Addressing Pain With Inpatient Integrative Medicine at a Large Children’s Hospital

Abstract

Background.

Pediatric integrative medicine (IM) includes the use of therapies not considered mainstream to help alleviate symptoms such as pain and anxiety. These therapies can be provided in the inpatient setting.

Methods.

This 10-week study involved the integration of acupuncture, biofeedback, clinical hypnotherapy, guided imagery, meditation, and music therapy to address pain in children admitted to a large US children’s hospital.

Results.

Of 51 patients enrolled, 60% of the patients, 66% of their mothers, and 56% of their fathers used CAM (complementary and alternative medicine) in the preceding 1 year. Although 51 families requested integrative therapies, only 18 patients received them because of inadequate provider availability. All recorded pain scores improved with integrative therapies. One parent reported a possible side effect of irritability in the child after clinical hypnotherapy while 5 children reported opiate side effects. All participating families interviewed responded that IM services helped their child’s pain and helped their child’s mood, and that our hospital should have a permanent IM consult service.

Conclusion.

Integrative therapies can be helpful to address pain without significant side effects. Further studies are needed to investigate the integration, cost, and cost-effectiveness of integrative therapies in pediatric hospitals.

Introduction

Complementary and alternative medicine (CAM) includes methods of care that are not considered conventional or mainstream. These include a variety of modalities such as use of herbs, supplements, guided imagery, music therapy, chiropractic, and yoga. In 2016, a survey of freestanding children’s hospitals in the United States indicated that 96% of pediatric hospitals offer CAM services to hospitalized children.¹ Commonly offered complementary services in children’s hospitals include music therapy, acupuncture, guided imagery, clinical hypnotherapy, meditation, and pet therapy. These modalities are used to create a sense of relaxation, lessen stress, decrease nausea and pain, reduce procedural discomfort, and improve well-being. In many hospitals, the complementary services are coordinated by an integrative medicine (IM) department. IM involves the practice of conventional medicine in conjunction with complementary modalities for which there is evidence of safety and efficacy. According to a study of 16 academic pediatric IM programs, 75% of the programs provided both outpatient and inpatient services and opportunities for education and research.² IM focuses on treating the whole child by combining the best of complementary and conventional medical therapies to develop holistic solutions for children with chronic illness, acute and chronic pain, side effects from medical treatments, and emotional challenges such as depression and anxiety. Providers of IM do not aim to replace traditional treatments but rather to enhance them.

We are in the midst of an opioid crisis. As a response to this crisis, alternatives to conventional medicine for pain are being offered at many hospitals. There is pressure for the field of pain medicine to shift away from reliance on opioids and ineffective procedures and surgeries and to move toward comprehensive pain management that includes evidence-based nonpharmacologic options.³ In pediatrics, the safety and feasibility of implementing massage therapy in the immediate postoperative period in pediatric heart surgery patients resulted in decreased usage of benzodiazepines in children who received massage therapy.⁴ Observed improvements in pain-related outcomes suggest that massage and healing touch may be useful integrative therapies to consider as pain management options in neonatal intensive care units.⁵ One adult study including massage therapy and acupuncture demonstrated that integrative therapies help alleviate pain and other symptoms and promote sleep in the inpatient setting.⁶ With regard to the financial cost of integrating therapies at children’s hospitals, it has been evident that funding is a very common challenge.^7,8 In Germany, a 2018 integration study demonstrated that it is absolutely necessary to have enough philanthropic support or available funds, as financial resources are often scarce and money is needed for paying salaries, educating staff, and generating research projects.⁹ Although there is a growing body of literature for integrative techniques and these therapies are increasingly requested and offered in children’s hospitals, at this time provision of these approaches is driven primarily by consumer demand rather than evidence-informed practice.¹⁰ At our large pediatric hospital, we launched an IM inpatient pilot consult service to investigate the benefits of a coordinated IM consult service to address pain in hospitalized children. We also aimed to investigate the feasibility of creating such a program.

Patients and Methods

This study was approved by the Baylor College of Medicine Institutional Review Board Protocol #H-40123. The study was made possible by a generous anonymous donation to our hospital to cover salary support for 2 research assistants. The donation did not support the salaries of the integrative therapy providers.

During a 10-week study in 2017 at a large children’s hospital, a convenience sample of patients ages 3 to 18 years were recruited to receive integrative services through a pilot IM inpatient consult service. When consults were placed through the hospital electronic health record system to the hospital pain consult service, our research assistants were notified. Patients and their parents were offered basic education on IM modalities and given the opportunity to enroll in our research study. Each family received a 6-page English-Spanish bilingual informational packet with information about the 6 complementary therapies offered as part of the service: acupuncture, biofeedback, clinical hypnotherapy, guided imagery, meditation, and music therapy. All patients received a conventional pain consultation and medications, as deemed appropriate, independent of the IM consult services. Hospital providers at our institution who already provide IM services in their own clinics or in our hospital were recruited to provide services as part of our inpatient IM pilot consult service. Three physicians, 1 nurse practitioner, 1 psychologist, and 1 music therapist provided the 6 therapies. At the time of study recruitment, a pre-intervention survey was completed by parents that addressed participant demographics, prior use of and interest in CAM, and willingness to participate in hospital integrative services.

Participants received up to 2 therapies during the hospitalization that would likely best suit the child’s age, interests, developmental stage, type of pain, and previous knowledge or use of CAM therapies. All services were provided free of charge. In preparation for the study, the providers offered 1 day during the week in which they could provide IM therapies. The providers did not have protected time for this study away from their clinic duties, so they planned to see the patients outside of their regular work hours, mostly in the early mornings and evenings. A calendar was created by our 2 research assistants with 1 provider and 1 backup provider for each day of the study (Monday through Friday). When patients enrolled to receive IM therapies, the scheduled provider was contacted. If the scheduled provider was unavailable within 1 day, the backup provider was contacted. Patients were seen by the available assigned provider, meaning they could not choose a specific therapy. However, if a patient or parent declined a particular therapy, that therapy was not provided. Medical records were reviewed daily for medication changes and medication side effects. An exit survey detailed the family’s experience with the IM services and the consult service itself.

Results

Summary statistics describe the demographics, follow-up, surveys, and provider information using mean with standard deviation, median with 25th and 75th percentiles, and frequency with percentage. Logistic regression is used to assess the association between demographics and CAM use in parents and child.

During our study period, 117 patients received pain consults and were eligible to participate in our study. Twenty families did not have the opportunity to participate, because the patient or parents were unavailable for consent. Ninety-seven families were approached for enrollment in the program, and 51 families (53%) agreed to participate in our study. Forty-six families declined to participate due to a variety of reasons, including (1) the child or parent was not interested, (2) the child was expected to be discharged within 24 hours, or (3) the parents felt that the child was already enrolled in too many research studies. Of the 51 who agreed to participate, 16 were discharged before we could complete the enrollment process, 34 patients (14 male) were enrolled in the study, and 18 (8 male) received complementary services. Table 1 describes the patients who accepted enrollment in receiving IM services. At the time of the IM consult, the enrolled patients were taking 1 to 5 pain medications including oral, intravenous, and epidural medications.

Table 1.

Intake Demographic Data From All Enrollees.

Demographics	All Patients (N = 51)	Received Services (N = 18)
Age in years, mean (SD)	13.5 (4.0)	12.9 (4.3)
Male, n (%)	22 (43%)	8 (44%)
Number of pain medications, mean (SD)	2.6 (1.3)	2.6 (1.5)
Pain score at time of intake, mean (SD) (scale = 0–10)	5.4 (2.3)	4.9 (2.4)
Ethnicity, n (%)
White	23 (45%)	8 (44%)
Hispanic	20 (39%)	6 (33%)
African American	4 (8%)	2 (11%)
Asian/Indian	1 (2%)	1 (6%)
Native American/Pacific Islander	0	0
Other	3 (6%)	1 (6%)
Patient health insurance, n (%)
Uninsured	1 (2%)	0
Medicaid	16 (34%)	4 (27%)
CHIP	1 (2%)	1 (7%)
Private insurance	26 (55%)	10 (67%)
Medicaid and private insurance	3 (6%)	0
Annual combined family income, n (%)
<$25 000	10 (20%)	3 (17%)
$25 000–50 000	7 (14%)	3 (17%)
$50 000–75 000	3 (6%)	1 (6%)
$75 000–100 000	5 (10%)	2 (11%)
>$100 000	16 (33%)	6 (33%)
Decline to answer	8 (16%)	3 (17%)

Abbreviation: CHIP, Children’s Health Insurance Program.

Of the 51 patients enrolled in our study, 30 (59%) of the patients, 31 (61%) of their mothers, and 23 (45%) of their fathers used CAM in the preceding 1 year. Only 10 (20%) of the families had previously discussed their child’s CAM use with their pediatrician. During the last 5 weeks of the study, we asked parents to rank their preferences for our offered services. Of the 38 parents who responded to this question, 53% preferred music therapy followed by 24% who preferred acupuncture. Before our IM interventions, 50 parents completed an intake survey about our integrative services. Forty-nine parents (98%) were interested in their child receiving IM services, 7 parents (14%) were nervous about the IM services, 42 parents (84%) felt that IM services would benefit their child’s pain, and 48 parents (96%) felt that our hospital should have an IM consult service (Table 2).

Table 2.

CAM-Related Information From Intake Survey.

	Responses
	N = 51 for Responses Below
Current CAM use in last year, n (%)
Mother	31 (61%)
Father	23 (45%)
Child	30 (59%)
Parents discussed CAM with child’s pediatrician, n (%)	10 (20%)
	N = 38 for Responses Below
IM first choice preference, n (%)
No preference	2 (5%)
Acupuncture	9 (24%)
Biofeedback	2 (5%)
Clinical hypnotherapy	1 (3%)
Guided imagery	1 (3%)
Meditation	3 (8%)
Music therapy	20 (53%)
	N = 50 for Responses Below
I am interested in child receiving IM, median (25th, 75th)	5 (4, 5)
I am nervous about child receiving IM, median (25th, 75th)	2 (1, 3)
I believe that IM services will help, median (25th, 75th)	4 (4, 5)
I believe that IM services have less side effects than pain	4 (4, 5)
medicines, median (25th, 75th)
I would consider continuing IM as outpatient, median (25th, 75th)	4 (4, 5)
I think that TCH patients would benefit from IM consult, median (25th, 75th)	5 (4, 5)

Abbreviations: CAM, complementary and alternative medicine; IM, integrative medicine; TCH, Texas Children’s Hospital.

Table 3 delineates CAM use variables. The odds of CAM use in the child were more likely as the patient’s age increased (P = .056). The odds of CAM use in the child was increased if the mother used CAM, father used CAM, or either parent used CAM. Parental use of CAM was strongly associated with child’s use of CAM. The odds of CAM use in mother was higher among white mothers compared with Hispanic mothers (P = .01). The odds of CAM use in mother was higher among those with private insurance (P = .091). No other variables were associated with CAM use in mother. No variables were statistically associated with CAM use in father.

Table 3.

Logistic Regression: Odds of CAM Use in Child.

Child	Odds Ratio	95% Confidence Interval	P > z
Male	1.86	0.58–5.95	.298
Ethnicity			.7023
White	Reference
Hispanic	0.59	0.17–2.056	.41
Other	0.89	0.17–4.72	.89
Private insurance	2.22	0.66–7.48	.197
Patient age	1.17	1.00–1.36	.056
Income			.3996
<$25 000	Reference
$25 000–50 000	9	0.76–106.00	.081
$50 000–75 000	3	0.199–45.24	.427
$75 000–100 000	6	0.48–75.34	.165
>$100 000	2.5	0.49–12.64	.268
Mom uses CAM	10.29	2.51–42.1	.001
Dad uses CAM	4.45	1.18–16.81	.028
Mom or dad uses CAM	11.25	2.48–51.04	.002
Mom	Odds Ratio	95% Confidence Interval	P > z
Male child	2.35	0.66–8.36	.188
Ethnicity			.0366
White	Reference
Hispanic	0.13	0.03–0.62	.01
Other	0.28	0.04–1.82	.182
Private insurance	3.11	0.83–11.59	.091
Patient age	1.08	0.92–1.26	.356
Income			.3505
<$25 000	Reference
$25 000–50 000	1.00E+00	0.13–7.57	1
$50 000–75 000	1
$75 000–100 000	1.5	0.17–13.23	.715
>$100 000	4.33	0.74–25.29	.103

Abbreviation: CAM, complementary and alternative medicine.

In total, 18 patients received integrative services during their hospitalization. In many instances, no provider was available before the child was discharged, so the child did not receive any IM services. Their demographic information is recorded (Table 1).

As part of our study, 10 patients received 1 complementary service and 8 patients received 2 complementary services. The duration of each service and pain scores (if documented) were recorded (Table 4). Pain score was derived from age-appropriate measures with 0 representing no pain and 10 representing maximum pain.

Table 4.

Integrative Services Provided.

Patient Number	First Integrative Service	Duration (Minutes)	Pain Score Change (Scale = 0-l0)a	Second Integrative Service	Duration (Minutes)	Pain Score Change (Scale = 0–10)
1	Clinical hypnosis	30	Pre = 3, post = 1	Biofeedback	35	Pre = 2–3, post = 1–2
2	Music therapy	25
3	Music therapy	60		Clinical hypnosis	30	Pre = 2, post = 0
4	Music therapy	60		Acupuncture	30	Pre = 6.5, post = 5
5	Biofeedback	35	Pre = 5–6, post = 4–5	Acupuncture	30	Pre = 9, post = 5
6	Biofeedback	20		Guided imagery	25
7	Music therapy	40
8	Clinical hypnosis	15
9	Music therapy	45		Guided imagery	45
10	Guided imagery	35		Music therapy	45
11	Meditation	20	Pre = 6, post = 3
12	Music therapy	50
13	Music therapy	45
14	Acupuncture	20	Right shoulder/chest, pre = 7/4; post = right shoulder = 3, right chest = l, and left chest = 4
15	Clinical hypnosis	30
16	Clinical hypnosis	30
17	Clinical hypnosis	30		Acupuncture	40	Head/abdomen: pre = 8/7, post = 0/4.
18	Acupuncture	20	Pre = 6–7, post = 3

^aZero is no pain; 10 is maximum pain.

Every patient who had recorded pain scores before and after our therapies showed a decrease in pain from the interventions. Further analysis of pain scores was not possible due to variability of readings, including ranges of scores and subscores for various body parts. After the interventions, only 1 parent noted that her child was more irritable after 1 treatment with clinical hypnotherapy. There were no other side effects noted from the integrative therapies. Five of the enrolled children complained of side effects during the study period from opiate pain medications. Those side effects included constipation, bloating, and sleepiness. All 15 of the 15 families interviewed after the study felt that IM services helped their child’s pain and helped their child’s mood and that our hospital should have a permanent IM consult service (Table 5).

Table 5.

Study Completion Survey

Exit Survey	N = 15, Median (25th, 75th)
IM services helped pain	4 (4, 5)
Child’s mood improved after IM	5 (4, 5)
IM practitioner #1 was attentive	5 (4, 5)
IM practitioner #2 was attentive (if applicable)	5 (4, 5)
IM services decreased need for medicines	4 (3, 5)
Will consider using complementary therapies at home	5 (4, 5)
IM services more effective than medicines	3 (2, 5)
IM services had negative side effects	1 (1, 1)
Hospital patients would benefit from permanent IM service	5 (5, 5)

Abbreviation: IM, integrative medicine.

Overall, parents and patients were very satisfied with our effort to introduce integrative therapies in the inpatient setting at our hospital. Table 6 lists selected comments about the service.

Table 6.

Selected Comments by Patients and Parents.

Therapy	Comments
Acupuncture	Patient thinks acupuncture was very helpful as she was finally able to walk down to the gift shop after the therapy. Parent believes that it is the combination of pain medicines and IM therapy that is ideal, and that the idea of one being more useful than the other is not black and white.
Biofeedback	Mom thinks biofeedback may have been more useful. She felt the acupuncture was minimally effective for her child.
Clinical hypnotherapy	The patient thinks the clinical hypnosis helped more with his pain than did the medicines.
Clinical hypnotherapy	Mom said patient had an episode of pain later in the day and she reminded her daughter to use the techniques she learned. Mom really thinks it helped to relax her daughter and decrease her pain.
Guided imagery	Mom was so happy with guided imagery. Their family regularly uses podcasts and acupuncture as relaxation therapy, but they have not tried IM therapies like this on patient. Mom will definitely continue to employ the techniques she learned after the session at home, and is considering finding an acupuncturist closer to home for the patient.
Meditation	The patient absolutely loved it and thinks the meditation helped his pain a lot.
Music therapy	Mom would use at home if she learned how to do it appropriately. She thinks it’s a good technique and can really decrease need for pain medication.
Overall	Even if the therapy didn’t help decrease pain that much, it made her comfortable, and for that reason the patient thinks it would be a good service to offer to patients.
Overall	This children’s hospital should make it a mission to give incoming patients a priority to get on the integrative medicine list. It would lessen the length of the stay and improve treatment in general.

Abbreviation: IM, integrative medicine.

Discussion

This integration of complementary therapies in our hospital was well received by our patients and their parents. Although it was a new coordinated inpatient service, all the therapies had been offered in our hospital previously in either our inpatient or outpatient systems by providers who provide these services to their own patients. Interestingly, the majority (60%) of the children enrolled in the study had used CAM services previously, and older children were more likely to use CAM. The mothers (66%) and fathers (56%) also used CAM services in the previous 1 year, and parental use positively influenced child’s use of CAM. Families are using these therapies at home, so it is not surprising that they would be interested in continuing therapies in the hospital and possibly even trying new therapies under the supervision of physicians. Of the families that ranked their interest in our various therapy options, highest demand was seen for music therapy and acupuncture. In general, parents were excited to hear that our hospital was offering nonpharmacologic pain management techniques.

This was a new service, but very few parents were nervous about the therapies being offered to their children. Previous experience with complementary therapies, provided written information about the therapies, and understanding that these therapies are already offered in the hospital likely reassured patients and their parents.

Overall, the integrative therapies were very well tolerated and only 1 child had a mild possible reaction of irritability after clinical hypnotherapy. In comparison, 5 children complained of side effects from their opioid pain medication including constipation, bloating, and grogginess.

After the integrative therapies, parents reported that their children had less pain and better mood, and that our providers were very attentive to their child’s needs. Some parents even felt that the integrative therapies helped more for pain than the pharmacologic medications. All of the parents responded that our hospital should have a permanent IM consult service to provide these therapies. The comments delineate the positive impact these therapies had on the patients and their parents.

Creating an IM consult service or department requires dedication and interest from the hospital as well as funding to support staff and providers. This study demonstrated that providers must have discrete time dedicated to this consult service for the program to be successful in reaching patient demand. Although there was interest from the patients, parents, and providers to offer integrative therapies to all the children who requested the services, it was not possible to provide therapies to all the children before their discharge. The providers participated in the study because they believe in the effectiveness of the therapies to help children with pain. However, without specific funding and support for provider and coordinator time, in our hospital, creation of an IM consult service is not feasible. A combination of grants and philanthropic donations can help start an IM consult service, but financial investment from hospital administration is crucial for sustainability. If the services align with the mission of a hospital, administrators may be willing to support the service. At our hospital, one of our therapies, music therapy, is supported by the child life department, which is a nonbilling department. Since child life and music therapy are considered essential to supporting a children’s hospital, the administration supports the department. In general, integrative services being provided by physicians and other health care professionals are not currently viewed in this same light. When integrative therapies are provided by physicians and other health care professionals, some of the therapies can be billed under provider time. However, reimbursement is poor and complicated for most of the interventions.

Conclusion

Integrative therapies can be helpful to address pain without significant side effects. Many families use CAM therapies regularly, and many patients and parents are eager for their children to receive integrative services in the hospital to help alleviate pain. Further studies are needed to investigate the integration, cost, and cost-effectiveness of integrative therapies in pediatric hospitals.