Play is the Best Medicine

When pain is managed effectively, kids can get back to doing what they do best—being kids. They’re able to be mobile, participate in recovery activities such as physical therapy, and get more sleep, all of which leads to quicker recovery. Pain control also reduces anxiety and emotional distress. It instills confidence among caregivers and patients, and fosters long-term positive perceptions of health, well-being and medical care. Less pain means shorter and fewer hospital stays, and more days building forts, playing tag with friends, dressing up like a princess, exploring the park, riding bikes, climbing trees and getting lost in a book. 

While the formal ChildKind certification process typically takes 9 to 12 months once an institution is “application‑ready,” Cook Children's has spent years developing policies, education, interdisciplinary structures, and quality‑improvement processes to meet ChildKind’s five principles. To be certified, a health care facility must demonstrate an institution-wide commitment to pain prevention and treatment; provide ongoing education and awareness of pain; use evidence informed and developmentally appropriate processes for acute and chronic pain assessment; implement policies and protocols for pain prevention and treatment that includes pharmacological, psychological and physical methods; and participate in self-monitoring and continuous quality improvement initiatives. 

The Tools of Comfort

Cook Children’s has a multi-disciplinary and comprehensive pain program that includes inpatient pain consultation services, an outpatient pain management clinic, an inpatient rehabilitation program, a procedural pain management program and an opioid stewardship committee. Two of Cook Children’s most notable pain management services include the Comfort Menu Program and Comfort Ability® Program. 

Cook Children’s Comfort Menu is a visual tool showcasing available pain management resources, such as breastfeeding, nonnutritive sucking, swaddling and sucrose administration for neonates, and distraction techniques and topical anesthetics for infants and older children. The menu helps engage patients, families and medical providers in conversations about pain and fear surrounding medical care so that they can collaborate to create an individualized comfort plan during hospital stays, medical procedures and even vaccinations. One of the resources showcased on the menu is the Comfort Kit, a box full of fun and creative items such as bubbles, balls and toys that help distract kids from the poke of a needle or the fear of a procedure. 

The Comfort Ability® Program utilizes cognitive behavioral therapy to equip children with proven, non-medical coping strategies to reduce their attention to their pain. For example, patients learn how to calm their nervous system with belly breathing, guided imagery, art therapy, mindfulness, aroma therapy, and biofeedback therapy. 

In addition to these resources, Cook Children’s offers a number of non-pharmacological and integrative pain management techniques for both inpatients and outpatients. They include everything from aromatherapy, massage therapy and acupuncture to virtual reality, music, art and so much more. But perhaps the most loveable resources of all are Brienne, Cayenne, Margo, Neely, Steve and Zuni, all cute and cuddly canine members of Cook Children’s Sit…Stay…Play facility dog program. These pups and their trained Child Life specialist handlers work all throughout the medical center bringing warm and fuzzy interactions that reduce stress and anxiety and promote physical, mental and emotional comfort and healing. 

Together these resources and techniques contribute to lowering opioid use for pain control, which is the goal of Cook Children’s opioid stewardship committee. This multidisciplinary committee consists of physicians, surgeons, nurses, advanced practice providers, pharmacists, social workers, clinical educators, and administrators led by the medical director of the Pain Management Program. Their mission is to improve patient safety and reduce the risk for potential child addiction, ingestion, misuse, overdose or death from opioid medications while promoting best practices through the safe and sound management of pain. In its site review report, the ChildKind certification committee noted Cook Children’s opioid stewardship and its efforts to effectively treat pain while reducing the risk of opioid exposure. 

“At Cook Children’s, we partner closely with our patients, their families, support systems, health care teams and each other because we are wholeheartedly committed to caring for every child’s comfort and easing their pain,” says Chansey Pullen, Pain Management Services coordinator. “We’ve all heard the saying, ‘It takes a village to raise a child.’ That same spirit of collaboration, which is one of our core values and woven into the fabric of our culture, is key to preventing, treating, and managing pediatric pain, no matter our role, as we strive to fulfill Our Promise. We have an incredible range of resources to support children in pain and their families, and achieving ChildKind certification is a tremendous honor that reflects our shared commitment to providing compassionate and comprehensive pediatric pain management.” 
 

In both settings, the pain management team is committed to improving patients’ quality of life by offering them the tools to manage and overcome their pain. They provide treatment options tailored to meet the patients’ goals, such as medication management, interventional pain procedures, physical therapy, cognitive behavior therapy, relaxation therapy, guided imagery, aromatherapy, medical acupuncture, massage therapy, yoga therapy and more. The team also provides education on how to manage pain through lifestyle modifications like paced physical activity, diet and improved sleep hygiene.

Watch the videos below to learn more about the aromatherapy, massage therapy and yoga therapy services at Cook Children’s.

Answers to Mila’s Pain

In January 2023, Mila was diagnosed with central sensitization syndrome, slipped rib syndrome and hypermobility syndrome. For four years, Mila’s mom, Shelley Hunter, had taken her daughter to countless doctor visits to find answers to why she limped when walking and the extreme pain all over her body. When Cook Children's Pain Management was recommended to her, Shelley was hesitant. She didn’t want Mila to just be given strong pain medications. She quickly realized this was not the approach at all.

At Cook Children's Pain Management, the doctor knew exactly what Mila was dealing with right away. 

“She answered all the questions we had for years,” Shelley said. “Instead of dismissing our concerns, she listened and helped us understand Mila’s conditions.”

Mila was referred to the Comfort Ability Program which she attended in March. The relief Mila felt when meeting others just like her was indescribable.

“For so long I felt alone because I was sick in a way that no one else was,” Mila said. “At the workshop, I learned a lot, but the most important thing was knowing there were other people just like me. I finally felt like I belonged.”

Life-changing Workshops Engage Children and Parents 

The Comfort Ability Program at Cook Children’s is one of a few of its kind in Texas. Boston Children’s Hospital is partnering with children’s hospitals throughout the world to give parents and kids the opportunity to engage in workshops that focus on proven coping skills using cognitive behavioral therapy. 

Artee Gandhi, M.D., medical director of pain management, said the six-hour workshops – one for children and one for parents – help children reduce their pain in non-medical ways. Clinical therapists and pain psychologists explain the science behind the pain and how they can best support their children. Through group therapy, children learn strategies to manage their pain and are taught more about their conditions so they can educate their friends, teachers and others. The program is meant to be one piece of a patient’s treatment plan and complement the entire host of options provided at Cook Children’s.

“Others may not see it on the outside, but these children are struggling on the inside, so we give them tools and strategies to employ anywhere and throughout life,” Dr. Gandhi said. “The brain is a powerful tool, and we help them use it.”

The program teaches both children and parents how the nervous system works in the body and why skills rooted in psychology can help. During the workshop, patients learn how to calm down their nervous system through belly breathing, guided imagery, art therapy, aroma therapy, mindfulness and biofeedback therapy.

Patients from 10 to 17 years old with any condition that causes chronic pain for more than three months can participate. Some of the conditions include central sensitization syndrome, chronic headaches, IBS, fibromyalgia and chronic back pain.

A Program Filled with Hope

Matthew Reed, pain management clinical therapist and site director of the Comfort Ability Program, has been at Cook Children’s for 10 years and treats children with chronic pain on an individual basis. He says the goal is always to reduce the attention on pain and get kids back to living. 

“We see a lot of patients who think the pain will last forever and believe there isn’t a path out of it,” Reed said. “There is a lot of hope built into this program, and one of the greatest benefits is the kids connecting with others.”

Patients who attend the workshops also have access to an online platform where they can engage with others around the world with the same condition. The first couple of workshops have been very successful and are now in high demand. 

“It has been very rewarding to see patients realize there is a path out of their pain,” Reed said. 

‘I feel like myself again’

Shelley said even Mila’s teachers noticed that in a matter of a few months, Mila is now a totally different person. She credits the Comfort Ability Program with Mila’s newfound confidence.

“My mental health is a lot better and so is my pain,” Mila said. “I’m starting to feel like myself again.”

A couple months ago, Pediatric Yoga Therapists Gina Shelton and Stacy Bush joined the Cook Children’s Pain Management team to lead yoga therapy classes and individual consults throughout the medical center, Inpatient Psychiatry Unit and Partial Hospitalization Program.

While yoga is a general term of practice, “yoga therapy is the process of empowering individuals to progress toward improved health and well-being through the application of the teachings and practice of yoga,” according to the International Association of Yoga Therapists.

Our yoga therapists are here to help alleviate physical and mental health conditions by cultivating the mind-body connection. 

“The main thing we teach is that your breath can change how you feel, then movement calms your nervous system. Our modern culture often forgets that our bodies are made to move, not sit still all day,” Shelton said. “And we also talk to them about their brains and how they work. So they get a little more awareness of themselves and how their brain, emotions, and body are interconnected.”

Cook Children's yoga therapy sessions consist of breathing exercises, postures, meditation and relaxation techniques. Conditions addressed may include stress, anxiety, depression, PTSD, ADHD, Musculoskeletal problems, autoimmune diseases, Insomnia, IBS, Cancer, and others. 

“Through these classes we have an opportunity to come in and teach the kids through experience,” Bush said. “When they feel it, it is easier to learn it and implement it as a coping skill. That’s the great thing about the focus we have on breath work. Your breath is always with you, no matter where you are. You don’t have to change what you’re doing – you just stop and breathe and have a moment to connect back.”

Each session is built around integrative learning approaches aimed at being more like play than therapy. The goal is to meet the patient where they are most comfortable and to implement techniques so that the patient engages willingly and in a joyful manner.

“Kids are going to have lots of energy and all kinds of different things going on, so we have to meet them where they are,” Shelton said. “In our classes, we pay attention to how we’re feeling and that brings us back to our bodies and connects mind, body and breath.”

Yoga therapy aligns the needs of the patient with the particular practice required. Our therapists are able to work with children of all developmental abilities, allowing them to participate with low back pain or physical disability with very specific yoga from their bed, chair or floor in their own room.

For example, with positions and postures to increase strength, circulation, range of motion, proprioception and balance. Likewise, with anxiety, there are specialized sessions to raise self-awareness and regulate the central nervous system.  

By developing a positive relationship with their body, the patient is more likely to have a beneficial outcome from other prescribed therapies that are part of their medical treatment.   

“We teach them to take a moment and take a breath to calm back down,” Bush said. “With this awareness, we can help them start to shift the way they think about themselves, the way they view the world and the way they move in the world. I think that’s a pretty powerful thing.”

These are common problems in the lives of a child.

But thanks to cyberbullying, the pressure to make it into college and a desperate need to fit in, anxiety has reached near epidemic proportions.

More than 40 million Americans suffer from Anxiety. According to the annual national survey by the American College Health Association, one in six college students has been treated for or diagnosed with anxiety in the past year.

For many of the kids at Cook Children’s, chronic pain only adds to that sense of stress and anxiety.

“Chronic pain affects every relationship in a child’s life. There’s a lot of bullying that can take place. They lose a lot. They lose their ability to play soccer or stay on the football team or they find themselves not being able to go to school regularly and some of our kids can’t go to school at all due to pain,” said Barbara Deleon, Pain Management Services coordinator at Cook Children’s. “So then they lose some of their friends. They lose those relationships that are important to children.”

To help the children who suffer from chronic pain, Pain Management Services uses many different types of therapies to help their patients including acupuncture, acupressure, aroma therapy, massage therapy and different types of physical therapies.

But yoga has always been at the top of the list to add to their pain management tools.

Two years ago, the Pain Management team wrote a proposal to bring a yoga program to Cook Children’s and they received the funding this year. Then the search was on for the right person to lead and teach yoga to the variety of patients dealing with pain and anxiety at Cook Children’s.

Tatiana Miller was that person. Miller brings with her a ton of expertise with hundreds of hours of yoga instruction, as well as a cognitive behavioral therapy practitioner, a stress management life coach and a health counselor.

She is also a wife and mother of two who lives in Fort Worth. Immediately, she knew this job at Cook Children’s was the one for her.

“When they called me in to meet with the Pain Management department I thought, ‘Oh my gosh this is divine. This is more than meant to be. All the knowledge I’ve gained, all the experience I have was for this moment. It was for this department. We’re taking these children and giving them these tools that they had not been given before. These kids are missing school because of their pain. They aren’t able to catch up on reading or math, but they also can’t catch up with just wanting to have a good life. To get their life back. If you don’t have the tools to cope with this pain, you can’t catch up to feeling depressed or angry or frustrated. Anxiety is paralyzing and these kids that once had normal lives aren’t able to do life anymore because of their pain and the anxiety that comes with it.”

The yoga instruction at Cook Children’s provides tools to make it easier for patients to cope with the challenges they may face, including:

• Anxiety
• Post-traumatic stress disorder
• Chronic headaches
• Sleep disorders
• Pain
• Grief
• Depression

The yoga is designed to accommodate all ages and fitness levels, based on 5 principles:

• Stillness – learn to quiet the mind and body, become self-aware and develop sensitivity, self-control and self-regulation.
• Listening – tune in to what your heart, mind and body have to say.
• Grounding – discover how to be physically present in your body and develop a sense of competence, physical safety and security.
• Strength – develop physical, mental and emotional strength.
• Community – enjoy a fun-loving environment where you can explore yoga through the use of movement, breathing and games.

Miller takes the principles with her to help her patients, but these are kids and no two sessions are the same.

“Part of the yoga therapy approach is meeting patients where they are at,” she said. “So I can’t show up with a plan because I might have a teenager and a toddler in a class or all teenagers for all toddlers. The kids may be very active or very tired. So my approach is to show up and to read them. That’s where I start off. I talk to them to make them feel safe. I try to connect to each participant in a way they can relate.”

For all of her training and expertise, Miller said any progress begins with one simple truth: “They have to like me. Because if they don’t, they aren’t going to participate and they aren’t going to listen to what I have to say.”

Miller walks into a room and scans for body language, where the kids are located in the room and their social cues such as are they looking her in the eye.

From there, she begins to reach into her bag of tricks to hook their attention. She may bring out a focus ball to help the kids with their breathing. She teaches them what breathing should feel like and how to slow down their breath.

“If I can get them to slow down their breathing, their nervous system says things are good. We can calm down,” Miller said. “The first goal is to get them in a happy place in their nervous system.”

From there, depending on age and the physical makeup of the class, students may do as many as 15 yoga poses.

But Miller works on more than just the physical during yoga. She works on their self-esteem. She talks to them about feeling empowered and feeling like a leader.

“The true understanding of yoga is the ability to be still and listen. That’s it. Yoga is not body postures. Yoga is not meditation. Yoga is not breathing. Yoga is the ability to be still and listen and not let external circumstances affect your internal state,” Miller said. “A crisis is any time your internal tools can’t keep up with the external demand. That’s why most teenagers live in crisis, which is anxiety, because they don’t have the internal tools to meet the external demands.

“If you teach them to be in the world but have the capacity to come back into themselves and say, ‘Is this real or is it in my head? My thoughts? My emotions? Can I do this? Is this right for me? That relationship within themselves … That’s the stillness and the listening.”

Miller is just beginning the program, but it is catching on throughout the medical center. She has taught children in Pain Management, Rehabilitation, Psychiatry and more is planned, including going to individual rooms for yoga therapy.

Yoga is a way to help the patients at Cook Children’s feel better about themselves. It’s one way to help kids who have lost control either physically or emotional to gain some control back.

“Pain is very physical and yoga can be physical,” Deleon said. “With pain, there is a mind, body connection and in yoga there is a mind, body connection. So the relationship between yoga and helping with their pain is very beneficial to our patients.”

How had it come to this for Madisyn Metaxas?

We will let her Little Monsters promote her new documentary and most recent album, we want to focus on why she says she had to cancel her European tour due to constant pain.

"I use the word 'suffer' not for pity, or attention, and have been disappointed to see people online suggest that I'm being dramatic, making this up, or playing the victim to get out of touring," Lady Gaga wrote. "If you knew me, you would know this couldn't be further from the truth. I'm a fighter. I use the word suffer not only because trauma and chronic pain have changed my life, but because they are keeping me from living a normal life. They are also keeping me from what I love the most in the world: performing for my fans."

The pop star later clarified on social media that the cause of her constant pain is Fibromyalgia. 

So what is Fibromyalgia?

“Pain comes in 3 varieties: pain from damaged tissue (nociceptive), pain from damaged nerves (neuropathic) and another type known as functional pain,” Artee Gandhi, M.D., medical director of the Pain Management Program at Cook Children’s. “Fibromyalgia is in the category of functional pain in that pain arises from neurological dysfunction and not tissue damage.”

To better understand what Dr. Gandhi means, she explains the “Gate Control Theory of Pain.”

Normally, if you were to hit your thumb with a hammer, pain signals would be sent along acute and chronic pain fibers to the spinal cord where the ‘gate’ is open. This pain message is then sent to the brain where the pain experience is perceived. This perception of pain depends on your genetic makeup, your coping mechanisms, what you have learned from others, your friends, parents, etc. So, to feel better you begin rubbing your thumb and messages are sent along touch and pressure fibers to the spinal cord causing the “gate” to close. No more pain messages are sent to the brain. You feel better and you move on.

“In fibromyalgia, the thumb heals but instead of the gate closing, it stays open and continues to send pain messages to the brain,” Dr. Gandhi said. “After time the area of pain spreads, becomes more sensitive, and hurts even if you touch it lightly. The pain is no longer from the site at which the pain is perceived to be but rather in the pain system itself. Dr. Gandhi explains this phenomenon of altered and exaggerated pain response is known as central sensitization and encompasses conditions such as fibromyalgia, irritable bowel syndrome, chronic daily headaches, postural orthostatic tachycardia syndrome (POTS), and chronic pelvic pain from endometriosis.”

Patients often present with widespread pain along with tenderness to touch, sensitivity to bright lights, loud noises, dizziness/lightheadedness. Associated symptoms include numbness, tingling, nausea, loss of appetite, muscle cramps, vomiting, change in taste, autonomic dysfunction, chest pain, etc.

With a child living in constant pain, it’s easy to see that this can lead to depression, anxiety, fatigue, loss of friends, activities, social isolation, missed school, and disability. This takes a toll on the patient and entire family. According to current data, 20 percent of children suffer from chronic pain while 25-40 percent of these patients suffer from central sensitization.

“Genetic factors play a role in that fibromyalgia tends to cluster in families, especially among female relatives,” Dr. Gandhi said.

Chronic pain may begin in childhood, but usually carries over into adulthood.

“The economic costs of pediatric chronic pain are in the range of $19.5 billion a year,” Dr. Gandhi said. At least 20 percent of young patients with chronic pain become adults with chronic pain.

“Parents of children with chronic pain are desperate for answers which often leads them down a long, complicated journey with expensive diagnostic studies, multiple hospital visits to clinics, ER, and inpatient hospitalization,” Dr. Gandhi said. “In the search for a biomechanical explanation for the pain, therapies are often ineffective and patients begin to feel helpless, only making the situation worse.”

To treat this condition, physicians begin with neuro-education explaining to patients and families that:

1. The pain the patient is experiencing is real, as real as pain arising from disease at the site the pain is perceived.
2. The problem is not with the joints themselves (or the head, GI tract, or other organ system) but in the pain system itself, and this explains why no test looking for disease in the tissues themselves is positive.
3. The disordered pain processing system and its connection with the central nervous system can explain the symptoms the patient is experiencing.
4. This is a “real” disease or disorder.
5. There’s treatment available which can allow the patient to have a functional and productive life. It is a disease that can be managed just as diabetes and high blood pressure are managed.

The most effective treatment centers provide multiple options for patients, ranging from medications such as anticonvulsants, anti-inflammatories, muscle relaxants, antidepressants, interventional procedures or pain blocks, physical therapy, cognitive behavioral therapy, psychotherapy, biofeedback, to complementary medicine such as massage, yoga, acupuncture, reflexology. Treatment is a process aiming to “re-set” this disordered system.

For those patients that fail conventional outpatient treatment, Cook Children’s offers a comprehensive inpatient rehabilitation program. We are the only multidisciplinary clinic in Texas that services children from all over the state and draws patients from Louisiana, Arkansas, Oklahoma, and New Mexico.

Tracy Jensen often thinks about her son, Ethan. He was someone with an amazing aptitude for learning. “He was a boy who had eyes to notice others who, like him, were in pain and suffered silently, Tracy said. “He was a boy who had the heart to care.”

Ethan never stopped caring about life. It was just the pain became too frequent and too painful for him. Ethan suffered from muscle pain in his back and right leg. At 5 months old he had a fatty tumor removed from his spine. His spinal cord was unable to be untethered and the scar tissue that remained was also troublesome.

Tracy and her husband, Eric, wonder when their son’s suffering began. Was it before his birth? Was it at 5 months old when he had the surgery? Was it later as scar tissue tangled the cord?

As they became aware of their son’s pain, they tried to help but they weren’t sure how, other than with over-the-counter medications, massage therapies and hugs.

Ethan didn’t really know how to help his pain and neither did most adults in his life. When he asked for medication or begged to lie down or go home, his requests were typically met with scoldings for him at school. Most didn’t understand how such a usually active child could truly be suffering.

Over time, Ethan learned to mask his pain.

“A child in chronic pain who is continually misunderstood is going to have emotional struggles such as depression,” Tracy said. “It is not reasonable to expect a child to know how to understand these issues, and my son was no exception. He struggled to process the facts of his life and this caused him to be more and more frustrated.”

Before he entered middle school, Tracy found a book on healing a child’s chronic pain. She continued to research and found that Cook Children’s offered a pain management program. It was there that the family met Artee Gandhi, M.D., medical director of pain management.

“Dr. Gandhi and company were incredibly responsive and devoted to Ethan's needs,” Eric said. “He was enamored with her in particular because she took his interests seriously and treated him as a young man rather than a child. However, Ethan was not always honest with her about the severity of pain he was experiencing. He sometimes believed that the doctors would not believe him or that they would think he was exaggerating his pain level to get medications.”

All through high school and beyond, Ethan studied science online. He taught himself subjects such as organic chemistry, DNA and gene therapy, and pharmacology. He learned how drugs, and different doses, acted and interacted in the body. He thought he understood enough to be safe with whatever he used for pain. He thought he was in control of his pain as he learned to manage it himself. He bought over-the-counter meds and used them off-label. He found ways to obtain prescription pain medication without a prescription.

The pain management team knew Ethan's level of self- education made him a challenge. Dr. Gandhi warned him about self-medicating and the dangers. Unfortunately, like many in their late teens, Ethan believed he was indestructible.

Ethan never stopped coming to clinic, but as time progressed he began to cancel and reschedule appointments more frequently. His parents believe that by mid-2015, Ethan thought surgery was his only chance for relief. The surgeons were able to straighten a significant portion of his lower spine regarding the pain, and as he was tapered off of his pain medication he began to once again self-medicate.

Eventually, drugs, especially opioids, were the only things that made him feel better. It was only slightly better, but that was OK for him, at least for a while. After the realization that his surgery failed to entirely alleviate his pain, Ethan became increasingly afraid of how his pain would continue to impact his life. He was afraid of what others would say, or what they thought of him. He believed no one would understand. He ultimately decided that he would have to treat his pain himself.

According to the Medical Examiner, Ethan died of mixed drug toxicity.

“We are only now looking back and asking ourselves if we could've done much better,” Eric said. “That day, my son was freed from his pain, but our pain would just be beginning.”

About the source

Artee Gandhi, M.D., is a pediatric pain management specialist and anesthesiologist. She has trained across the country including residency at the University of Missouri and fellowship at Stanford Univeristy. Cook Children's Pain Management program cares for infants, children and adolescents with chronic and acute pain. C​ook Children's is one of a few children's hospitals in the U.S. providing a comprehensive pediatric pain management program.

About Pain Management

The Cook Children's Pain Management program uses a team approach in caring for infants, children and adolescents with chronic and acute pain. Cook Children's is one of a few children's hospitals in the United States providing a pediatric pain management program. 

Our team includes a board certified anesthesiologist trained in pain management, a licensed clinical social worker specializing in psychophysiology, a dedicated physical therapist and pain management nurse coordinator.

Because of our team approach, patients will see their physician, physical therapist and psychophysiologist in one visit. 

Patients can make an appointment and physicians may refer a patient by calling our offices at: 682-885-PAIN (7246). New patients, for your convenience, please have your insurance information ready when you call.

The FDA will require several changes to the labels of all prescription medicines containing these drugs:

• Codeine should not be used to treat pain or cough and tramadol should not be used to treat pain in children younger than 12 years.
• A label warning against its use in children younger than 18 years to treat pain after surgery to remove the tonsils and and/or adenoids.
• A recommendation against their use in adolescents between the ages of 12 and 18 years who are obese or have conditions such as obstructive sleep apnea or severe lung disease, which may increase the risk of serious breathing problems.
• Breastfeeding mothers should not take codeine or tramadol medicines due to the risk of serious adverse reactions in breastfed infants. These can include excessive sleepiness, difficulty breastfeeding, or serious breathing problems that could result in death.

“Opioid abuse has become a public health concern and should be addressed as such. The more awareness we have for providers and families the better the communication can be amongst the community,” said Artee Gandhi, M.D., medical director of the Pain Management Clinic at Cook Children’s.

Dr. Gandhi said tramadol has generally been considered a “safe” drug. However, the physicians in the pain clinic recognize it as an opioid with the same risks as medications such as codeine. In addition to the physiologic effects, there are the psychological concerns of addiction and overdose.

“Early exposure to opioids also increases the risk of misuse and abuse even if prescribed for medical reasons,” Dr. Gandhi said. “Adolescents do not have the cognitive ability to appraise the situation and deem the consequences of prolonged exposure. If prescribed by a physician they must be safe. It is the duty of health care providers to educate patients and families on the correct use of these medications.”

For more information

Cook Children's Pain Management improves the quality of life for our pediatric patients by providing a balance between medicine and therapy.

If you want proof, read this diverse list of our most popular stories of 2016. We hope you enjoy our look back:

10. 7 Ear Infection Myths Every Parent Should Know. Parents flocked to this blog from Doc Smitty. Can your child go swimming with an ear infection? Do all ear infections need antibiotics? If your child gets ear tubes, will the infections stop?  All this and more was answered in this blog.

9. 7 Online Challenges This ER Doctor Warns Could Be Deadly Oh the Internet. Where kids do all kinds of things to get noticed and maybe go to hospital in the process. We asked our medical director of the Emergency Department to look at seven really silly, really dangerous dares that kids (or grownups for that matter) shouldn't try at home. 

8. Almond Milk: A Nutty Fad or Healthy Alternative. Almond milk sales have gone through the roof over the past decade. But is it the right drink for your child? Doc Smitty gave the answer in this informative piece. 

7. The Death of Ethan: A Life of Chronic Pain Ends in Tragedy. This is the most recent entrant in our list of top 10 stories. Only the fact that it was published in December kept this story out of the top five. We were so honored that Ethan's parents shared their son's story of a life filled with chronic pain. They want you to read it to learn about their son and hopefully help other children who may be suffering as well.

6. New Hope In Fight Against Deadly Brain-Eating Amoeba. The Lewis family holds a special place in the hearts of everyone involed in the Checkup Newsroom. Following the tragic death of their son Kyle to a brain infection caused by a water-born amoeba, Jeremy and Julie Lewis created Kyle Cares. Read their inspiring story as they fought to bring a drug to Cook Children's and other hospitals around the nation that may save children's lives.

5. 11 Tips That Could Save Your Daughter's Life.  In Janaury 2016, Rylie Whitten made national headlines after suffering one of the worst cases of toxic shock syndrome (TSS)  that her doctors had ever seen. Rylie's story moved us to run this informative piece on TSS that we hope every parent of a daughter reads.

4. A Sign From Heaven: Family Travels Across U.S. For Care at Cook Children's. A family's desperate search for answers on Google led them to Cook Children's. Read the fascinating story of what led this family to travel from Detroit, Mich. to Fort Worth, Texas, to be treated for a rare condition called hyperinsulinism.

3. The Most Common Rash You Never Knew About. Ever heard of molluscum contagiosum? We hadn't when Dr. Diane Arnaout wrote this blog for the newsroom. Dr. Diane's informative blog "that will save you and your child pain, money, time and anxiety" went viral quickly and became our third most read story of the year.

2. RSV On The Rise: 6 Things Every Parent Should Know. Here we are at the beginning of 2017 and we have been lucky in that we haven't seen much flu yet at Cook Children's. But we have seen plenty of RSV (respiratory syncytial virus), which explains the popularity of this great blog from Dr. Lizy Varughese.

1. Let's Learn Something: Bouncers, Jumpers and Walkers. Dr. Diane Arnaout's "Let's Learn Something" series was a big hit this year and none were bigger than this tale of caution. Dr. Diane's blog on how baby bumpers, bouncers and activity centers could play a role in your baby's motor delays is our most read new story of 2017. You've probably read this blog. But if you aren't one of the more than 117,000 readers who took a look, now's the time. And if you have read it, feel free to click again.

Well, that's it for 2016. Thank you all for reading. We'll be back with plenty more stories to tell in 2017.

Recent studies show that the use of prescription opioids doubled for adolescents, 15 to 19 years of age, between 1994 and 2007. The Centers for Disease Control and Prevention (CDC) reports that nearly 2 million Americans 12 years of age or older either abused or were dependent on opioid painkillers in 2013.

In one study of illicit drug use among teens, opioids accounted for 100 percent of the deaths.

“These are kids that were prescribed opioids for some reason, most of the time for some pain-related condition by dentists, emergency room doctors or primary care physicians,” Dr. Gandhi says. “These kids are going back and taking these medications at a later time. They are using these left overs for non-medical use. We now know that the risk of death from overdose has increased. We also know that the use of opioid prescriptions leads to a higher incidence of anxiety and depression. Interestingly enough, even those kids that are given opioids for a legitimate reason will tend to misuse and abuse drugs.”

The CDC, the U.S. Surgeon General, and President Obama have all taken strong stances on addressing the epidemic of opioid misuse and related deaths.

However, most programs and position statements refer to adults and do not address the issues our children are combatting.

The Pain Management Program at Cook Children’s treats kids with pain ranging from fibromyalgia to migraine headaches to end-of-life patients to kids with life- limiting conditions such as neuromuscular disorders, and pain related diseases such as arthritis, cerebral palsy, etc.

The specially trained physicians at Cook Children’s create a treatment plan that is focused on each particular child and opioids aren’t often the first or only pain medicine used to treat children.

“The danger comes when physicians think the only way they can treat pain is through a narcotic and that’s not the case,” Dr. Gandhi says. We need to know what type of pain the patient is having and take into account the child’s experience of pain. We are all individuals and no two people react the same way."

Dr. Gandhi says that between 15 to 20 percent of the kids seen at her clinic are on chronic opioids, but they are kids that have life-limiting medical conditions or end- of-life conditions.

The other 80 percent of the pain management patients work with physical and occupational therapists and receive therapies such as massage, biofeedback, cognitive behavioral therapy and acupuncture. Music, art and animal assisted therapies are also available for children. They look at all factors that contribute to the pain experience such as diet, nutrition, sleep habits, stress management and coping mechanisms. They create an environment of integrative health where practitioners and patients work together.

“We need to be much more vigilant on how we treat kids’ pain and how we create centers that address that pain,” Dr. Gandhi says. “If you look in Fort Worth or Tarrant County, there are probably 60 adult pain centers in this area, but for kids there are 35 in the entire country. That’s a huge difference. That perspective is crazy.”

About the source

Artee Gandhi, M.D., is a pediatric pain management specialist and anesthesiologist. She has trained across the country including residency at the University of Missouri and fellowship at Stanford Univeristy. Cook Children's Pain Management program cares for infants, children and adolescents with chronic and acute pain. C​ook Children's is one of a few children's hospitals in the U.S. providing a comprehensive pediatric pain management program.

James saw Nickolas with a football. He’d waited a long time to throw and catch a football once again with his dad.

It wasn’t that long ago that Nickolas was in tears from the sharp, stabbing feeling in his abdomen. The nerve block procedure he’d just awoken from did little to ease his pain. Groggy from anesthesia, he didn't know what he was saying to Cook Children's pain management physician, Artee Gandhi, M.D. He only knew that the years he'd spent laying on the couch because it hurt too much to move had to end.

"He kept saying 'please help me, you're all I have Dr. Gandhi, you have to help me,'" said Julie McCanless, Nickolas' mother.

The pain in the upper right quadrant of Nickolas' abdomen began suddenly in 2011, when he was just 10 years old. Though he was an active child who enjoyed playing football, there was no injury or incident the family could point to as the trigger for his pain. His parents began searching for someone who could provide a diagnosis and also relief. Despite seeing physicians in Texas, Oklahoma and even Minnesota, no one could tell the North Richland Hills family what was plaguing their son.

"It was out of control. He couldn't play sports anymore. It affected his appetite, his mood, nothing seemed to help," said Julie.

The family tried everything they could think of to ease the pain. Essential oils, massage therapy, acupuncture, they even visited a chiropractor, but none could offer Nickolas reprieve. Out of ideas, they turned to a Dallas pain clinic.

"They put him on every kind of pain medication you could think of from hydrocodone to ibuprofen, Tylenol, all the way to oxycodone and oxycontin," said Julie.

She says the drugs gave him some comfort, but left Nickolas with zero quality of life. He was often too drowsy from the medication to interact with family or friends. Attending school was also made difficult. The McCanless family spent nine months trying to find a prescription that would help without the negative side effects, all while hoping someone would one day give them a diagnosis. Then they turned to the Pain Management program at Cook Children's, one of only 35 pediatric pain clinics in the United States.

Dr. Gandhi helped launch the Pain Management program seven years ago. At the time, she was the only pain management physician at Cook Children’s and would visit patients in their rooms while carrying charts in a roller bag. The program has since grown into a multidisciplinary department complete with two board-certified physicians, clinical, physical and massage therapists, nurses and a biofeedback therapist. Instead of treating pain solely with medication, Dr. Gandhi and her team aim to help patients manage it with relaxation techniques, diet, exercise, lifestyle modifications and sleep.

In Nickolas’ case, Dr. Gandhi used many of these treatments as well as nerve block injections, which interrupt how pain signals are sent to the brain. He’d undergone these injections at other hospitals, and they usually offered temporary relief.

“We decided to try the nerve block injections, but every time it would wear off the pain would return, ” said Dr. Gandhi.

She started to think that Nickolas might have a rare condition known as abdominal cutaneous nerve entrapment syndrome (ACNES). It occurs when a nerve becomes ‘entrapped’ in the abdominal wall. Because it’s not common, ACNES is often overlooked and misdiagnosed for a gastrointestinal issue. Dr. Gandhi knew she would have to think outside of the box in treating Nickolas if she was going to keep her promise to him.

“She said she wasn’t going to give up and she didn’t. No matter how many times the pain blocks failed, she would try to find something else,” said Nickolas.

Dr. Gandhi’s search for a cure led her to believe that surgery might be the answer they were all looking for. She tuned to Chad Hamner, M.D., Trauma Medical Director at Cook Children’s for help.

“I told Dr. Hamner what I thought Nickolas had and that a neurectomy may be helpful,” said Dr. Gandhi.

A neurectomy is performed by removing all or part of a nerve. Dr. Gandhi thought that by removing the nerve she believed was ‘entrapped’ that his pain could be stopped. Dr. Hamner agreed to meet Nickolas to see if surgery was a feasible avenue to explore.

“He did some more investigation as well as an exam and decided to do the surgery, and low and behold, it worked,” said Dr. Gandhi.

Nickolas underwent surgery in April. By mid-May, he was doing things he didn’t think he’d ever do again.

“I asked Nickolas what he’d want to do if the surgery worked. He said ‘throw a football,” said Julie.

Three weeks after surgery, Nickolas bought a football. When his dad arrived home from work that evening, his sister told their father that Nickolas had a surprise for him.

“He put his stuff down and I came running out. I threw him the football and he gave me a big hug. We both started crying,” said Nickolas.

He’s now well on his way to being a normal kid again, running, throwing and hanging out with his friends. His mother says she couldn’t be more thankful.

“I know there are hundreds of children out there going through what my son went through,” Julie said. “The only thing I can tell them is don’t give up.”

To make an appointment with Pain Management, call 682-885-PAIN (7246) phone. Click here to learn more about the program. 

Pain Management at Cook Children's

Cook Children's Pain Management program cares for infants, children and adolescents with chronic and acute pain. C​ook Children's is one of a few children's hospitals in the U.S. providing a comprehensive pediatric pain management program.

The program's goal is to improve the quality of life for our patients by giving them the tools to cope with and overcome pain. Some of the therapy options are medications, interventional pain procedures, medical acupuncture, relaxation therapy, guided imagery, biofeedback, hypnosis and cognitive behavioral therapy. The team also teaches patients and families how to manage pain through exercise, diet, lifestyle modifications, and sleep hygiene.

The team includes two board certified anesthesiologists trained in pain management, a licensed clinical social worker specializing in psychophysiology, a physical therapist, a clinic nurse coordinator, and referral to a dedicated clinical therapist. Click here to learn more.

More and more young athletes are experiencing pain while participating in sports. Some have traumatic injuries like sprained ankles and torn ligaments, while others experience overuse injuries like low back pain and tennis elbow. All of these athletes can suffer from significant pain on and off the field. No athlete is exempt.

All sports require a baseline of flexibility, strength, stability and endurance, as well as a time of rest between activities to safely perform the required activities. With the rise in athlete specialization in a single sport, played year-round, we have seen an increase in injuries and pain in these young athletes. These young athletes are also starting at a much younger age. Many more stress injuries have resulted, such as ligament tears, shoulder strains, stress fractures and back strains. In addition, there has been a rise in chronic pain (pain lasting longer than 3 months) among younger athletes. I never heard of a teenager with chronic pain when I was growing up! How do we deal with this growing population? “No pain, no gain?” “Just grin and bear it, the pain will go away?” “Slap some ice on it and get back out there?” There needs to be a better way. Fortunately, there is!

The best plan is obviously prevention. However, for the purpose of this article, we will assume the athlete is already experiencing pain. In this case, there are several things to be done. Pain should not be ignored! Our body is trying to tell us there is something wrong. Acute pain should be addressed with the gold standard: Rest, Ice, Compression and Elevation (RICE). We are typically willing to ice, compress and elevate, but many times rest is not followed properly. “He’s our best pitcher!” “If she’s not playing, we will lose our chance to make it past district!” “I really want to play, so I won’t tell coach about the pain.” If we do not allow the tissue to heal properly, the tissue can become weaker and will be at a higher risk for being injured again, maybe even worse than the first time. Now that pain is being addressed properly, what do we do? Now is the time to work on the basics again:

Flexibility: Muscular flexibility is vital. Tight muscles are much more prone to injury than flexible muscles. Tight muscles can be damaged during high velocity movements. Also, tight muscles can alter how our joints move, making other structures more prone to injury, such as ligaments, joints and bones.

Strength: Muscular strength is also very important. Strong muscles allow our bodies to perform the tasks that we put them through. Strong muscles also allow greater protection from injury.

Balance/control: And don’t forget about core strength! This is maybe the most missed strengthening component in most sports and possibly the most important muscle group for any sport! A weak core places an increased stress on other body parts and increases our risk for injury. How can we expect a soccer player to avoid ankle or knee injuries if he/she can’t even balance on one foot?

Return-to-sport: If the athlete’s strength is improving and the pain is under control, we can work on sport specific activities. This is where a physical therapist or athletic trainer with a strong knowledge of sports performance is vital. Coaches properly trained in technique can do this as well as long as they are able to spend dedicated one-on-one time with the athlete.

If pain from a recent injury is not properly dealt with, or the injury leaves the athlete with pain that lasts more than 3 months, chronic pain may develop. Now our focus as a physical therapist is more on return of function versus the pain itself. Seeing a physician that specializes in pain, such as Dr. Artee Gandhi and Dr. Aimee McAnally at Cook Children’s, can be beneficial as well. The physician could prescribe or recommend one or more of the following treatments in conjunction with the physical therapy:

1. Medications to reduce pain or inflammation while working on regaining function.

2. Biofeedback therapy with a psychotherapist, such as Wayne Martin, LCSW, psychophysiologist at Cook Children’s, to help the athlete learn how to relax muscles, reduce stress and visualize performance for relief of pain and return to normal activities.

3. Pediatric massage therapy to address tension and/or increased sensation.

4. Acupuncture therapy to help control pain.

Related links:

• Football injury prevention
• Baseball injury prevention
• Softball injury prevention
• Basketball injury prevention
• Soccer injury prevention
• Hockey injury prevention
• Gymnastic injury prevention
• Tee-ball injury prevention
• Swimming injury prevention
• Tennis injury prevention
• SPORTS resources
• Does your child play one sport?
• 9 ways to prevent injuries in young athletes
• Cheerleader injuries
• Dance injury prevention
• Top 10 questions parents have about sports injuries
• Young athlete's injury prevention guide
• Strength training in children/adolescents (5-15 years)
• Rise of overuse injuries in school-age athletes
• The basics of sports injury prevention for kids
• When growing pains are not growing pains
• Preventing children's sports injuries
• Pain that won't go away