TEAM TRAINING: PAIN IN CHILDREN

Pain in Children

In our series designed to help pharmacists train their OTC teams, we cover a range of healthcare topics that are important for patient consultations and product recommendations at the OTC counter. Thanks to the team at totalhealth and Haven Pharmacies for this month’s topic: Pain in Children.

What is a ‘child’?

For the purpose of this article, a child refers to anyone aged 12 or under. An infant is a child from birth to the end of the first year. While the ingredients of pain relief products for children are similar to those for adults, children react to medicines in very different ways. It is therefore crucial that medicines suitable for children are recommended and that clear dosage instructions are communicated according to the age of the child. Gather all necessary information by following WWHAM protocol at all times.

Types of Pain in Children

Pain in children should always be treated. If it is not, it can cause anxiety or emotional distress. Some of the most common types of pain that we will be asked about in the pharmacy are: • Teething • Colic

• Dental

• Growing/Joint Pain • Injury • Cuts and Scrapes • Sunburn

• Sore Throat

• Earache

• Headache

• Stomach-ache

• Post-Immunisation Pain.

Assessing Pain in Children

Every child will experience pain differently and assessment of pain may be difficult, especially in infants and children who have difficulty describing pain. Where children can communicate, always aim to identify the source of the pain, e.g., tooth, knee, ear. Non-verbal indications that a child is in pain may include: • Changes in crying pattern or behaviour – prolonged or more intense • Squeezing eyes shut or grimacing • Visible signs (flushed cheeks, red gums, dribbling, bruising, swelling) • Withdrawal or lack of usual responsiveness • Holding or rubbing a particular part of the body • Irritability or acting out. It may also be difficult to ascertain the severity of pain, even if the source is clear. The Wong-Baker Face Pain Scale is a helpful tool in discovering how much pain the child is experiencing, using smiley faces to help the child point to how bad they are feeling.

OTC Pain Relief for Children

Products containing paracetamol or ibuprofen are the only pain-killers suitable to recommend for children’s pain in the pharmacy. They are both effective and generally safe, and available in different forms for children.

Paracetamol is suitable for babies and children from 2 months of age and who weigh at least 4kg. Use in children under that weight or age, or who are premature, must be under doctor supervision. Paracetamol is available in suppository, liquid and meltable tablet form. There are different dosage guidelines and products for children aged from 2 months and for those aged 6 years and older. Parents should be reminded of the importance of reducing the risk of paracetamol by ensuring only one paracetamol-containing product is used at any time. Ibuprofen is suitable for use in children aged 3 months and older. It is available in liquid,

Consider:

Reflect on the following in assessing your own knowledge and your team’s training:

 Is your knowledge up to date on children’s pain and treatments?

 Do you know what patients should be referred to a GP?

 Does the team follow WWHAM protocol at all times?

 Are all staff confident and comfortable explaining the varying instructions and dosages for all children’s pain products?

 Are all staff aware of age limits on aspirin use in children?

 Are product instructions explained in easyto-understand language?

Key Points:

Ensure your team understands and is confident explaining the following:  The various types of pain that may be experienced by children  The products available and the dosages and ages for each one  The additional products that may further relieve symptoms  The warnings and precautions associated with all products  The additional advice that should be given for non-drug relief of pain  WWHAM protocol and which patients must be referred to the pharmacist  All patient conversations are conducted with discretion, sensitivity, and appropriate tone. chewable tablet and suppository form. Again, dosage guidelines and products vary for children aged from 3 months, those aged 6 and over, and those aged 7 and over. Ibuprofen should be used with caution in children with asthma.

Concurrent use of paracetamol and ibuprofen may be suitable for more severe pain. It is helpful to remember the importance of clear explanation of dosages to parents, who may be experiencing stress or upset due to their child’s pain. Try to explain directions as if explaining to a family member, making sure they understand the instructions thoroughly.

Other products and advice for pain relief

Depending on the type of pain, there are additional medicated and homeopathic products which may relieve symptoms, including colic drops, teething gels, and teething granules. Additional relief may be gained from cooling teething rings, applying cold compress to painful body parts, applying heat or giving a warm bath, and best of all, ensuring that children in pain are comforted and reassured.

Referral to Pharmacist

Using WWHAM questions, refer to the pharmacist if the child: • Is under 2 months or under 4kg • Has a head injury • Is in severe distress • Is experiencing persistent pain with no known cause • Has unexplained swelling, bruising, or bleeding • Has lost their appetite or is losing weight • Has persistent vomiting • Has had no relief from OTC pain products.

Actions:

Your action plan for Children’s Pain should include the following:

 Your own knowledge is up to date, on types of pain, treatments, and GP referral

 You are up to date with post-immunisation guidelines on pain-relief products

 The appropriate training has been provided to all team members, and assessed, for example through observation or role play

 You have the appropriate range of products available

 WWHAM Protocol forms the basis of all interactions at the OTC counter

 Update your CPD record.

ICO Annual Conference –Latest Developments in Eye Care

The Irish College of Ophthalmologists Annual Conference 2022 took place from Monday 16th to Wednesday 18th May 2022 at the Kilkenny Convention Centre, Lyrath Estate. Over 200 ophthalmologists in practice and training gathered for the three-day meeting to hear the latest clinical and scientific updates and developments in the specialty from national and international eye experts. Symposia topics included a clinical session on Ocular Surface Disease; a service delivery session on ‘Planning for the Future’ examining Medical Retina and Telemedicine/Virtual Review, IOP Clinics and Glaucoma Diagnostic Hubs; whilst a separate symposium focused on the Integrated Eye Care Team highlighted the model of eye care implementation at national, regional and community level. A separate clinical session on Recent Clinical Trials in Glaucoma, Myopia and Retina also featured on the programme. It was a great honour and privilege for the ICO to welcome Professor Stanley Chang, K.K. Tse and Ku Teh Ying Professor of Ophthalmology, Columbia University, New York to present this year’s Annual Mooney Lecture. A specialist in vitreoretinal disorders and surgery, Prof Chang has pioneered many of the surgical techniques currently used in this field. Parallel workshop sessions on Ocular Movement and OCTA, in addition to the paper and poster sessions (ICO Honorary Medals and prize presentations) and the SOE Young Ophthalmologist Lecture 2022 were among the other highlights of this year’s reunion conference, following a two year break for the conference due to Covid restrictions.

Professor Stanley Chang, K.K. Tse and Ku Teh Ying Professor of Ophthalmology, Columbia University Department of Ophthalmology, Annual Mooney Lecturer 2022 with Professor David Keegan, Clinical Professor of Ophthalmology and Retina (University College Dublin) and Consultant Ophthalmic Surgeon, Mater Misericordiae University Hospital, Dublin. Mr Tim Fulcher, President, Irish College of Ophthalmologists with keynote speakers from the 'Delivering Integrated Care in Ireland' symposium which took place on the opening day of the OCO Annual Conference 2022 L-R Dr Margarat Morgan, Consultant Medical Ophthalmologist, Royal Victoria Eye and Ear Hospital, Professor William Power, Clinical Lead for Ophthalmology and Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Dublin; Ms Chriosa O’Connor, Optometrist, Mater Misericordiae University Hospital, Dublin and Professor David Keegan, UCD Clinical Professor of Ophthalmology and Retina, UCD School of Medicine, University College Dublin. National Clinical Lead for Diabetic Retinopathy Screening.

Addressing delegates, ICO President, Mr Tim Fulcher said it was wonderful to return to an in person meeting for members in 2022 following a difficult two years throughout Covid. “Our Annual Conference has always been an extremely valuable educational meeting for the specialty and important collegiate occasion for our members. It is crucial to return to in person engagement forums to discuss the latest developments and learnings amongst colleagues, difficult and unusual cases and of course all we have learnt about our specialty and service delivery management as a result of the pandemic. “Despite the challenges of the past two years, much progress has taken place in the specialty of ophthalmology with investment into the new Integrated Eye Care Teams at community and hospital level, and the establishment of dedicated cataract theatres. There is much more to be done to address the waiting lists in ophthalmology and our focus, alongside the work of the National Clinical Programme led by Prof William Power, remains on delivering a service equipped to manage the areas of greatest patient demand. “We are very fortunate to once again be welcoming leading experts from home and overseas to the ICO Annual Conference, who will impart their exceptional knowledge to the benefit of all in attendance and our health service over the three-day meeting.”

Annual Mooney Lecture 2022 ‘Improving the Outcomes of Surgery for Retinal Detachment’

Professor David Keegan formally introduced Professor Chang, noting the incredible contribution Professor Chang has made to the speciality throughout his career, retina in particular and his status as a pioneer of several revolutionary surgical approaches to treat complicated forms of retinal detachment which have led to improved outcomes for patients worldwide. Professor Chang’s subject for the 2022 Mooney Lecture discussed the four different methods of treating retinal detachment – pneumatic retinopexy (injection of a gas bubble, with positioning, and laser), scleral buckling alone, vitrectomy, and vitrectomy and scleral buckling. The characteristics of the retinal detachment, such as size and number of tears or extent, cannot be determined by the surgeon, but the selection of the procedure and the adjuncts used in the surgical management are critical to achieving a successful outcome. Evidence -based data on the outcomes of the different methods of the treatment for retinal detachment were discussed and surgical techniques that enhance the outcomes.

Professor Chang highlighted the exciting future developments for improving the anatomic and visual outcomes in retinal detachment surgery.

Planning for the Future

Ms Dawn Sim, Medical Director in Product Development Ophthalmology, Genentech Roche, Honorary Consultant Ophthalmologist,, Moorfields Eye Hospital, UK, Associate Professor, Institute of Ophthalmology, University College London gave her talk ‘The Idiosyncrasies of Telemedicine in Ophthalmology’ virtually at the Planning for the Future Symposium. Ms Dawn Sim opened the ‘Planning for the Future’ symposium (Wednesday, 18th May) with her (virtual) talk on the topic ‘The idiosyncrasies of Telemedicine in Ophthalmology’. Ms Sims obtained her PhD from the UCL Institute of Ophthalmology for her work on endothelial progenitor stem cells and has published extensively on diabetic retinopathy, age-related macular degeneration, and retinal vein occlusions.

Her presentation at the ICO Conference discussed new technologies in retinal imaging, digital health, and the field of teleophthalmology. Dawn is working with device-agnostic platforms to facilitate the acceleration of new technology and artificial intelligence software into clinical practice. Ms Aoife Doyle, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital and St James’s Hospital, Dublin highlighted the work of the Lean Team at Ireland East Hospital Group and of the ophthalmology team at RVEEH with CHO6 and CHO7 in her talk ‘Transitioning Stable Glaucoma Care to the Community’. Having closely followed developments in glaucoma care in the UK in recent years, Ms Aoife Doyle set up a virtual glaucoma clinic Ms Dawn Sim, Medical Director in Product Development Ophthalmology, Genentech Roche

at RVEEH in 2018. A key component of this was the early adoption of an electronic record (Medisight) for patient management. During the Covid-19 pandemic Ms Doyle worked together with the Lean Team at Ireland East Hospital Group and Professor Colm O’Brien to set up a Drive-Through IOP clinic at the City West Facility that saw over 650 patients from RVEEH and MMUH between August 2020 – July 2021. She participated in a Lean Healthcare initiative on glaucoma in 2020-2021 and after further training was awarded a Bronze qualification for work on delivery of virtual care, improving visual field capacity and establishing and managing the RVEEH side of the City West Initiative.

With her team, Ms Doyle has recently extended that model to the CHO7 area together with

Mr Jonathan Clarke, Consultant Ophthalmologist, Moorfields Eye Hospital, London, Ms Evelyn O'Neill, Consultant Ophthalmologist, Mater Misericordiae University Hospital, Dublin, Mr Tim Fulcher, (Chair), ICO President and Consultant Ophthalmic Surgeon, Mater Misericordiae University Hospital, Dublin, and Ms Aoife Doyle, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital and St James's Hospital, Dublin

TALK OVERVIEWS

Professor David Keegan Clinical Professor of Ophthalmology and Retina (University College Dublin) Consultant Ophthalmic Surgeon (Mater University and Mater Private Hospitals) Talk: Establishment of a Novel Governance Structure to Transform, Integrate and Deploy Regional Eye Care - the virtual Accountable Care Organisation (vACO) Professor David Keegan said, "We have established, over the last year, a novel governance structure to manage integrated eye care in the North East thus opening a path to tackling one of the longest wait lists, by specialty, in the region. Ophthalmology also has one of the highest waitlists in the country with nearly 50000 patients waiting for an outpatient appointment and > 8000 waiting for surgery. In the North East alone we estimate 14000 patients are awaiting an outpatient appointment with over 3000 patients waiting for surgery, most of whom for cataract surgery. Eye care is delivered by 6 distinct healthcare organisations who have all committed to working together to achieve our goals. Our clear focus is on reducing avoidable vision impairment and blindness by reorganising our service delivery via a transformation plan and unique voluntary governance structure. “As a means to tackle this, we have instituted the collaborative governance structure called the Virtual Accountable Care Organisation (vACO) to integrate, transform and deploy eye care services in the North East. We are near completion of the first year of the development of this pathway and already we are seeing impact on our wait lists.”

Dr Margaret Morgan Consultant Medical Ophthalmologist, Royal Victoria Eye and Ear Hospital, Dublin and CHO7

Talk: Eye Care in the non-Acute Setting Dr Margaret Morgan provided an update on the CHO7 Adult Ophthalmology Service one year on from the establishment of the team and unit. Dr Margaret Morgan discussed how the service came about, the set-up process, progress made to date and the future direction.

Dr. Margaret Morgan, Consultant Medical Ophthalmologist (Royal Victoria Eye and Ear Hospital and CHO7) with staff training commenced to introduce a similar clinic in CHO6. This is helping to more efficiently deliver care to people with glaucoma in the community and closer to home. Ms Doyle said it will also help to improve capacity for the hospital eye services to see the more complex and surgical patients and reduce waiting times, improving outcomes in glaucoma care through the collaboration of the hospital and community eye care services. In his talk, panelist guest speaker Mr Jonathan Clarke, Moorfields Eye Hospital, London, discussed the set up and safe assessment of diagnostic (virtual) clinic pathways

Professor Conor Murphy, Professor of Ophthalmology, Royal College of Surgeons in Ireland, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Mr Samer Hamada, Clinical Lead and Consultant Ophthalmic Surgeon, Queen Victoria Hospital NHS Foundation Trust, UK, Ms Nikolina Budimlija, Ocular Surface Specialist, Institute of Eye Surgery, Waterford and Mr Tom Flynn, Consultant Ophthalmic Surgeon, Bon Secours Hospital, Cork.

Mr David Sullivan, Chairman, Board of Directors, Tear Film & Ocular Surface Society (TFOS), Boston, US Miss Yvonne Delaney, Dean of Postgraduate Education, Irish College of Ophthalmologists is pictured during her talk to delegates

A consultant in the glaucoma service at Moorfields Eye Hospital since 2009, Mr Clarke is Clinical Trials Lead for the glaucoma service with a responsibility for delivering clinical trials for new pharmaceutical treatments. He is also Joint Director of the Moorfields North Division, involved in testing and setting up new models of care including virtual clinics for glaucoma and medical retina patients. Ms Evelyn O’Neill, Consultant Ophthalmologist, Mater Misericordiae University Hospital, Dublin provided an overview of the changes that were made at the Mater Eye Emergency Department during the pandemic in her talk highlighting the transitioning of care and lessons learned during COVID.

Ocular Surface Disease Symposium

Keynote speakers at the ICO Annual Conference 2022 (16th-18th May Kilkenny Convention Centre, Lyrath Estate Hotel) Ocular Surface Disease Symposium were; Professor Conor Murphy, Professor of Ophthalmology, Royal College of Surgeons in Ireland, Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Mr Samer Hamada, Clinical Lead and Consultant Ophthalmic Surgeon, Queen Victoria Hospital NHS Foundation Trust, UK, Ms Nikolina Budimlija, Ocular Surface Specialist, Institute of Eye Surgery, Waterford and Mr Tom Flynn, Consultant Ophthalmic Surgeon, Bon Secours Hospital, Cork

Mr David Sullivan, Chairman, Board of Directors, Tear Film & Ocular Surface Society (TFOS), Boston, US and former Associate Professor, Department of Ophthalmology, Harvard Medical School gave a virtual presentation ‘Ménage à Trois: Sex, Sex Steroids and Dry Eye Disease’ at the Ocular Surface Disease Symposium,

Mr Tom Flynn, Bon Secours Hospital Cork opened the Ocular Surface Disease symposium on day 2 (Tuesday, 17th May) of the ICO Annual Conference with his talk ‘Allergic eye disease: myths, mysteries and modern medicine’ . Mr Flynn discussed how allergic eye disease is a broad umbrella term for a variety of ocular surface conditions each with specific and different presentation and prognosis. He outlined the presentation and treatment of seasonal allergic conjunctivitis and atopic keratoconjunctivitis, with emphasis on management of steroid-dependent disease. New biologic treatments for atopic dermatitis were also discussed.

Guest panelist, Mr Samer Hamada from Queen Victoria Hospital London continued the same topic in children in his talk entitled ‘Paediatric Ocular Surface Disease: JOMO (joy of missing out!) to FOMO and also talked about specific ocular surface problems in peadiatric population. Professor Conor Murphy of the Royal Victoria Eye and Ear Hospital and RCSI presented on complex inflammatory disorders of the anterior segment that lead to progressive and often sight threatening and painful conjunctival fibrosis. The principles of the diagnosis and management in both the acute and chronic phases of mucous membrane pemphigoid and Stevens Johnson syndrome were described. The key message was that early recognition and appropriate immunosuppressive and supportive therapies lead to a far better prognosis and quality of life in the long term for affected patients. The final lecture was given (virtually) by former Associate Professor at Harvard Medical School and Chairman of TFOS Mr David Sullivan PhD. Mr Sullivan discussed the influence of an individuals sex (male or female) and steroid hormones on dry eye disease. Mr Sullivan said, “One of the most compelling epidemiologic features of dry eye disease (DED) is that it occurs predominantly in females. That such a sex-related difference exists in the prevalence of an eye disease is not a surprise, as the influence of sex on the eye has been known since the time of Hippocrates. In the late 1800s there was widespread belief among European physicians that ocular health was dramatically influenced by sex, and that males were by no means as prone to diseases of the eye from sexual causes as females. Since that time, many sex-related differences in the eye have been attributed to the effects of sex steroids (e.g. androgens and estrogens).” Mr David Sullivan discussed how researchers at the Tear Film & Ocular Surface Society (TFOS) believe that recognition of these sexrelated differences and the determination of their underlying basis (e.g. sex steroid action) are extremely important. He explained such understanding may be translated into new insights into the physiological control of ocular tissues, as well as the generation of novel therapeutic strategies to treat DED. Miss Yvonne Delaney, Dean of Postgraduate Education, Irish College of Ophthalmologists is pictured during her talk to delegates at the ICO Annual Conference on the significant milestones and recent developments of the ICO National Training Programmes, and in particular the dedicated Medical Ophthalmology specialty training programme which was launched in 2017 in response to demand for specialists in the area.

Pictured (l-r) at the 'Recent Clinical Trials' session at the Irish College of Ophthalmologists Annual Conference were chair Ms Janice Brady, Consultant Ophthalmologist, University Hospital Waterford, Prof Ian Flitcroft, Consultant Ophthalmologist, Children’s Health Ireland (CHI) Temple Street and Mater Misericordiae University Hospital, Dublin (myopia focus) and Prof Tunde Peto Professor of Clinical Ophthalmology, Queen’s University, Belfast (medical retina)

ICO Dean of Postgraduate Education, Miss Yvonne Delaney, hosted a session at the ICO Conference to update members on the significant progress and development of the ICO National Training Programmes over recent years. In particular, Miss Delaney discussed the advancement of the dedicated Medical Ophthalmology specialty training programme, launched in 2017. The standalone programme was developed in response to the demand for ophthalmic specialists to treat patients in the areas of greatest eyecare demand, namely medical retina, glaucoma amd paediatric ophthalmology, coupled with an increasing ageing demographic and the huge expansion of new medical treatments for sight threatening conditions. This has led to a big shift in how we practice and deliver medical ophthalmology and the reconfigured national training programme has been designed to address workforce and service demands, with the curriculum mapped to the National Clinical Programme for Ophthalmology Model of Care. Professor Anthony King, Consultant Ophthalmologist, Nottingham University Hospital, NHS and Honorary Professor of Clinical Ophthalmology at the University of Nottingham, UK gave a virtual presentation at the session on ‘The Treatment of Advanced Glaucoma Study - Outcomes at 24 months’. Ms McElnea delivered the European Society of Ophthalmology (SOE) Lecture 2022 on the topic “Oculoplastics and Orbit Today” at the ICO Annual Conference which took place from 16-18th May in the Kilkenny Convention Centre, Lyrath Estate Hotel. Ms McElnea presented and reviewed a number of emergent ophthalmic plastics and orbit related cases of interest to trainees, general ophthalmologists and sub-specialists alike, and the safe and appropriate management of these conditions all of which have important systemic associations. Ms McElnea completed fellowship training in oculoplastic, orbit and lacrimal disease at the Royal Victorian Eye and Ear Hospital in Melbourne, Victoria and in cornea and anterior segment disease at Royal Perth Hospital in Perth, Western Australia before returning to Ireland and her current post at University Hospital Galway.

Ms Elizabeth McElnea (centre), Consultant Ophthalmologist, University Hospital Galway with Miss Yvonne Delaney, Dean of Postgraduate Education, ICO and Prof Colm O'Brien, Consultant Ophthalmic Surgeon, Mater Misericordiae and Chair of the ICO Scientific Committee.

TALK OVERVIEWS:

Professor Billy Power Clinical Lead for Ophthalmology and Consultant Ophthalmic Surgeon, Royal Victoria Eye and Ear Hospital, Dublin Talk: The National Clinical Programme for Ophthalmology: Supporting the Delivery of Integrated Care Professor Power provided an overview and historical context of the Clinical Programme for Ophthalmology and Model of Care, focusing on the implementation of the integrated eye care team and dedicated cataract clinics. He also discussed the new clinical pathways for cataract, medical retina and paediatrics, the benefits and the potential challenges going forward. Ms Chriosa O Connor

Optometrist, Mater Misericordiae University Hospital, Dublin Talk: The Role of an Optometrist in a Multidisciplinary team Optometry is a new profession to join the HSE Ophthalmology Multidisciplinary (Integrated Eye Care) team in Ireland. Chriosa O’Connor gave an overview of what roles optometrists are currently involved in since joining, including paediatrics and adult roles and transformation teams. Also what roles they could do in the future, with training and support.