Innovative Teaching for Humira (adalimumab) Injections to Children with Inflammatory Bowel Disease

Abstract

Humira (adalimumab) is a fully human anti-TNF- alpha monoclonal antibody used to treat Inflammatory Bowel Disease in Adults and Children. It is available in both prefilled syringes and prefilled pens. The injections are widely reported to cause varying degrees of discomfort. The pH of Humira is 5.2, which may contribute to the pain. Children are especially reluctant to receive any treatments that involve needles. The goal of teaching is to encourage any child over the age of 7 to be involved with their injections and over time gain independence. The degree of involvement will progress with their comfort and acceptance of therapy. Methods of coping with the injection site discomfort and the progressive involvement were developed to promote self injection and tolerance of side effects. Children are given the option to be taught to self inject when therapy begins or participating while a parent or caregiver administers the medication. Most children prefer the Humira pen so they do not see the needle or have to watch it penetrate the skin. Depending on the child's developmental level, a multistep process in introduced. If a child is hesitant to self administer, they are asked to clean the skin and/ or gently squeeze the skin while the infection is given. This actively engages the child in the treatment. When they are more comfortable, the next step is to have the child press the activator button. The last step before independence is having the child do the injection while the parent holds the syringe to prevent them from inadvertently lifting it before the medication is fully infused. Dealing with the pain of the injection is a significant skill for a child to acquire. We developed several strategies to distract and calm the child during the administration. These include the use of specific music via earphones that allows the child to focus and prepare to depress the activator at a certain point the song and know when the music comes to a another point the pain will be gone. Ice applied to the site for 20 minutes prior to injections is helpful to some children as is a warm pack after the injection. Giving the injection after soaking for 5-10 minutes in the bathtub to relax and then immediately immersing the limb after the injection is effective. Lastly allow the child to choose a piece of very sour candy and place in their mouth just prior to injection. Count to 3 and then bite into the candy while you depress the activator in the pen. This gives them 2 powerful sensations and they are distracted. This method is met with enthusiasm. Children were able to progress to independence and develop skills to assist them in coping with a difficult treatment. These skills can be transferred to other treatment settings and give the child a sense of control and self efficacy. Children need creative methods to cope with painful procedures and can become independent with a program that encourages a gradual progression in their involvement.