Using Virtual Reality to Manage Pediatric Pain – PediaCast 563

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  • Dr Henry Xiang visits the studio as we explore the use of virtual reality games in the management of pediatric pain. This approach has shown promise for reducing stress during painful procedures, such as burn dressing changes. We hope you can join us!

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  • Virtual Reality
  • Pediatric Pain

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Episode Transcript

Dr Mike Patrick: This episode of PediaCast is brought to you by the Center for Injury Research and Policy and the Center for Pediatric Trauma Research at Nationwide Children's Hospital.

Hello everyone, and welcome once again to PediaCast. It is a pediatric podcast for moms and dads. This is Dr. Mike coming to you from the campus of Nationwide at Children's Hospital. We're in Columbus, Ohio. It's episode 563. We're calling this one using virtual reality to manage pediatric pain. I want to welcome all of you to the program.

So today we are examining pain management in kids with a particular focus on children undergoing long, painful procedures, such as daily burn dressing changes in hospitalized patients and then also pain Uh, when they go home now, as most of you know, we are trying to cut down on the use of opioids for pain management in children and adults.

Of course, there's a time and a place for opioid use initial management of pain associated with broken bones and large burns, for example, but we like to avoid using opioids over a long period of time because of the need for higher doses as time goes by and dependence issues, uh, also side effects that opioids have.

And we all know that this has really been an enormous problem in the United States. Now we have talked about management for chronic pain many times on this program. And most recently in our CME podcast, which was chronic pain in children and teenagers, that was episode 98. And I'll put a link to that in the show notes so you can find it easily.

That was one of our continuing medical education podcasts for healthcare providers on chronic pain in children and teenagers. But what about recurrent episodes of severe pain, such as the need for daily dressing changes of large burns? Well, a physician at Nationwide Children's Hospital has developed a novel approach to pain management in these kids.

And I think it's an approach that will find many, many more uses moving forward. In the treatment of pain for children and teenagers and probably adults as well. This novel approach involves playing virtual reality games. And there is science behind this approach, which means we have evidence that it really does work.

The therapy is called VR-PAT, and you're going to hear that quite a few times in this podcast. VR-PAT, that stands for virtual reality pain alleviation therapy. More details to come on all of this as we chat with Dr. Henry Xiang. He is the Center for Pediatric Trauma Research Director and a Principal Investigator with the Center for Injury Research and Policy at Nationwide Children's Hospital.

I want to remind you the information presented in PediaCast is for general educational purposes only. We do not diagnose medical conditions or formulate treatment plans for specific individuals. If you are concerned about your child's health, be sure to call your healthcare provider. Also, your use of this audio program is subject to the PediaCast Terms of Use Agreement, which you can find at PediaCast .org.

So, let's take a quick break. We'll get Dr. Xiang settled into the studio, and then we will be back to talk about the use of virtual reality to manage pediatric pain. It's coming up right after this.

Dr. Henry Xiang is director of the Center for Pediatric Trauma Research and a principal investigator with the Center for Injury Research and Policy at Nationwide Children's Hospital.

He's also a professor of pediatrics at the Ohio State University College of Medicine. Dr. Xiang has a passion for supporting children and families dealing with painful medical treatments, such as burn care, with the innovative use of virtual reality games, that is what he's here to talk about, using virtual reality to manage pediatric pain.

But first, let's give a warm PediaCast welcome to our guest, Dr. Henry Xiang. Thank you so much for visiting with us today.

Dr Henry Xiang: Dr. Patrick, thank you so much for inviting me.

Dr Mike Patrick: Yeah, absolutely. We're really, really, uh, pleased to have you on today. Can you explain really what we're talking about here with a virtual reality and how that can be used to manage pain in pediatric patients?

Dr Henry Xiang: Yes. Virtual reality is a three-dimensional computer-generated environment. Which can be explored and interacted with by a person. The mainstream theory for how VR manages acute pain is the attention distraction theory. Which means VR will distract patient's attention from the medical procedures or the current real-world situation, so they feel less pain.

New scientific discovery found that VR could increase a person's pain threshold as well as their pain tolerance level. That's how currently we understand virtual reality magic pain in pediatric patient.

Dr Mike Patrick: Yeah. And what is it that inspired you to see if this could actually help these kids?

Dr Henry Xiang: Our team started the development of VR pain alleviation a bit, with a little bit.

Serendipity and inspiration. The inspiration came from our decade long epidemiology research on opioid pain medication use and national opioid crisis during the past 10 to 15 years. We published papers to highlight this. national crisis in the United States and our team have thought can we sort of develop new technology or use new technologies to help patients to manage their pain better.

I also collaborated with other virtual reality researchers who used VR for pediatric traffic safety training and then around 2015 With a little bit of serendipity, our team started the development of VRPAT with our own game developer here at Nationwide Children's Hospital.

Dr Mike Patrick: So VRPAT, that's the name of the system, and that stands for virtual reality, and then what's the PAT part?

Dr Henry Xiang: Pain and Evasion Therapeutic. It stands for virtual reality. Pain and Deviation Therapeutics.

Dr Mike Patrick: Okay, and so this is like a headset that the child wears and then engages with something that's displayed on the headset, is that correct? We have two

Dr Henry Xiang: versions of VRPAD. One is, like you said, displayed on a headset.

We call it Pico Neo Virtual Reality Headset. Another version is We create a smartphone version. Patients can play this on their smartphone. And then using a VR goggle, they can purchase from Amazon or other online shopping and use that at home. Okay,

Dr Mike Patrick: so, the, they can purchase a sort of like a cardboard headset that their phone sets in and that's the screen.

Is that, is that right?

Dr Henry Xiang: Yes, it's not, uh, cardboard now, they actually have very nice, looks very nice, feel very nice virtual, virtual reality system you can purchase from Amazon and other shopping sites.

Dr Mike Patrick: Gotcha. So that's really something that anybody could do if you have a smartphone at home. I mean, you could do virtual reality in that way.

Dr Henry Xiang: Yeah, that's a, that's a great advantage is what we want to do. Yeah. We realized that, uh, the, the professional VR asset could cost about, uh, 600 to 700 minimum. There are some like 400 to 300. Uh, we are, we are hazard, but we still think that's a little bit too high for some of the families. So, we developed the, this, uh, smartphone version.

The, the hazard you can purchase from Amazon. Could cost about 30 to 40 bucks, which we think is very reasonable for a lot of feminists. Yeah,

Dr Mike Patrick: and so that's the one that you would slip your phone into and use your phone as the screen. And that's the reason that that's a lot less expensive. Yeah,

Dr Henry Xiang: you use your phone because a lot of families and a lot of teenagers have phones so they can scan a code from our side and then download the game on their smartphone and then play the game and put that into the headset that will work.

Dr Mike Patrick: Yeah. And so, the, the inspiration for this really came because of the opioid crisis and really not wanting kids to necessarily become addicted to those or experience the side effects that can happen with, with chronic opioid use. And so, you know, when you think about the way that pain medicine works, and then when you compare that to using virtual reality and gaming to help with pain, you know, some may say, well, does that really help?

You know, are they still just distracted and still experiencing the pain? But your research would say otherwise that it really does help the pain itself, not just through distraction. Is that correct?

Dr Henry Xiang: Yes, we have done research among patients who actually experienced the pain during the medical procedures, and we found out actually virtual reality can significantly reduce the pain.

during the medical treatment. You made a very good point. You said, you know, people can still use pain medications or opioid pain medications. But however, we found out for two reasons. One reason is because of this opioid crisis in the United States, scientists and our communities and other professionals are trying to figure out alternatives to manage pain without pain medications.

That can be done for certain type of medical procedures such as, um, you know, brain dressing changes at outpatient clinic because the pain for most of those patients are not that severe. The pain score is about 3. 5, 3. 25, moderate. Pain, we found out virtual reality can help them manage their pain very well.

Another factor is, you know, virtual reality actually can help alleviate the anxieties during the procedures.

Dr Mike Patrick: Yeah. Yeah. And it's interesting because when we think about it, when we think about it deeply, pain really is. An experience in our head, so there's signals coming in from the area where the pain is, and those signals, you know, through nerves, the brain interprets as pain.

And so, if you have the brain doing other things, then maybe it doesn't process the pain is that I'm, I'm sure that I'm oversimplified this, but just in terms of helping parents understand, it's not necessarily blocking pain signals, but because we're involved in something else and, and using our brain, those pain signals maybe get processed differently or something.

Dr Henry Xiang: Uh, yes, the, the, the mainstream theory behind the virtual and pain alleviation. is the attention distraction theory, which means if you distract the patient's attention from the actual medical treatment toward a fun and immersive environment, those patients were paying less attention to the actual medical treatment and the pain.

But however, as we learn more about virtual reality and the effectiveness of virtual reality, people are thinking about maybe there are more mechanisms such as Virtual reality actually help the patient to process the pain differently. So, in, at different brain regions, the pain signals are processed differently if the patient is in the virtual reality environment.

Unfortunately, at this moment, the exact underlying mechanism for that is still unknown.

Dr Mike Patrick: Yeah. We can make theories, but we have to still be able to prove those theories are true or that they're not true. I guess another theory might be that when you're playing a game that you're really excited about, that you have some dopamine release and maybe even in turn, you know, your own sort of opioid like endorphins, you know, so that, that you are getting a reward.

That's a good reward. Just like, you know, for some folks that shopping and for others, it's eating a great meal. And so, if we can help, you know, kids with their own endorphins and help their own pain, I suppose that would be another theory as to why this may help.

Dr Henry Xiang: Yeah, you gave me some hands up for another study.

I think that's a very good suggestion. So, we found out among the three key features virtual reality. Number one is the immersion. The number two is the fun. And the third one is the engagement. You can see in a fun environment. You are happy. You have this, you know, chemicals released make you very happy.

So,

Dr Mike Patrick: yeah. Yeah. So, speaking of this game that hopefully is making kids happy as they're experiencing painful procedures. So, there's a game called the virtual river cruise game to tell us about that game.

Dr Henry Xiang: Yeah. Okay. So, um, we are dealing with a pediatric patient. We must be very careful when we design virtual reality games.

Our virtual reality game used this age-appropriate virtual river cruise game. The whole environment is a virtual river landscape where the riverbank is covered with snow. During the burn dressing changes, children play the VR game by slightly tittering. their heads, so no hand, no finger, no arm involvement.

Because of that, we can minimize interference with the medical procedure. The VR game is created so a fun and immersive environment could be used to create a calming effect that will reduce the anxieties. Another important factor is the snow. The snow creates a cold, instead of a hot, sensational environment for burn patient, that is super important.

In our subsequent studies, we found out immersion fun and interaction of players with the virtual objects in the VR platform. Environments are super important for the pain elevation effect.

Dr Mike Patrick: So, there's snow on a riverbank. And then, when the child moves their head one way or another, does that, that impacts the snow?

Dr Henry Xiang: There is a crystal object in front of you, you gaze, you aim at that crystal and the crystal were broken. That's sort of the virtual object, the kids can interact with that. What is more interesting is, actually when you play more of this, if you can quickly. Break that crystal, you got a reward, you got a score, and the score card on the board will tell you how good you are.

That is kind of like a rewarding system for some of the kids.

Dr Mike Patrick: Yeah, yeah. So maybe they get a certain score, and they want to try it again and get a better score and then a better score. And, uh, the, the quicker that they are able to look at the crystal and then they get a cool thing that shows up. Yes.

Yeah. Very nice. And then the, the snow part of it. So, when you say that that really is helpful for burn patients, the snow part, have, did you try it with and without the snow to see if there was a difference?

Dr Henry Xiang: Oh, unfortunately, we didn't try that. There's a new concept called the co-development of virtual reality, which means when we develop this virtual reality pain and division app, we cannot just isolate ourselves and do it on our own.

What we do is, is to co design this with families. With patients and also with nurses and physicians, physicians, nurses told us you cannot have fire or other things for the burn patient. So, they want us to have a snowy environment. So, we didn't develop a landscape without snow. Okay, gotcha.

Dr Mike Patrick: It just kind of made sense that, that the, that the snow and a cold environment might help, especially for someone who's undergoing burn dressings.

Are, have you tried this with, uh, other types of pain other than just burn dressings?

Dr Henry Xiang: Yes, we try that at outpatient burn clinic, emergency department, plastic surgery clinic, orthopedic clinic, and laser dermatology clinic. Currently, we have an ongoing study going on trying to evaluate the effectiveness with effectiveness of virtual reality during laser treatment at the outpatient dermatology clinic.

So, we found out among all of those patients who received treatment at different type of medical procedures, all virtual reality is very effective in helping patients to manage their pain and anxiety.

Dr Mike Patrick: I'm sure they've really loved, loved this, and it makes a big difference for, for the kids and probably for the parents too, because, you know, when you see your child having something painful done that needs done, rather than them being upset to see them engaged in something.

I'm sure from the parent standpoint also really helps them feel more comfortable with what's happening and seeing that their child is not in distress.

Dr Henry Xiang: That is true. Most of time. The parents or guardians are around, they watched how we implemented virtual reality. They watched how their children or child did in the virtual reality.

Some of them had prior experience without virtual reality. So, they saw the difference between previous one without virtual reality and the one with virtual reality. They really like the idea; they want us to implement this at clinics. Some patients even said, why don't you actually implement this at the routine clinical practice?

We told them, currently, we need to get IRB approval to do the study. When we got the IRB approval, and in the future, maybe FDA clearance. We can disseminate to a lot of clinics.

Dr Mike Patrick: Yeah. Yeah. And is there in addition to reports of less pain and that, you know, they had a better experience when they use the V.

R. Versus when they didn't. Is there also less opioid use? I would imagine that there's some kids that still need some pain medication in addition to the virtual reality device. Is that true?

Dr Henry Xiang: Oh, can't it? We have a federally funded study trying to look at the issue. We are trying to. Implement this virtual reality for at home brain dressing changes.

One of the objectives of study is to say whether virtual reality can actually help reduce the opioid use during repeated at home brain dressing care.

Dr Mike Patrick: And in the hospital, itself, do you find that the kids that use the virtual reality have less need for opioid during their procedure?

Dr Henry Xiang: We are trying to do the study.

We are planning to figure it out. Uh, one. The third type of medical treatment is the inpatient brain dress and changes, which is very simple, very painful. A lot of time, high dose of opioid pain medications are used, including sometimes, you know, patients and nurses need to use pain medication we called rescue pain medication, which means the pain is not tolerable.

So, the parents or the child ask for additional pain medications. We have a theory. If we can help the patient manage their pain very well, they are less likely to ask for that additional pain medication.

Dr Mike Patrick: Yeah, I, I really love this so much. So, what you're saying is that in the beginning, so when, when kids are getting their first few dressing changes, when the things are going to be, you know, much more painful, potentially, like when they're in the hospital, they opioids.

But if we can reduce the number. And slowly transition them to rely more on the virtual reality game than the opioids. And then by the time they get home and are doing burn dressings, hopefully it's just the virtual reality game that they need and don't need the opioids anymore. And do, how do parents, what do parents think about this?

Is it, is it something that they, I'm sure that they appreciate it or is it, you know, would they rather be talking to their kid and, you know, being able to see them and comfort them or do they accept the headset on their child pretty easily

Dr Henry Xiang: so, can't really are the age range for virtual reality pain elevation is six years six to seventeen years old so.

You can see a lot of this, I would say 99 percent of the case, parents and patients accept this, sometimes welcome these new technologies. There may be one or two patients, they say, I don't want to use the virtual reality because I want to watch what is going on during the medical procedure. I don't want my eyes covered.

So very few people, one or two out of 100. Another important factor for us to evaluate this new digital technology is the side effect. Luckily, virtual reality has a very few almost a non-side effect. Out of these 100 patients we have tried the virtual reality, maybe one or two, you can see less than 1 percent experience very mild short lived side effects such as dizziness.

We call it cyber sickness. So, the research community and our experience Told us virtual reality is a very safe technology that can be used at medical procedure.

Dr Mike Patrick: Yeah, I think that's a really good point, too. We always want parents to know what the risks and the benefits are of anything that we do. And that would include virtual reality games.

And so, if you, if you potentially could get a little lightheaded or dizzy, you let parents know that ahead of time. Yes. Yeah. You might not want the kid to know because sometimes if you suggest. You might feel a little dizzy with this, then maybe they will feel a little dizzy. Do you know what I'm saying?

Dr Henry Xiang: Yeah, actually, when we introduced this, um, study to the participant, we explained all of the things, including the potential side effect. We didn't notice any difference. We didn't notice the, you know, the increase of the side effect because of the introduction or explanation of this. Side effects, potential

Dr Mike Patrick: side effects.

Yeah, good. Good to know. And the one or two that would rather watch the procedure. Those are probably the future doctors and nurses, right?

Dr Henry Xiang: Yes. Yes. Yeah.

Dr Mike Patrick: Yeah. And then, uh, speaking of doctors and nurses, what has the feedback been from the medical providers who are doing the procedures? Do they find that, uh, that, you know, the kids hold still and it's a more pleasant experience for them?

Dr Henry Xiang: Their feedback and experience are very positive. This is different from the studies and publications I did before. Before, I did studies and published papers in a peer reviewed medical journal. Some of the researchers may use my papers to improve their care, or something like that. But, after I started virtual reality pain alleviation, A lot of clinicians came to our team and to say, I heard you are doing this.

Can you help us implement at medical clinic? So that's for a researcher that that is very exciting because now you can see the impact of your research on the patient. Actual practice and then the physician nurses and other health care professional come to you instead of you reach out to them and then back them to implement that study.

So, I the feedback from nurses and health care professional are very positive and supportive.

Dr Mike Patrick: Yeah, that is that's really fantastic. So, we've talked about the, the way that, that virtual reality helps with pain itself. The other thing that often happens with painful procedures like burn dressing changes is a lot of anxiety in addition to the pain and the anxiety may be there because of the pain, or it may just be that, you know, a kid is nervous about a procedure that's about to happen, maybe because it hurt the last time.

Does the virtual reality system help with that anxiety in addition to helping with actual pain?

Dr Henry Xiang: Yes, you made a very important point here. We actually published a paper that established a correlation between anxiety and pain perception. in pediatric patients during medical procedures. Furthermore, we have a research hypothesis that anxiety is actually contagious between children and their parents and guardians, which means the anxiety level among children could increase the anxiety of their parents or guardians during the medical treatment, or vice versa.

So, it is important for us to consider both anxiety and pain During the medical procedures, and I'm very glad to say the virtual reality has some effect on both anxiety and pain levels. Yeah.

Dr Mike Patrick: And as you said that anxiety crosses both ways in the exam room, so parents become anxious when their kids are anxious, but kids can also become more anxious when they see that their parent might be anxious.

Yeah. But you can interrupt all of that with the headset and, uh, you know, the parent can see that the child is happy and not distressed and the child can't really see what the parents doing because they're they don't want to. They're involved with the game and having fun.

Dr Henry Xiang: Yeah, that is true. Actually, anxiety is very important during the chronic pain management.

For a lot of patients who suffer from chronic pain, parents actually have a lot of anxieties. So, how do we help them manage their anxiety? Will actually help the child recover from the chronic pain or help the patient to manage their pain better in an environment where the anxiety is not playing a big, big role in, in that environment.

So, in my opinion, reducing both parents’ anxiety and children's anxiety is very important.

Dr Mike Patrick: Yeah, yeah, absolutely. And then can you tell us about the study itself? So, the study that you've done with pediatric burn patients, what were, what was the study? What did you do? And what were the main findings from that research?

Dr Henry Xiang: Yeah, our team has, uh, started the clinical trials around, we developed the VR pad around 2015. We started a pilot project and clinical trials over the past, uh, about nine, nine years, we have published several papers that investigate the effectiveness of VRPAD for pain alleviation among pediatric burn patients.

Our first paper published on the JAMA Open Network report that VR pad is effective in managing pain among 6 to 17 years old during outpatient brain dressing changes. More importantly, we found active VR, which means the child can interact with the VR objects in the VR environment. It's more effect, it's more effective than passive VR.

Passive VR, which means the child only watch the exact same content of VR environment. They do not interact with the objects. the object in the VR environment. We found out active VR is more effective than passively. The second paper we investigated the effectiveness of VR during repeat, repeated at home brain dressing changes.

We found out VR could achieve clinically meaningful pain alleviation during repeated brain dressing changes. This is very important. Most of the time, a lot of the time, our scientists say we achieve this statistically significant difference. But what we aim for here is clinically meaningful treatment effect.

Our study proved that VR can achieve clinically meaningful difference in terms of pain reduction. The third paper actually we evaluate the three key features of VR pain alleviation and their impact on pain management. Actually, among the three key features, immersion, fun, and engagement, engagement is the most significant factors.

Dr Mike Patrick: Do you, so when you think about the cost of the headset, is that something that insurance would cover for a kid? I mean, cause you're really using it, you know, instead of opioids. And so, the insurance company is saving on not, you know, paying for those medications. So, will they pay for the headset or we're not quite there yet?

Dr Henry Xiang: We're not quite there yet. The field is moving to that direction. In order to ask, in order to get the insurance company to pay for this type of treatment, we need to have like a billing code. Luckily, there's one billing code approved by the federal regulatory agencies for chronic management using VR among adult populations.

None of the virtual reality pediatric pain elevation got approval for that building purpose. Our goal is to work together with all kinds of stakeholders trying to get a billing code for reimbursement of the virtual reality payment deviation.

Dr Mike Patrick: Yeah, I and I would imagine that that that would be helpful for some families, but it's also good to know that the total cost isn't really great if you're using your iPhone or your Android phone.

In the, you know, in the headset rather than the headset that has a screen and maybe a computer chip in it and it's going to, that's certainly going to cost a lot more money.

Dr Henry Xiang: Yes, I would say if you think about the professional virtual reality head goggle is cost, uh, our system costs about 700, but you can use in reuse that with appropriate, uh, infection control procedures.

That could be a tool used by the nurses and child life specialists. It's part of their, uh, work. And we think, uh, the service provided through virtual reality help the children's, help the patient recover. And, uh, they have a better outcome, the service should be reimbursed.

Dr Mike Patrick: Yeah. Totally agree with that. And really that's a, a greater use of money I would think than opioids.

Now, obviously if a child, you know, when you said they're like their pain scales at three or a four, if they're an eight to 10, you know, obviously we're going to, we want the kids to be comfortable. We're not going to say, oh, you have virtual reality. You don't need these other medicines. So, it's really, we want to use less of them, but we're not saying that no child can have them at all.

Dr Henry Xiang: Yeah, that, that's a very good point. So, the current position we have is virtual reality pain elevation is an adjunctive pain management tool. Could be used together with pain medication and other pain management tools. We are not seeing virtual reality pain inhibition well or should replace the pain medications that could be prescribed by doctors to manage their pain.

Dr Mike Patrick: And then what do you think the future holds for the use of this technology in a pain control for both kids and adults? Do you see it being used for more things as, as you know, awareness and interest increase?

Dr Henry Xiang: At this moment, I can think about three important areas, or we may call it priorities, for pain alleviation research and practice for both pediatric and adult patients.

The number one, for those well established and clinical proving VR pain alleviation We need to work together with clinical professionals such as hospital leaders and division leaders, physicians, nurses, and child life specialists to disseminate and implement VR and adapt the VR into pain and pain alleviation clinical practice.

So, there's a new branch of research is called dissemination and implementation studies. We published studies and we did this study at, uh, one hospital, but we want to widely disseminate and implement There is clinical proving via pain elevations. That's the sort of number one priority. Number two priority, in my opinion, is to develop and test more virtual reality pain elevation for chronic pain management.

Our team focus on acute pain management, but however, chronic pain is more complicated and harder to manage than the acute pain. Another reason is because so many adults as well as pediatric patient are suffering devastating chronic pain, virtually any pain relief will have a significant impact implication.

The third priority is research on understanding the neural mechanism behind the VR pain alleviation. Not only it is exciting to discover the neurological mechanism of VR pain alleviation, but also this kind of research will advance science and support more We are paying elevation and, uh, allow a lot of patient and healthcare professional to accept and adapt the virtual reality into their clinical practice.

Dr Mike Patrick: Yeah. Yeah. So, so important. And, uh, I think if we had this conversation five years from now, hopefully we'll be using this more and more. And, uh, it'll, it really will make a difference in lots of kids lives throughout the country and around the world. So, Dr. Henry Xiang, Director of the Center for Pediatric Trauma Research and Principal Investigator with the Center for Injury Research and Policy at Nationwide Children's Hospital.

Thank you so much for stopping by today.

Dr Henry Xiang: Thank you so much, Dr. Patrick, for inviting me to talk about This fascinating and innovative technology.

Dr Mike Patrick: We are back with just enough time to say thanks once again, to all of you for taking time out of your day and making PediaCast a part of it. Really do appreciate that. Also, thanks again to our guests this week, Dr. Henry Xiang, Center for Pediatric Trauma Research, the director of that center and a principal investigator with the Center for Injury Research and Policy at Nationwide Children's Hospital.

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