Joshua Zeichner, MD: How do you approach the idea of taking a drug given by injection to a small child? For adults, it might be an easier conversation, but it’s definitely a challenge when dealing with kids.
Vikash Oza, medical doctor: I’m sure we all have different techniques. Most of the time we are injecting for the first time in our office, so we try to go through some of the techniques, and obviously we teach at the same time. For those of us in pediatrics, there are several things we do. The first is distraction. My kids barely know when I’m home because they’re constantly distracted by a screen, so screen power is very important. It helps to have them in a comfortable position and distract them, and then even hold them in a certain way. As an adult, you’re just used to laying them on the table and injecting them. But in children there’s what we call the comfort hold: being held in the arms of the parent, where they’re secured in some way and the limb is secured, but they’re also held by a parent, that which is comforting for a child. .
There are also ways to reduce pain, such as topical anesthetic, having EMLA [lidocaine, prilocaine] sitting there for an hour before injecting yourself. Some children sometimes seem to do a little better with ice cream. Making this available and doing it in the office for the first time to show them is important. Some children will even balance their own risks and benefits. They realize the injection hurts at that time, but especially those with severe atopic dermatitis, if they are in a certain age group, they will realize the impact it has on them. When they see the improvements, you sometimes get their buy-in too.
Elizabeth Swanson, MD: At this stage, I will often say to children, especially those 5 to 8 years old who are old enough to understand: “Yes, the blow hurts. But those 3 seconds of ouch are worth feeling better every two seconds every other day, so bear it for those 2 or 3 seconds, and then you’ll feel so much better the rest of the time. In younger kids, 2-4 year olds, when they start Dupixent, or dupilumab, I often have them sit on their parent’s lap, facing their parent in a hug. Then we’ll give it to either the thigh or the arm, whichever is more accessible and easier to do.
The biggest problem I noticed when starting to use the drug in younger patients, 2-4 year olds, is not the first shot or the second or the third, but after that. They begin to have anticipation. They know that the last 2 or 3 times they came to this office, they had a chance. I would be interested to know if other panel members are dealing with this, and how, because I find it has become a bit more difficult. By then, parents have pretty much bought into the process because they see the impact it has on their child, and they like it a lot. But it gets a little more difficult with the kids themselves, as they anticipate the ouch factor.
Brittany Craiglow, MD: I agree 100%. I like to try to get families to do it at home, because for the child, with the car ride, the waiting room and the exam room, the anxiety builds. But many parents don’t want to be the only one doing it. I totally understand that too. I recently started asking, “Is there anyone around you who could do this?” One of my patients has his aunt do it. For another, their neighbor was a nurse. It doesn’t even have to be a doctor, just someone who’s helpful because they’re a little more comfortable with it. Not the parent, but someone else, so you can avoid all that hoarding for that little thing.
Lisa, at your point, acknowledging that it hurts is important. We have this tendency, especially parents, to say, “Oh, that’s not so bad. You’re fine.” But with anxious children, it’s important to say, “Yes, it’s uncomfortable, but you can handle it,” for those ages 6 and up. ambient is also important. I always tell families to take it out of the fridge the night before. Put the reminder in your phone and take it out the night before so when you’re ready, you’re ready. It keeps everyone from watching it on the kitchen counter, counting the time Dupilumab is good at room temperature for 2 weeks, so if you don’t do it that day, you do it the next day. make it easier. In some cases this is still going to be difficult, but we can make it work for the majority of them.
Joshua Zeichner, MD: It’s such an interesting discussion. There are so many social factors that we have to consider. It is the art of medicine.
Transcript edited for clarity