Author: Rizwana Hussain, Archana Ganesh.
Sunflower Children’s Network recently hosted a Pediatric Palliative Care CME Webinar on the topic “COMFORT Promise,” led by Dr Michael McNeil MD, MPH, Director of the Global Palliative Care Program at St. Jude Global and Assistant Member in the Department of Global Pediatric Medicine at St. Jude Children’s Research Hospital. Held on May 27, the session focused on preventing and relieving pain and anxiety associated with needle-based procedures in children with cancer, particularly in low and middle-income countries.
An Overlooked Dimension of Pediatric Cancer Care
The webinar drew attention to an important yet often overlooked aspect of children’s palliative care and pediatric oncology: pain caused by repeated needle-based procedures. Children undergoing cancer treatment routinely experience injections, blood draws, intravenous insertions, lumbar punctures, and other painful procedures throughout their treatment journey. Dr. McNeil noted that needle pokes and needle-based procedures were consistently reported as one of the most painful and distressing experiences for children and accounted for one of the highest contributing factors to their pain as reported by children themselves.
He also highlighted the importance of asking children directly about their pain experience, rather than relying on parental or family reports to avoid missing critical insights. In many resource-constrained healthcare settings, limited access to pain prevention strategies, inadequate supplies, insufficient training, and cultural misconceptions contribute to unnecessary treatment and system-related suffering.
The session placed this concern within a broader imperative: improving survival alone is not sufficient in childhood cancer care. Reducing suffering and improving quality of life must remain central to the goals of care during treatment of cancer. This position is aligned with the World Health Organization’s Global Initiative for Childhood Cancer, which aims to improve the survival rate of children with cancer globally to at least 60% by 2030, while simultaneously reducing suffering and improving quality of life.
The Global Comfort Promise: An evidence-based Bundle
The webinar was an introduction to the Global Comfort Promise, an evidence-based intervention package designed to reduce children’s experience of pain and anxiety during needle-based procedures during their treatments at the hospital. Building upon the ‘Children’s Comfort Promise’ of Dr. Stefan Friedrichsdorf, COMFORT promise initiative supported the implementation of procedural pain management across diverse healthcare systems worldwide.
The package includes several simple, low-cost, and effective evidence-based interventions that work best when used together as a bundle. Components include: application of topical anesthetics (numbing creams), comfort positioning, age-appropriate distraction techniques, breastfeeding or sucrose solution for infants under one year, and effective communication including praise and reward with children over 1 year, before, during, and after procedures. Dr. McNeil emphasized that combining these approaches creates a less traumatic experience not only for children and their families, but also for care providers.
He cautioned that progress indicators must not become an end in themselves; doing so risks distorting care priorities and rendering the measures meaningless, a familiar tension in quality improvement work.
Local Adaptation and Cultural Sensitivity
A major focus of the webinar was the importance of contextualizing implementation without compromising fidelity. Rather than applying a rigid model, hospitals and care providers are encouraged to contextualize implementation according to available resources, staffing structures, patient needs, and cultural realities. A sustainable change requires securing buy-in from relevant stakeholders through influence and relationship-building, not positional authority alone.
Global Pilot and outcomes:
The pilot implementation of the program across four St. Jude Global Alliance partner sites in Peru, Brazil, South Africa, and the Philippines demonstrated encouraging outcomes: high patient and parent satisfaction, increased use of comfort interventions, and higher provider satisfaction. Importantly, these improvements were achieved without increasing procedure time or reducing procedural success. Following the success of the pilot phase, the initiative expanded globally through a partnership with the Institute for Healthcare Improvement, resulting in the co-development of the ‘Improvement Science in Action Course’.
Findings from 22 Hospitals across 18 countries
Participating hospitals engaged in virtual learning sessions, coaching calls, collaborative learning activities, and quality improvement cycles designed to integrate procedural pain prevention into routine clinical care. The data from 22 hospitals across 18 countries included 12,000 needle stick procedures. Results demonstrated a 50 percent reduction in self-reported procedural pain among children undergoing needlestick procedures, which translated to over 7,300 procedures reported as pain-free. Additional findings showed reductions in severe pain among children older than four years of age and improvements in patient and parent satisfaction. Notably, pain prevention outcomes improved as more elements of the Comfort Promise package were used together, reinforcing the value of a bundled and multidisciplinary approach. Families were actively involved in developing educational materials and supporting comfort interventions, strengthening trust between families and healthcare teams
Dr. McNeil concluded the session by affirming that reducing procedural pain is both a clinical and ethical responsibility. The Global Comfort Promise demonstrates that evidence-based procedural pain management can be implemented successfully across diverse healthcare systems through collaboration, education, and quality improvement, even with simple and low-cost interventions.
The webinar served as a powerful reminder that quality children’s palliative care encompasses the full journey, including addressing the everyday experiences of pain, fear, and anxiety that shape how children and families live through cancer care.
