Gender differences in post-operative pain and patient controlled analgesia use among adolescent surgical patients

Reasons and Risk Factors for Same-Day Discharge Following Total Joint Arthroplasty: A Systematic Review

Background

Nowadays, emphasis is being given to same-day discharge (SDD) following total joint arthroplasty. Unfortunately, despite a high degree of success, there are instances of failed SDD. Therefore, we aim to conduct a systematic review to evaluate factors contributing to failed SDD after total joint arthroplasty.

Methods

Pubmed, Scopus, Cochrane, and Google Scholar were searched. The Newcastle Ottawa score was used for the quality assessment of selected studies. All the studies were evaluated through a narrative synthesis. A total of 11 studies evaluating 157,045 patients were selected. The mean age of patients was 62.5 years.

Results

Elderly patients (odds ratio [OR] 1.01 to OR 3.13), women (OR 1.63 to OR 2.87), non-white race (OR 1.31 to OR 2.19), hypertension (OR 1.11 to OR 1.41), diabetes (OR 1.25 to OR 4.06), cardiovascular diseases (OR 1.67 to OR 12.06), chronic obstructive pulmonary disease (OR 1.30 to OR 1.96), bleeding disorders (OR 1.32 to OR 1.52), obesity (OR 1.35 to OR 3.30), steroid use (OR 1.23 to OR 1.52), late procedure start time (OR 1.22 to OR 5.16), higher postoperative pain (OR 1.93 to OR 5.85), high American Society of Anesthesiologists score (OR 0.92 to OR 3.50) were major predictors of failed SDD.

Conclusions

Through our review, we highlighted that elderly patients, women, non-white race, hypertension, diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, bleeding disorders, obesity, steroid use, late procedure start time, higher postoperative pain, and high American Society of Anesthesiologists score were major predictors of a failed SDD. Many factors evaluated in our study were presented in one or two studies only; therefore, high-quality studies are required to supplement our findings.

Regional anaesthesia truncal blocks for acute postoperative pain and recovery: a narrative review

Significant acute postoperative pain remains prevalent among patients who undergo truncal surgery and is associated with increased morbidity, prolonged patient recovery, and increased healthcare costs. The provision of high-quality postoperative analgesia is an important component of postoperative care, particularly within enhanced recovery programmes. Regional anaesthetic techniques have become increasingly prevalent within multimodal analgesic regimens and the widespread adoption of ultrasonography has facilitated the development of novel fascial plane blocks. The number of described fascial plane blocks has increased significantly over the past decade, leading to a burgeoning area of clinical investigation. Their applications are increasing, and truncal fascial plane blocks are increasingly recommended as part of procedure-specific guidelines. Some fascial plane blocks have been shown to be more efficacious than others, with favourable side-effect profiles compared with neuraxial analgesia, and are increasingly utilised in breast, thoracic, and other truncal surgery. However, use of these blocks is debated in regional anaesthesia circles because of limitations in our understanding of their mechanisms of action. This narrative review evaluates available evidence for the analgesic efficacy of the most commonly practised fascial plane blocks in breast, thoracic, and abdominal truncal surgery, in particular their efficacy compared with systemic analgesia, alternative blocks, and neuraxial techniques. We also highlight areas where investigations are ongoing and suggest priorities for original investigations.

Sex related difference in postoperative pain and opioid use following posterior spinal fusion for adolescent idiopathic scoliosis

PURPOSE

This project aims to evaluate the relationship between biological sex and postoperative pain and in patients receiving posterior spinal fusion for adolescent idiopathic scoliosis.

METHODS

This is a retrospective study of patients (n=137) aged 10-17 receiving posterior spinal fusion for adolescent idiopathic scoliosis between 01/2018 and 09/2022. Each patient received surgery by the same pediatric orthopedic surgeon with identical postoperative pain management regimen at a children's hospital or a tertiary referral center with a pediatric spine program.

RESULTS

There were no significant differences in any background characteristics between the male and female patients, including age, BMI, number of levels fused, preoperative degree of scoliosis, and length of surgery and anesthesia (p>0.05). There were no differences in amount given of any intraoperative medications, nor in amount of postoperative scheduled analgesics (p>0.05). Female patients demonstrated higher average pain scores on Visual Analogue Scale evaluations during the first 24 hours postoperatively (5.0 vs 3.6, p<0.0001), 24-48 hours postoperatively (4.9 vs 4.0, p=0.03), and at the first physical therapy evaluation (5.3 vs 3.8, p<0.001). These patients received significantly greater amounts of morphine milligram equivalents in the first 24 hours postoperatively (42.2 vs 31.5, p=0.01) and for the hospitalization in total (63.8 vs 51.3, p=0.048). There was no difference in hours until hospital discharge (44.3 vs 42.6, p=0.62) nor until first ambulation (20.1 vs 21.3, p=0.24) between the female and male patients.

CONCLUSION

The influence of biopsychosocial factors on postoperative pain in adolescents is complex. This study adds to the existing pool of literature suggesting differences in pain perception between adolescent female and male patients. Female patients undergoing posterior spinal fusion for adolescent idiopathic scoliosis may benefit from increased preoperative counseling and more aggressive intra- and postoperative pain management regimens.

Perioperative Risk Factors for Persistent Postsurgical Pain After Inguinal Hernia Repair: Systematic Review and Meta-Analysis

Persistent postsurgical pain (PPSP) is one of the most bothersome and disabling long-term complications after inguinal hernia repair surgery. Understanding perioperative risk factors that contribute to PPSP can help identify high-risk patients and develop risk-mitigation approaches. The objective of this study was to systematically review and meta-analyze risk factors that contribute to PPSP after inguinal hernia repair. The literature search resulted in 303 papers included in this review, 140 of which were used for meta-analyses. Our results suggest that younger age, female sex, preoperative pain, recurrent hernia, postoperative complications, and postoperative pain are associated with a higher risk of PPSP. Laparoscopic techniques reduce the PPSP occurrence compared to anterior techniques such as Lichtenstein repair, and tissue-suture techniques such as Shouldice repair. The use of fibrin glue for mesh fixation was consistently associated with lower PPSP rates compared to tacks, staples, and sutures. Considerable variability was observed with PPSP assessment and reporting methodology in terms of study design, follow-up timing, clarity of pain definition, as well as pain intensity or interference threshold. High or moderate risk of bias in at least one domain was noted in >75% of studies. These may limit the generalizability of our results. Future studies should assess and report comprehensive preoperative and perioperative risk factors for PPSP adjusted for confounding factors, and develop risk-prediction models to drive stratified PPSP-mitigation trials and personalized clinical decision-making. PERSPECTIVE: This systematic review and meta-analysis summarizes the current evidence on risk factors for persistent pain after inguinal hernia repair. The findings can help identify patients at risk and test personalized risk-mitigation approaches to prevent pain. PROSPERO REGISTRATION: htttps://www.crd.york.ac.uk/prospero/display_record.php?RecordID=154663.

Perioperative Management and Outcomes in Patients With Autism Spectrum Disorder: A Retrospective Cohort Study

BACKGROUND

Autism spectrum disorder (ASD) is a neurocognitive disorder characterized by impairments in communication and socialization. There are little data comparing the differences in perioperative outcomes in children with and without ASD. We hypothesized that children with ASD would have higher postoperative pain scores than those without ASD.

METHODS

Pediatric patients undergoing ambulatory tonsillectomy/adenoidectomy, ophthalmological surgery, general surgery, and urologic procedures between 2016 and 2021 were included in this retrospective cohort study. ASD patients, defined by International Classification of Diseases-9/10 codes, were compared to controls utilizing inverse probability of treatment weighting based on surgical category/duration, age, sex, race and ethnicity, anesthetizing location, American Society of Anesthesiology physical status, intraoperative opioid dose, and intraoperative dexmedetomidine dose. The primary outcome was the maximum postanesthesia care unit (PACU) pain score, and secondary outcomes included premedication administration, behavior at induction, PACU opioid administration, postoperative vomiting, emergence delirium, and PACU length of stay.

RESULTS

Three hundred thirty-five children with ASD and 11,551 non-ASD controls were included. Maximum PACU pain scores in the ASD group were not significantly higher than controls (median, 5; interquartile range [IQR], 0-8; ASD versus median, 5; IQR, 0-8 controls; median difference [95% confidence interval {CI}] of 0 [-1.1 to 1.1]; P = .66). There was no significant difference in the use of premedication (96% ASD versus 95% controls; odds ratio [OR], 1.5; [95% CI, 0.9-2.7]; P = .12), but the ASD cohort had significantly higher odds of receiving an intranasal premedication (4.2% ASD versus 1.2% controls; OR, 3.5 [95% CI, 1.8-6.8]; P < .001) and received ketamine significantly more frequently (0.3% ASD versus <0.1% controls; P < .001). Children with ASD were more likely to have parental (4.9% ASD versus 1.0% controls; OR, 5 [95% CI, 2.1-12]; P < .001) and child life specialist (1.3% ASD versus 0.1% controls; OR, 9.9 [95% CI, 2.3-43]; P < .001) presence at induction, but were more likely to have a difficult induction (11% ASD versus 3.4% controls; OR, 3.42 [95% CI, 1.7-6.7]; P < .001). There were no significant differences in postoperative opioid administration, emergence delirium, vomiting, or PACU length of stay between cohorts.

CONCLUSIONS

We found no difference in maximum PACU pain scores in children with ASD compared to a similarly weighted cohort without ASD. Children with ASD had higher odds of a difficult induction despite similar rates of premedication administration, and significantly higher parental and child life specialist presence at induction. These findings highlight the need for future research to develop evidence-based interventions to optimize the perioperative care of this population.

Postoperative pain perception and associated risk factors in children after continuous rotation versus reciprocating kinematics: A randomised prospective clinical trial

To compare the postoperative pain of continuous rotation and reciprocating movements after pulpectomy of non-vital primary molars and determine associated risk factors. 146 children aged 4-8 years with one primary molar indicated for pulpectomy were randomly assigned to two equal groups: those instrumented with continuous rotation motion (Hyflex EDM Coltene/Whaledent) and reciprocating motion (Reciproc R25 (VDW)). A 4-point pain scale was used to assess postoperative pain frequencies, which were compared at different intervals using the Chi-square test. Postoperative pain risk factors were determined using logistic regression analysis. There was no statistically significant difference between the follow-ups. Gender, pulp status, and radiographic radiolucency increased the risk of postoperative pain incidence. Postoperative pain likelihood in children with chronic apical periodontitis was 8.72 times that of children with necrotic pulps. Postoperative pain after instrumentation with both kinematics was comparable. Postoperative pain incidence is increased by preoperative pulp condition, radiographic radiolucency, and gender.

Correlation between skin conductance measurements and subjective pain scales in children after otolaryngological procedures

Introduction

Pain assessment in children is crucial in managing postoperative analgesia; it is therefore necessary to determine the most accurate tool for assessing pain in children. The aim of this study was to evaluate the correlation between skin conductance measurements and self-reporting pain scales in children after otolaryngology procedures.

Materials and methods

Thirty-three children (N=33) were assessed for eligibility for the research. Postoperative pain was assessed using the Visual Analogue Scale; the Wong-Baker Faces Pain Rating Scale; the Face, Legs, Activity, Cry, and Consolability scale; and a skin conductance algesimeter. The postoperative pain was measured 1 and 2 hours after the surgery.

Results

There was no statistically significant correlation between self-reported pain scores and the skin conductance fluctuations in the children studied, regardless of gender or age. A statistically significant correlation was found between the existing subjective pain scales in children.

Conclusions

The skin conductance measurements do not provide an additional reliable tool for assessing pain in patients after otolaryngological procedures. The existing self-reported pain scales are sufficient to assess postoperative pain in children.

Inpatient Opioid Consumption Variability following Total Knee Arthroplasty: Analysis of 4,038 Procedures

This study examined an early iteration of an inpatient opioid administration-reporting tool, which standardized patient opioid consumption as an average daily morphine milligram equivalence per surgical encounter (MME/day/encounter) among total knee arthroplasty (TKA) recipients. The objective was to assess the variability of inpatient opioid administration rates among surgeons after implementation of a multimodal opioid sparing pain protocol. We queried the electronic medical record at our institution for patients undergoing elective primary TKA between January 1, 2016 and June 30, 2018. Patient demographics, inpatient and surgical factors, and inpatient opioid administration were retrieved. Opioid consumption was converted into average MME for each postoperative day. These MME/day/encounter values were used to determine mean and variance of opioids prescribed by individual surgeons. A secondary analysis of regional inpatient opioid consumption was determined by patient zip codes. In total, 23 surgeons performed 4,038 primary TKA. The institutional average opioid dose was 46.24 ± 0.75 MME/day/encounter. Average intersurgeon (IS) opioid prescribing ranged from 17.67 to 59.15 MME/day/encounter. Intrasurgeon variability ranged between ± 1.01 and ± 7.51 MME/day/encounter. After adjusting for patient factors, the average institutional MME/day/encounter was 38.43 ± 0.42, with average IS variability ranging from 18.29 to 42.84 MME/day/encounter, and intrasurgeon variability ranging between ± 1.05 and ± 2.82 MME/day/encounter. Our results suggest that there is intrainstitutional variability in opioid administration following primary TKA even after controlling for potential patient risk factors. TKA candidates may benefit from the implementation of a more rigid standardization of multimodal pain management protocols that can control pain while minimizing the opioid burden. This is a level of evidence III, retrospective observational analysis.

The effect of age and gender on acute postoperative pain and function following lumbar spine surgeries

BACKGROUND AND PURPOSE

Understanding the factors contributing to the variability in postoperative pain and function following lumbar spine surgeries (LSS) is necessary to plan inpatient rehabilitation and optimize surgical outcomes. In particular, variability due to age and gender has not been studied. This study's aim was to evaluate the variability in postoperative pain and function, during hospital stay, due to age and gender following LSS.

METHODS

We conducted a retrospective analysis of 585 patients who underwent LSS during their hospital stay. Univariate ANCOVA was performed to study the differences in postoperative pain, and multivariate ANCOVA was performed to study the differences in postoperative function (gait distance, independency combined score, and balance combined score) between age groups (older adults [≥65 years of age] vs. younger adults) and gender.

RESULTS

Younger patients reported statistically, but not clinically, significant higher postoperative pain than older patients (β = 0.652 [95% CI (0.382-0.986)], p < 0.001), and males reported statistically, but not clinically, significant lower postoperative pain than female patients (β = -0.583 [95% CI (-0.825 to -0.252)], p < 0.001) with adjustment of covariates. Male patients walked significantly longer distance than female patients (β = 0.272 [95% CI (0.112-0.432)], p = 0.001) with adjustment of covariates. However, these were clinically insignificant. With adjustment of preoperative diagnosis, type of surgery, severity of illness, and prior level of function, there was no statistically significant difference between age groups in walking distance, and between age and gender groups in independency combined score and balance combined scores.

DISCUSSION

Following LSS, the difference in postoperative pain between age groups and gender are statistically but not clinically significant, suggesting patients require similar effective postoperative pain management regardless of age and gender. The apparent difference in age and gender in postoperative functional outcomes could be due to other factors.

Common Biological Modulators of Acute Pain: An Overview Within the AAAPT Project (ACTTION-APS-AAPM Acute Pain Taxonomy)

OBJECTIVE

The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) project relies on the identification of modulators to improve characterization and classification of acute pain conditions. In the frame of the AAAPT effort, this paper presents an overview of common biological modulators of acute pain.

METHODS

Nonsystematic overview.

RESULTS

Females may experience more acute pain than males, but the clinical significance may be modest. Increasing age is associated with decreasing analgesic requirement and decreasing pain intensity after surgery and with higher risk of acute low back pain. Racial and ethnic minorities have worse pain, function, and perceived well-being. Patients with preexisting chronic pain and opioid use are at higher risk of severe acute pain and high opioid consumption. The OPRM1 gene A118G polymorphism is associated with pain severity and opioid consumption, with modest quantitative impact. Most studies have found positive associations between pain sensitivity and intensity of acute clinical pain. However, the strength of the association is unclear. Surgical techniques, approaches, and complications influence postoperative pain.

CONCLUSIONS

Sex, age, race, ethnicity, preexisting chronic pain and opioid use, surgical approaches, genetic factors, and pain sensitivity are biological modulators of acute pain. Large studies with multisite replication will quantify accurately the association between modulators and acute pain and establish the value of modulators for characterization and classification of acute pain conditions, as well as their ability to identify patients at risk of uncontrolled pain. The development and validation of quick, bed-side pain sensitivity tests would allow their implementation as clinical screening tools. Acute nonsurgical pain requires more investigation.

The effects of primary and recurrent pediatric urological surgeries on parental anxiety levels

INTRODUCTION

Invasive diagnostic and therapeutic procedures in pediatric urology may generally cause distress and pain in children. As a result, it may have a negative effect on adult and child behaviors. The anxiety, depression levels or distress and fear status caused by recurrent diseases or repetitive medical interventions in adult patients or the parents of pediatric patients have been investigated previously.

OBJECTIVE

To the best of our knowledge, we have not found a study evaluating the effects of primary or recurrent pediatric urological operations on parental anxiety. Our main aim was to compare the effects of primary and repetitive pediatric urological surgeries on the anxiety levels of both mothers and fathers. We also aimed to investigate the effects of other factors related to parents and children on parental anxiety.

DESIGN

A total of 163 patients under 14 years old who had undergone primary or recurrent pediatric urological operations and also their parents were included in a prospective, cross-sectional study. Demographic and clinical data of the patients and their parents were recorded. Before the surgeries, the Children's Fear Scale was applied to all patients over 3 years old and the State-Trait Anxiety Inventory was applied to all parents. The participants were divided into two main groups: primary surgery group (n:84) and recurrent surgery group (n:79). A subgroup analysis was performed according to surgery type (day surgery, minor surgery and major surgery).

RESULTS

We found that repetitive surgeries, higher fear scores of children, parents' being younger, having low education level, not having enough information about the surgeries and presence of someone in the immediate vicinity who previously experienced the same surgery increased parental anxiety levels. Day surgeries did not affect fathers' state anxiety levels as much as minor and major surgeries, whereas mothers' state anxiety levels were higher than fathers' regardless of the surgery type. Children's fear level was not affected by child age, gender, surgery type or previous history of surgery.

DISCUSSION

The majority of studies in the literature show no significant difference in terms of pain and fear levels in pediatric patients undergoing repeated diagnostic interventions but there are contradictory results about parental anxiety levels. There is also a lack of studies on the effects of recurrent surgeries.

CONCLUSION

According to our findings, repetitive surgeries and presence of someone who previously experienced the same surgery are the most significant predictive factors increasing parental anxiety levels.

Predictors of chronic pain after laparoscopic inguinal hernia repair

BACKGROUND

Multiple studies have analyzed predictors for chronic pain after open hernia repair. The purpose of this study is to determine which factors predict the development of chronic pain after a laparoscopic inguinal hernia repair.

METHODS

We identified patients who underwent laparoscopic inguinal hernia repair between 2008 and 2020 at a single institution. Quality of life was measured using the Surgical Outcomes Measurement System and Carolinas Comfort Scale. We categorized patients with chronic pain if their score on Carolinas Comfort Scale was greater than or equal to 3. Multivariable logistic regression analysis was used to identify predictors of chronic pain.

RESULTS

A total of 960 patients met inclusion criteria. Mean age was 59 (± 14, standard deviation) years, 89 (9.3%) of whom were female. Six percent of patients met criteria for chronic pain (Carolinas Comfort Scale ≥3). On multivariable analysis, predictors for chronic pain were age 45 (P < .001), female sex (P = .006), preoperative pain visual analog scale ≥1 (P = .025), prior inguinal hernia repair (P = .045), higher American Society of Anesthesiologists class (P = .041), use of multifilament polyester mesh (P = .0448), and intraoperative placement of a urinary catheter (P = .009).

CONCLUSION

Laparoscopic inguinal hernia repair results in 6.0% of patients experiencing chronic pain. We identified multiple predictors for chronic pain.

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.

Sex Comparisons in Opioid Use and Pain After Colorectal Surgery Using Enhanced Recovery Protocols

BACKGROUND

Differences in nociception and use of opioids between sexes are of particular interest, considering higher rates of persistent opioid use among women after surgery. Although enhanced recovery protocols (ERPs) have improved postoperative pain control in colorectal surgery, sex-based comparisons of inpatient opioid use after surgery in an ERP remain understudied.

METHODS

This retrospective study analyzed data from adults after colorectal surgery using an ERP at a single hospital between 2015 and 2017. The main outcome was the rate of opioid consumption measured as oral morphine equivalents per inpatient day. Poisson regression determined association between sex and opioid consumption, accounting for early discharge, using inverse probability weighting and adjusting for covariates that retained significance on univariate analysis. Linear regression assessed the association between sex and pain scores on postoperative days 0-5 adjusting for covariates.

RESULTS

Of 588 patients included, 43% were men and 57% were women. In the unadjusted model, malignancy, prehospital psychiatric medication and analgesic use, tobacco, ileostomy creation, operative time, and postoperative complications were associated with increased opioid consumption. In multivariate analyses, prehospital opioid and nonopioid analgesic use, operative time, anastomotic leak, and postoperative ileus remained significantly associated with increased inpatient opioid consumption. However, there was no significant association between sex and opioid use in crude or adjusted analysis (incidence rate ratio: 1.09; 95% confidence interval: 0.90, 1.32). Women reported higher average daily pain scores (coefficient: 0.29; 95% confidence interval: 0.04, 0.55) in adjusted analyses.

CONCLUSIONS

Among patients undergoing colorectal surgery using an ERP, sex-based differences exist in pain scores but not early postoperative opioid consumption. Identification of intragroup differences in postoperative pain and opioid use among patients managed with an ERP serves as targets for customization and enhancement of current protocols. Furthermore, incongruence between reported pain and analgesic administration may have important implications for sex-related differences in persistent opioid use.

Current Evidence for Acute Pain Management of Musculoskeletal Injuries and Postoperative Pain in Pediatric and Adolescent Athletes

OBJECTIVE

Sports-related injuries in young athletes are increasingly prevalent with an estimated 2.6 million children and adolescents sustaining a sports-related injury annually. Acute sports-related injuries and surgical correction of sports-related injuries cause physical pain and psychological burdens on pediatric athletes and their families. This article aims to evaluate current acute pain management options in pediatric athletes and acute pain management strategies for postoperative pain after sports-related injuries. This article will also elucidate which areas of pain management for pediatric athletes are lacking evidence and help direct future clinical trials.

DATA SOURCES

We conducted a literature search through PubMed and the Cochrane Central Register of Controlled Trials to provide an extensive review of initial and postoperative pain management strategies for pediatric sports-related musculoskeletal injuries.

MAIN RESULTS

The current knowledge of acute pain management for initial sports-related injuries, postoperative pain management for orthopedic surgeries, as well as complementary and alternative medical therapies in pediatric sports-related injuries is presented. Studies evaluating conservative management, enteral and nonenteral medications, regional anesthesia, and complementary medical therapies are included.

CONCLUSIONS

Adequate pain management is important for sports injuries in children and adolescents for emotional as well as physical healing, but a balance must be achieved to provide acceptable pain relief while minimizing opioid use and side effects from analgesic medications. More studies are needed to evaluate the efficacy of nonopioid analgesic medications and complementary therapies in pediatric patients with acute sports-related injuries.

Influence of preoperative information support on anxiety, pain and satisfaction with postoperative analgesia in children and adolescents after thoracic surgery: A randomized double blind study

AIMS/BACKGROUND

The proportion of patients who experience anxiety prior to planned surgery, even a minimally invasive one, is estimated at 50-70%. Thoracic surgery, causes significant preoperative anxiety, especially in children. The aim of this study was to determine the effect of an important component of psychological preparation for a surgery as information support on levels of anxiety, pain and satisfaction with postoperative analgesia.

METHODS

The randomized double blind study including patients aged 9-18 years qualified for lateral thoracotomy or Ravitch procedure. The subjects were randomized to the control group (n=56) provided with a routine preoperative information by a nurse, and the experimental group (n=56) offered additional psychological consultation. Data were collected via the State-Trait Anxiety Inventory.

RESULTS

In the experimental group, the level of state anxiety at 48 h post-surgery was significantly lower than prior to the procedure, but only in subjects with preoperative trait anxiety Conclusion: Information support from a psychologist offered prior to a thoracic surgery decrease the level of postoperative state anxiety solely in children with lower levels of trait anxiety. Higher level of postoperative state anxiety negatively affect patients' satisfaction with post-surgical analgesia.

TRIAL REGISTRATION

ClinicalTrials.gov; Influence of Preoperative Support on Anxiety, Pain and Satisfaction With Postoperative Analgesia; NCT03488459, https://clinicaltrials.gov/ct2/show/record/NCT03488459?cntry=PL&city=Rabka-Zdr%C3%B3j&rank=1.

Variations in Pain, Sleep, and Activity During Hospitalization in Children With Cancer

This study examines the pain experiences of children with cancer during hospitalization. A descriptive design with repeated measures was used to describe the location, intensity, and quality of pain, pain medications, amount of pain relief, and perceptions of sleep and activity during hospitalization. Data were collected once daily from the day of admission for up to a maximum of 5 consecutive days during hospitalization. Results show that more than half of the patients (27 of 49 patients) indicated they were having pain. Eleven patients (22.4%) had mild pain (mean = 2.3 ± 0.9 SD; range, 0.3-3.6), 10 (20.4%) had moderate pain (mean = 5.3 ± 0.2 SD; range, 5.0-5.5), and 6 (12.2%) had severe pain (mean = 7.6 ± 1.3 SD; range, 6.5-10.0). The highest pain intensity ratings occurred on day 1. Overall, most patients reported good relief after pain medications during hospitalization. Consistent assessment and implementation of pain interventions within the 24 hours of admission is recommended, with particular attention to persistent pain after painful procedures.

Systematic Review: Predisposing, Precipitating, Perpetuating, and Present Factors Predicting Anticipatory Distress to Painful Medical Procedures in Children

OBJECTIVE

To conduct a systematic review of the factors predicting anticipatory distress to painful medical procedures in children.

METHODS

A systematic search was conducted to identify studies with factors related to anticipatory distress to painful medical procedures in children aged 0-18 years. The search retrieved 7,088 articles to review against inclusion criteria. A total of 77 studies were included in the review.

RESULTS

31 factors were found to predict anticipatory distress to painful medical procedures in children. A narrative synthesis of the evidence was conducted, and a summary figure is presented.

CONCLUSIONS

Many factors were elucidated that contribute to the occurrence of anticipatory distress to painful medical procedures. The factors that appear to increase anticipatory distress are child psychopathology, difficult child temperament, parent distress promoting behaviors, parent situational distress, previous pain events, parent anticipation of distress, and parent anxious predisposition. Longitudinal and experimental research is needed to further elucidate these factors.

Appendicitis in children from a gender perspective

BACKGROUND

The incidence in appendicitis and the appendectomy rate are different between boys and girls. This study aimed to further evaluate appendicitis in children from a gender perspective. Gender differences in presentation, perioperative care, and outcome after appendectomy were examined.

METHOD

A single, institution-based, retrospective study was conducted at a tertiary pediatric surgery center. All children <15 years of age who underwent appendectomy for suspected appendicitis or who were conservatively treated for an appendiceal abscess, from 2006 to 2014, were included. Patient demographics, symptoms, preoperative management including time to appendectomy, operative characteristics, and postoperative course including complications and length of hospital stay were evaluated.

RESULTS

The study included 427 children: 183 girls and 244 boys. The median postoperative follow-up time was 40 (range 1-106) months. The genders did not differ significantly in age, mean weight, symptoms, laboratory results, time to appendectomy, postoperative complications, postoperative pain management, antibiotic treatment, and length of hospital stay. The frequencies of hopping/percussion/coughing tenderness in the right lower quadrant (61 and 51%, p = 0.042), phlegmonous appendicitis (56 and 45%, p = 0.032), perforated appendicitis (18 and 10%, p = 0.043), and open appendectomy (57 and 28%, p = 0.048) were significantly higher in boys. Girls had significantly higher frequencies of preoperative imaging (50 and 38%, p = 0.021), negative appendectomy (18 and 7%, p = 0.005), gangrenous appendicitis (18 and 11%, p = 0.049), and operative complications (7 and 2%, p = 0.015). In girls, the Pediatric Appendicitis Score (PAS) was more specific (59 and 41%, respectively, p = 0.032) and had a greater negative predictive value (33 and 11%, respectively, p = 0.003) than in boys.

CONCLUSION

In children with appendicitis, there are some gender differences. Girls had negative appendectomies more often, despite having more preoperative imaging and they had operative complications more frequently, despite having less frequent perforations. Boys had a higher frequency of perforation even though their time to appendectomy equaled that of girls. These findings and the reasons behind them must be further studied.

Estratégias de enfrentamento em crianças em situação pré-cirúrgica: relação com idade, sexo, experiência com cirurgia e estresse

O estudo objetivou verificar as estratégias de enfrentamento de crianças, com idade entre 7 e 12 anos, em situação pré-cirúrgica, e sua relação com variáveis sociodemográficas, presença de estresse na criança, no acompanhante e experiência prévia com cirurgia. Para tanto, 58 crianças internadas para realização de cirurgias eletivas responderam ao instrumento de avaliação das estratégias de enfrentamento da hospitalização e a um questionário de avaliação do estresse. O acompanhante respondeu a um levantamento sociodemográfico e ao inventário de sintomas de estresse de Lipp. As estratégias mais utilizadas foram distração e solução do problema e as menos utilizadas, afastamento social e oposição. Meninas e filhos de pais com estresse usaram significativamente mais estratégias de regulação da emoção. Observou-se maior uso de reestruturação cognitiva em crianças mais velhas e com experiência prévia em cirurgia. Os resultados sinalizam a necessidade de considerar as variáveis estudadas quando da elaboração de programas de preparação cirúrgica.

Acute and chronic postsurgical pain after living liver donation: Incidence and predictors

Despite its prominence as a concern among potential surgical candidates, there is little information in the literature regarding the short- and long-term pain experience after living liver donation. We undertook a prospective study to examine (1) the nature and incidence of acute and chronic pain after living donor hepatectomy and (2) the factors associated with an increased or decreased risk of adverse pain outcomes. Before donation, a comprehensive assessment of potential predictors of acute and chronic pain outcomes was conducted; this included donors' pain expectations, psychosocial factors, medical histories, and demographic factors. Detailed data regarding pain outcomes were collected postoperatively (days 1 and 2) and again during 6- and 12-month follow-up telephone interviews. Sixty-five adults (32 females and 33 males) scheduled for donor hepatectomy participated. Substantial proportions of the donors reported a moderate-to-severe level of pain intensity (≥4 on a 0-10 scale) at rest and after movement on day 1 (42% and 74%, respectively) and day 2 (33% and 32%, respectively). Persistent postsurgical pain was reported by 31% of the donors at the 6-month follow-up and by 27% of the donors at the 12-month follow-up. Generally, this pain was mild, and pain-related life interference was minimal. Female sex, a younger age, and several predonation measures of pain-related anxiety were associated with a significantly greater risk of developing persistent postsurgical pain. In conclusion, this study has identified a subset of patients who experience persistent pain after living liver donation. Additional prospective research using larger samples of liver donors is needed to replicate this work, to obtain a more detailed account of the acute and long-term pain experience, and to determine whether targeted interventions can minimize the frequency and severity of chronic pain.

Effects of cocaine combined with a social cue on conditioned place preference and nucleus accumbens monoamines after isolation rearing in rats

RATIONALE

Social interaction during drug exposure can potentiate cocaine reward. Isolation rearing (ISO) during adolescence increases social interaction and may amplify this potentiation.

OBJECTIVES

The objectives of this study are to determine whether ISO alters conditioned place preference (CPP) for cocaine when combined with a social cue and to determine whether ISO alters the effects of cocaine when combined with social cue on nucleus accumbens shell (NAcS) dopamine (DA) and serotonin (5-HT).

METHODS

Male and female rats were either ISO or group (GRP) reared for 4 weeks during adolescence. CPP was performed using a low dose of cocaine (2 mg/kg or saline) with or without exposure to a novel same-sex conspecific during conditioning. In vivo microdialysis was performed using the same parameters.

RESULTS

ISO rats engaged in more social and aggressive behaviors during conditioning relative to GRP. Cocaine reduced social and aggressive behaviors in all rats. CPP was not influenced by rearing condition. Cocaine produced significant CPP, and a social cue produced CPP only in males. In contrast, the interaction of cocaine and a social cue on NAcS DA and 5-HT differed depending upon rearing condition. In isolates, cocaine-induced DA was attenuated, while cocaine plus a social cue produced potentiated DA and 5-HT.

CONCLUSIONS

Exposure to a low dose of cocaine in the presence of a social cue produced additive effects on CPP while producing synergistic effects on DA and 5-HT in the NAcS of ISO rats. The aversive effects of this compound stimulus may negate the rewarding effects in isolates.

Clinical utility of PPPM and FPS-R to quantify post-tonsillectomy pain in children

OBJECTIVES

As pain is a subjective and difficult parameter to assess in children, we aimed to evaluate the correspondence of two pain scales - parents' post-operative pain measure (PPPM) and faces pain scale-revised (FPS-R) with analgesic intake in the assessment of post-tonsillectomy pain in a pediatric population.

METHODS

Children aged 4-10 years (n=174) undergoing tonsillectomy with or without adenoidectomy had their pain monitored by PPPM and FPS-R over 7 days following surgery. The amount of analgesic (acetaminophen or dipyrone) intake was also recorded each day. Linear regression and correlation analysis were performed for pain scales and Poisson regression model for analgesic administration. To evaluate influence of gender linear regression and logistic regression with random effects were performed.

RESULTS

PPPM and FPS-R presented a significant positive correlation (τ=0.5; R(2)=0.36; p<0.001). PPPM and FPS-R also showed a significant correlation with analgesic use over the 7 post-operative days (p<0.0001). No influence of gender was observed in pain levels by both scales.

CONCLUSIONS

Our data demonstrate that PPPM and FPS-R are equivalent pain scales to quantify post-tonsillectomy pain in children and are useful tools in post-tonsillectomy clinical research.

Comparison of skin conductance measurements and subjective pain scores in children with minor injuries

AIM

Objective measures of perceived pain may aid clinicians in decision-making regarding analgesia. This study aimed to assess the effectiveness of an algesimeter to assess the pain response of children to minor injury when compared with self-report.

METHODS

A commercially available skin conductance algesimeter was used to record pain in children presenting with a minor injury to a district general hospital. The recordings were compared with self-reported pain scores using the Wong-Baker FACES(®) Pain Rating Scale.

RESULTS

Sixty-seven children below 16 years of age (36 females, 53.7%, mean age 11.9 years, standard deviation 3.1 years) were assessed. There was a significant correlation between self-reported pain and number of fluctuations in skin conductance per second for girls (r = 0.325, p = 0.027), but not for boys (r = 0.160, p = 0.194). There was no significant association between self-reported pain and number of fluctuation in skin conductance per second and patient age.

CONCLUSION

There was a significant correlation between self-reported pain and the number of fluctuations in skin conductance in girls, but not boys. There may be a number of reasons for this gender variation, including difficulty in rating pain and lack of sensitivity in the pain rating scale.

Perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures: a quantitative systematic review

AIMS

To examine the relationship between perioperative anxiety and postoperative pain in children and adolescents undergoing elective surgical procedures and the differences in children's perioperative anxiety and postoperative pain among subgroups of demographics.

BACKGROUND

While anxiety and pain are regarded as two common problems experienced by children and adolescents perioperatively and the relationship between them has been reported in previous studies, there has been no review paper examining this phenomenon.

DESIGN

A quantitative systematic review.

DATA SOURCES

Nine electronic databases were searched for studies published in English from the inception date of the databases to December 2010, using various combinations of search terms of 'adolescents', 'anxiety', 'child', 'pain', 'surgery' and 'correlation/relationship'.

REVIEW METHODS

Using the Joanna Briggs Institute's comprehensive systematic review strategies, relevant studies were independently appraised and extracted by two reviewers using the standardized critical appraisal instruments and data extraction tool from Joanna Briggs Institute Meta Analysis of Statistics Assessment and Review Instrument.

RESULTS

Ten studies were included in this review from 943 studies initially retrieved. Children and adolescents who had higher level of perioperative anxiety experienced a higher level of postoperative pain. Inconclusive evidence was found regarding differences of perioperative anxiety and postoperative pain between demographic subgroups of gender, age and past surgical experience.

CONCLUSION

Results of this review inform healthcare providers of the role perioperative anxiety plays on children's and adolescents' postoperative pain and indicate the need to use interventions to reduce perioperative anxiety and, therefore, optimize their postoperative pain management during the perioperative period.

Exploring influencing factors of postoperative pain in school-age children undergoing elective surgery

PURPOSE

The purpose of this study was to examine the influencing factors of postoperative pain among children undergoing elective surgery.

DESIGN AND METHODS

A survey was conducted in 2011 with a convenience sample of 66 children, 6 to 14 years old, in a tertiary hospital in Singapore.

RESULTS

Children experienced moderate preoperative anxiety and postoperative pain. Gender, preoperative anxiety, and negative emotional behaviors were significant influencing factors for postoperative pain. Boys reported less postoperative pain than girls.

PRACTICE IMPLICATIONS

Effective strategies for assessing and managing children's preoperative anxiety are needed to achieve an optimal postoperative pain management outcome.

Pain-related psychological correlates of pediatric acute post-surgical pain

Background

Post-surgical pain is prevalent in children, yet is significantly understudied. The goals of this study were to examine gender differences in pain outcomes and pain-related psychological constructs postoperatively and to identify pain-related psychological correlates of acute post-surgical pain (APSP) and predictors of functional disability 2 weeks after hospital discharge.

Methods

Eighty-three children aged 8–18 (mean 13.8 ± 2.4) years who underwent major orthopedic or general surgery completed pain and pain-related psychological measures 48–72 hours and 2 weeks after surgery.

Results

Girls reported higher levels of acute postoperative anxiety and pain unpleasantness compared with boys. In addition, pain anxiety was significantly associated with APSP intensity and functional disability 2 weeks after discharge, whereas pain catastrophizing was associated with APSP unpleasantness.

Conclusion

These results highlight the important role played by pain-related psychological factors in the experience of pediatric APSP by children and adolescents.

Pain, discomfort, and use of analgesics following the extraction of primary canines in children with palatally displaced canines

BACKGROUND. Pain following the extraction of the primary canine in children with palatally displaced canines (PDC) as an interceptive treatment has not been investigated. AIMS. To describe pain, discomfort, dental anxiety, and use of analgesics following the extraction of primary canines in children with PDC. DESIGN. Forty-four children, aged 10-13 with PDC, were included. Pain intensity, discomfort, and analgesic consumption were rated the first evening and 1 week after the extraction of the primary canine. Dental anxiety was assessed pre-extraction, using the dental anxiety scale (DAS). A matched reference group also completed the DAS. RESULTS. No significant differences were found between the study and the reference group regarding the pre-extraction assessments. Post-extraction pain and discomfort was low. The experience of the injection was graded worse than the extraction, and more pain was rated at the evening post-extraction than during the extraction. Analgesics were used only the first evening. High correlation was detected between DAS and pain during injection and extraction. CONCLUSIONS. The experience of pain and discomfort during and after extraction of the primary canines is low, despite that 42% of the children used analgesics. Therefore, appropriate analgesics and recommendation doses pre- and post-extraction should be prescribed.

Sex-related differences of patient-controlled epidural analgesia for postoperative pain

Gender differences in pain modulation are evident but data are rare with regard to perioperative regional analgesia. The aim of the present analysis was to assess gender-related differences in pain ratings, analgesic consumption, and adverse events in a large group of patients treated with patient-controlled epidural analgesia (PCEA) after major surgery. Data from 14,988 adult patients (6506 women; 8482 men) receiving a PCEA between January 1998 and December 2009 were examined. Demographic data and postoperative measurements assessed by the Acute Pain Service, including total PCEA consumption, pain scores, and complications, were analyzed by using PASW Statistics (18.0; SPSS Inc, Chicago, IL, USA). Beyond standard descriptive analyses, gender-related differences were investigated using a stepwise multivariate analysis of variances. Postoperative pain scores during rest and movement were almost equal between men and women. However, women showed lower total PCEA consumption consistently throughout the 5-day observation period (relative reduction by 1.7%-10.2% compared to men; P=0.00). Total PCEA consumption did not interact with surgical site (abdomen, thorax, extremity) (P=0.379) or age (<50, 50-75, >75 years; P=0.330), but was influenced by body mass index (P=0.017) and vomiting (P=0.011). Furthermore, motor blockade was greater in females compared to males (P=0.000). In patients treated with PCEA, gender differences in numeric rating scale scores exist but are not clinically relevant. However, reduced total PCEA consumption in women might be a consequence of an increased incidence of motor blockade and vomiting; the latter point towards an opioid-free PCEA solution in female patients at high risk for vomiting.

Effectiveness of an anesthetic continuous-infusion device in children with cerebral palsy undergoing orthopaedic surgery

BACKGROUND

Effective postoperative pain management is a vital component of orthopaedic surgical care in the pediatric population. In children with cognitive impairments pain management can be difficult, making these children vulnerable to ineffectively managed postoperative pain. This prospective, randomised study evaluated the use of a local anesthetic continuous infusion device (pain pump) to manage postoperative pain in children with cerebral palsy (CP) undergoing lower extremity orthopaedic surgical procedures.

METHODS

Children with a diagnosis of CP who were undergoing select orthopaedic outpatient procedures were enrolled in this study. Postoperatively, patients were randomised to receive either a pain pump in addition to oral analgesics or oral analgesics only. Patient's parents were asked to record the amount of medication administered and assess pain intensity with the use of a modified visual analogue scale for 3 days postoperatively. Parents also completed an overall pain management satisfaction questionnaire at the end of the study participation period.

RESULTS

Fifty-four patients were enrolled in this study and data were analyzed on 37 patients. The mean daily pain intensity in the pain pump group was significantly lower for the day of surgery and for 2 days postoperatively, and there was an overall significant difference between the groups (P<0.0001). The amount of analgesic medication administered was significantly lower for the first 2 postoperative days, but there was not a significant difference between the 2 groups overall (P=0.29). Parent satisfaction with both pain management techniques was high and responses were similar between the 2 groups.

CONCLUSIONS

Children with CP present unique postoperative pain management concerns that can be effectively addressed through the use of multimodal analgesic techniques. This study found that the pain pump is an effective pain management technique that significantly reduces pain intensity in children with CP after lower extremity orthopaedic procedures.

LEVEL OF EVIDENCE

Therapeutic Level II.

[Predictive factors and prevention of chronic postoperative pelvic and perineal pain]

INTRODUCTION

Chronic postoperative pain has been defined as pain arising after a surgical operation, present for at least 2 months, with no organic (active cancer or chronic infection) or preexisting cause. The purpose of this article is to review the risk factors and prevention of chronic postoperative pelvic and perineal pain.

MATERIAL AND METHODS

A review of the literature was performed by searching PubMed for articles on risk factors and prevention of chronic postoperative pelvic and perineal pain.

RESULTS

Chronic postoperative pain is frequent, disabling and represent a high cost to the community. This pain is generated by variable and complex interactions between the surgical procedure (the operated zone, perioperative management, the disease requiring the operative procedure) and the patient (age, gender, genetics, concomitant diseases, personal history). The multifactorial nature of chronic postoperative pain suggests the need for multidisciplinary management with prevention and reduction of the main risk factors. Similarly, appropriate management of acute postoperative pain has a major impact on the risk of chronic pain.

CONCLUSION

A good knowledge of the risk factors and appropriate prevention can decrease the incidence and consequences of chronic postoperative pain.

Do sex differences exist in opioid analgesia? A systematic review and meta-analysis of human experimental and clinical studies

Although a contribution of sex in opioid efficacy has garnered much attention, the confirmation and direction of any such difference remain elusive. We performed a systematic review of the available literature on sex differences in μ and mixed μ/κ opioid effect on acute and experimental pain. Fifty unique studies (including three unpublished studies) were included in the analyses. Across the 25 clinical studies on μ-opioids there was no significant sex-analgesia association. Restricting the analysis to patient-controlled analgesia (PCA) studies (irrespective of the opioid) yielded greater analgesia in women (n=15, effect size 0.22, 95% c.i. 0.02-0.42, P=0.028). Further restricting the analysis to PCA morphine studies yielded an even greater effect in women (n=11, effect size=0.36, 95% c.i. 0.17-0.56, P=0.003). Meta-regression indicated that the longer the duration of PCA, the difference in effect between the sexes further increased. Across experimental pain studies on μ-opioids women had greater antinociception from opioids (n=11, effect size=0.35; 95% c.i. 0.01-0.69, P=0.047), which was predominantly due to 6 morphine studies. Female patients had greater μ/κ opioid analgesia (n=7, effect size 0.84; 95% c.i. 0.25-1.43, P=0.005), but no sex-analgesia association was present in experimental studies (n=7). Sex differences exist in morphine-induced analgesia in both experimental pain studies and clinical PCA studies, with greater morphine efficacy in women. The data on non-morphine μ and mixed μ/κ-opioids are less convincing and require further study.

Children's tonsillectomy experiences: influencing factors

The aim of this study was to explore factors influencing children's (7-13 years) tonsillectomy experiences and outcomes. A prospective, repeated measures, design was used to investigate the effect of age, gender, ethnicity, time, and previous pain, hospitalization and surgery on children's (N = 60) perceptions of anxiety, pain intensity, quality of pain and sleep, and oral intake. The relationship between postoperative pain and anxiety was also examined. Using a diary, three days of data were collected. Descriptive statistics, Pearson correlation coefficient, and a mixed linear regression model were used for analysis. Children's tonsillectomy experiences and outcomes were affected by time, previous experience, age, and anxiety. Moderate correlations were found between level of anxiety and pain intensity. These findings provide clinicians with additional knowledge to guide their perioperative practice and care of children.

Dental anxiety among survivors of childhood cancer: a cross-sectional study

BACKGROUND

Childhood cancer survivors may have experienced a high number of invasive medical and dental procedures which are known to be risk factors for dental anxiety.

AIM

The aim of this study was to examine the prevalence of dental anxiety among children who have survived cancer.

DESIGN

In a cross-sectional study, we examined 51 6- to 14-year-old children who had been treated for cancer at Aalborg Hospital, and 192 children without cancer. All children answered the Dental Subscale of the Children's Fear Survey Schedule. Dental anxiety was defined as a dental anxiety score exceeding the mean dental anxiety score + 1 standard deviation for the children without cancer.

RESULTS

Children with cancer did not have an increased prevalence of dental anxiety compared with children without cancer: the prevalence ratio was 0.41 [95% confidence interval (CI): 0.10-1.24]. The mean dental anxiety score was 23.1 (95% CI: 21.2-25.0) among children who had been treated for cancer, and 24.7 (95% CI: 23.4-26.0) among children without cancer (mean difference: 1.6; 95% CI: 1.1-4.3).

CONCLUSION

Cancer and cancer treatment during childhood were not associated with an increased risk of dental anxiety in this population.

Interpretation of the large red-and-white visual analog scale by children compared with adults

The red-and-white visual analog scale (VAS) is a modification of the traditional VAS. The purpose of this study was to compare how children of various ages and adults rate their anticipatory pain intensity on the red-and-white VAS. One hundred children were interviewed as part of the anesthesiologist's preoperative visit before elective eye surgery. For comparison, 50 healthy adults were interviewed in a similar manner. The medians and ranges describing mild, moderate, and severe pain, or pain intensity at which medicine would be requested, did not differ between preschool children, young schoolchildren, and adolescents or between children and adults. The median score of anticipated need for pain medication was 50% of the maximum for children.