Postoperative Pain in Children: Association Between Anxiety Sensitivity, Pain Catastrophizing, and Female Caregivers' Responses to Children's Pain

Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.

Predicting Health-Related Quality of Life Outcomes Following Major Scoliosis Surgery in Adolescents: A Latent Class Growth Analysis

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To identify patient trajectories of recovery defined by change in health-related quality of life (HRQOL) following surgery for adolescent idiopathic scoliosis (AIS). To explore possible predictors of trajectory membership.

METHODS

Adolescent patients scheduled to undergo spinal fusion for AIS were enrolled in the Post-Operative Recovery following Spinal Correction: Home Experience (PORSCHE) study. Responses to the Pediatric Quality of Life Inventory-version 4 (PedsQL-4.0) were collected prior to surgery and 4 to 6 weeks, 3, 6, and 12 months post-operatively. Latent class growth analyses identified patient subgroups based on their unique trajectories of physical health (PH) and psychosocial health (PSH) outcomes using the PedsQL-4.0 subscale scores. Predictors included demographic, clinical, and psychosocial factors.

RESULTS

Data from up to 190 patients were included (87.4% female; mean±SD age = 14.6 ± 1.9 years). Three trajectory subgroups were identified for PH and 4 trajectories were found for PSH, with a majority of patients scoring within the established range of healthy adolescents 12 months post-surgery. Increased child and parent pain catastrophizing, child trait anxiety and previous hospitalizations were associated with poorer PH outcomes, whereas increased child and parent pain catastrophizing, child state and trait anxiety, and parent state and trait anxiety were associated with poorer PSH trajectories.

CONCLUSIONS

The PH and PSH trajectories identified in this study and the factors associated with their membership may inform surgical decision-making for AIS while facilitating patient and family counselling regarding peri-operative recovery and expectations.

Pain-related hospitalization and emergency room visit following initial analgesic prescription after outpatient surgery

PURPOSE

Our study examined the association between outpatient postsurgical analgesic prescription and risk of insufficiently managed pain characterized by pain-associated hospital admission and emergency room (ER) visit.

METHODS

Eligible individuals were children 1-17 years of age who filled an incident analgesic following an outpatient surgery during 2013-2018. Pain-associated hospital admission or ER visit were measured within 30 days following the outpatient surgical procedure. A hierarchical multivariable logistic regression model with patients nested under prescribers was fitted to test the association between incident analgesic prescription and risk of having pain-associated hospital admission or ER visit.

RESULTS

Of 14 277 children meeting the inclusion criteria, 6224 (43.6%) received an incident opioid and 8053 (56.4%) received an incident non-opioid analgesic prescription respectively. There were a total of 523 (3.7%) children undergoing surgical procedures that had pain-related hospital admissions or ER visits with 5.1% initiated on non-opioid analgesics and 1.8% on opioid analgesics. The multilevel model indicated that initial opioid analgesic recipients were 32% less likely of having a pain-associated hospital admission or ER visit [aOR: 0.68 (95% CI: 0.3-0.8)].

CONCLUSION

Majority of postsurgical patients do not require additional pain management strategies. In the 3.7% of patients requiring additional pain management strategies, those initiated on non-opioid analgesics are more likely to have a pain-associated hospital admission or ER visit compared with their opioid recipient counterparts.

Easing the Burden on Caregivers- Applications of Artificial Intelligence for Physicians and Caregivers of Children with Cleft Lip and Palate

OBJECTIVE

Many caregivers of children with cleft lip and palate experience a high level of anxiety throughout their child's medical and surgical care. We aim to evaluate artificial intelligence (AI) as a tool to mitigate these feelings and can aid clinicians in the development of robust pediatric educational materials for caregivers and families.

DESIGN

Thirteen of the most common postoperative questions following cleft lip and/or palate repair were developed by an expert panel of senior Pediatric Plastic Surgeons and were posed to ChatGPT. Professional answers from the expert panel were provided and compared to responses from ChatGPT. A literature review was also conducted to generate a new support model for caregivers with children undergoing a surgical procedure.

SETTING

Department of Pediatric Plastic Surgery at a metropolitan Children's Hospital.

PARTICIPANTS

Senior Pediatric Plastic Surgeons at a metropolitan Children's Hospital.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The primary outcome was to determine the ability of ChatGPT to respond to common postoperative questions and to develop a model for AI assistance in family-centered perioperative care.

RESULTS

ChatGPT had a postoperative question response accuracy rate of 69% when compared with subject matter expert responses, with its greatest errors being information errors. An extensive literature search revealed that AI can assist in multiple traditional perioperative strategies to reduce caregivers and patient anxiety.

CONCLUSIONS

Artificial Intelligence can help to reduce the burden of generating patient education materials as well as support caregivers in multiple aspects and perioperative care.

Virtual psychoeducation for improvement of pain catastrophizing in pediatric presurgical patients and caregivers: a proof-of-concept study

PURPOSE

Pain catastrophizing (PC) is the tendency to magnify the threat value of pain sensations and is associated with greater postsurgical pain intensity, functional disability, and pain chronicity. Higher parental PC predicts higher chronic postsurgical pain in youth. Treating PC in caregivers and youth prior to surgery may improve recovery and surgical outcomes. We developed and evaluated a psychoeducational workshop addressing PC for presurgical youth and their parents/caregivers. We hypothesized that parent/caregiver and youth PC scores would decrease over time. We also explored preintervention levels of youth anxiety and depression as moderators of outcome.

METHODS

Youth (n = 43) and caregivers (n = 41) attended a virtual, group-based single-session intervention (SSI). Single-session intervention content addressed pain neuroscience, PC, and adaptive coping strategies for managing pain and PC drawn from cognitive-behavioural, acceptance and commitment, and dialectical behaviour therapy approaches. Participants completed questionnaires assessing PC at preintervention, postintervention, and two weeks postsurgery. Youth mood and anxiety were assessed at preintervention.

RESULTS

Caregiver PC scores decreased from pre- to postintervention (P = 0.006), and this was maintained at postsurgery (P = 0.002). Youth PC scores decreased from preintervention to postsurgery, but only for those with higher preintervention anxiety (P = 0.01).

CONCLUSION

Our results provide proof-of-concept support for a virtual SSI targeting caregivers and youth PC during the perioperative period. The present findings highlight the possible need to screen presurgical candidates for symptoms of anxiety. Replication with larger and more diverse samples, and a more robust design are warranted.

Is Pain Perception Communicated through Mothers? Maternal Pain Catastrophizing Scores Are Associated with Children's Postoperative Circumcision Pain

The aim of this study was to evaluate the relation of maternal pain catastrophizing score with children who underwent circumcision postoperative pain. This prospective cohort study was performed between March 2022 and March 2023 at Samsun University, Turkey. Demographic characteristics of mothers and children, mothers' education level, presence of chronic pain, and Beck Depression Inventory scores were recorded preoperatively. Pain catastrophizing was assessed by applying the pain catastrophizing scale (PCS) to the mothers of children who experienced postoperative circumcision pain. The mothers were divided into low-pain catastrophizing (Group 1) and high-pain catastrophizing (Group 2) group. A total of 197 mothers and sons participated in the study, with 86 (43.6%) in Group 1 and 111 (56.4%) in Group 2. Significant differences were found between the two groups in terms of the mothers' PCS scores (p < 0.001), education levels (p = 0.004), chronic pain scores (p = 0.022), and Beck Depression Inventory scores (p < 0.001). Our findings showed that children with high pain catastrophizing mothers experience greater postoperative pain than those with low pain catastrophizing mothers. This may be attributable to a mother's specific cognitive style for coping with pain, which is associated with the child's responses to painful experiences.

Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people.

DESIGN

This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis.

METHODS

32 children and adolescents from two children's hospitals completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale Child (PCS-C) pre-and 4-6 months post spinal fusion surgery. Between-group differences were assessed using an independent samples t-test. Pearson's correlations and stepwise linear regression were used to assess the relationship between variables at both time points.

RESULTS

56% of patients endorsed pain post-surgery. They were more sensitive tomechanical detection on both a control non-pain site (r = -2.87, p = .004) and the back (r = -1.83, p = .04), as well as pressure pain (r=-2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r = .67 p < .001), and age was negatively correlated with the post-surgical catastrophizing total score (r =-.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery.

CONCLUSIONS

Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP.

Factors affecting how parents cope with their preterm infant's pain: A cross-sectional study

AIMS AND OBJECTIVES

This study examined the relationships between parents' catastrophising about their infants' pain, parental self-efficacy in the management of their infants' pain, perceived social support and the parental coping strategies for their infants' pain-related stress.

BACKGROUND

Preterm infants hospitalised in the neonatal intensive care unit experience painful procedures causing stress to their parents. Coping with stress may be emotion- or problem-focused. Adults' coping with their own pain has been associated with pain catastrophising, pain management self-efficacy and social support. However, little is known about the associations between parents' catastrophising, their self-efficacy to manage, their perceived social support and their coping strategies when dealing with their infants' pain.

DESIGN

This was a cross-sectional, correlational study design.

METHODS

The STROBE guidelines for cross-sectional studies were followed. Participants included 149 parents of preterm infants hospitalised in a neonatal intensive care unit. They completed measures to assess infant pain catastrophising, self-efficacy regarding infant pain management, social support and emotion- and problem-focused coping.

RESULTS

Positive associations were found between parental self-efficacy regarding infant pain management, social support, parental catastrophising about their infants' pain and problem-focused coping. Parental catastrophising was positively associated with emotion-focused coping. Gender moderated the relationships between parental self-efficacy regarding infant pain management and emotion-focused coping. Specifically, amongst mothers, the higher their level of self-efficacy, the lower their emotion-focused coping. Amongst fathers, the relations were reversed.

CONCLUSIONS

Parents coping with their preterm infants' pain were associated with catastrophising about their infants' pain, self-efficacy regarding infant pain management and social support. Mothers had different ways to cope emotionally to that of fathers in relation to their self-efficacy in managing their infants' pain.

RELEVANCE TO CLINICAL PRACTICE

Nursing interventions that provide support to parents and promote parental self-efficacy in managing their infants' pain may allow parents to more effectively cope with their infants' pain.

PATIENT OR PUBLIC CONTRIBUTION

Patients or public were not involved in setting the research question, the outcome measures and the design or implementation of the study. Parents of preterm infants answered the research questionnaires.

Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents

OBJECTIVE

This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents.

METHODS

Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery.

RESULTS

Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01).

CONCLUSIONS

Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.

Development and assessment of an efficient pediatric affect and cooperation scale

STUDY OBJECTIVE

HRAD± was developed to quickly evaluate pediatric preprocedural affect and cooperativity during mask induction of anesthesia and peripheral intravenous (PIV) placement. HRAD± represents: Happy, Relaxed, Anxious, Distressed, with a yes/no answer to cooperativity. The primary aim of this study was to compare HRAD± to previously published scales.

DESIGN

We conducted an observational study.

SETTING

Videos of pediatric patients were collected in the perioperative environment.

PATIENTS

Twenty-four children, twenty-one pediatric anesthesiologists and twenty pediatric perioperative providers were included.

INTERVENTIONS

To assess the reliability of HRAD±, standard patient videos were created. Children underwent mask induction or PIV placement, and these interventions were video recorded. Mask induction and PIV placement videos were rated by pediatric anesthesiologists and perioperative non-physician providers respectively using HRAD±.

MEASUREMENTS

Two trained researchers provided the modified Yale Preoperative Anxiety Scale (mYPAS), Observation Scale of Behavioral Distress (OSBD), and Induction Compliance Checklist (ICC) scores, and we calculated correlations to HRAD±, inter-rater reliability, and intra-rater reliability.

MAIN RESULTS

HRAD± scores strongly correlated with mYPAS (r = 0.846, p < 0.0001) and OSBD scores (r = 0.723, p < 0.0001). Cooperativity scores correlated strongly with ICC scores in the mask induction group (r = -0.715, p < 0.0001) and in the PIV group (r = -0.869, p < 0.0001). HRAD± inter-rater reliability for mask induction was 0.414 (p < 0.0001) and for PIV assessment was 0.378 (p < 0.0001). Inter-rater reliability for cooperativity on mask induction was 0.797 (p < 0.0001) and PIV assessment was 0.683 (p < 0.0001). Intra-rater reliability for mask induction was 0.675 and PIV assessments was 0.678. Intra-rater reliability for cooperativity for mask induction was 0.894 and for PIV assessments was 0.765.

CONCLUSIONS

HRAD± is an efficient and reliable scale that serves as a practical alternative for measuring pediatric affect during mask induction and PIV placement. The results demonstrate strong correlation with commonly utilized yet more complex affect scales.

Effectiveness of Flippits and Virtual Reality Therapy on Pain and Anxiety Among Children Undergoing Painful Procedures

Introduction

Pain experienced by children during painful procedures may cause stress, fear, and anxiety. Currently, a number of interventions are used to reduce pain perception during medical procedures and distraction therapy is one of the most commonly used interventions.

Method

A randomized control trial was conducted among 105 children aged between three years and 12 years undergoing painful procedures such as intravenous cannulation, blood sampling, and injections to evaluate the effect of flippits and virtual reality therapy (VRT) on pain and anxiety. Through a computerized random approach, 35 samples were allotted to each group. Experimental group -1 received VRT, experimental group -2 received flippit (distraction card) therapy during painful procedures, and the control group received the conventional intervention. Standard tools were used to assess the pain and anxiety.

Result

Total 128 children were admitted to the ward and 23 were not included in the study for various reasons. Total 105 children undergone randomization to three groups, 35 in each group. All were analyzed for primary and secondary outcomes. After adjusting for confounding factors using multiple logistic regression, it was found that pain scores of VRT and flippit groups were less than the control group (aOR, 95% CI 0.635, 0.504-0.799, P = 0.000 and aOR, 95% CI 0.705, 0.572-0.868, P = 0.001, respectively) and no difference was observed between VRT and Flippit group (aOR, 95% CI; 0.901, 0.723 - 1.123, P 0.353). Flippit group perceived less intensity of pain compared to control group (aOR, 95% CI 0.542, 0.322-0.912, P = 0.021) and children received VRT perceived less intensity of pain than both control and flippit groups of children (aOR, 95% CI 0.258, 0.132-0.503, P = 0.000 and aOR, 95% CI 0.476, 0.252-0.900, respectively). Children received VRT and flippit therapy perceived less anxiety compared to control group (aOR, 95% CI 0.589, 0.348-0.999, P = 0.050 and aOR, 95% CI 0.385, 0.217-0.682, P = 0.001, respectively). But, there was no difference between VRT and flippit groups (aOR, 95% CI 1.532, 0.940-2.498, P = 0.087).

Conclusion

Flippit therapy and virtual reality therapy were better than conventional therapy in reducing the perception of anxiety and pain in children, aged three to 12 years, undergone painful procedures. Virtual reality therapy had an edge over flippit therapy in reducing the worst hurt.

Trajectory of Pain, Functional Limitation, and Parental Coping Resources Following Pediatric Short-stay Surgery: Factors Impacting Rate of Recovery

OBJECTIVES

Although there are many benefits of short-stay hospital admissions for high volume, pediatric surgical procedures, this model of care places greater responsibility on parents for the management of children's pain. This study aimed to document the trajectory of child pain outcomes and a range of parent-reported functional outcomes following discharge from a short-stay surgical admission. Moreover, we aimed to document the trajectory of parental perceived personal coping resources. Second, we assessed whether parental dispositional factors, assessed before hospital discharge, predicted the child's pain intensity and parent-reported functional recovery.

METHODS

Participants included children (aged 4 to 14 y) admitted for a short-stay tonsillectomy or appendectomy, and their parents. Parents completed a questionnaire before discharge from hospital. Demographic and surgical information was recorded from medical records. Following discharge, daily assessments of pain and functioning were carried out over a 10-day period using iPods or mobile phones. Predischarge and postdischarge data were obtained for 55 child and parent dyads.

RESULTS

Pain intensity scores returned to low levels (2/10 or less) by day 5 for appendectomy and day 10 for tonsillectomy. Parents' perceived personal coping resources increased more slowly following tonsillectomy than appendectomy. Controlling for time since surgery and parental coping resources, parental pain-related catastrophizing was a significant predictor of child pain and functional recovery.

DISCUSSION

Short-stay surgery results in parents facing considerable burden in managing their child's pain and functional impairment over a 10-day period. The potential value of screening for parental pain-related catastrophizing before discharge from hospital warrants further consideration and may enable identification of children likely to experience poorer recovery.

Pain Catastrophizing Throughout the Perioperative Period in Adolescents With Idiopathic Scoliosis

OBJECTIVES

Pain catastrophizing in children and adolescents has been associated to unfavorable postsurgical outcomes. However, pain catastrophizing is rarely measured throughout the perioperative period. Using a prospective longitudinal approach, the present study aimed to identify how pain catastrophizing changes over the perioperative period in pediatric surgical patients with adolescent idiopathic scoliosis.

MATERIALS AND METHODS

Adolescent patients undergoing spinal fusion surgery completed the Pain Catastrophizing Scale for Children and additional questionnaires to assess pain intensity, state and trait anxiety, and kinesiophobia before surgery, and 1, 2, 5 days, 6 weeks, and 6 months after surgery.

RESULTS

Patients who had higher levels of pain catastrophizing before surgery were more likely to be anxious, avoid activity that may cause pain, report higher pain intensity before surgery and anticipate more pain after surgery. Low pain catastrophizers increased into a moderate level of pain catastrophizing before decreasing after discharge from the hospital. Meanwhile, moderate and high pain catastrophizers both decreased into lower and moderate levels of catastrophizing, respectively, after discharge from the hospital.

DISCUSSION

These findings demonstrate that pain catastrophizing in adolescents changes over the perioperative period. Observing changes in pain catastrophizing throughout the perioperative period may help in recognizing when patients are most vulnerable during this time. Decreasing pain catastrophizing before surgery or in the acute postoperative period through therapies that target pain catastrophizing may help reduce the patient's likelihood of experiencing unfavorable postoperative outcomes.

Gender Biases in Estimation of Others' Pain

Caregiving and other interpersonal interactions often require accurate perception of others' pain from nonverbal cues, but perceivers may be subject to systematic biases based on gender, race, and other contextual factors. Such biases could contribute to systematic under-recognition and undertreatment of pain. In 2 experiments, we studied the impact of perceived patient sex on lay perceivers' pain estimates and treatment recommendations. In Experiment 1 (N = 50), perceivers viewed facial video clips of female and male patients in chronic shoulder pain and estimated patients' pain intensity. Multi-level linear modeling revealed that perceivers under-estimated female patients' pain compared with male patients, after controlling for patients' self-reported pain and pain facial expressiveness. Experiment 2 (N = 200) replicated these findings, and additionally found that 1) perceivers' pain-related gender stereotypes, specifically beliefs about typical women's vs. men's willingness to express pain, predicted pain estimation biases; and 2) perceivers judged female patients as relatively more likely to benefit from psychotherapy, whereas male patients were judged to benefit more from pain medicine. In both experiments, the gender bias effect size was on average 2.45 points on a 0-100 pain scale. Gender biases in pain estimation may be an obstacle to effective pain care, and experimental approaches to characterizing biases, such as the one we tested here, could inform the development of interventions to reduce such biases. Perspective: This study identifies a bias towards underestimation of pain in female patients, which is related to gender stereotypes. The findings suggest caregivers' or even clinicians' pain stereotypes are a potential target for intervention.

A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPalTM): study protocol for a multisite randomized controlled trial

BACKGROUND

Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPalTM) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery.

METHODS

Adolescents 12-18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPalTM or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery.

DISCUSSION

Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery.

TRIAL REGISTRATION

NCT04637802 ClinicalTrials.gov. Registered on November 20, 2020.

Severe acute postoperative pain self-reported by children after ambulatory surgeries: a cohort study

OBJECTIVES

to estimate the incidence and the risk factors for severe acute postoperative pain self-reported on the first day after hospital discharge.

METHODS

cohort study with 279 children from both sexes (5-12 years old), indicated for ambulatory surgery in two Brazilian hospitals. Children were assessed at the pre-surgery, immediate postoperative and first postoperative day. Faces Pain Scale-Revised and Yale Preoperative Anxiety Scale Modified were used. Severe postoperative pain was defined as score ≥6. Cox regression analyses were used.

RESULTS

the incidence of severe postoperative pain was 15.8% (95%CI:10.7%-20.4%) on the first postoperative day. Preoperative anxiety (HR=2.23; p=0.049), severe preoperative pain (HR=2.78; p=0.031) and having undergone two surgical procedures (HR=2.91; p=0.002) were associated with severe postoperative pain.

CONCLUSIONS

the incidence of severe postoperative pain self-reported after hospital discharge was high. Anxiety and severe preoperative pain, in addition to performing two surgical procedures at the same time were confirmed as risk factors.

Predictive variables of prescription opioid misuse in patients with chronic noncancer pain. Development of a risk detection scale: A registered report protocol

BACKGROUND

Opioid therapy is utilized for a broad range of chronic pain conditions. Several studies have highlighted the adverse effects of opioid medication due to the misuse of these drugs. The gradual increase in the use of opioids has become a global phenomenon and is generating social concern. Several treatment guidelines have strongly recommended assessing the risks and benefits of pharmacological treatment with opioids. These guidelines also recommend the psychological assessment of patients with chronic noncancer pain in order to make informed decisions on the advisability of intervention with opioids. Some authors have emphasized the relevance of assessing the risk of opioid misuse in patients with noncancer chronic pain before initiating treatment.

METHODS AND ANALYSIS

Two studies will be conducted, each with a different primary objective. The primary objective of the first study (Study 1) will be to conduct a comprehensive investigation to identify the factors most closely associated with subsequent opioid misuse; and based on the results of Study 1, the primary objective of the second study (Study 2) will be to develop a brief, reliable, valid, and useful instrument that would enable health care providers to make decisions on opioid prescription and on the required level of monitoring and follow-up. These decisions would have positive consequences for patient wellbeing. Study 1 will include a logistic regression analysis to test the hypothetical model. Study 2 will have a longitudinal design and include three assessment sessions in order to develop a measure to assess the risk of prescribed opioid misuse and to analyse its reliability and validity. Participants will be individuals with chronic noncancer pain attending three Pain Units. These individuals will either be undergoing pharmacological treatment that includes opioid analgesics (Study 1, N = 400) or are going to commence such treatment (Study 2, N = 250).

A Multi-Method Approach to Understand Parent Behaviors During Child Acute Pain

Abstract. Parent behaviors strongly predict child responses to acute pain; less studied are the factors shaping parent behaviors. Heart rate variability (HRV) is considered a physiological correlate of emotional responding. Resting or “trait” HRV is indicative of the capacity for emotion regulation, while momentary changes or “state” HRV is reflective of current emotion regulatory efforts. This study aimed to examine: (1) parent state HRV as a contributor to parent verbal behaviors before and during child pain and (2) parent trait HRV as a moderator between parent emotional states (anxiety, catastrophizing) and parent behaviors. Children 7–12 years of age completed the cold pressor task (CPT) in the presence of a primary caregiver. Parents rated their state anxiety and catastrophizing about child pain. Parent HRV was examined at 30-second epochs at rest (“trait HRV”), before (“state HRV-warm”), and during their child’s CPT (“state HRV-cold”). Parent behaviors were video recorded and coded as coping-promoting or distress-promoting. Thirty-one parents had complete cardiac, observational, and self-report data. A small to moderate negative correlation emerged between state HRV-cold and CP behaviors during CPT. Trait HRV moderated the association between parent state catastrophizing and distress-promoting behaviors. Parents experiencing state catastrophizing were more likely to engage in distress-promoting behavior if they had low trait HRV. This novel work suggests parents who generally have a low (vs. high) HRV, reflective of low capacity for emotion regulation, may be at risk of engaging in behaviors that increase child distress when catastrophizing about their child’s pain.

The role of anxiety and related states in pediatric postsurgical pain

Background: Nearly 20% of children and adolescents have pain with disability 1 year after surgery, and they experience poor sleep, school absence, and decreased activities. Negative clinical, psychological, and developmental effects include greater pain medication use, longer recovery, and fear of future medical care. Research has found psychological and family influences (i.e., child and parental anxiety) on pediatric chronic postsurgical pain (CPSP), but a better understanding of the role of perioperative anxiety and its related states in predicting pediatric postsurgical pain is needed. The poor understanding of the causes of child CPSP can lead to misdiagnosis and inadequate treatment, with significant short- and long-term effects. Objectives: The aim of this review was to summarize the literature on children's perioperative anxiety and parental anxiety in relation to acute postsurgical pain, CPSP, and pain trajectories. We also examined other related psychological factors (i.e., anxiety sensitivity, catastrophizing, pain anxiety, and fear of pain) in relation to pediatric acute and chronic postsurgical pain. Lastly, we discuss the interventions that may be effective in reducing children's and parents' preoperative anxiety. Conclusions: Our findings may improve the understanding of the causes of CPSP and highlight the gaps in research and need for further study.

A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents

Acute and chronic pain are highly prevalent and impactful consequences of surgery across the lifespan, yet a comprehensive conceptual model encompassing biopsychosocial factors underlying acute to chronic pain transition is lacking, particularly in youth. Building on prior chronic postsurgical pain models, we propose a new conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain. This review aims to summarize existing research examining key factors underlying acute to chronic postsurgical pain transition in order to guide prevention and intervention efforts aimed at addressing this health issue in children. As pain transitions from acute nociceptive pain to chronic pain, changes in the peripheral and central nervous system contribute to the chronification of pain after surgery. These changes include alterations in sensory pain processing and psychosocial processes (psychological, behavioral, and social components), which promote the development of chronic pain. Patient-related premorbid factors (eg, demographic factors, genetic profile, and medical factors such as premorbid pain) may further modulate these changes. Factors related to acute injury and recovery (eg, surgical and treatment factors), as well as biological response to surgery (eg, epigenetic, inflammatory, and endocrine factors), may also influence this process. Overall, longitudinal studies examining temporal pathways of biopsychosocial processes including both risk and resiliency factors will be essential to identify the mechanisms involved in the transition from acute to chronic pain. Research is also needed to unravel connections between the acute pain experience, opioid exposure, and sensory pain processing during acute to chronic pain transition. Furthermore, future studies should include larger and more diverse samples to more fully explore risk factors in a broader range of pediatric surgeries. The use of conceptual models to guide intervention approaches targeting mechanisms of transition from acute to chronic pain will significantly advance this field and improve outcomes for children and adolescents undergoing surgery.

The Co-occurrence of Pediatric Chronic Pain and Anxiety: A Theoretical Review of a Developmentally Informed Shared Vulnerability Model

The development and maintenance of pediatric chronic pain and anxiety are complex, underscoring the need to better understand the interactive forces contributing to their co-occurrence. The shared vulnerability model (SVM) was developed to explain the co-occurrence of chronic pain and posttraumatic stress disorder in adults. Although many core tenets have been well supported by pediatric research, the SVM has yet to be extended to pediatric pain populations. We propose a developmentally informed pediatric SVM for advancing our understanding of the co-occurrence of pediatric chronic pain and anxiety disorders. The proposed SVM postulates that youth at increased risk for the development of chronic pain and/or anxiety share predisposing vulnerabilities, including anxiety sensitivity, and that these shared vulnerabilities give rise to negative emotional responses (child and parent) in the context of stressful events. Consequences of fear and anxiety, including avoidance behavior, further contribute to the development of chronic pain, anxiety, and their co-occurrence. The parental, school, and peer contexts in which these problems develop and are maintained in youth are pertinent to integrate into a SVM, as pediatric chronic pain and anxiety disorders share several social-contextual risk and maintenance factors. We also highlight new areas of inquiry.

The Potential Role of Preoperative Pain, Catastrophizing, and Differential Gene Expression on Pain Outcomes after Pediatric Spinal Fusion

BACKGROUND

Adolescent idiopathic scoliosis is one of the most common spinal deformities in children and adolescents requiring extensive surgical intervention. Due to the nature of surgery, spinal fusion increases their risk of experiencing persistent postsurgical pain. Up to 20% of adolescents report pain for months or years after corrective spinal fusion surgery.

AIMS

To examine the influence of preoperative psychosocial factors and mRNA expression profiles on persistent postoperative pain in adolescents undergoing corrective spinal fusion surgery.

DESIGN

Prospective, longitudinal cohort study.

SETTING

Two freestanding academic children's hospitals.

METHODS

Utilizing a longitudinal approach, adolescents were evaluated at baseline (preoperatively) and postoperatively at ±1 month and ±4-6 months. Self-report of pain scores, the Pain Catastrophizing Scale-Child, and whole blood for RNA sequencing analysis were obtained at each time point.

RESULTS

Of the adolescents enrolled in the study, 36% experienced persistent pain at final postoperative follow-up. The most significant predictors of persistent pain included preoperative pain severity and helplessness. Gene expression analysis identified HLA-DRB3 as having increased expression in children who experienced persistent pain postoperatively, as opposed to those whose pain resolved. A prospective validation study with a larger sample size is needed to confirm these findings.

CONCLUSIONS

While adolescent idiopathic scoliosis is not often classified as a painful condition, providers must be cognizant of pre-existing pain and anxiety that may precipitate a negative recovery trajectory. Policy and practice change are essential for early identification and subsequent intervention.

A retrospective cohort study of predictors and interventions that influence cooperation with mask induction in children

BACKGROUND

Uncooperative pediatric mask induction is linked to perioperative anxiety. Although some risk factors for uncooperative inductions have been reported, there are no large cohort studies that identify intrinsic patient characteristics associated with cooperation.

AIM

The primary aim was to identify patient characteristics associated with cooperative mask inductions. The secondary aim was to determine whether preoperative interventions were associated with increased cooperation.

METHODS

This retrospective cohort study included patients 2-11 years old and ASA class I-IV who underwent mask induction. Our primary outcome of interest was cooperation with mask induction, which was correlated against the Induction Compliance Checklist. The variables analyzed for association with cooperation were age, sex, ASA class, class of surgery, preferred language, and race. Interventions examined for association with induction cooperation included premedication with midazolam, exposure to distraction technology, parental presence, and the presence of a Child Life Specialist. Multivariate mixed-effects logistic regression was used to assess the relationship between patient characteristics and cooperation. A separate multivariate mixed-effects logistic regression was used to examine the association between preoperative interventions and cooperation.

RESULTS

9692 patients underwent 23 474 procedures during the study period. 3372 patients undergoing 5980 procedures met inclusion criteria. The only patient characteristic associated with increased cooperation was age (OR 1.20, p-value 0.03). Involvement of Child Life Specialists was associated with increased cooperation (OR 4.44, p-value = 0.048) while parental/guardian presence was associated with decreased cooperation (OR 0.38, p-value = 0.002).

CONCLUSION

In this cohort, increasing age was the only patient characteristic found to be associated with increased cooperation with mask induction. Preoperative intervention by a Child Life Specialists was the sole intervention associated with improved cooperation.

Psychosocial Predictors of Acute and Chronic Pain in Adolescents Undergoing Major Musculoskeletal Surgery

Acute and chronic pain delay recovery and impair outcomes after major pediatric surgery. Understanding unique risk factors for acute and chronic pain is critical to developing effective treatments for youth at risk. We aimed to identify adolescent and family psychosocial predictors of acute and chronic postsurgical pain after major surgery in adolescents. Participants included 119 youth age 10 to 18 years (M_age = 14.9; 78.2% white) undergoing major musculoskeletal surgery and their parents. Participants completed presurgery baseline questionnaires, with youth reporting on baseline pain, anxiety, depression, insomnia and sleep quality, and parents reporting on parental catastrophizing and family functioning. At baseline, 2-week, and 4-month postsurgery, youth completed 7 days of daily pain diaries and reported on health-related quality of life. Sequential logistic regression models examined presurgery predictors of acute and chronic postsurgical pain, defined as significant pain with impairment in health-related quality of life. Acute pain was experienced by 27.2% of youth at 2 weeks, while 19.8% of youth met criteria for chronic pain at 4 months. Baseline pain predicted acute pain (odds ratio [OR] = 1.96; 95% confidence interval [CI] = 1.32-2.90), while depressive symptoms (OR = 1.22; 95%CI = 1.01-1.47), and sleep quality (OR = 0.26; 95%CI = 0.08-0.83) predicted chronic pain. Tailored interventions need to be developed and incorporated into perioperative care to address risk factors for acute and chronic pain. PERSPECTIVE: Longitudinal results demonstrate adolescents' presurgery pain severity predicts acute postsurgical pain, while depressive symptoms and poor sleep quality predict chronic postsurgical pain. Tailored interventions should address separate risk factors for acute and chronic pain after adolescent surgery.

Parent Factors are Associated With Pain and Activity Limitations in Youth With Acute Musculoskeletal Pain: A Cohort Study

OBJECTIVES

Biopsychosocial models emphasize the influence of parent/family factors on pediatric chronic pain. Little is known about how parent factors differ across the acute to chronic pain continuum, or contribute to youths' pain experience in the acute pain period. The purpose of the study was to describe parent factors in youth with acute musculoskeletal pain (n=84) compared with youth with chronic pain (n=60) and youth without pain (n=61). Further, within the acute pain sample, we tested parent factors as predictors of child pain characteristics, as well as the moderating role of child sex on associations.

METHODS

Participants were 205 youth (age, 10 to 17) and one biological parent per child. Children reported on their own pain and activity limitations. Parents reported on their own chronic pain, somatization, and protective pain responses.

RESULTS

Parents of youth with acute pain had higher prevalence of chronic pain and greater somatization than parents of youth without pain. Parents of youth with acute and chronic pain did not differ. Linear regressions within the acute pain sample revealed presence of parent chronic pain and protective behavior were associated with child pain. Moreover, parent somatization was associated with child activity limitations. Within the acute pain sample, associations between parent protectiveness and child pain were moderated by child sex, with relationships stronger for female children.

DISCUSSION

Findings highlight the importance of parent factors on pain experiences of youth with acute musculoskeletal pain. Future longitudinal research can elucidate temporal associations that underlie how parent factors may impact transition from acute to chronic pain.

Reducing Children's Pain and Parents' Anxiety in the Postoperative Period: A Therapeutic Model in Turkish Sample

PURPOSE

This study was conducted to determine the effect of a new therapeutic model (a therapeutic play/play therapy (TP/PT) program) on alleviating pain in children receiving inpatient treatment in paediatric surgery units and parents' anxiety levels in the post-operative period.

DESIGN AND METHODS

The study was designed as a semi-experimental model using the TP/PT program. Four measurements (pre-test, two interim tests and post-test) for children and two measurements (pre-test and post-test) for parents were performed. The data were collected using the Child and Parent Information Form, the Wong-Baker Faces Pain (WBFP) Rating Scale and the State-Trait Anxiety Inventory (STAI).

RESULTS

The mean pain score for children after TP/PT decreased in each measurement, and a significant difference was found between these measurements. The mean state anxiety score for parents significantly decreased after the TP/PT program, and a statistically significant difference was found between these measurements (p = 0.000).

CONCLUSIONS

This study determined that the post-operative TP/PT program was an effective method to reduce acute post-operative pain in children. Parental anxiety levels were found to correlate with levels of pre- and post-operative pain in children.

PRACTICE IMPLICATIONS

The findings of this study provide a basis for using a new therapeutic model that is easy to apply and effective for reducing children's pain and parents' anxiety.

Predicting Acute Postoperative Pain Trajectories and Long-Term Outcomes of Adolescents after Spinal Fusion Surgery

Objectives

Acute pain trajectories are associated with long-term outcomes such as persistent pain and functional disability in adults. However, there are limited data on acute postoperative pain trajectories in the pediatric population. The aims of this study were to investigate acute postoperative pain trajectories, their predictors, and their impact on long- term outcomes in adolescents with idiopathic scoliosis.

Methods

We evaluated the preoperative pain intensity, use of analgesics, psychosocial measures and physical functioning of adolescents scheduled to undergo spinal fusion, and their average 6-hour self-reported pain intensity scores for their entire hospital stay. Six months after surgery, baseline variables were reassessed. We used growth mixture modeling to conduct acute postoperative pain trajectory analysis and to identify predictors of pain trajectories. Generalized linear models were conducted to determine whether acute pain trajectories predict long-term outcomes.

Results

One hundred and six patients were included in the best-fitted acute pain trajectory model that included four classes that differed in initial pain intensity and rates of change over time. Preoperative pain catastrophizer status and use of analgesics significantly predicted pain trajectory membership. Furthermore, at the 6-month follow-up, patients experiencing moderate-to-severe pain in the acute postoperative period were more likely to report higher levels of pain severity, use pain medication, and miss a greater number of school/work days due to back pain in the last three months. Discussion. Preoperative assessment and analyzing the progression of pain in the acute postoperative period can help identify those at risk of negative long-term outcomes after surgery.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child’s pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children’s self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

Pain Catastrophizing in Childhood Migraine: An Observational Study in a Tertiary Headache Center

Background: Migraine is the most common cause of primary headache in children leading to a decrease in the quality of life. During the last decade, pain catastrophizing construct became a major focus of interest in the study and treatment of pain.

Aim of the study:

To evaluate pain catastrophizing in episodic and chronic migraine children and adolescents selected in a tertiary headache Center.

To test whether the children's pain catastrophizing might be associated (a) with the frequency of attacks and disability (b) with psychopathological aspects (c) with allodynia and total tenderness score as symptom of central sensitization.

To test the best discriminating clinical variables and scores between episodic and chronic migraine, including pain catastrophizing.

Methods: We conducted a cross sectional observational study on consecutive pediatric patients affected by migraine. We selected 190 headache patients who met the diagnostic criteria for Migraine without aura, Migraine with aura and Chronic migraine. We submitted all children to the Child version of the Pain Catastrophizing Scale (PCS-C), and to the disability scale for migraine (PedMIDAS), general quality of life estimated by children (PedsQL) and parents (PedsQL-P), anxiety and depression (SAFA-A; SAFA-D) scales. We also evaluated headache frequency and the presence and severity of allodynia and pericranial tenderness.

Results: No difference was detected in Total Pain Catastrophizing score (PCS-C) between chronic and episodic migraine groups (ANOVA F = 0.59, p = 0.70); the PedMIDAS, the PedsQL-P for physical functioning and the Total Tenderness Score were discriminant variables between episodic and chronic migraine. The PCS-C was not correlated with migraine related disability as expressed by Ped MIDAS, but it was significantly correlated with general low quality of life, allodynia, pericranial tenderness, anxiety, and depression.

Conclusion: Pain catastrophizing seems a mental characteristic of a clinical phenotype with psychopathological traits and enhanced expression of central sensitization symptoms. This clinical profile causes general decline in quality of life in the child judgment, with a probable parents' underestimation. In childhood age, it would not be a feature of chronic migraine, but the possibility that it could predict this evolution is consistent and worthy of further prospective evaluation.

Randomized Trial Evaluating the Effectiveness of Coloring on Decreasing Anxiety Among Parents in a Pediatric Surgical Waiting Area

Anxiety is common among pediatric surgical patients and their parents. Numerous studies have examined interventions to reduce pediatric patients' anxiety; however, less is known about reducing parental anxiety. In other populations, producing art has been shown to significantly reduce anxiety.

PURPOSE

This study aimed to determine whether parents' anxiety decreased after coloring while their child is in surgery.

DESIGN AND METHODS

A block randomized controlled trial was conducted with a convenience sample of 106 parents of children who were having a scheduled surgery. Each day of data collection was randomized where all parents enrolled that day would either color a pre-drawn art template for 30min or would simply wait in the waiting room for 30min. The primary outcome measure was anxiety, measured by the 6-item short form of the Spielberger State Trait Anxiety Inventory (STAI).

RESULTS

Parents' average anxiety score decreased from the initial measurement to the measurement 30min later in both the control group and the intervention group. The reduction in anxiety was significantly greater for those parents who participated in coloring during their wait (p<0.0001).

CONCLUSIONS

Coloring is a creative, simple, low cost, and effective activity to reduce anxiety among parents in a pediatric surgical waiting area.

PRACTICE IMPLICATIONS

Providing coloring materials and information about the benefits of coloring in pediatric surgery waiting areas is an easy to implement intervention to reduce parental anxiety.

Cold Pressor Pain Response in Children With Cancer

OBJECTIVE

The goal of this study was to examine pain responses in pediatric patients with cancer.

METHOD

Children (ages 6 to 18) undergoing treatment for cancer (N=68) completed the cold pressor task.

RESULTS

Average pain tolerance was 118.22 seconds (SD=101.18) and 40% of the children kept their hand in the water the entire 4-minute ceiling. On a 0 to 10 numeric rating scale, children reported a pain severity of 5.07 (SD=3.47) at their first report of pain, a pain severity of 5.94 (SD=3.54) at their maximum report of pain, and a pain severity of 5.33 (SD=3.72) at the time they reached pain tolerance. Children receiving chemotherapy agents (N=56) with possible neuropathic effects exhibited higher pain tolerance compared with children not receiving such treatments (N=10), β=0.84, SE=0.38, Wald χ1=4.88, P=0.027, hazard ratio=2.33, 95% confidence interval (1.10-4.92).

CONCLUSIONS

This study provides data on experimental pain responses in a sample of children undergoing cancer treatment and suggests that pain experience may be moderated by cancer treatment type.

Child and parent pain catastrophizing and pain from presurgery to 6 weeks postsurgery: examination of cross-sectional and longitudinal actor-partner effects

Child and parent pain catastrophizing are reported preoperative risk factors for children's acute and persistent postsurgical pain. This study examined dyadic relations between child and parent pain catastrophizing and child and parent ratings of child pain prior to (M = 4.01 days; "baseline") and following surgery (M = 6.5 weeks; "acute follow-up"), as well changes in pain catastrophizing during this time in 167 youth (86% female; Mage = 14.55 years) undergoing spinal fusion surgery and 1 parent (89% mothers). Actor-partner interdependence models assessed cross-sectional and longitudinal intra- and interpersonal effects. Cross-sectionally, child pain catastrophizing was positively associated with child pain at baseline and acute follow-up (actor effects: βbaseline = 0.288 and βfollow-up = 0.262; P < 0.01), and parents' ratings of child pain at baseline (partner effect: βbaseline = 0.212; P < 0.01). Parent pain catastrophizing was not cross-sectionally associated with ratings of child pain. Longitudinally, higher pain catastrophizing at baseline predicted higher pain catastrophizing at acute follow-up for children (actor effect: β = 0.337; P < 0.01) and parents (actor effect: β = 0.579; P < 0.01) with a significantly smaller effect for children (respondent × actor interaction: β = 0.121; P < 0.05). No longitudinal partner effects for catastrophizing were observed. Baseline child and parent pain catastrophizing did not predict child pain at acute follow-up. In conclusion, child, not parent, pain catastrophizing was associated with children's pre- and postsurgical pain, and showed significantly less stability over time. There is a need to better understand contributors to the stability or changeability of pain catastrophizing, the prospective relation of catastrophizing to pain, and contexts in which child vs parent pain catastrophizing is most influential for pediatric postsurgical pain.

Safety of Patient-Controlled Analgesia After Surgery in Children And Adolescents: Concerns And Potential Solutions

Patient-controlled analgesia (PCA) is common practice for acute postoperative pain management. Postoperative PCA use decreases pain intensity and improves patient satisfaction when compared to non-PCA routes of medication administration. Although PCA has several advantages regarding efficacy and safety, adverse events remain a concern. Programming errors and protocols, patient monitoring, and PCA by proxy or with continuous infusion are recurring silent dangers of PCA use in children and adolescents. Innovative considerations need to be emphasized for future improvement of PCA devices for elective surgical patients. With technology within the healthcare setting advancing at a fast pace, smart pump technology is something to look forward to.

Factors Predicting Parent Anxiety Around Infant and Toddler Postoperative and Pain

BACKGROUND AND OBJECTIVES

Understanding of parent anxiety and its effect on infant postoperative pain is limited. We sought to identify psychological factors associated with preoperative anxiety for parents of infants and toddlers undergoing elective surgery and to determine whether parent anxiety is associated with child postoperative pain.

METHODS

This was a prospective cohort study of consecutively eligible patients aged ≤18 months undergoing craniofacial surgery and their parents. Preoperative parent assessment included anxiety, coping, parent health locus of control, and self-efficacy. Postoperative inpatient child pain scores and medication use were collected. Analyses included hierarchical multivariable logistic and linear regression models.

RESULTS

Parents (n = 71, 90% female) of young children (mean age 6.6 months) undergoing cleft lip or palate (n = 59) or cranial vault repair (n = 13) were enrolled. Maladaptive coping (odds ratio 1.3; 95% confidence interval, 1.1-1.6), low parent self-efficacy (odds ratio 2.4; 95% confidence interval, 1.3-4.5), and external locus of control (odds ratio 1.74; 95% confidence interval, 1.1-2.9) were independently associated with high parental anxiety. The adjusted odds of moderate/severe parent anxiety was 3.6 (95% confidence interval, 1.5-9.1) higher with each SD increase in maladaptive coping. High parental anxiety was correlated with significantly higher hospital mean child pain scores (1.87 points on 0-10 scale; 95% confidence interval, 0.42-3.70; P = .045).

CONCLUSIONS

Coping and self-efficacy are modifiable factors that contribute to parent anxiety before and during hospitalization and may be targets for intervention. Infants and toddlers undergoing elective craniofacial surgery with highly anxious parents may be at greater risk for higher postoperative pain.

Dyadic analysis of child and parent trait and state pain catastrophizing in the process of children's pain communication

When explored separately, child and parent catastrophic thoughts about child pain show robust negative relations with child pain. The objective of this study was to conduct a dyadic analysis to elucidate intrapersonal and interpersonal influences of child and parent pain catastrophizing on aspects of pain communication, including observed behaviours and perceptions of child pain. A community sample of 171 dyads including children aged 8 to 12 years (89 girls) and parents (135 mothers) rated pain catastrophizing (trait and state versions) and child pain intensity and unpleasantness following a cold pressor task. Child pain tolerance was also assessed. Parent-child interactions during the cold pressor task were coded for parent attending, nonattending, and other talk, and child symptom complaints and other talk. Data were analyzed using the actor-partner interdependence model and hierarchical multiple regressions. Children reporting higher state pain catastrophizing had greater symptom complaints regardless of level of parent state pain catastrophizing. Children reporting low state pain catastrophizing had similar high levels of symptom complaints, but only when parents reported high state pain catastrophizing. Higher child and parent state and/or trait pain catastrophizing predicted their own ratings of higher child pain intensity and unpleasantness, with child state pain catastrophizing additionally predicting parent ratings. Higher pain tolerance was predicted by older child age and lower child state pain catastrophizing. These newly identified interpersonal effects highlight the relevance of the social context to children's pain expressions and parent perceptions of child pain. Both child and parent pain catastrophizing warrant consideration when managing child pain.

Trajectories of postsurgical pain in children: risk factors and impact of late pain recovery on long-term health outcomes after major surgery

Over 1 million children undergo inpatient surgery annually in the United States. Emerging research indicates that many children have longer-term problems with pain. However, limited data exist on the course of pain over time and the impact of pain recovery on long-term health outcomes. We sought to prospectively characterize children's postsurgical pain trajectories using repeated assessments over 12 months. In addition, we identified presurgical child and parent psychological risk factors associated with persistent pain and examined relationships between pain trajectories and long-term health outcomes. Sixty children aged 10 to 18 years undergoing major surgery and their parent/guardian were enrolled. Participants completed assessments at 5 time points: presurgery, inhospital, 2 weeks, 4 months, and 1 year postsurgery. Child and parent pain catastrophizing was assessed during the week before surgery. Children completed daily monitoring with an electronic pain diary and reported on pain characteristics, health-related quality of life, and activity limitations. Group-based longitudinal modeling revealed 2 distinct trajectories of postsurgical pain: early recovery (n = 49, 82%) and late recovery (n = 11, 18%). In a logistic regression model controlling for age and sex, parental pain catastrophizing before surgery significantly predicted membership in the late recovery group (odds ratio = 1.11, P = 0.03), whereas child catastrophizing and baseline pain did not (Ps < 0.05). In a multivariate regression controlling for age and sex, late pain recovery was significantly associated with poorer health-related quality of life (β = -10.7, P = 0.02) and greater activity limitations (β = 3.6, P = 0.04) at 1 year. Our findings suggest that preoperative interventions that modify parent behaviors and cognitions might be beneficial in this population.

Anxiety sensitivity is associated with attentional bias for pain-related information in healthy children and adolescents

This investigation explored the association between anxiety sensitivity and attentional bias for threatening information in children and adolescents ( N = 40). Participants completed a pictorial version of the visual-probe task, featuring pain-related, health-threat and general-threat images presented for 500 and 1250 ms. Regression analyses revealed significant associations between anxiety sensitivity and attentional bias towards pain-related images presented for 500 ms and between state anxiety and attentional bias towards general-threat images presented for 1250 ms. These results suggest that in children and adolescents, anxiety sensitivity is associated with attentional bias for negative information of personal relevance.

Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall

Children's memories for pain play a powerful role in their pain experiences. Parents' memories may also influence children's pain experiences, by influencing parent-child interactions about pain and children's cognitions and behaviors. Pain catastrophizing of children and parents has been implicated as a factor underlying memory biases; however, this has not been empirically examined. The current longitudinal study is the first to examine the role of pain catastrophizing of children and parents in the development of their pain memories after surgery. Participants were 49 youth (32 girls) aged 10 to 18 years undergoing major surgery and their parents. One week before surgery, children and parents completed measures of pain catastrophizing. Two weeks after surgery (the acute recovery period), children and parents completed measures of child pain intensity and affect. Two to 4 months after surgery, children's and parents' memories of child pain intensity and affect were elicited. Hierarchical linear regression models revealed that over and above covariates, parent catastrophizing about their child's pain (magnification, rumination) accounted for a significant portion of variance in children's affective and parents' sensory pain memories. Although parent catastrophizing had a direct effect on pain memories, mediation analyses revealed that child catastrophizing (helplessness) indirectly influenced children's and parents' pain memories through the child's postoperative pain experience. Findings highlight that aspects of catastrophic thinking about child pain before surgery are linked to distressing pain memories several months later. Although both child and parent catastrophizing influence pain memory development, parent catastrophizing is most influential to both children's and parents' evolving cognitions about child pain.

Effects of a Clown-Nurse Educational Intervention on the Reduction of Postoperative Anxiety and Pain Among Preschool Children and Their Accompanying Parents in South Korea

This study examined the effects of a clown-nurse educational intervention on children undergoing day surgery for strabismus. This was a quasi-experimental study, using a nonequivalent control group, non-synchronized design. Fifty preschool children and their parents were invited to participate. The children in the intervention group (n=23) received clown therapy and subsequently reported significantly lower states of physiological anxiety, which was evidenced by systolic blood pressure, standardized behavioral anxiety tests, and post-surgery pain, than the control group (n=27). In addition, the parents in the experimental group showed a low state of physiological anxiety, evidenced by systolic blood pressure, pulse rates, standardized behavioral anxiety tests, and state-trait anxiety. The use of preoperative clown intervention may alleviate postoperative problems, not only for children, but also for their parents.

Can Preoperative Psychological Assessment Predict Outcomes After Temporomandibular Joint Arthroscopy?

PURPOSE

Psychological assessment has been used successfully to predict patient outcomes after cardiothoracic and bariatric surgery. The purpose of this study was to determine whether preoperative psychological assessment could be used to predict patient outcomes after temporomandibular joint arthroscopy.

MATERIALS AND METHODS

Consecutive patients with temporomandibular dysfunction (TMD) who could benefit from arthroscopy were enrolled in a prospective cohort study. All patients completed the Millon Behavior Medicine Diagnostic survey before surgery. The primary predictor variable was the preoperative psychological scores. The primary outcome variable was the difference in pain between the pre- and postoperative periods. The Spearman rank correlation coefficient and the Pearson product-moment correlation were used to determine the association between psychological factors and change in pain. Univariable and multivariable analyses were performed using a mixed-effects linear model and multiple linear regression. A P value of .05 was considered significant.

RESULTS

Eighty-six patients were enrolled in the study. Seventy-five patients completed the study and were included in the final analyses. The mean change in visual analog scale (VAS) pain score 1 month after arthroscopy was -15.4 points (95% confidence interval, -6.0 to -24.7; P < .001). Jaw function also improved after surgery (P < .001). No association between change in VAS pain score and each of the 5 preoperative psychological factors was identified with univariable correlation analyses. Multivariable analyses identified that a greater pain decrease was associated with a longer duration of preoperative symptoms (P = .054) and lower chronic anxiety (P = .064).

CONCLUSIONS

This study has identified a weak association between chronic anxiety and the magnitude of pain decrease after arthroscopy for TMD. Further studies are needed to clarify the role of chronic anxiety in the outcome after surgical procedures for the treatment of TMD.

Eating behaviors and quality of life in preadolescents at risk for obesity with and without abdominal pain

OBJECTIVES

We evaluated eating behaviors and quality of life (QOL) in preadolescent children at risk for obesity, with and without abdominal pain (AP).

METHODS

Participants were parent-child dyads enrolled in a randomized, controlled obesity prevention trial. The children were between 5 and 10 years of age and at risk for obesity (70th-95th percentile of body mass index, n = 420). Parents completed measures of their child's eating behaviors, QOL, AP, and bowel function and their own depression status, concern about child weight, and feeding practices. Children's height and weight were also measured.

RESULTS

Children with frequent AP (≥2/month, n = 103) were compared with children reporting infrequent AP (<2/month, n = 312). Age and body mass index did not differ between groups, but AP was more prevalent in girls. Child emotional overeating and parental depression scores were higher in the frequent AP group (P < 0.01), and child QOL was lower (P < 0.01). In multivariable analysis, female gender (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.20-3.97), emotional overeating (OR 2.28, 95% CI 1.37-3.81), and parental depression (OR 1.23, 95% CI 1.12-1.35) were associated with more frequent AP. Secondary analyses were completed for children who met Rome III criteria for irritable bowel syndrome.

CONCLUSIONS

Clinicians working with children with AP at risk for obesity should consider assessing for and, when appropriate, addressing parent and child factors that could exacerbate AP.

The effect of audio therapy to treat postoperative pain in children undergoing major surgery: a randomized controlled trial

PURPOSE

To evaluate the analgesic effect of music and audiobooks in children undergoing major surgical procedures when compared to a control (silence) group.

METHODS

The study was a prospective and randomized trial. Children undergoing major surgeries were randomized to one of the three groups: music, audiobook or control (silence). The primary outcome was the pain burden reduction by two treatments within 48 h postoperatively. Pain burden was measured using the area under the pain scale versus the 30 min interval for each treatment.

RESULTS

60 patients were recruited and 56 completed the study. Pain burden was reduced in the music and audiobook groups compared to control, median (IQR) of -60 (-90 to 0), -45 (-90 to 0) and 0 (-30 to 90) (min × pain score), respectively, P = 0.04. A linear regression analysis demonstrated an independent group effect on pain reduction even after adjusting for the mean pain scores recorded at the beginning of the treatment, slope of regression line -56.8 ± 24 goodness of fit r (2) = 0.25 and slope significantly different from 0 (P = 0.02).

CONCLUSIONS

Audio therapy is an efficacious adjunct method to decrease post-surgical pain in children undergoing major surgeries. Audio therapy should be considered as an important strategy to minimize pain in children undergoing major surgery.

Presurgical psychosocial predictors of acute postsurgical pain and quality of life in children undergoing major surgery

Limited research has examined presurgical risk factors for poor outcomes in children after major surgery. This longitudinal study examined presurgical psychosocial and behavioral factors as predictors of acute postsurgical pain intensity and health-related quality of life (HRQOL) in children 2 weeks after major surgery. Sixty children aged 10 to 18 years, 66.7% female, and their parent/guardian participated in the study. Children underwent baseline assessment of pain (daily electronic diary), HRQOL, sleep (actigraphy), and psychosocial factors (anxiety, pain catastrophizing). Caregivers reported on parental pain catastrophizing. Longitudinal follow-up assessment of pain and HRQOL was conducted at home 2 weeks after surgery. Regression analyses adjusting for baseline pain revealed that presurgery sleep duration (β = -.26, P < .05) and parental pain catastrophizing (β = .28, P < .05) were significantly associated with mean pain intensity reported by children 2 weeks after surgery, with shorter presurgery sleep duration and greater parental catastrophizing about child pain predicting greater pain intensity. Adjusting for baseline HRQOL, presurgery child state anxiety (β = -.29, P < .05) was significantly associated with HRQOL at 2 weeks, with greater anxiety predicting poorer HRQOL after surgery. In conclusion, child anxiety, parental pain catastrophizing, and sleep patterns are potentially modifiable factors that predict poor outcomes in children after major surgery.

PERSPECTIVE

This study addresses an important gap in literature, examining presurgical risk factors for poorer acute postsurgical outcomes in children undergoing major surgery. Knowledge of these factors will enable presurgical identification of children at risk for poorer outcomes and guide further research developing prevention and intervention strategies for these children.

Tablet-based Interactive Distraction (TBID) vs oral midazolam to minimize perioperative anxiety in pediatric patients: a noninferiority randomized trial

INTRODUCTION

Perioperative anxiety is a common and undesirable outcome in pediatric surgical patients. The use of interactive tools to minimize perioperative anxiety is vastly understudied. The main objective of the current investigation was to compare the effects of a tablet-based interactive distraction (TBID) tool to oral midazolam on perioperative anxiety. We hypothesized that the TBID tool was not inferior to midazolam to reduce perioperative anxiety.

METHODS

108 children, ages 1-11 years, presenting for outpatient surgical procedures were prospectively randomized to oral midazolam (0.5 mg·kg(-1); 20 mg max) or TBID. The primary outcome was the change in anxiety level from baseline to parental separation and anesthetic induction. Other data collected included emergence delirium, parental satisfaction, time-to-PACU discharge, and posthospitalization behavior.

RESULTS

The mean difference (95% CI) in the increase of anxiety at parental separation between the TBID and the midazolam group was -9 (-2.6 to -16.4), P = 0.006, demonstrating superiority to midazolam group (one-sided P = 0.003). For children 2-11 years, the mean difference (95% CI) in anxiety at induction was significant between the TBID and midazolam groups, -14.0 (-6.1 to -22.0), P < 0.001. The median (IQR) time-to-PACU discharge was 111 (75-197) min in the midazolam group and 87 (55-137) min in the TBID group, P = 0.03. Decreased emergence delirium and increased parental satisfaction were also observed in the TBID group.

CONCLUSIONS

A TBID tool reduces perioperative anxiety, emergence delirium, and time-to-discharge and increases parental satisfaction when compared to midazolam in pediatric patients undergoing ambulatory surgery.