The doctor’s office can turn any happy-go-lucky kid into a nervous wreck. At most children’s well-visits, vaccinations are the primary source of dread.  When I was a kid in the 1980’s, pain management was hardly addressed during inoculations, aside from the occasional paltry attempt at distraction (“’Hey! Is that a bird outside?’…Insert needle”). Fortunately, today’s health care professionals acknowledge that these frightening childhood experiences could affect patients permanently. Something must be done about children’s pain. 

Despite popular portrayals of robots as unfeeling instruments of war, robots are useful in kinder, gentler settings. New research demonstrates that robots can alleviate children’s pain and distress during medical procedures. Though not intended as a substitute for human intervention, they can be used to fill certain gaps in pain management. In this article, I will outline current issues in children’s pain management, and then detail several promising pediatric studies involving robots.

Analgesics for children
According to the World Health Organization, access to pain relief is a basic human right.[1] 

In contrast to adult pain, however, children’s pain is trickier to address.[2]  For one, children—especially babies and toddlers—do not communicate their needs as reliably as adults. In order to assess the efficacy and safety of particular medications in children, clinical trials involving children are necessary. But testing drugs on children is risky from ethical and procedural standpoints.[3] 

Children react to analgesics differently from adults. Children under 16 should not be given aspirin, since it has been linked to Reye’s syndrome,[4] and the risks of paracetamol (Tylenol)—administered commonly to infants and young children—are now being assessed. Overdoses of paracetamol have caused liver failure[5], and its use has also been associated with the development of asthma.[6]

For moderate to severe pain, the two “weak opioids” codeine and traumadol (perceived as less dangerous than “strong opioids” oxycodone and morphine) have been mainstays of children’s pain management. In response to multiple pediatric fatalities, however, the FDA now restricts codeine in children under 17.[7] Traumadol has therefore picked up the slack as an alternative to codeine. In 2017, incidences of respiratory depression among pediatric traumadol users (in rare cases leading to death) forced the FDA to release a boxed warning recommending against the prescription of tramadol for children under 12.[8] Despite these stern warnings, traumadol is still commonly prescribed to children off-label.[9] That leaves morphine as an acceptable option, though the risk of respiratory depression still exists, as in all strong opioids.[10] [11] Due to possible side effects, overdose and future addiction, a national effort to reduce opioid use among minors is underway.[12]

In a recent Canadian study, children’s pain was found to be inadequately treated in emergency rooms.[13] Since emergency room physicians focused on the acute conditions that brought the children to the ER, children did not receive enough analgesics. Though such prioritization may seem understandable, short-term negligence may result in long-term problems: traumatized patients who avoid medical treatment.

Alternatives to pharmaceuticals
Considering the dangers of administering pain meds to children, healthcare professionals should be using non-pharmacological methods for pediatric pain and distress whenever feasible. For the care of infants, breastfeeding, cuddling and playing recorded music have all been used successfully.[14]  For toddlers and older children, play therapy, guided imagery, distraction and hypnosis have been helpful. In a study investigating nurses’ use of non-pharmacological methods in children’s postoperative pain, techniques such as imagery, positive reinforcement, thermal regulation, massage and positioning were found to be effective.[15] Unfortunately, these non-pharmacological techniques are not implemented enough, because overworked nurses lack the time to administer labor-intensive measures.  Care providers also need more training to utilize these methods.

Vaccinations with robotic diversions
As adults, we may not think of inoculations as significantly painful, but they can frighten and traumatize children profoundly. Anna Taddio, professor at University of Toronto’s Leslie Dan Faculty of Pharmacy, maintains that parents’ recent lack of adherence to vaccination schedules can be attributed in part to children’s (and parents’) fear of pain, and the perception that needles will cause further damage.[16] She cautions that “not managing pain and fear can have serious long-term consequences, including less uptake of vaccines and avoidance of health care throughout life.”[17] Pain management during these procedures could increase vaccination rates and encourage patients to visit doctors, yet over 50% of pediatricians in Taddio’s study did not incorporate any pain management techniques or medications when performing vaccinations. 

In a 2013 Canadian study, psychologists used NAO, a $14000 humanoid robot, as a diversion during children’s flu vaccinations.[18] By blowing, talking about movies and moving a toy, the robot managed to effectively divert the children’s attention from the painful procedure. The children, healthcare providers and parents all reacted enthusiastically to the robot’s presence, and the children themselves reported significantly less pain and distress than in vaccinations without other pain-management methods. The researchers stressed the ease of administering the procedure, which only requires a health care worker to power it on and off. Additionally, the robot’s speech and actions can be programmed for different ages and different medical procedures.

Robotic cancer patient procedural pain study
Much like vaccinations, other procedures involving needles scare children and cause significant pain. Sometimes the anticipation is worse than the procedure itself—particularly for children, who lack coping mechanisms for anxiety. Children with chronic health problems, who are routinely poked and prodded, need procedural pain management desperately. Anesthesiologist Elaine Wilson Smith laments:

Repeated painful episodes can trigger significant anxiety and behavioural changes both at the time and with escalation on subsequent re-exposure if the child's anxiety and pain are not managed effectively. This can lead to longer term emotional and psychological implications for both the child and the family, in addition to potentially having a detrimental effect on clinical course.[19]

In 2018, Canadian researchers utilized the MEDIport robot to effectively reduce pediatric cancer patients’ distress during needle insertion.[20]  The humanoid robot was placed next to the child at eye-level, and performed pre-programmed series of behaviors (such as dancing) to distract the patient before, during, and after the SCP needle insertion. The robot significantly helped combat distress. 

Robot as therapist
In another study, the NAO robot was used as a learning tool to teach pediatric cancer patients coping methods to prevent distress.[21]  Serving as assistant to a psychologist, NAO was programmed to inform a group of children about their illness and treatment, sympathize with them, and provide an opportunity for the children to express their fears and concerns. The robot also taught the children relaxation techniques to help combat stress. In another group, the human psychologist performed the same activities without the robot. As compared to the psychologist-only group, the children’s stress, anger and depression were greatly alleviated by the robot’s presence, leading the researchers to posit that “one can anticipate that utilizing a humanoid robot with different communication abilities can be beneficial, both in elevation of efficacy in interventions, and fomenting kids to be more interactive and cooperative in their treatment sessions.” It would appear that robots provide an invaluable service not possible with humans alone.

Why Robots?
Children have a special affinity for robots. A Latitude study of social robots at children’s schools found that “robots are a useful proxy for understanding kids’ social, creative and learning aspirations in ways that might be more illuminating than if we engaged them directly on such issues.”[22] For children with autism, who typically struggle to engage with other humans, robots have been shown to foster conversation with other people.[23] As non-humans, robots may seem less judgmental to children. Because robots are embodied, children may engage more with them socially than they might with digital avatars, or other disembodied technologies.[24] Children routinely anthropomorphize their stuffed animals and pets, so why not a robot? 

Robots demonstrate significant advantages over other non-pharmacological pain management methods. After an initial investment, robots require minimal maintenance, and healthcare workers require no special training to implement them. As opposed to a one-size-fits-all solution, they can be programmed to suit children of different ages and needs. Most importantly, robots are emotionally and physically reliable, unlike healthcare workers and live animals, who may suffer from job-related exhaustion and stress. Mechanical bots do not go “postal” when overworked or underpaid.

Live animal therapy provides enormous benefits to children, but such programs are limited in scope. Since live animals are not sanitary or trustworthy enough to facilitate higher-risk wards and procedures, robots could fill that gap. At hospitals, live animals only visit periodically—usually once a week. A resident companion robot, however, could spend all day and night with the patient for cuddles and companionship. This would be ideal for post-operative pain. Furthermore, robots can be used in conjunction with other non-pharmacological (or even pharmacological) pain management. 

Many fret that robots are going to replace human interaction. In the case of vaccine and needle insertion, robots fill a gap where there is currently little to no pain management. As  psychologist’s assistants, the robots serve as a tool rather than substitutes for educated clinicians. In other words, these robots augment care. We need to shed our “killer robots” biases and embrace robots’ ability to provide pain reduction services children are not currently receiving.

These encouraging studies make a strong case for robots in our arsenal against children’s pain. Once pain-fighting robots become available for home use, even more children will be helped. For that to happen, their price point will need to drop considerably, and/or insurance providers must reimburse for robotic medical devices. Fortunately, the medical community now understands that children’s pain is a serious, undertreated issue. We need all hands (and robotic arms) on deck.

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[1] “Access to Pain Management as a Human Right.” Brennan, Frank; Lohman, Diederik; Gwyther, Liz.

Am J Public Health.  2019 January; 109 (1): 61-65.

[2] “When the Safe Alternative Is Not That Safe: Tramadol Prescribing in Children.” Rodieux, F; Vutskits, L; Posfay-Barbe, KM; Habre ,W; Piguet, V; Desmeules , JA; Samer, CF. Front Pharmacol. 2018 Mar 5;9:148.

[3] Ibid.

[4]“Reye's syndrome and aspirin: lest we forget.” McGovern, MC; Glasgow, JFT; Stewart, MC. BMJ. 2001 Jun 30; 322(7302): 1591–1592.

[5] “Pediatric acetaminophen overdose: risk factors associated with hepatocellular injury.” Alander SW;  Dowd, MD; Bratton, SL; Kearns GL.  Arch Pediatr Adolesc Med. 2000 Apr; 154(4): 346-50.

[6] “The acetaminophen enigma in asthma.”  Holgate, ST.  Am J Respir Crit Care Med. 2011 Jan 15, 183(2): 147-8.

[7] US Food and Drug Administration (2017). “FDA Drug Safety Communication: FDA Restricts Use of Prescription Codeine Pain and Cough Medicines and Tramadol Pain Medicines in Children; Recommends Against use in Breastfeeding Women.”  Available at: https://www.fda.gov/downloads/Drugs/DrugSafety/UCM553814.pdf [accessed April 20 2017]. 

[8] Also not recommended for obese children, those with obstructive sleep apnea or severe lung disease, or those under 18 recovering from ear-nose-and-throat (ENT) surgery.  Ibid. 

[9] “Characterizing the Toxicity and Dose-Effect Profile of Tramadol Ingestions in Children.” Stassinos, GL; Gonzales, L; Klein-Schwartz, W.  Pediatr Emerg Care. 2019 Feb, 35(2): 117-120.

[10] “Recommended use of morphine in neonates, infants and children based on a literature review: Part 2--Clinical use.” Kart, T; Christrup, LL; Rasmussen, M.  Paediatr Anaesth. 1997, 7(2): 93-101.

[11] “Respiratory effects of intravenous morphine infusions in neonates, infants, and children after cardiac surgery.”  Lynn, AM; Nespeca, MK; Opheim, KE; Slattery, JT. Anesth Analg. 1993 Oct, 77(4): 695-701.

[12] https://www.hhs.gov/ash/oah/adolescent-development/substance-use/drugs/opioids/index.html#prevention.  Accessed 5/28/2019

[13] “Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians.” Ali, Samina; Chambers, Andrea; Johnson, David W.; Newton, Amanda S.; Vandermeer, Ben; Williamson, Janie; Curtis, Sarah J. CJEM. 2014 Sep; 16(5): 352-60.

[14] Pölkki, Tarja^; Korhonen, Anne;  Laukkala, Helena.  “Parents’ use of non-pharmacologic methods to manage procedural pain in infants.”  JOGNN, January 2018, Vol 47, Issue 1: 43–51.

[15] He, HG; Jahja, R; Lee, TL; Ang, EN; Sinnappan, R; Vehviläinen-Julkunen, K; Chan, MF.  “Nurses’ use of non-pharmacological methods in children’s postoperative pain management: educational intervention study.”  J Adv Nurs. 2010 Nov; 66 (11):2398-409.

[16] Taddio, Anna; Chambers, Christine T; Halperin, Scott A; Ipp, Moshe; Lockett, Donna; Rieder, Michael J; Shah, Vibhuti. “Inadequate Pain Management During Routine Childhood Immunizations: The Nerve of It.” Clin Ther. 2009; 31 Suppl 2: S152-67, S 152.

[17] Qtd. In “U of T expert in children’s pain wins million-dollar CIHR grant for work reducing fear of needles in youth.” University of Toronto.edu, 7/25/2018.  https://www.utoronto.ca/news/u-t-expert-children-s-pain-wins-million-dollar-cihr-grant-work-reducing-fear-needles-youth

[18] “Reducing children’s pain and distress towards flu vaccinations: A novel and effective application of humanoid robotics.” Beran, TN; Ramirez-Serrano, Alex; Vanderkooi, Otto; Kuhn, Susan.  Vaccine.  2013 Jun 7;31(25):2772-7.

[19] “Procedural Pain Management in Neonates, Infants and Children.” Rev Pain. 2011 Sep; 5(3): 4–12.

[20] Jibb, Lindsay A; Birnie, Kathryn A; Nathan, Paul C; Beran, Tanya N; Hum, Vanessa; Victor, J Charles; Stinson, Jennifer N. “Using the MEDiPORT humanoid robot to reduce procedural pain and distress in children with cancer: A pilot randomized controlled trial.” Pediatric Blood and Cancer, 2018, Vol 65, Issue 9.

[21] Alemi, Minoo; Ghanbarzadeh, Ashkan; Meghdari, Ali; Moghadam, Leila Jafari. “Clinical Application of a Humanoid Robot in Pediatric Cancer Interventions.” International Journal of Social Robotics, November 2016, Vol 8, Issue 5: 743–759.

[22] https://latd.com/Latitude-Robots-at-School-Findings.pdf

[23] Kim, Elizabeth S.; Berkovits, Lauren D.; Bernier, Emily P.; Leyzberg, Dan; Shic, Frederick; Paul, Rhea; Scassellati, Brian. “Social Robots as Embedded Reinforcers of Social Behavior in Children with Autism.” J Autism Dev Disord. 2013, 43:1038–1049.  https://www.ncbi.nlm.nih.gov/pubmed/23111617. 

[24] Young, James Everett; Sung, Ja-Young; Voida, Amy; Sharlin, Ehud; Igarashi, Takeo; Christensen, Henrik; Grinter, Rebecca. “Evaluating human-robot interaction - focusing on the holistic interaction experience.” International Journal of Social Robotics 3(1):53-67. January 2011.