On the Need for a Multidisciplinary Approach for Pediatric Pain Management

In an effort to reduce unnecessary opioid use and associated adverse outcomes, increasing attention has focused on the use of multidisciplinary approaches that combine pharmacologic and integrative nonpharmacologic therapies for pain management. The effectiveness of multidisciplinary treatments for the management of acute and chronic pain in adult and pediatric patients is supported by evidence, and this approach is also associated with improved psychological functioning, higher quality of life, and reduced opioid consumption.¹

In a review published in February 2019 in Children, investigators emphasized that the integration of nonpharmacologic therapies has become the gold standard of care in pediatric multidisciplinary pain clinics.¹ “In contrast to short-term pharmacologic management, which provides patients transitory benefit, integrative nonpharmacologic techniques can lead to long-term results via changes in neural circuits that regulate habits, affect, and cognitive pain responses,” noted the authors.

They summarized the evidence on integrated nonpharmacologic treatments used in pediatric pain clinics in the United States, as highlighted below.

Cognitive behavioral therapy (CBT). As is the case in adults with chronic pain, evidence supports the effectiveness of CBT in youth with chronic pain. In a meta-analysis of 9 studies (n=406), the use of CBT was found to be associated with a significant reduction in pain in children and adolescents with chronic pain.² “This evidence-based treatment is well accepted by patients and providers and is increasingly available to pediatric patients,” note the review authors.¹ “Although youth in more remote areas may have limited access to cognitive behavioral interventions for chronic pain, the advent of web-based treatments holds promise for reaching a wider pediatric audience.”

Mindfulness-based interventions. A growing body of research has linked the use of mindfulness-based interventions with improved pain outcomes, quality of life, and psychological comorbidities in adult patients. These interventions may have similar effects in children and adolescents with a range of chronic pain conditions, according to recent evidence, including a pilot randomized trial in which adolescent girls with chronic pain were found to have improved pain coping and reduced levels of salivary cortisol after completing an 8-week mindfulness-based intervention.³ In a randomized controlled trial, a mindfulness-based stress reduction intervention was associated with improvements in depressive and posttraumatic symptoms, negative coping, and other aspects of psychological functioning in fifth to eight grade students at urban US schools.⁴

“Clinical judgment is recommended until published research can better guide the use of [mindfulness-based interventions] among youth with pain,” noted the review authors.¹ “That being said, mindfulness interventions may be low cost or free adjunctive treatments that have fewer side effects as compared [with] pharmacologic interventions.”

Hypnosis. Several studies indicate that hypnotic analgesia benefits adult patients with chronic pain. “[H]ypnotic analgesia is hypothesized to enhance nervous system inhibitory processes that attenuate pain experiences through a variety of brain areas involved in pain processing,” noted the authors.¹ In a meta-analysis of 18 studies (n=933), hypnosis was found to significantly reduce pain and to be superior to other psychological interventions.⁵

Studies in which hypnosis was examined in pediatric patients with chronic pain are scarce, but evidence suggests that this approach may be beneficial. In one randomized controlled trial, patients who underwent hypnosis vs standard medical therapy reported greater reductions in pain frequency and intensity.⁶ In another randomized controlled trial, self-hypnosis training was associated with better pain control and reduced morphine use during a 5-day hospital stay in adolescents.⁷