Principal Investigator
Amy Baxter, M.D.
Alleviating pediatric suffering across disciplines
While an undergraduate at Yale University in 1989, Amy Baxter, M.D. thought her path to make a real difference in life was through medical education. While completing her residency at Cincinnati Children’s HospitalMedicalCenter, however, Dr. Baxter found herself fully committed to research.
“Research is spectacular; it provides a fulcrum by which to raise the quality of existence for millions. Beyond the technical complexity, research requires a level of creative perception and questioning that keep practice interesting,” Dr. Baxter said. “Investigators have the ability to look at the literature, see what’s not there, then reach beyond traditional boundaries to seek innovative methods of care.”
After making up maternity leave time, she completed a research project during a child abuse fellowship in Cincinnati. During her pediatric emergency medicine fellowship at the Children’s Hospital of the King’s Daughters in Norfolk, Va., she identified a theme defining her research arc: avoiding unnecessary suffering.
Lumbar puncture study
One of the first clinical procedures that pediatric emergency medical residents learn is the lumbar puncture (LP) for febrile infants who need cerebrospinal fluid. Failure to obtain fluid or contamination with peripheral blood can result in unnecessary hospitalization or a prolonged course of antibiotics. Unsuccessful and traumatic LPs are common when procedures are performed by trainees. Dr. Baxter’s early research efforts included a prospective study examining the association of procedural techniques, local anesthetic use and postgraduate training level with LP success rates.
The primary study hypotheses were that early stylet removal and local anesthetic use would be associated with successful LPs among infants. Study findings demonstrated that pain control decreased the rates of failed LPs for younger infants. In addition to compassionate considerations, the association with improved success offers a further rationale for the use of pain control. “That study has changed behaviors and led to other supporting studies, which is what research is all about,” Dr. Baxter said.
Nausea rating scale study
Realizing that some painful procedures are too much for analgesics alone, Dr. Baxter became interested in procedural sedation. This led to examining better ways to treat and manage nausea, fostered by anesthesiologist mentor Paul White, M.D. at the University of Texas Southwestern in Dallas, Texas. Nausea and vomiting are major concerns with procedural sedation, post-operative recovery and pediatric cancer patients—as it is the most common and feared side effect of treatment. In addition, nausea and vomiting are a major public health concern. Gastroenteritis and dehydration are a leading cause of worldwide morbidity and mortality, accounting for more than 300 deaths a year in the U.S. Even the act of vomiting itself poses a significant health risk, potentially leading to aspiration, esophageal tears and electrolyte imbalances.
Dr. Baxter discovered that for adults, pain is often preferable to nausea, “As I started to read more articles about nausea and procedures, I learned that for adults they won’t take pain medicine even for severe pain if it makes them nauseated,” she said. While very familiar with modalities for pain assessment in children, she realized that there was not a method to rate young children’s nausea. What research there was suggested that children younger than age 9 were unable to describe their level of nausea, and that, in contrast to pain, parents were poor estimators. This thought set in motion a research project to create an animated faces scale, to be easily understood by children to rate nausea. With protocol design assistance from mentors and Dr. White, Dr. Baxter secured a grant from Hope Street Kids, a charity devoted to pediatric cancer research. She developed a Nausea Rating Scale, which was recently presented at Pediatric Academic Societies and is currently enrolling patients for the validation phase, a collaborative effort with anesthesiologists at Baylor College of Medicine in Houston.
Pain reduction device study
Hospitalized children claim needle sticks are their greatest source of pain. The fear of needles impacts parents’ willingness to have their children immunized and affects children’s subsequent healthcare experiences. In thinking about ways to overcome the barriers to needle pain control, Dr. Baxter invented a non-invasive device to decrease the pain of immunizations and venipunctures.
Initial prototyping was supported by the Mayday Fund, a foundation devoted to pain research, and has been refined by another local engineering company. The device is reusable, inexpensive, easy to clean and works within 15 seconds.
Nicknamed “Buzzy,” this vibrating cold pack is a nonpharmacological, portable device. The battery-powered device is applied proximal to the cannulation site prior to venipuncture. Once the device is placed on the appropriate site it is switched on to vibrate throughout the I.V. A removable card design can be placed on top of the device or held to the side to use for additional distraction.
A successful pilot project conducted at Children’s at Scottish Rite with adult volunteers, found the device reduced pain significantly compared to no intervention.
Further research is planned to identify the contributions of mechanical and psychological distraction in collaboration with GeorgiaStateUniversity. A study to evaluate pediatric pain response for both I.V. pain just completed, and one for immunization pain is awaiting funding. By correlating findings from these studies, caregivers who administer injections will have a safe and effective method for reducing pain while helping to decrease needle phobia. Parents and their children will have the added confidence of knowing they can carry Buzzy with them. Dr. Baxter recently presented these findings at the International Association for the Study of Pain conference in Glasgow, Scotland.
As a private practice physician/researcher, Dr. Baxter enjoys conducting studies she believes will make a clinical difference. “I try to make it fun and relevant for the people who are involved because it is so much extra work,” she said. “But knowing research has a purpose that will out live me makes it worth it.”
Dr. Baxter is a part of the Children’s emergency medicine community. In addition to her work with Pediatric Emergency Medicine Associates, investigators at Children’s at Egleston and others on the Children’s at Scottish Rite campus conduct multiple research studies addressing conditions present in the immediate care and urgent care settings. Current studies cover a spectrum of areas, such as: traumatic brain injury in children, injury prevention, epidemiologic surveillance, pain management, cost-effectiveness, quality and outcomes research. At Children’s at Egleston, Pediatric Emergency Medicine is one of the largest academic divisions of pediatric emergency medicine in the country. Major collaborative efforts include working with the Centers for Disease Control and Prevention (CDC) and Georgia Institute of Technology with funding from federal, state and foundations.