Assessment and management of pain in pediatric otolaryngology

Postoperative accurate pain assessment of children and artificial intelligence: A medical hypothesis and planned study

Although the pediatric perioperative pain management has been improved in recent years, the valid and reliable pain assessment tool in perioperative period of children remains a challenging task. Pediatric perioperative pain management is intractable not only because children cannot express their emotions accurately and objectively due to their inability to describe physiological characteristics of feeling which are different from those of adults, but also because there is a lack of effective and specific assessment tool for children. In addition, exposure to repeated painful stimuli early in life is known to have short and long-term adverse sequelae. The short-term sequelae can induce a series of neurological, endocrine, cardiovascular system stress related to psychological trauma, while long-term sequelae may alter brain maturation process, which can lead to impair neurodevelopmental, behavioral, and cognitive function. Children's facial expressions largely reflect the degree of pain, which has led to the developing of a number of pain scoring tools that will help improve the quality of pain management in children if they are continually studied in depth. The artificial intelligence (AI) technology represented by machine learning has reached an unprecedented level in image processing of deep facial models through deep convolutional neural networks, which can effectively identify and systematically analyze various subtle features of children's facial expressions. Based on the construction of a large database of images of facial expressions in children with perioperative pain, this study proposes to develop and apply automatic facial pain expression recognition software using AI technology. The study aims to improve the postoperative pain management for pediatric population and the short-term and long-term quality of life for pediatric patients after operational event.

The effectiveness of topical 1% lidocaine with systemic oral analgesics for ear pain with acute otitis media

BACKGROUND

Acute otitis media (AOM) is one of the most common childhood infections. Ear pain, the main symptom of AOM, results in parents frequently seeking medical assistance for their children. The aim of this study was to compare the effectiveness of topical 1% lidocaine ear drops administered with oral analgesics with that of oral analgesics alone.

METHODS

This multicenter randomized, open-labeled study was conducted at 15 centers with 184 pediatric AOM patients with bilateral ear pain (aged 1-5 years) between May 1, 2016, and June 31, 2018. All patients received oral paracetamol or ibuprofen and topical 1% lidocaine, which was administered to each ear according to the randomization list. The ear pain score was evaluated within 48 h using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale, and the patients were followed up for 10 days.

RESULTS

The median age was 31.8 months (min-max, 12-84.2 months). Of those patients enrolled, 22.3% received paracetamol, and 24.5% received paracetamol with lidocaine ear drops; 23.4% received ibuprofen, and 29.9% received ibuprofen with lidocaine ear drops. Lower pain scores were significantly measured at baseline and 10th minutes by a reduction 25% (RR 13.64, 95% CI 4.47-41.63, p = 0.001, RR 0.14, 95% CI 0.06-0.35, p = 0.001) and 50% (RR 4.76, 95% CI 1.63-13.87, p = 0.004, RR 0.14, 95% CI 0.05-0.4, p = 0.001) in the paracetamol and lidocaine versus paracetamol groups and the ibuprofen and lidocaine versus ibuprofen groups, respectively. No serious side effects were evident during follow-up.

CONCLUSION

This randomized study suggests that topical 1% lidocaine ear drops with paracetamol or ibuprofen seems to provide effective and rapid relief for children presenting with ear pain attributed to AOM.

Effect of fasting time before anesthesia on postoperative complications in children undergoing adenotonsillectomy

OBJECTIVES

Although the guidelines clearly recommend the fasting time of children before anesthesia, it is usually difficult to control. For pediatric patients, prolonged fasting time before surgery will lead to dehydration and hypoglycemia. Adenotonsillectomy is one of the most common operations in pediatric patients, but its complications are not rare. The purpose of this study is to analyze the relationship between preoperative fasting time and postoperative complications in children undergoing adenotonsillectomy.

METHODS

The medical and surgical records of 480 pediatric patients who underwent adenotonsillectomy were analyzed retrospectively. They were divided into three groups, including adenoidectomy group, tonsillectomy group, and adenotonsillectomy group. Logistic regression analysis was used to analyze the effect of preoperative fasting time on postoperative complications and hospital stay in pediatric patients of the three groups.

RESULTS

The postoperative bleeding rate in the adenoidectomy group (5.16%) was lower than tonsillectomy group and adenoidectomy group (P < .001). Logistic regression analysis showed that the fasting time was positively correlated with the vomiting and pain in adenoidectomy group, tonsillectomy group, and adenotonsillectomy group. And, the postoperative hospital stay was also positively correlated with fasting time in three groups.

CONCLUSION

The prolonged fasting time before otolaryngology surgery in children is related to the occurrence of postoperative complications like vomiting and pain, and also to the increase of postoperative hospital stay.

Predictive Factors for Anxiety during Blood Sampling and Insertion of Peripheral Intravenous Catheters in Paediatric Patients in Spain

INTRODUCTION

Invasive procedures for diagnosis purposes such as venepuncture and peripheral venous catheter insertion are painful procedures that cause great stress for paediatric patients. The objective of this study is to find out the factors that have an impact on the level of anxiety experienced by children undertaken these procedures.

DESIGN AND METHODS

Prospective study, 359 children between 2 and 15 years old were included, treated in a tertiary reference hospital in the region of Navarra (Spain). The impact of the variables recorded was analysed using a regressive analysis, the Wong-Baker and FLACC scales were used to measure the level of pain and the PACBIS scale to measure the level of stress and anxiety.

RESULTS

The average age of the participants was 7.93 years (SD: 4.04), with 51.8% (n = 186) boys and 48.2% (n = 173) girls. The mean value of pain recorded was 4.43 (SD:3.10). 45.7% (n = 123) of the venepuncture techniques was associated with minimum level of anxiety, including 11.1% of intravenous catheterization. Variables determining the anxiety has been detected such as age, sex, level of pain, parental conduct and time spent on the procedure.

CONCLUSIONS

Paediatric patients experience high levels of anxiety when undergoing painful procedures which are conditioned by multifactorial reasons. The increase in stress is directly related to the older age (>6 years old) of the patient, and statistically significant by the female gender, the longer duration of the technique and the parental block.

PRACTICE IMPLICATIONS

Healthcare professionals should work on some of the variables and apply measures aimed to mitigate anxiety levels. For example, reducing the duration of the procedure, training parents, and distracting techniques.

Does ibuprofen, prednisolone, or amoxicillin reduce post-tonsillectomy pain in children? A prospective randomized controlled trial

OBJECTIVE

To evaluate whether the use of anti-inflammatory or antibiotic in the postoperative period modifies pain in children undergoing tonsillectomy.

METHODS

225 children who underwent cold knife tonsillectomy ± adenoidectomy were randomized into five groups, receiving #1 metamizole/acetaminophen, #2 amoxicillin, #3 ibuprofen, #4 prednisolone, or #5 amoxicillin plus prednisolone. All groups received oral analgesics (metamizole/acetaminophen) to use as needed. Pain was monitored during the 7 days following surgery using the Parents' Postoperative Pain Measurement (PPPM) and the Faces Pain Scale - Revised (FPS-R). Pain was also indirectly evaluated by the dose of analgesics administered on each day and by the time needed to return to a solid diet.

RESULTS

After losses (24%), 170 individuals were submitted for analysis. Multiple comparisons demonstrated that the evolution of pain between the different groups, as matched day-per-day, was not significantly different by either PPPM or FPS-R (p > 0.05). The instances of analgesic intake were also similar in all the groups (p > 0.05), as was the return to solid food ingestion (p = 0.41). All groups presented a similar standard of clinical improvement at intervals of 2 days (p < 0.01). Independent of postoperative pain management, patients developed significant pain up to the day 4 following surgery.

CONCLUSION

The addition of amoxicillin, ibuprofen, prednisolone, or amoxicillin and prednisolone does not modify postoperative pain in children undergoing cold-knife tonsillectomy. Special pain control should be performed on the first 4 days following tonsillectomy in children.

Comparison of Oral Loading Dose to Intravenous Acetaminophen in Children for Analgesia After Tonsillectomy and Adenoidectomy: A Randomized Clinical Trial

BACKGROUND

Acetaminophen is a frequently used adjunct analgesic in pediatric patients undergoing tonsillectomy and adenoidectomy. We compared opioid administration following preoperative intravenous (IV) or oral acetaminophen in addition to a standard multimodal regimen to test the hypothesis that 1 loading dose approach would provide superior opioid sparing effects among pediatric surgical patients undergoing tonsillectomy and adenoidectomy.

METHODS

This single-center, double-blind, double-dummy prospective randomized study was conducted in patients ages 3 to 15 years undergoing tonsillectomy and adenoidectomy with or without myringotomy and tube placement between September 2017 and July 2019. Subjects received 1 dose of either oral acetaminophen 30 mg/kg with IV placebo (oral group) or IV acetaminophen 15 mg/kg with oral placebo (IV group). Acetaminophen plasma levels were measured at 2 timepoints to evaluate safety and determine plasma levels attained by each dosing regimen. Intraoperative opioid administration and postoperative analgesia were standardized. Standardized postoperative multimodal analgesia included opioid if needed to control pain assessed by standardized validated pediatric pain scales. The primary outcome measure was total opioid administration in the first 24 hours after surgery. Continuous data were not normally distributed and were analyzed using the Wilcoxon rank sum test and the Hodges-Lehman estimator of the median difference. Clinical significance was defined as a 100 µg/kg IV morphine equivalents per day difference.

RESULTS

Sixty-six subjects were randomized into and completed the study (29 women, 37 men; age 5.9 ± 3.0 years; percentile weight for age 49.5 ± 30.2; no differences between groups). There was no opioid dose difference between oral (median 147.6; interquartile range [IQR], 119.6-193.0 µg/kg) and IV groups (median 125.4; IQR, 102.8-150.9 µg/kg; median difference 21.3; 95% confidence interval [CI] -2.5 to 44.2 µg/kg IV morphine equivalents; P = .13). No acetaminophen levels exceeded the predefined safety threshold (40 mg/L). No difference was found in the percentage of patients with severe pain: 50.0% oral group, 47.2% IV group; relative risk of severe pain in IV 0.94; 95% CI, 0.57-1.6; P = .82. Postoperative plasma acetaminophen levels were higher in oral (22; IQR, 16-28 mg/L) than IV (20; IQR, 17-22 mg/L) group (median difference 7.0; 4.0-8.0 mg/L; P = .0001).

CONCLUSIONS

Opioid-sparing effects did not differ following an oral or standard IV acetaminophen loading dose with no identified acetaminophen toxicity in pediatric patients undergoing tonsillectomy and adenoidectomy who received standardized multimodal postoperative analgesia. An oral loading dose may provide more consistent serum acetaminophen levels at lower cost compared to a standard IV dose.

Single dose of intraoperative intravenous morphine for analgesia in children undergoing tonsillectomy: Randomized, double-blind clinical trial

INTRODUCTION

Children undergoing tonsillectomy have severe pain in the postoperative period. One of the pharmacological options for analgesia is opioids, such as morphine. However, the risks of adverse effects, such as increased recovery time from anesthesia and respiratory depression, can limit its use.

OBJECTIVES

To evaluate the use of intraoperative intravenous morphine to reduce immediate postoperative pain in children undergoing tonsillectomy.

METHODS

In this double-blind randomized study, children aged 3-10 years were submitted to tonsillectomy, with or without adenoidectomy, and divided into two groups. Children in group M received 0.1 mg/kg of intravenous morphine during anesthetic induction, while those in the control group received conventional anesthesia without morphine. Postoperative pain perceptions were assessed at 30, 60, 120, 180 and 240 min after recovery from anesthesia, by the children themselves and also by their parents or guardians, using a facial pain scale.

RESULTS

A total of 57 children were included, 30 in the group with morphine and 27 in the group without morphine. According to the children themselves, the postoperative pain was less at the evaluations performed at 30 min after awakening from anesthesia (p =  0.023), while according to their parents/guardians, the pain was less intense in the evaluations performed at 30 (p =  0.002), 60 (p =  0.006) and 180 min (p =  0.007) after awakening. Moreover, postoperative analgesics were less requested by children in the morphine group. No observed side effects were associated with the use of morphine.

CONCLUSION

A single dose of intravenous morphine during anesthetic induction reduced the intensity of immediate postoperative pain in children undergoing tonsillectomy, without increasing the time of awakening from anesthesia and with lower consumption of rescue analgesics.

Nonopioid Adjuncts and Alternatives

Multimodality nonopioid analgesia can be effective for pain control. Balancing risks and benefits of treatment should guide the appropriateness of opioid versus nonopioid pain control.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.

Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery

This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.

Pain in child patients: A review on managements

Pain has been known as one of the major universal health concerns about ill children, because of its morbidity and potential mortality. Pain suitable evaluation is a challenge in children because the verbalization is difficult. Low clinical information, few pediatric researches, and the worry of opioid side effects make difficult to provide satisfactory treatments. Many pharmacologic and non-pharmacologic strategies to manage pain exist for pediatric pain treatment. The purpose of this review article is to describe exhaustively pain mechanism, evaluation and management by review literature from January 2000 to January 2019 using PubMed, EMBASE, MEDLINE, LILACS databases. Pharmacological and integrative non-pharmacological therapies has been indicated in acute and chronic pain treatment. Opioids and opioid-sparing agents target nociceptive and neuropathic pain. With due attention to available results, an early combination of pharmacological and integrative non pharmacological treatments are indicated in children pain management.