CMT use toward other modalities such as physical therapy or acupuncture.

In conclusion, the purpose of this study was to provide the demographics, descriptions of stressors, and food habits of low-income, racially diverse children presenting with chronic pain. More research is needed to further explore the connection between stressors, such as bullying and school and academics, within low-income pediatric chronic pain populations. This is also some of the first research to explore the food habits and diets among children with chronic pain. Future research should explore the association and long-term effects of nutrition and eating behaviors on chronic pain among low-income children. These findings may help primary care providers and chronic pain specialists screen children from low-income families for food insecurity and vitamin deficiencies; however, these results need to be verified.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Funding Information

This study was funded by the Marino Foundation.

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