Speaker: Hazel Gutiérrez

In low- and middle-income countries (LMICs), where Pediatric Palliative Care (PPC) and pediatric pain services are limited, pain treatment in children faces multiple challenges that can be difficult to overcome. This session describes the Costa Rican experience in organizing a national Pediatric Palliative Care and Pain Control program for children and adolescents with life-limiting/life-threatening conditions (LLC/LTCs) and reflects on its strengths and pitfalls. We will discuss the different care scenarios and services available in the country, along with the adaptations made to address specific patient and family needs. We will also detail the strategies developed to facilitate pediatric pain management and treatment in the tertiary-level hospital. Finally, we will describe the most frequent barriers to adequate pain treatment in children with LLC/LTCs faced by Central American countries.


Learning Objectives:
1. Describe the care scenarios for children with LLC/LTCs and the pain services available in the Pediatric Palliative Care program in Costa Rica.
2. Summarize the facilitators and strategies used to improve pain management in children and adolescents in Costa Rica.
3. Describe the region's most frequent barriers to adequate pain treatment in children with LLC/LTCs.

Speaker: Karel Allegaert

Pharmacotherapy is a powerful tool to improve outcomes in neonates. Clinical pharmacology aims to estimate drug-specific (side)-effects based on pharmacokinetics (PK) and pharmacodynamics (PD). PK (absorption, distribution, metabolism, excretion, ADME) describes the drug concentration over time in a given compartment, like plasma, subcutaneous tissue, or cerebrospinal fluid. PD describes the link between drug concentrations and (side)-effects over time. For analgesics, this can be illustrated by concentration-time profiles in plasma- or cerebrospinal fluid for PK, while PD covers both effects (analgesia) and side effects (sedation, bladder retention, obstipation). Clinical pharmacology also aims to predict and explain variability, a key characteristic of children. The dynamic changes related to maturation and growth in newborns result in a unique setting with extensive variability. Non-maturational changes (like disease, drug-drug interactions, and pharmacogenetics) add to this variability.
Consequently, neonates are a particularly vulnerable subgroup. Analgesics selected, and their dosing regimens should take into account the severity and type of pain, the therapeutic window of the drug, but also the age or developmental state. Translation to safe and effective pharmacotherapy of pain in neonates or infants necessitates a thorough understanding of these clinical pharmacology principles.
These PK-related differences are reflected in age- or weight-dependent changes in dosing, and this will be illustrated for commonly used analgesics. Specific points of interest are differences in metabolism (other metabolites = other safety/efficacy profile), the relevance of a loading dose to ensure effective analgesia, the strengths of multimodal analgesia, and the emerging techniques on loco-regional analgesia. Despite the increasing knowledge, gaps, and questions still remain in the field of neonatal pain. These relate to assessment, prevention, and treatment, as well as long-term outcomes.



Learning Objectives:
1. Upon completion, participants will be able to better use observations on pharmacokinetics and -dynamics in neonates in their clinical practice.
2. Upon completion, participants will be able to better select analgesics and its dosing; this includes aspects related to loading doses and multimodal analgesia in neonates
3. Upon completion, participants will be able to integrate the practice of selection of analgesics with aspects on the safety/efficacy balance. 

Chronic pain is a common comorbidity in children and young people with cerebral palsy with reported prevalence up to 77%, however it is poorly understood, identified and managed. Assessment of pain in people with cerebral palsy is challenging due to varying communication, cognitive, visual and functional abilities. Many existing pain assessment tools are inappropriate as they rely on the ability to self-report, are not feasible for those with complex communication needs or contain items requiring functional skills that may not be present, such as walking and running. This workshop will explore assessment tools suitable for assessing chronic pain for all people with cerebral palsy within a biopsychosocial framework, which aims to facilitate accurate identification, assessment beyond pain intensity, and ensure timely referral to multidisciplinary teams for best practice management. Adaptations to key assessment tools to ensure they are appropriate for use in cerebral palsy will be presented and discussed. ‘Hands on’ opportunity to apply the framework and tools to case-based clinical scenarios will be incorporated, including for children who are unable to self-report, those with complex communication needs and those with cognitive impairment. The workshop will be presented by clinician-researchers and people with lived experience of cerebral palsy. 

This interactive panel presentation will focus on lessons learned in some of the most well-established intensive interdisciplinary pediatric pain treatment (IIPT) programs regarding how to apply the IIPT model of care to patients presenting with “pain-adjacent” conditions and with common comorbidities that present challenges to the traditional treatment approaches. We will also discuss how to adapt the model for patients with a variety of demographic characteristics beyond the historically-typical adolescent female profile. Integrating clinical outcomes data with case examples that will highlight both successes and challenges/areas for improvement, the panelists will discuss how their programs have managed the following presentations: (1)   Pain-adjacent presenting conditions: e.g. Postural orthostatic tachycardia syndrome (POTS); Functional Neurologic Disorders (FND); (2)   Common comorbidities:  e.g. Hypermobility; Neurodivergent conditions (3)   Demographic characteristics: e.g. Gender diverse identities; Young adults; Social determinants of health Presenters will briefly present IIPT outcome data on the patient populations listed above. The majority of the time will focus on a lively, dynamic discussion amongst panelists including frank discussions of treatment efforts that worked and did not work and debates about appropriateness of IIPT for specific patient groups. Through active moderation, the panelists will also engage the audience in this discussion format.

Quantitative sensory testing (QST) is increasingly used in pediatric pain research to inform understanding of pain outcomes and the transition from acute to chronic pain. The focus of this workshop is to: present brief QST protocols used in pediatric pain samples, discuss feasibility and methodological issues, and provide hands-on training in QST methods. As chair, Dr. Holley will provide a brief overview and introduce learning objectives. Next, presenters Drs. Li and Sieberg will present QST protocols used in ongoing pediatric pain research studies introducing paradigms of temporal summation of pain, conditioned pain modulation, and offset analgesia. They will present data on feasibility and methodology and include considerations for selecting stimulation modality (e.g., thermal, mechanical) and identifying body locations for pain threshold and tolerance tasks. Following theses presentations, a hands-on workshop will demonstrate QST methodologies including measurement of temporal summation, heat pain thresholds, and mechanical pain thresholds at multiple body sites.  The workshop will conclude with a panel discussion (moderated by session chair Amy Holley PhD) which will: address key methodological controversies in QST assessment in pediatric pain samples, discuss challenges faced in conducting QST studies, and promising future directions for using QST to advance pediatric pain research. 

This session will provide an overview of school-based interventions for chronic pain and somatic symptoms: What has been successful, what do we know, and what are the barriers and facilitators for pain-specific health promotion interventions in schools? What is important for success and sustainable implementation? Kory Zimney will give a general introduction reviewing the significance of chronic pain in childhood. He will then map out the course of a series of studies on the development and implementation of pain neuroscience education in middle schools in the US, sharing lessons learned. Afterward, other real-world examples will be presented: Catherine Stewart presents her findings with school nurse-delivered interventions for youth anxiety and related somatic symptoms. Henrike Brunsmann introduces a web-based educational headache intervention to 5th and 6th-grade students that have been evaluated in a randomized-controlled trial. 

Adolescents and young adults (AYAs) with chronic pain are an underserved population, with little research conducted and few clinical services available to patients in this age group. Additionally, there are currently no standards of care to facilitate health care transition (HCT) in AYAs with a primary chronic pain condition. This panel will briefly summarize literature on other AYA chronic illnesses where pain is a salient feature to highlight transition risk factors and HCT interventions that may apply to chronic pain. We will explain why HCT is fundamentally different in persons with chronic pain. The panel will then highlight existing and upcoming research in the field of healthcare transition in AYAs with chronic pain. The final segment of the panel will describe two of the few existing transition programs for AYAs with chronic pain, which may serve a model for future transition services and standards of care in this population.  We will describe development and implementation of an AYA Transition Clinic housed within a pediatric pain center. Furthermore, the development of an Intensive Interdisciplinary Pain Treatment program specifically tailored for AYAs. We hope to stimulate fruitful dialogue about the future of AYA treatment and research. 

The main purpose of this workshop is to present the creative process related to the innovative development of therapeutics virtual reality solutions used to manage pain and anxiety in pediatric medical procedures. This workshop will cover the following topics: creative process from conceptual phase through development, integration, design thinking and implementation in an hospital context. As part of the covid19 vaccination campaign for 5–17-year-old conducted in Quebec in the winter of 2021, one of the virtual reality solutions developed by our team of researchers was deployed on a massive scale in vaccination centers in the Montreal region and more than 50,000 children were able to benefit from this solution. This workshop will also address the challenges and issues related to the large-scale use of a solution that was initially developed and validated in a university research context. Participants to this workshop will be offered the opportunity to try on our virtual reality solutions product with an HMD provided by the speakers. This interactive workshop will allow participant to provide their feedback on their personal and professional experiences with virtual reality. 

The global health care landscape has made significant strides towards improving the quality of pediatric health care through new models of care, emerging technology, and increased awareness and advocacy. Evidence-based standards are pivotal in integrating these advances into practice, creating a cohesive and effective health care journey for children, and ensuring they receive comprehensive and equitable care. The aim of this session is to explore the integration of recently released Health Standards Organization (HSO) standard, CAN/HSO 13200:2023 (E) Pediatric Pain Management, developed in partnership with Solutions for Kids in Pain (SKIP), within the context of children's health care journey through the lens of people-centred care (PCC). The session will also delve into opportunities for collaboration with international colleagues with similar aims and missions, such as ChildKind International, to boost engagement and impact. 

Session Objectives:  

Lunch will be provided to all attendees
Lunch Box Sponsors JIT Industrial Supply & Distribution Ltd. and Dalhousie University

Clinical networks are explicitly designed to mobilize health system change by promoting evidence-based practice and improving access to care (Manns & Wasylak, 2019). Moreover, they are adept at addressing key health system problems as they can effectively identify gaps in care, efficiently innovate, and support under resourced health systems.  In this symposium, we will discuss how a clinical network has supported systematic integration of psychological skills training for adolescents with chronic pain and their parents/caregivers across variable pediatric health systems.  exists, reducing gaps in psychological care such as problems with access, wait times, and clinical efficiency. The Comfort Ability Program (CAP), founded more than a decade ago, has developed a collaborative clinical network including over 30 children’s hospitals who have a shared goal of efficiently and effectively enhancing access to psychological care and for pediatric patients with chronic pain and their parents/caregivers (Coakley et al, 2018). This symposium will present CAP’s unique clinical network model--based on an implementation science framework--and present two illustrated case examples of network partnerships that addressed the challenging issues of low resources, limited healthcare access, and equity. Further, we will discuss how a specialized clinical network can generate collaborative research and spur ongoing innovation.  

Virtual Reality in Pediatric Pain Management: A Systematic Review                                                
Presenter: Courtney Hess

Exploring the barriers, facilitators, and strategies for the implementation of pain interventions in the NICU: A systematic integrative review

Presenter: Shelly-Anne Li

Measuring Change in IIPT: Using Self-Report and Performance-Based Measures to Predict Improvement in Functional Disability    
Presenter: Sara Williams

Longitudinal Effect of Skin-to-Skin Contact Compared to 24% Sucrose on Stress Response in Infants and Mothers During 2, 6, 12, and 18-Month Vaccinations: A Secondary Analysis
Presenter:  Morgan MacNeil

The influence of chronic pain by prevalence and severity on health care access and educational engagement: a representative cross-sectional study of Aotearoa New Zealand high school students
Presenter: Bridget Farrant

Validation of a digital assessment scale for pain                                                                                  
Presenter: Angelica Höök, RN 
 

The aim of this skills workshop is to introduce attendees to concepts of Play and two techniques in managing procedural fear and pain in children and adolescents: mindful distraction and guided imagery.Effective communication is essential in assessing and managing procedural fear and pain.   Attendees will learn how therapeutic play can be used to prepare the child and parent as well as in the heat of the moment.  The emphasis will be on ‘take home’ skills and techniques for immediate application across disciplines.Attendees will engage in a group mindful distraction exercise and observe a demonstration of guided imagery.  Clinical application will be presented in video of the techniques during procedures with children.  Potential apprehension around taking the first steps in applying the techniques will be addressed.  Attendees will pair up and practice guided imagery and then swap so both have a chance at guiding and being in imagery.The workshop will conclude with a group discussion on attendees’ practice in the workshop and any questions or concerns about applying the techniques in the clinical setting.

Virtual reality (VR) has been studied over the past 20 years as a powerful tool for minimizing acute and chronic pain in children. Despite this evidence, immersive VR has not been widely adopted in clinical practice. This workshop will provide a brief overview of history of VR in pediatric pain; describe the development, mission, and growth of INOVATE-Pain, a multisite collaborative network committed to advancing research and development of immersive technologies in the treatment of pediatric pain; discuss evidence on impact of VR on clinical outcomes and recommendations for conduct of clinical trials using VR and provide specific examples of co-design and evaluation of VR for chronic pain rehab and school re-entry. Presenters will include examples of successful implementation and evaluation of VR interventions for pediatric pain as well as highlight lessons learned from challenges along the way. Addressing the conference theme of "Better Together," presenters will describe how they have forged partnerships with stakeholders (e.g. patients, philanthropic funders) and technology experts (e.g. software developers) to improve pediatric pain care through strategic partnerships. Recommendations will also be made on strategies to help scale the implementation of VR as a clinical tool in everyday practice.

Prematurely born neonates are often admitted to the neonatal intensive care unit (NICU), where they will experience adverse life events like stress, pain, and exposure to analgesics. This kind of events in early life influences the postnatal maturation of the nociceptive system, and can therefore alter future responses to painful events. However, the neurobiological mechanisms leading to these lifelong effects are still unclear. In this symposium, we address new findings on how early life exposure to adversities like stress, pain, and analgesics is received by the developing nociceptive system and can influence its maturation. First, we will describe optimized methods to quantify personalized profiles of adversity experiences in the NICU, and explore pain processing changes that occur during the weeks that preterm or ill newborns spend hospitalized. By incorporating preclinical models, this symposium will examine how early life adversities can influence key stages of nociceptive development in the postnatal phase. Finally, we will assess how exposure to analgesics during early development can shape nociception and analgesic efficacy throughout the lifespan. 

The International Association for the Study of Pain’s 2022 Global Year for Translating Pain Knowledge into Practice highlighted the importance of partnering with patients across professional undertakings to ensure relevance and impact in both research and clinical care. Partnering with patients and caregivers in planning, conducting, and disseminating research can improve research quality and delivery of pediatric pain services and policies; however, many researchers, clinicians, and other health care stakeholders are at best uncertain about, if not completely unaware of, how to partner with patients. Drawing on the experiences of international panelists, including a patient, we will outline and discuss a variety of creative and meaningful ways patients and caregivers can and have been engaged as part of research and clinical implementation teams. Concrete examples will be shared across a spectrum of patient involvement and engagement (inform, consult, involve, collaborate, and empower) to guide pediatric pain research and development of clinical services.

Speaker: Elliot Krane

At the conclusion of a four-decade career in pediatric pain management and pediatric anesthesiology, this talk will give a retrospective of what the speaker sees as some of the important advancements in the management of pain in children and a glimpse into the crystal ball, describing some innovations still in the pipeline that may come to fruition in the coming years that will further push the envelope in treating children with pain.


Learning Objectives:
1. Upon completion, the participant will be better able to understand where pediatric pain management began and how it came to its present state.
2. Upon completion, the participant will be better able to appreciate the contributions of some of the thought leaders that allowed the specialty to evolve and mature.
3. Upon completion, the participant will be better able to anticipate some of the new technology, drugs, and techniques that may further benefit and advance the treatment of pediatric pain.