The Use of CAM Therapy to Manage Pain in Children

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Significance and Background

Healthcare Problem

Pain is an unpleasant sensation that is linked to illness or potential tissue damage. Acute pain occurs in response to inflammatory responses, thermal, chemical, or mechanical impetus, surgical procedures, or physical injury and often subsides within a few days or weeks. Conversely, chronic pain persists for at least three months notwithstanding treatment (Wren et al., 2019). Measuring and treating pain in pediatric patients are obfuscated by the inability to construe pain accurately, which is associated with poor communication between medical personnel and patients. Furthermore, opioid therapy, which is the mainstream pain treatment has numerous adverse effects. Consequently, the application of complementary and alternative medicine (CAM) is desirable. CAM encompasses unconventional treatments, for example, acupuncture, homeopathy, massage, yoga, osteopathic medicine, dietary supplements and adjustments, herbal medicine, music among others (McClafferty et al., 2017). This paper investigates the application of CAM treatments to alleviate pain in children.

Significance

Chronic pain is documented in 15 to 25% of children and is associated with hospital emergency room visits and reduced quality of life (Brown et al., 2017). Even though opioids are beneficial in pain management, they cause numerous side effects such as changes in breathing, gastrointestinal disturbances, and cognitive dysfunction, physical tolerance, increased pain sensation, dependence, and addiction (Timmerman et al., 2019). Therefore, the use of CAM can mitigate some of these side effects while managing pain effectively.

Current Healthcare Practices

Current pain management practices among children follow the stepwise approach recommended by the World Health Organization (Kahsay, 2017). The first-line treatment for mild to moderate pain is non-opioids such as acetaminophen (paracetamol), which is preferred because of relatively fewer side effects. The next line of drugs is non-steroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen, diclofenac, ketoprofen, and acetylsalicylic acid. As the magnitude and severity of pain increases, opioids such as morphine, codeine, tramadol, and fentanyl are considered.

Impact of the Problem on the Organization and Patients

In the practice setting, many pediatric patients experience acute and chronic pain as a result of various health conditions. Numerous cases of side effects of pain medications have been documented. Underinsured patients with chronic health conditions have reported poor quality of life due to the inability to afford pain medications. Furthermore, increases in opioid diversion, over-prescription, and misuse have been reported. Implementing CAM therapies will curtail misconduct related to analgesics, minimize undesirable upshots, and enhance patient outcomes in children experiencing pain.

Search Strategy

A literature search was performed on the institutions library database to find peer-reviewed publications related to the healthcare problem. The key search terms used were pain management, complementary and alternative medicine, standard care, and pediatric patients. The search was limited to articles published within the last five years. Abstracts of retrieved items were read to determine their relevance to the problem. A total of seven articles were selected for further review. They included five research and two non-research articles. A summary of all the seven publications is provided in the evidence matrix.

Of the two research evidence sources, the first article by Bertrand et al. (2019) examined the effect of foot reflexology in the management of relentless pain in children. The authors conducted a prospective study in which all children experiencing pain received the intervention. The effectiveness of the intermediation was determined by pain assessment using the visual analog scale (VAS). The key finding was that foot reflexology resulted in a significant reduction in pain scores, indicating the effectiveness of the approach. In a separate study, Marom et al. (2016) conducted a systematic review of the literature to determine beneficial CAM approaches to manage pain associated with otitis media in children. The use of CAM in otitis media incorporated methods such as phytotherapy, acupuncture, ear candling, homeopathy, vitamin D supplementation, herbal medicine, xylitol, osteopathy, chiropractic care, and probiotics.

The non-research evidence sources that were considered included a clinical guide for clinicians in pediatric pain management. McClafferty et al. (2017) acknowledge the use of CAM and provide relevant information regarding common interventions, their application, educational resources, and communication tactics for the discussion of CAM approaches between patients and clinicians. Vohra et al. (2017) proposed a clinical trial to evaluate the cost-effectiveness of CAM in inpatient settings. The proposed pediatric divisions in which the study would be conducted include oncology, cardiology, and general medicine. Findings from this study would guide the use of CAM in hospitals.

PICO Question

In pediatric patients experiencing pain, will the use of CAM compared to usual care lead to a reduction in pain?

Evidence Matrix

Authors	Journal Name	Year of Publication	Research Design	Sample Size	Outcome Variables Measured	Quality (A, B, C)	Results/Authors Suggested Conclusions
Bertrand, A., Mauger-Vauglin, C. E., Martin, S., Goy, F., Delafosse, C., & Marec-Berard, P.	Bulletin du Cancer	2019	Quantitative	192 pediatric patients	Pain scores as measured by the Visual Analog Scale (VAS)	A	Foot reflexology was an effective CAM technique for pain management in children and should be considered during treatment. However, its application should be investigated in larger patient groups in controlled, randomized trials.
Mahmood, L. A., Reece-Stremtan, S., Idiokitas, R., Martin, B., Margulies, S., Hardy, S. J., Bost, J.E. & Darbari, D. S.	Complementary Therapies in Medicine	2020	Quantitative	12	Pain scores before and after acupuncture	B	Acupuncture is a well-tolerated CAM technique in the management of chronic pain in children with sickle-cell anemia. High quality data is needed to facilitate the coverage of acupuncture as a component of pain management in sickle cell disease.
van der Heijden, M. J., Jeekel, J., Rode, H., Cox, S., van Rosmalen, J., Hunink, M. G., & van Dijk, M.	Burns	2018	Quantitative (randomized controlled trial)	135	Primary measure- distress. Secondary measure- pain.	A	Live music therapy did not result in significant changes in distress and pain in young children receiving burn wound care. However, the intervention was more beneficial in older children. Post-procedural support may also be required for this intervention.
Jong, M. C., Boers, I., van Wietmarschen, H., Busch, M., Naafs, M. C., Kaspers, G. J., & Tissing, W. J.	Supportive care in Cancer	2019	Mixed method	A systematic review of 11 randomized controlled trials. Survey of A focus group consisting of 7 parents	Evidence for CAM. Parents need to make CAM-related decisions.	A	Hypnotherapy led to a significant reduction in procedural cancer pain compared to standard care. Parents require adequate and accurate information regarding CAM.
Marom, T., Marchisio, P., Tamir, S. O., Torretta, S., Gavriel, H., & Esposito, S.	Medicine	2016	Systematic review	An unspecified number of studies	Efficacy of various CAM approaches in otitis media pain	B	CAM approaches in otitis media are conservative and do not entail drugs even though they display varying levels of efficacy. Common methods include phytotherapy, acupuncture, ear candling, homeopathy, vitamin D supplementation, herbal medicine, xylitol, osteopathy, chiropractic care, and probiotics.

Recommended Practice Change

Healthcare practitioners should incorporate CAM into the routine management of acute and chronic pain in pediatric patients. The reviewed studies have demonstrated the benefits of CAM in the alleviation of pain. For instance, foot reflexology has shown immense benefits in chronic pain alleviation in children, teenagers, and young adults aged 25 years or below (Bertrand et al., 2019). Acupuncture shows promise in pain relief for patients with sickle cell disease (Mahmood et al., 2020), whereas hypnotherapy improves procedural pain in cancer (Jong et al., 2019). For children aged 5 years and older, music therapy eases anxiety and pain (van der Heijden et al., 2018). Additional CAM strategies that can be considered include probiotics, herbal remedies, acupuncture, ear candling, homeopathy, vitamin D supplementation, herbal medicine, xylitol, osteopathy, and chiropractic care (Marom et al., 2016). However, precise interventions should be chosen based on available supporting evidence.

Implementing the Practice Change

Key Stakeholders

The three key stakeholders in the implementation of the practice change are the nurse, caregiver, and primary physician. The primary physician is tasked with evaluating the patents pain and making pertinent referrals to pain specialists. The role of the nurse is to assess the patients pain, interpret it, administer the intervention in clinical settings, and evaluate the efficacy of the intermediation. In contrast, the role of the caregiver is to oversee or implement the recommended CAM intervention when the patient is away from the hospital. These three stakeholders would be involved in determining and working towards precise treatment goals for the patient.

Barriers

One barrier to the implementation of CAM therapies is patient and caregiver doubts regarding the effectiveness of CAM, which results in non-adherence and poor clinical outcomes. A second barrier is poor communication and knowledge gaps, which may bring about unintended consequences. For instance, the concurrent use of certain dietary supplements with pharmacological agents may result in adverse reactions. Patients may not open up about the use of CAM therapies at home.

Strategies to Overcome the Barriers

Doubts concerning the effectiveness of CAM therapies can be erased through patient education, which may also involve the caregivers. The nurse should provide a brief rationale for the proposed CAM methods to the patients to encourage compliance. Conversely, clinicians need to find out about supplement use, include it in the patients medical records, and find any potential drug interactions. Encouraging open communication about any CAM practice that the patient engages in can minimize the likelihood of adverse reactions.

An Indicator to Measure the Outcome

The primary indicator to measure the outcome of the intervention is pain. The visual analog scale (VAS) will be used for this measurement. This tool uses an unmarked line that is 100 millimeters long with the words no pain and unbearable pain written on the left and right ends, respectively (Bendinger & Plunkett, 2016). During the assessment, the patient is required to mark a point along the scale that corresponds to the extent of their pain.

References

Bendinger, T., & Plunkett, N. (2016). Measurement in pain medicine. BJA Education, 16(9), 310-315.

Bertrand, A., Mauger-Vauglin, C. E., Martin, S., Goy, F., Delafosse, C., & Marec-Berard, P. (2019). Evaluation of efficacy and feasibility of foot reflexology in children experiencing chronic or persistent pain. Bulletin du Cancer, 106(12), 1073-1079. Web.

Brown, M. L., Rojas, E., & Gouda, S. (2017). A mind-body approach to pediatric pain management. Children, 4(6), 1-13.

Jong, M. C., Boers, I., van Wietmarschen, H., Busch, M., Naafs, M. C., Kaspers, G. J., & Tissing, W. J. (2019). Development of an evidence-based decision aid on complementary and alternative medicine (CAM) and pain for parents of children with cancer. Supportive Care in Cancer, 1-15.

Kahsay, H. (2017). Assessment and treatment of pain in pediatric patients. Current Pediatric Research, 21(1), 148-157.

Mahmood, L. A., Reece-Stremtan, S., Idiokitas, R., Martin, B., Margulies, S., Hardy, S. J., Bost, J.E. & Darbari, D. S. (2020). Acupuncture for pain management in children with sickle cell disease. Complementary Therapies in Medicine, 49, 102287.

Marom, T., Marchisio, P., Tamir, S. O., Torretta, S., Gavriel, H., & Esposito, S. (2016). Complementary and alternative medicine treatment options for otitis media: a systematic review. Medicine, 95(6), 1-9.

McClafferty, H., Vohra, S., Bailey, M., Brown, M., Esparham, A., Gerstbacher, D., Golianu, B., Niemi, A.K., Sibinga, E., Weydert, J., & Yeh, A. M. (2017). Pediatric integrative medicine. Pediatrics, 140(3), 1-23. Web.

Timmerman, L., Stronks, D. L., & Huygen, F. J. (2019). The relation between patients beliefs about pain medication, medication adherence, and treatment outcome in chronic pain patients: A prospective study. The Clinical Journal of Pain, 35(12), 941-947. Web.

Van der Heijden, M. J., Jeekel, J., Rode, H., Cox, S., van Rosmalen, J., Hunink, M. G., & van Dijk, M. (2018). Can live music therapy reduce distress and pain in children with burns after wound care procedures? A randomized controlled trial. Burns, 44(4), 823-833. Web.

Vohra, S., Schlegelmilch, M., Jou, H., Hartfield, D., Mayan, M., Ohinmaa, A., Wilson, B., Spavor, M., & Grundy, P. (2017). Comparative effectiveness of pediatric integrative medicine as an adjunct to usual care for pediatric inpatients of a North American tertiary care centre: A study protocol for a pragmatic cluster controlled trial. Contemporary Clinical Trials Communications, 5, 12-18.

Wren, A. A., Ross, A. C., DSouza, G., Almgren, C., Feinstein, A., Marshall, A., & Golianu, B. (2019). Multidisciplinary pain management for pediatric patients with acute and chronic pain: A foundational treatment approach when prescribing opioids. Children, 6(2), 1-22. Web.

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