Interview with Dr. Lonnie Zeltzer

Pediatrician and Author

Dr. Lonnie Zeltzer is Director of the Pediatric Pain Program at Mattel Children's Hospital UCLA and a Professor of Pediatrics, Anesthesiology, Psychiatry, and Biobehavioral Sciences at UCLA's David Geffen School of Medicine. She has written hundreds of publications on pediatric pain, including her recently published book, Conquering Your Child's Chronic Pain: A Pediatrician's Guide for Reclaiming a Normal Childhood.

What made you want to focus on pain?
I like challenging situations…I guess I am a detective at heart. I have always been interested in mind-body connections. Initially, I was getting the patients nobody else wanted to take care of because the specialists couldn't figure out what to do. It seemed like a great population to work with – and that's the only kind of patient I see now clinically. I also became interested in clinical research to understand why these kids have chronic pain and how to help them get better.

What are some examples of chronic pain in children?
SCommon examples include migraines, chronic daily headaches, abdominal pain, fibromyalgia (widespread pain in your muscles), leg or arm pain, back pain, complex regional pain syndrome (used to be called RSD), arthritis, cancer pain, neuropathic pain, and lots of other types of pain, such as inflammation in the intestinal tract as seen in Crohn's disease or Ulcerative Colitis. Many of these children and adolescents have seen subspecialists, such as neurologists, gastroenterologists, rheumatologists, and orthopedists, who might have diagnosed and treated what were thought to be the reasons for the pain, but the pain still remains.

Why is chronic pain so difficult to treat?
Pain that is persistent is by nature complex. This means that persistent pain most often is not caused by a single thing that can be fixed by taking a magic pill. More often there are many contributors. Time for talking with the child and parents is critical to hear the "story" of the pain. Usually spending time listening to a child and parent narrative might be the only way to discern all the many reasons for not only how the pain started but also the many factors that keep it going. Also, for the child and parent, being able to tell their story to someone who is interested can be therapeutic in itself.

I think there are more and more children with complex, chronic pain. I wonder if changes in our healthcare system do not allow enough time for a primary care physician to get to know a family over time and be able to spend time alone with the child.

So does experiencing chronic pain often take an emotional toll?
Pain is often like a snowball. The longer it keeps going, the more snow ("stuff") it picks up along the way causing it to get bigger and bigger. For example, if the child is used to getting good grades in school and starts missing lots of school because of the pain and/or doctors' appointments, then the child may start worrying about getting caught up in school and grades might slip as the unfinished work grows. For many children, this school absenteeism and pile of make up work can become a major stressor. The school is not necessarily the "cause" of the pain but this process now makes the pain even worse, causing more school absenteeism.

Is pain a condition that parents often misunderstand?
Yes. Often, a child will have stomach aches or headaches that start getting in the way of their sleep and ability to concentrate. Before you know it, the child misses school and becomes anxious about it. The child disengages from sports and group activities and slowly becomes isolated from his or her peers. Often, the parent brings the child to a general pediatrician who may be unable to figure out the cause of the pain or how to manage it. Then, the child is referred to a pediatric sub-specialist and the child continues to miss school and is still in a lot of pain. If the many tests for a specific "cause" for the pain come out negative, typically, the child is then sent to a psychiatrist or other mental health clinician and becomes disillusioned in the process. The child often feels that no one believes that the pain being suffered is "real." Family members are affected too; siblings get less attention because their parents are busy shuttling the child to different doctors and many times parents have to miss work because the child is not well enough to go to school. It's a snowball effect. Unfortunately, most physicians are not trained in state-of-the-art pain evaluation/pain management and so they don't know what to do and, as noted above, either don't take the time or have the time to listen long enough to "get the whole picture."

Can emotional stress cause or increase pain?
We know that stress increases the volume of pain signaling. All pain is physical, with documentable neural signaling in bodily, spinal cord, and brain pain systems, as well as having neurotransmitter/neural chemical components. We also know now that emotions, thoughts, and the reactions to the environment can also change our neural and specifically brain signaling, causing more real, physical pain. This is why we can no longer think of pain as physical or psychological. It is always both.

So stress at home, social stress, academic stress, and economic stress will increase any type of pain, even arthritis. I would imagine that the country's economic decline is placing greater stress on families with a concomitant increase in pediatric pain. Also, many children have difficulty expressing negative emotions such as anger, sadness, worry, etc. and hold those feeling inside. The body often responds as a pressure cooker and can react to these held-in emotions with muscles that remain in spasm, contributing to headaches, or increased hypersensitivity in different parts of the body, such as in the intestinal tract in irritable bowel syndrome or in a hypersensitive leg as in complex regional pain syndrome (RSD). Thus, analgesic medications alone will not treat the pain which now has become complex with many contributors. All need to be discovered and addressed for the pain to go away and stay away. It all takes time for communication, often seen as a luxury in a busy medical practice with today's broken health care system.

How can parents help their children feel less stressed?
There are all kinds of things that parents and kids can do. I am very much a believer in using different modalities in preventative ways, things such as exercising regularly, eating right so that you put on muscle rather than fat, and sleeping well at night. I also recommend that children learn breathing, imagery, meditation, music, dance, drama, writing, yoga, and other stress-reducing, preventive techniques so that they don't worry so much. In fact, I think these things should be part of the school curriculum.

Given that every patient is different, what is an example of how you go about evaluating and managing a person's pain?
The key I believe in evaluating these kids is to take enough time, at least in the initial visit, to listen to their story. The child and parent may each have his or her own story that might be different from each other's. In hearing the narrative and observing body language and facial expression, tone and volume of voice, I learn an enormous amount about the child and family. I can then probe more specifically for areas that are confusing, missing, or insufficiently detailed. My evaluation also includes not only the story about the pain and how the pain is interfering with sleep, eating, physical and social activities, and school, but other aspects of birth and development, family, and current school and social environment. I also inquire, typically with the child alone without the parent, about the child's emotional status, including any traumas and substance abuse history. This prolonged history taking enables me to formulate some complex hypotheses about the reasons for the pain and these hypotheses guide me in my physical examination of the patient. I look at the child's overall appearance, posture, eye contact, check for muscle tender points, and check out joints, muscle strength and flexibility, in addition to the rest of a complete pediatric physical examination. Based on all of this information and through review of any past medical records as well as questionnaires that we ask parents and the child to complete before they come to clinic, I form my working hypothesis about how the pain started, and the many different types of factors that may keep it going and make it worse. Typically, this initial working model (hypothesis) forms the basis for the initial treatment recommendations, which may include targeted medication, and mind-body interventions, such as physical therapy and biofeedback, as examples. Over time, both my working hypotheses and my treatments respectively will be modified by what I learn about the child and how the child responds to my treatment plan.

How has your profession changed since you first started as a pediatrician?
There have been several changes; one is in the tools we use and the other is in the area of genetics. Now, we know more about the brain than we ever knew before because of high-tech imaging. Genetics has also changed the profession, especially in terms of preventable diseases. Pregnant women can now find out if they are at risk for certain kinds of diseases. I also think the Internet has been an important breakthrough. Both patients and parents are much more informed; they can bring questions to the pediatrician based on things they read. However, the downside of the Internet is kids are spending less time outside interacting directly with other kids.

When choosing a pediatrician, what do you suggest a parent look for?
A good first step is to Google them to see where they trained. You want to find a pediatrician who is not only smart, but also someone you can communicate with well. If it is a large practice, ask if you can be followed by the same doctor. Take time out to assess the doctor's personality and how that matches your needs. Some doctors can be kind of cold; they may be very smart, but they are not warm and fuzzy. It's important to find a pediatrician that suits your personality. Lastly, check out if the pediatrician is a member of the clinical faculty at the local medical school. If so, then you know they are still teaching residents and are more likely on top of the latest advances.

Do you have any children?
I have three daughters, two granddaughters, and one more on the way.

Do you think being a parent helps you with your job?
Absolutely. As a parent, you have much more empathy for a parent who is trying to do the best for his or her child. Unless you have experienced the trials and tribulations of child-rearing yourself, it's hard to have sufficient empathy as well as provide appropriate guidance. Is it a necessity? No. You can be a terrific pediatrician without being married, without having a partner, without having children. But, I think being a parent certainly helps.

Interviewed by Lynn O'Donnell