Parents' perceptions and use of analgesics at home after children's day surgery

Using Consumer Wearable Devices to Profile Postoperative Complications After Pediatric Appendectomy

INTRODUCTION

Markers of postoperative recovery in pediatric patients are difficult for parents to evaluate after hospital discharge, who use subjective proxies to assess recovery and the onset of complications. Consumer-grade wearable devices (e.g., Fitbit) generate objective recovery data in near real time and thus may provide an opportunity to remotely monitor postoperative patients and identify complications beyond the initial hospitalization. The aim of this study was to use daily step counts from a Fitbit to compare recovery in patients with complications to those without complications after undergoing appendectomy for complicated appendicitis.

METHODS

Children ages 3-17 years old undergoing laparoscopic appendectomy for complicated appendicitis were recruited. Patients wore a Fitbit device for 21 d after operation. After collection, patient data were included in the analysis if minimum wear-time criteria were achieved. Postoperative complications were identified through chart review, and step count trajectories for patients recovering with and without complications were compared. Additionally, to account for the patients experiencing a complication on different postoperative days, median daily step count for pre- and post-complication were analyzed.

RESULTS

Eighty-six patients with complicated appendicitis were enrolled in the study, and fourteen children developed a postoperative complication. Three patients were excluded because they did not meet the minimum wear time requirements. Complications were divided into abscesses (n = 7, 64%), surgical site infections (n = 2, 18%), and other, which included small bowel obstruction and Clostridioides difficile infection (n = 2, 18%). Patients presented with a complication on mean postoperative day 8, while deviation from the normative recovery trajectory was evident 4 d prior. When compared to children with normative recovery, the patients with surgical complications experienced a slower increase in step count postoperatively, but the recovery trajectory was specific to each complication type. When corrected for day of presentation with complication, step count remained low prior to the discovery of the complication and increased after treatment resembling the normative recovery trajectory.

CONCLUSIONS

This study profiled variations from the normative recovery trajectory in patients with complication after appendectomy for complicated appendicitis, with distinct trajectory patterns by complication type. Our findings have potentially profound clinical implications for monitoring pediatric patients postoperatively, particularly in the outpatient setting, thus providing objective data for potentially earlier identification of complications after hospital discharge.

Consumer Wearables Define a Normative Recovery Trajectory Following the Modified Nuss Procedure

INTRODUCTION

The modified Nuss procedure is an elective procedure associated with a lengthy recovery, uncontrolled pain, and risk of infrequent, yet life-threatening complications. The absence of objective measures of normative postoperative recovery creates uncertainty about the postdischarge period, which remains highly dependent on the patients' and their caregivers' expectations and management of recovery. We aimed to describe an objective-normative, physical activity recovery trajectory after the modified Nuss procedure, using step counts from the Fitbit.

METHODS

This observational study enrolled children ≤18 y with pectus excavatum who underwent the modified Nuss procedure from 2021 to 2022. The Fitbit was worn for 21 postoperative days. Postdischarge outcomes and health-care utilization were evaluated. For patients without postoperative complications, piecewise linear regression analysis was conducted to generate a normative recovery trajectory model of daily step counts.

RESULTS

Of 80 patients enrolled, 66 (86%) met eligibility criteria (mean age, 15.1 ± 1.3 y; 89.4% male, 62.1% non-Hispanic White). The mean number of telephone and electronic message encounters regarding concerns with the patient's recovery within 30 d postoperatively was 2.1 (standard deviation = 2.7). Ten patients (15.2%) returned to the emergency department (ED) within the 30-d postoperative period. Seven patients (10.6%) presented to the ED one time, and three patients (4.5%) presented to the ED twice. Thirty-day readmission rate was four patients (6.0%). Piecewise regression model showed that patients without complications steadily increased their daily step count on each postoperative day and plateaued on day 18.

CONCLUSIONS

We have developed a normative recovery trajectory following the modified Nuss procedure using step count data collected by a consumer wearable device. This offers the potential to inform preoperative patient expectations and reduce avoidable health-care utilization through informed preoperative counseling, thus laying the ground work for the use of consumer wearable devices as a postdischarge remote monitoring tool.

Applying machine learning to consumer wearable data for the early detection of complications after pediatric appendectomy

When children are discharged from the hospital after surgery, their caregivers often rely on subjective assessments (e.g., appetite, fatigue) to monitor postoperative recovery as objective assessment tools are scarce at home. Such imprecise and one-dimensional evaluations can result in unwarranted emergency department visits or delayed care. To address this gap in postoperative monitoring, we evaluated the ability of a consumer-grade wearable device, Fitbit, which records multimodal data about daily physical activity, heart rate, and sleep, in detecting abnormal recovery early in children recovering after appendectomy. One hundred and sixty-two children, ages 3-17 years old, who underwent an appendectomy (86 complicated and 76 simple cases of appendicitis) wore a Fitbit device on their wrist for 21 days postoperatively. Abnormal recovery events (i.e., abnormal symptoms or confirmed postoperative complications) that arose during this period were gathered from medical records and patient reports. Fitbit-derived measures, as well as demographic and clinical characteristics, were used to train machine learning models to retrospectively detect abnormal recovery in the two days leading up to the event for patients with complicated and simple appendicitis. A balanced random forest classifier accurately detected 83% of these abnormal recovery days in complicated appendicitis and 70% of abnormal recovery days in simple appendicitis prior to the true report of a symptom/complication. These results support the development of machine learning algorithms to predict onset of abnormal symptoms and complications in children undergoing surgery, and the use of consumer wearables as monitoring tools for early detection of postoperative events.

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study

STUDY OBJECTIVE

To determine the optimal sedative dose of intranasal dexmedetomidine for children undergoing laceration repair.

METHODS

This dose-ranging study employing the Bayesian Continual Reassessment Method enrolled children aged 0 to 10 years with a single laceration (<5 cm), requiring single-layer closure, who received topical anesthetic. Children were administered 1, 2, 3, or 4 mcg/kg intranasal dexmedetomidine. The primary outcome was the proportion with adequate sedation (Pediatric Sedation State Scale score of 2 or 3 for ≥90% of the time from sterile preparation to tying of the last suture). Secondary outcomes included the Observational Scale of Behavior Distress-Revised (range: 0 [no distress] to 23.5 [maximal distress]), postprocedure length of stay, and adverse events.

RESULTS

We enrolled 55 children (35/55 [64%] males; median [interquartile range {IQR}] age 4 [2, 6] years). At 1, 2, 3, and 4 mcg/kg intranasal dexmedetomidine, respectively, the proportion of participants "adequately" sedated was 1/3 (33%), 2/9 (22%), 13/21 (62%), and 12/21 (57%); the posterior mean (95% equitailed credible intervals) for the probability of adequate sedation was 0.38 (0.04, 0.82), 0.25 (0.05, 0.54), 0.61 (0.41, 0.80), and 0.57 (0.36, 0.76); the median (IQR) Observational Scale of Behavior Distress-Revised scores during suturing was 2.7 (0.3, 3), 0 (0, 3.8), 0.6 (0, 5), and 0 (0, 3.7); the median (IQR) postprocedure length of stay was 67 (60, 78), 76 (60, 100), 89 (76, 109), and 113 (76, 150) minutes. There was 1 adverse event, a decrease in oxygen saturation at 4 mcg/kg, which resolved with head repositioning.

CONCLUSION

Despite limitations, such as our limited sample size and subjectivity in Pediatric Sedation State Scale scoring, sedation efficacy for 3 and 4 mcg/kg were similarly based on equitailed credible intervals suggesting either could be considered optimal.

Association Between Initial Opioid Prescription Duration and 30-Day Risk of Receiving Repeat Opioid Among Children

OBJECTIVE

Our study evaluated the association between initial opioid prescription duration and receipt of a repeat opioid prescription in children.

METHODS

Eligible individuals were children between 1 and 17 years of age who enrolled in a Medicaid Managed Care plan and filled an incident opioid prescription during 2013 to 2018. An incident prescription was defined as receipt of an opioid analgesic without a prior use for 12 months. A repeat opioid prescription was defined as receipt of a subsequent opioid prescription within 30 days since the end of incident opioid prescription. A hierarchical multivariable logistic regression model was fitted to test the association between incident opioid prescription duration and the likelihood of receiving a repeat prescription.

RESULTS

The cohort consisted of 17,086 children receiving an incident opioid prescription in which 6272 (36.7%) received 1 to 3 days' supply, 8442 (49.4%) received 4 to 7 days' supply, 1434 (8.4%) received 8 to 10 days' supply, and 938 (5.5%) received >10 days' supply. Of these incident opioid recipients, 1780 (10.4%) filled a repeat opioid prescription. The multilevel model results indicated that, children receiving 4 to 7 days' supply (adjusted odds ratio [aOR]: 0.98 {0.9-1.1}), 8 to 10 days' supply (aOR: 1.03 [0.8-1.3]), and >10 days' supply (aOR: 0.85 [0.7-1.1]) had comparable likelihoods of receiving a repeat prescription as those receiving 1 to 3 days' supply.

DISCUSSION

Nearly 10% of children who filled an opioid prescription for acute pain received a repeat prescription. Initial prescription duration was not associated with the risk of receiving a repeat prescription.

Effect of consumer-grade wearable device data on clinician decision making during post-discharge telephone calls after pediatric surgery

BACKGROUND

During post-discharge telephone calls after pediatric surgery, clinicians must rely on parents/caregivers' assessment of symptoms, which can be inaccurate and often lead to unnecessary emergency department (ED) visits. Physiology (heart rate and physical activity) data from consumer-grade wearables, e.g., Fitbit™, may inform clinical decision making, yet there has been little study of clinician interpretation of this data. This study assessed whether wearable data availability, during simulated telephone calls about postoperative, post-discharge pediatric patients, affects clinician decision making.

METHODS

Three simulated telephone call scenarios were presented to a diverse group of pediatric surgery clinicians. The scenarios were based on actual postoperative patients (scenarios 1 and 3 have worrisome symptoms and scenario 2 has non-worrisome symptoms) who had worn a Fitbit™ postoperatively. Each scenario was presented to clinicians (1) without any wearable data; (2) with "concerning" wearable data; and (3) with "reassuring" wearable data. Clinicians rated their likelihood, on a scale of 1-10, of recommending an emergency department (ED) visit for the three instances of each scenario, 10 being definitely ED.

RESULTS

Twenty-four (24) clinicians participated in the study. When presented with "reassuring" wearable data, clinicians' likelihood of recommending an ED visit decreased from a median score of 6 to 1 (p < 0.001) for scenario 1 and from 9 to 3 (p < 0.001) for scenario 3. When presented with "concerning" wearable data, the median likelihood of recommending an ED visit increased from 1 to 6 (p = 0.003) for scenario 2.

CONCLUSION

This study showed that wearable data affect clinicians' decision making and may be useful in triaging postoperative, post-discharge pediatric patients.

LEVEL OF EVIDENCE

V.

Utilization of opioid versus non-opioid analgesics in Medicaid and CHIP enrolled children with current asthma

PURPOSE

Opioid analgesics are frequently dispensed in children despite its known risk in children with a compromised airway function. The objectives of the study were to assess the prevalence of opioid analgesic dispensing in children with current asthma and to identify patient and prescriber factors associated with the dispensing of opioid versus non-opioid analgesics.

METHODS

Children <18 years of age, having current asthma and receiving an incident analgesic prescription were identified from a large Medicaid Managed Care Plan during years 2013 through 2018. Current asthma was defined as both receiving an asthma diagnosis and filling an anti-asthmatic medication during the 12-month period prior to the analgesic medication initiation. A scoring algorithm was applied to associate analgesic prescription with procedures and diagnoses according to perceived need for analgesia and time proximity.

RESULTS

Of the 9529 children meeting the inclusion criteria, 2681 (28.1%) received an opioid prescription. Opioid analgesic dispensing was most common among children who had an outpatient surgery/procedure (29.4%), trauma (19.4%) dental procedure (18.4%), and respiratory infection (10.6%). Multivariable analysis indicated that non-Hispanic Black (AOR: 0.39[0.3-0.5]) and Hispanic (AOR: 0.51[0.4-0.6]) children were less likely to receive an opioid analgesic compared to their non-Hispanic White counterparts. Children with prior history of asthma-related emergency department visit (AOR: 1.24[1.0-1.5]) and short acting beta agonist overuse (AOR: 1.33[1.1-1.7]) were more likely to fill an opioid analgesic prescription than those without.

CONCLUSION

Opioid analgesics are frequently dispensed to children with asthma. A higher dispensing rate was observed among non-Hispanic White children and among those with a history of uncontrolled asthma.

State of the Art: Immersive Technologies for Perioperative Anxiety, Acute, and Chronic Pain Management in Pediatric Patients

Purpose of Review

This review summarizes and provides a comprehensive narrative synthesis of the current evidence on immersive technology’s (i.e., virtual and augmented Reality) use for perioperative anxiety, acute, and chronic pain in pediatrics.

Recent Findings

Researchers have increasingly studied immersive technology as a non-pharmacological alternative for perioperative anxiety, acute, and chronic pain management. We found several research studies published over the last 3 years: almost all studies examined the use of virtual reality for perioperative anxiety and pain; only one case report was about the use of augmented reality for preoperative anxiety. Most studies showed that virtual reality intervention is effective and safe for perioperative anxiety, acute, and chronic pain. However, the studies are heterogeneous with relatively small sample sizes.

Summary

This review shows that more high-quality studies (i.e., randomized controlled trials with larger sample sizes and standardized methods for measuring and reporting outcomes) are needed to examine the effectiveness and adverse effects of virtual reality intervention on perioperative anxiety, acute, and chronic pain in pediatrics.

Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy

BACKGROUND

A previous cohort of adenotonsillectomy patients at our institution demonstrated moderate-severe post-tonsillectomy pain scores lasting a median (range) duration of 6 (0-23) days and postdischarge nausea and vomiting affecting 8% of children on day 1 following surgery. In this subsequent cohort, we evaluate the impact of changes to our discharge medication and parental education on post-tonsillectomy pain and recovery profile.

METHODS

In this follow-on, prospective observational cohort study, all patients undergoing tonsillectomy at our institution during the study period were discharged with standardized analgesia. Parents received a revised education package and a medication diary which were not provided to the previous cohort. Pain scores, rates of nausea and vomiting, medication usage and unplanned representation rates were collected by telephone from parents.

RESULTS

Sixty-nine patients were recruited. Moderate-severe pain lasted a median (range) of 5 (0-12) days. Twenty-nine (42%) had pain scores ≥4/10 beyond postoperative day 7. By postoperative day 5, only 37 (53%) parents continued to administer regular analgesia. The median number of oxycodone doses used was 5 (0-22), and only 28 (41%) parents had disposed of leftover oxycodone within 1 month of surgery. Twenty-four (35%) patients experienced nausea or vomiting postdischarge. The median (range) time for return to normal activities was 6 (0-14) days. Thirty-two/sixty-nine (46%) patients had unplanned medical representations. Most occurred between postoperative day 5 and 7. Pain contributed to 16 (35%) representations.

CONCLUSIONS

Despite extensive changes to our discharge protocols parents continued to report a prolonged period of pain, post operative nausea and vomiting, and behavioral changes. Further work is required to examine barriers to compliance with simple analgesia and education in appropriate methods of opioid disposal.

Children's Opioid Use at Home After Laparoscopic Appendectomy

BACKGROUND

To combat the opioid epidemic, prescribers need accurate information about pediatric home opioid requirements to manage acute pain after surgery. Current opioid use estimates come from retrospective surveys; this study used medication adherence technology (eCAP) to track home opioid use.

PURPOSE

To describe children's pain treatment at home after laparoscopic appendectomy, and to compare self-reported opioid analgesic use to eCAP data and counts of returned pills.

DESIGN

Prospective exploratory and descriptive study METHODS: A convenience sample of 96 patients, 10-17 years of age, from a single urban nonprofit children's hospital consented to self-report pain treatment in 14-day diaries and use eCAP to monitor prescribed opioid use at home after laparoscopic appendectomy.

RESULTS

Patients were prescribed 5-45 opioid-containing pills (mean ± standard deviation 15 ± 7.2). Of 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills were dispensed, 167.5 were used for the reason prescribed, 488 were returned to families for disposal, and 53.5 were missing. The majority of the 49 patients were opioid naïve (72%), Caucasian (64%), and male (56%), with a mean age of 14 years. Patients used 6.6 ± 6.3 opioid-containing pills by pill count and 5.6 ± 5.1 by self-report, a significant difference (p = .004). Unreported eCAP-enabled pill bottle openings typically occurred on weekends.

CONCLUSION

Medication adherence technology (eCAP) is a more rigorous method than self-report to estimate opioid needs and detect early opioid misuse. Additional rigorously designed studies of postoperative opioid use are needed to guide opioid prescribing.

Utility of Wearable Sensors to Assess Postoperative Recovery in Pediatric Patients After Appendectomy

BACKGROUND

Despite more than two million pediatric operations performed in the United States annually, normal postoperative recovery remains difficult to define. Wearable sensors that assess physical activity and vital signs in real time represent a tool to assess postoperative recovery. This study examined the use of a wearable, the FitBit Inspire HR, to describe recovery in children after appendectomy and to determine the sensitivity of wearable data to distinguish disease severity.

MATERIALS AND METHODS

Children 3-18 y old undergoing appendectomy in a tertiary children's hospital were invited to participate. Participants wore the FitBit Inpire HR after surgery for 21 d. t-tests compared daily step counts, and piecewise linear regression models were fit to examine recovery trajectories for patients with simple and complicated appendicitis.

RESULTS

Thirty-two patients were enrolled, and 26 met eligibility criteria. Nine (35%) children had complicated appendicitis, and 14 (54%) were female; the mean age was 9.1 y (standard deviation: 2.9). Four hundred nineteen postoperative days were captured (range: 8-22 d; median: 16 d). Step counts increased after surgery; however, piecewise models showed that patients with simple appendicitis had a more rapid increase (P < 0.01) and reached a plateau (approximately 8000 steps/d) on postoperative day 9, whereas patients with complicated appendicitis did not reach a plateau and had lower step counts during the entire 21-postoperative day period (P < 0.01).

CONCLUSIONS

Recovery in children after surgery can be characterized using wearables, which can also distinguish recovery trajectories based on disease severity. Establishing such "normative" recovery patterns may lead to earlier detection of complications.

Is the Use of Opioids Safe after Primary Cleft Palate Repair? A Systematic Review

Pharmacologic treatment of postoperative pain after cleft palate repair includes opioids and nonopioid analgesics, nerve blocks, and local anesthetic infiltration. Use of opioids in infants has concerns regarding sedation, risk of aspiration, respiratory depression, and respiratory distress. The main objective of this review was to analyze information available on the safety of the use of opioids during perioperative management of pain related to primary cleft palate repair in published studies.

Methods

A systematic review of the literature for studies published until March 2020 was performed to evaluate the safety of opioid drugs during primary cleft palate repair pain management. The authors chose the following MesH terms for this systematic review: cleft lip and palate AND opioids AND pain management. The investigators performed a systematic literature search using the Pubmed/MEDLINE, Embase, Web of Science, and Cochrane Library databases.

Results

After a literature search resulting in 70 identified studies, 9 were qualified for the final analysis, which included 772 patients. There was a high level of evidence in the selected studies according to the Oxford CEBM Level of Evidence classification and GRADE scale. The most common adverse event reported was postoperative nausea and vomiting (from 5% to 25%). Episodes of oxygen desaturation have been reported from 2.5% to 7.4% of the studied patients.

Conclusion

s: Definitive conclusions about the safety of opioid drugs during primary cleft palate repair pain management cannot be drawn. Vomiting and oxygen desaturation have been associated with the use of opioids in the studied population.

Unilateral Acupuncture Reduces Postoperative Pain Scores in Children Undergoing Adenotonsillectomy: A Randomized Controlled Trial

Purpose

Acupuncture ameliorates several pain disorders including postoperative pain. This can help to decrease the need for postoperative analgesics. We aimed to evaluate the effectiveness of acupuncture as an adjuvant scheme reduce both intraoperative and postoperative analgesia needs in children undergoing adenotonsillectomy.

Methods

This was a randomized controlled single-blinded trial that was performed over sixty children scheduled for adenotonsillectomy. They were randomly allocated to either an intervention group that received general anesthesia plus acupuncture or a control group which received general anesthesia alone. The primary outcome was the measurement of postoperative pain scores. Secondary outcomes included measurement of time to the first request of postoperative analgesia, the number of children requesting postoperative analgesics in the first 2 hours, the incidence of postoperative complications including postoperative nausea and/or vomiting (PONV), and emergence agitation (EA).

Results

AThe Wong-Baker FACES pain scores at rest and on swallowing were significantly lower in the intervention group than in the control group postoperatively. The time to the first request of postoperative analgesia was delayed in the intervention group versus the control group, with less number of patients who have requested additional analgesia during the first 2 hours postoperatively. Postoperative agitation was lower in the intervention group versus the control group patients. However, the incidence of PONV was not statistically different between study groups.

Conclusion

Combined acupuncture with general anesthesia in children undergoing adenotonsillectomy provided better postoperative pain control with no adverse effects.

Assessment of Saudi Mothers' Attitudes towards Their Children's Pain and Its Management

Background and objective: Pain is a bothersome issue that is common among newborns and children of all ages. Pain can be managed using various pharmacological and/or non-pharmacological strategies, which can be delivered by healthcare providers or parents. The aim of this study is to assess the attitude of mothers toward their children’s pain and its management. Methods and materials: A descriptive cross-sectional web-based study was conducted using a developed self-reported questionnaire, from March 2018 to April 2018. Participants involved were Arabic-speaking mothers of children aged between 0 and 12. The data collected included pharmacological and non-pharmacological treatment methodologies utilized to treat pain and the mothers’ attitude towards pain management. Statistical Package for Social Sciences, version 25 was applied to analyze the data, and descriptive statistics were performed. Results: As per the results of this study, the most common site of children’s pain as reported by the mothers was mouth/throat (211; 52.9%), abdomen (199; 49.9%), followed by head (58; 14.5%), and finally, ears (69; 17.3%). The frequency of children’s pain, as stated by the mothers, was less than once a month (196; 49.1%), once in a month (137; 34.3%), and once in a week (48; 12%). The non-pharmacological methods used by mothers at home for the management of their children’s pain were as follows: letting them take rest or sleep (250; 62.6%), feeding them with fluids (228; 57.1%), applying cold packs (161; 40.4%), providing massage therapy (147; 36.8%), using warm packs (141; 35.3%), and taking them to play (119; 29.8%). Conclusion: The misconceptions about pediatric pain management among Saudi mothers that can affect the children’s quality of life are quite noticeable. Implementing educational and awareness programs about the management of child pain could play a major role in making the parents understand the impacts of their misconceptions.

Adaptive randomised controlled non-inferiority multicentre trial (the Ketodex Trial) on intranasal dexmedetomidine plus ketamine for procedural sedation in children: study protocol

INTRODUCTION

Up to 40% of orthopaedic injuries in children require a closed reduction, almost always necessitating procedural sedation. Intravenous ketamine is the most commonly used sedative agent. However, intravenous insertion is painful and can be technically difficult in children. We hypothesise that a combination of intranasal dexmedetomidine plus intranasal ketamine (Ketodex) will be non-inferior to intravenous ketamine for effective sedation in children undergoing a closed reduction.

METHODS AND ANALYSIS

This is a six-centre, four-arm, adaptive, randomised, blinded, controlled, non-inferiority trial. We will include children 4-17 years with a simple upper limb fracture or dislocation that requires sedation for a closed reduction. Participants will be randomised to receive either intranasal Ketodex (one of three dexmedetomidine and ketamine combinations) or intravenous ketamine. The primary outcome is adequate sedation as measured using the Paediatric Sedation State Scale. Secondary outcomes include length of stay, time to wakening and adverse effects. The results of both per protocol and intention-to-treat analyses will be reported for the primary outcome. All inferential analyses will be undertaken using a response-adaptive Bayesian design. Logistic regression will be used to model the dose-response relationship for the combinations of intranasal Ketodex. Using the Average Length Criterion for Bayesian sample size estimation, a survey-informed non-inferiority margin of 17.8% and priors from historical data, a sample size of 410 participants will be required. Simulations estimate a type II error rate of 0.08 and a type I error rate of 0.047.

ETHICS AND DISSEMINATION

Ethics approval was obtained from Clinical Trials Ontario for London Health Sciences Centre and McMaster Research Ethics Board. Other sites have yet to receive approval from their institutions. Informed consent will be obtained from guardians of all participants in addition to assent from participants. Study data will be submitted for publication regardless of results.

TRIAL REGISTRATION NUMBER

NCT0419525.

Postoperative pain course after paediatric tonsillectomy: A prospective observational study comparing one behavioural and one numerical pain assessment tool

INTRODUCTION

Paediatric tonsillectomy is often performed as outpatient surgery, although postoperative pain may be severe and protracted. This prospective observational study evaluated two paediatric pain assessment tools for use in telephone interviews with parents.

METHODS

ASA I-II children, ≥1 and < 13 years, undergoing outpatient tonsillectomy were recruited. Anaesthesia (propofol-remifentanil) and intraoperative analgesia were standardized. Sedating premedication was not given. Before discharge, a "smiley face" numerical pain assessment tool was introduced to parents. In telephone interviews on postoperative days 1, 3, 7 and 14, parents scored their childrens pain numerically (0-10) and on the behavioural Postoperative Pain Measure for Parents (PPMP, 0-15). Number of analgesic doses (paracetamol/ibuprofen) per 24 h was noted. Values are median (quartiles).

RESULTS

22 consecutive children were included, age 4 (3-6) years. Parents had administered analgesics to 100%, 95%, 80%, and 5% of children at the four interview times. Numerical pain scores were 3.5 (1-7) at hospital discharge, and 5.5 (3-7), 3 (2-6), 3.5 (0-6), and 0 (0-0) on postoperative days 1, 3, 7, and 14, respectively. In 12/22 children, pain declined to a value of 1 (0-2) on day 7. In 6/22 children pain initially declined, but surged to 5.5 (4-7) on day 7. Significant, protracted pain (9 (6-10) on day 7) was reported in 3/22 children. Behavioural (PPMP) scores were positively correlated to numerical pain scores (day 3: R² = 0.48, day 7: R² = 0.31, day 14: R² = 0.85). With increasing age, children systematically had lower behavioural pain scores for the same numerical pain score (0.61 per years age; p < 0.023).

CONCLUSION

In structured telephone interviews, parents effectively pain scored their children after outpatient tonsillectomy. Numerical and behavioural pain scores correlated well, however age-dependent. Pain courses varied considerably, and a majority of children had significant pain. Pain after paediatric tonsillectomy should be assessed and treatment individualised.

A comprehensive examination of the immediate recovery of children following tonsillectomy and adenoidectomy

OBJECTIVES

Using multiple well-validated measures and a large sample size, the goal of this paper was to describe the immediate clinical and behavioral recovery of children following tonsillectomy with or without an adenoidectomy (T&A) during the first two weeks following surgery.

STUDY DESIGN

Observational, longitudinal study.

SETTING

Four major pediatric hospitals in the U.S. consisting of Children's Hospital of Orange County, Children's Hospital of Los Angeles, Lucile Packard Children's Hospital, and Children's Hospital Colorado.

SUBJECTS

and Methods: Participants included 827 patients between 2 and 15 years of age who underwent tonsillectomy with or without adenoidectomy surgery. Baseline and demographic information were gathered prior to surgery, and measures of clinical, behavioral, and physical recovery were recorded immediately following and up through two weeks after surgery.

RESULTS

Pain following T&A was clinically significant through the first post-operative week and nearly resolved by the end of the second week. Negative behavioral changes were highly prevalent after surgery (75.6% of children at Day 0) through the first week (63.9% at Week 1), and over 20% of children continued to evidence new onset negative behavioral changes at two weeks post-operatively. Children were rated as experiencing significant functional impairment in the immediate three days following surgery and most children returned to baseline functioning by the end of the second week.

CONCLUSIONS

Results of this study suggest that children show immediate impairment in functioning and experience clinically significant pain throughout the first week following T&A, and new onset maladaptive behavioral changes persisting even up to the two-week assessment period.

A two-centre survey of caregiver perspectives on opioid use for children's acute pain management

Background

Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers' a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids.

Methods

A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children.

Results

Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were 'unsure'; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were 'unsure'. Caregivers' primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use.

Conclusions

Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers' fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making.

Variation in postoperative narcotic prescribing after pediatric appendectomy

BACKGROUND

Overuse of prescription opioids by both pediatric and adult patients has garnered significant attention in recent years. Educational interventions have been shown to decrease prescription opioids post-operatively in the adult population; similar data have not previously been reported in pediatrics.

METHODS

Educational interventions included staff education, institution of opioid standardization protocol, and distribution of educational materials to families. Chart review was performed pre- and post-intervention to compare prescribing practices following appendectomy in patients less than 19 years of age. Follow-up phone calls were used to assess patient satisfaction and pain control.

RESULTS

Three hundred thirteen cases were identified pre-intervention [PRE] and compared to 119 cases postintervention [POST]. 84.3% of patients were given a prescription for opioids at time of discharge in the PRE cohort compared to 6.7% (p < 0.001) POST. There was a significant increase in non-opioid analgesia (p < 0.001) POST. There was no significant variability in opioid usage by type of surgery performed, attending provider, or patients' gender or age. Of the patients in the POST cohort, 60.5% were available for telephone follow-up. More than 80% of patients were given acetaminophen and/or ibuprofen POST and 94.4% reported adequate pain control; 88.9% reported that they would agree to avoid opioids again in the future. On follow-up survey, there was no increase in emergency department visits or phone calls for poorly controlled pain following the intervention.

CONCLUSION

Low-fidelity educational interventions and creation of a standardized pathway is an effective tool to reduce opioid prescribing and promote alternative means of analgesia without an increase in readmissions or presentation for pain.

LEVEL OF EVIDENCE

III.

Postoperative pain: factors and tools to improve pain management in children

Outpatient surgery has made it increasingly common for parents to manage pain in the home setting. Studies have shown that parents often under treat pain, leaving children vulnerable to the negative side effects of suboptimal pain management. Multiple factors affect pain management like child’s age and developmental stage, language, cultural values like stoicism, parental beliefs about medication, biological differences among groups, etc. Understanding all the factors involved can help healthcare providers and parents better understand pain and contribute to optimal pain management. Multiple tools and technological interventions have been created to help create a better understanding of pain and a holistic approach to care.

An interactive web-based educational program improves prescription opioid risk knowledge and perceptions among parents

Aim: This study evaluated the effect of an interactive, web-based educational program on parents' opioid risk knowledge, risk perceptions, analgesic self efficacy and decision-making. Patients & methods: Totally, 64 parents from a tertiary care pediatric healthcare setting were assessed for risk understanding at baseline, immediately and 3 days after receiving the educational program. Results: Participants gained increased opioid risk knowledge, enhanced risk perceptions as well as enhanced analgesic self efficacy after program exposure. The program had no effect on parental decisions about when to give or withhold a prescribed opioid. Conclusion: The interactive web-based program improved parental knowledge about opioid risks. Program enhancements may be needed to improve pain management decisions about when it is safe to use opioids and when they should be withheld.

Resilience in children and their parents enduring pediatric medical traumatic stress

Due to the general lack of familiarity with the concept in the medical field, resilience is rarely considered in pediatric medical traumas. Resilience is an ability that enables recovery after adversities such as traumas, surgeries, serious health problems, or social issues. Stress from medical traumas encompasses both the psychological and physical responses of children and their families. Lack of resilience in children with medical traumatic stress may contribute to poor adjustment, slow recovery, disruptive behaviors, and psychiatric disorders. Furthermore, persistent parental distress increases the child's risk of low resilience. Consequently, these patients and their parents require early identification. This is achievable using a common stress measure such as the Perceived Stress Scale. Moreover, health care providers can screen patients' risks for low resilience, which include few social contacts, poor family functioning, and low cohesion among family members. Findings from the stress scale and screened risks could indicate the need for additional psychosocial support at the time of diagnosis of a serious illness, soon after injuries, and before and after operations. Such interventions can include decreasing distress, counseling children and their parents, and enabling strong connections to health care providers. Health care providers can help parents to minimize distress and adjust to their child's illness, thereby supporting the child's resilience, adjustment, and recovery.

Nebulized analgesia during laparoscopic appendectomy (NALA): A randomized triple-blind placebo controlled trial

PURPOSE

Postoperative pain remains a considerable concern for patients and families. We assessed whether nebulized ropivacaine reduces morphine consumption and pain after laparoscopic appendectomy for uncomplicated appendicitis in children.

METHODS

Patients 7-17 years old with uncomplicated appendicitis were randomized to ropivacaine (intervention arm) or saline nebulization (placebo arm) at the onset of laparoscopy. Nonconsenting individuals were treated with standard care and invited to provide clinical data (baseline arm). The primary outcome was in-patient morphine utilization. Secondary outcomes included pain scores at multiple time-points, markers of recovery, operative times, and surgeon satisfaction. The trial was registered (NCT02624089).

RESULTS

Study enrollment was 116 patients over a 1-year period: Intervention (n = 43), Placebo (n = 39), Baseline (n = 34). No differences in baseline characteristics were noted between groups. No difference was noted in overall in-patient morphine consumption between randomized groups (0.31 vs. 0.35 mg/kg, p = 0.42) or between ropivacaine and baseline (0.31 vs. 0.277 mg/kg, p = 0.62). Although operative times were comparable between groups, 63% of surgeon respondents felt that nebulization obscured visualization.

CONCLUSION

Nebulized ropivacaine did not reduce postoperative morphine consumption or pain scores after laparoscopic appendectomy for simple appendicitis in children. Given that it decreases visualization and likely increases costs, nebulized administration of intraperitoneal analgesia does not appear warranted in this context.

TYPE OF STUDY

Treatment study.

LEVEL OF EVIDENCE

Level I.

Pain relief after ambulatory surgery: Progress over the last decade

The concept of fast-track or ambulatory surgery appeared to facilitate early recovery and discharge from the hospital and early resumption of normal daily activities after elective surgical procedures as well to reduce the health-care costs. Multimodal/balanced analgesia is an increasingly popular approach for this. The use of conventional modalities including central neuraxial blockade and opioids cannot be extended to patients undergoing fast-track surgery. Hence, an aggressive perioperative analgesic regimen/protocol is required for effective pain relief, with minimal side effects and which could be managed easily by the patient or the relatives at home away from the hospital setting. Pharmacological therapy and regional anesthesia techniques have been utilized for postoperative pain management. The use of perineural, incisional, and intra-articular catheters and local anesthetic administration through elastomeric and electronic pumps is promising approach for effective pain management at home. The key to successful pain management of such procedures requires individually tailored education to patients or caregivers including information on treatment options for postoperative pain and use of multimodal analgesia. This review provides an overview of the current armamentarium of drugs and modalities available for effective management of patients undergoing day care surgeries and sheds light on newer modalities available.

A Model of the Intersection of Pain and Opioid Misuse in Children and Adolescents

Despite being a significant public health concern, the role of opioid prescriptions in potentiating risk of opioid misuse in the context of pediatric pain has been under-investigated. To address this gap, the present review identifies theory-based hypotheses about these associations, reviews the extant literature on opioid prescriptions that supports these hypotheses, and provides routes for future empirical studies. A multi-level model of mechanisms through which opioid prescriptions may impact pain and other negative outcomes in youth, including risk for opioid misuse and related problems, is proposed with particular attention paid to the role that psychologists can play in informing policies and developing preventative interventions in healthcare settings.

Postoperative pain and analgesia administration in children after urological outpatient procedures

INTRODUCTION

There are limited data about pain patterns, analgesic requirements and factors predicting opioid requirements of children undergoing outpatient urologic surgery. This prospective study aimed to assess recovery profiles and pain medication requirements.

METHODS

Patients between 6 months and 12 years of age were recruited prospectively between December 2013 and June 2014. Demographic and operative characteristics were collected. Following discharge home, the parents were asked to administer both acetaminophen and ibuprofen Q6H at a weight-adjusted dose, based on a schedule, until the end of postoperative day 2, and to administer the medication as required on postoperative day 3. Pain severity was recorded using validated pain scores (Face, Legs, Activity, Cry, Consolability/Parents' Postoperative Pain Measurement). A morphine prescription was provided for breakthrough pain. A Likert scale was used to assess parent's satisfaction with the pain management.

RESULTS

A total of 249 patients were recruited, 111 patients (45%) returned appropriately completed surveys and were included in the final analysis. Mean age was 44.1 months (SD = 37.3). The performed procedures were orchidopexy (31), hypospadias repair (26), hernia/hydrocele repair (15), Fowler-Stephens procedure (13), meatoplasty (7), phalloplasty (4), scrotoplasty (1), circumcision (7), and diagnostic laparoscopy (5). After discharge home 17 patients (15.3%) received morphine. Mean utilization of non-opioid analgesia was 79% on postoperative day 1, 67% on day 2, 36% on day 3, and 2% on day 4. Parental satisfaction was high (92.0% satisfied/very satisfied). No patient, anaesthetic or surgical factors were associated with opioid use or prolonged need for postoperative analgesia.

CONCLUSION

The combination of scheduled non-opioid medications for maintenance and opioids for breakthrough pain provided satisfactory pain control after outpatient urologic surgery in children. There were no specific patient, anesthetic or surgical factors that predicted postoperative opioid requirements.

Changes in sensory processing after anesthesia in toddlers

BACKGROUND

Anesthesia and surgery may influence toddlers' sensory processing and consequently postoperative adjustment and behavior. This is the first study to: 1) test pre- to postoperative changes in sensory processing after pediatric anesthesia using the validated Infant/Toddler-Sensory Profile for 7-36 months (ITSP7-36); 2) identify putative predictors of these changes.

METHODS

This prospective cohort study included 70 healthy boys (ASA I & II), aged 18-30 months, who underwent circumcision for religious reasons. Exclusion: boys with prior surgery and known developmental delay.

PRIMARY OUTCOME

changes in sensory processing from the day of admission to day 14 postoperatively. The accompanying parent completed the ITSP7-36. Putative predictors: 1) child's preoperative emotional/behavioral problems; 2) child's state anxiety at induction; 3) postoperative pain at home. All children received standardized anesthesia and pain management.

RESULTS

For 45 boys, assessments were completed at both time points. Significant changes in sensory processing (mean ITSP7-36 scores) were found on: low registration (47.5 to 49.8; P=0.015), sensory sensitivity (45.2 to 48.0; P=0.011), sensation avoiding (48.2 to 51.3; P=0.010), low threshold (93.4 to 99.4; P=0.007), auditory processing (39.3 to 43.3; P=0.000) and tactile processing (53.9 to 58.4; P=0.002). Higher scores on emotional/behavioral problems predicted changes on sensory processing.

CONCLUSIONS

Sensory processing of these toddlers had changed after anesthesia. Children with more pre-existent emotional/behavioral problems are more vulnerable to these changes.

Oral morphine versus ibuprofen administered at home for postoperative orthopedic pain in children: a randomized controlled trial

BACKGROUND

Oral morphine for postoperative pain after minor pediatric surgery, while increasingly popular, is not supported by evidence. We evaluated whether oral morphine was superior to ibuprofen for at-home management of children's postoperative pain.

METHODS

We conducted a randomized superiority trial comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) in children 5 to 17 years of age who had undergone minor outpatient orthopedic surgery (June 2013 to September 2016). Participants took up to 8 doses of the intervention drug every 6 hours as needed for pain at home. The primary outcome was pain, according to the Faces Pain Scale - Revised, for the first dose. Secondary outcomes included additional analgesic requirements, adverse effects, unplanned health care visits and pain scores for doses 2 to 8.

RESULTS

We analyzed data for 77 participants in each of the morphine and ibuprofen groups. Both interventions decreased pain scores with no difference in efficacy. The median difference in pain score before and after the first dose of medication was 1 (interquartile range 0-1) for both morphine and ibuprofen (p = 0.2). For doses 2 to 8, the median differences in pain score before and after the dose were not significantly different between groups. Significantly more participants taking morphine reported adverse effects (45/65 [69%] v. 26/67 [39%], p < 0.001), most commonly drowsiness (31/65 [48%] v. 15/67 [22%] in the morphine and ibuprofen groups, respectively; p = 0.003).

INTERPRETATION

Morphine was not superior to ibuprofen, and both drugs decreased pain with no apparent difference in efficacy. Morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a better first-line option after minor surgery.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01686802.

Treatment of Pain in Pediatric Patients

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.

Parents' experiences of managing their child's postoperative pain at home: an exploratory qualitative study

AIMS AND OBJECTIVES

To understand parents' experiences of managing their child's postoperative pain at home.

BACKGROUND

Recent changes in children's health care services often shift the responsibility of managing children's postoperative pain to parents. Although pain management is important for good postoperative outcomes, it can be a challenging task for families, and children's pain is often under-managed.

DESIGN

This qualitative study used semi-structured interviews to explore parents' experiences of managing their child's postoperative pain at home.

METHODS

Participants were parents of 10 typically developing 5- and 6-year olds, who underwent (adeno)tonsillectomy, and experienced no complications leading to hospitalisation in the postoperative period. One-on-one interviews were conducted with parents within three months of their child's surgery. Interviews were transcribed verbatim and content analysis was used to identify themes in parents' experiences.

RESULTS

All children experienced some postoperative pain. Parents' experiences of managing their child's pain were impacted by balancing the pros and cons of administering analgesic medications, managing the emotional and psychological effects of their child's pain, as well as parents' information needs.

CONCLUSIONS

Most parents' information needs were met yet they still struggled to manage their child's pain. These findings provide insight into some of the barriers that make this process challenging for many families, and what health care centres can do to help support parents manage their child's postoperative pain at home.

RELEVANCE TO CLINICAL PRACTICE

The results of this study may aid in the design of interventions that will support parents when managing their child's postoperative pain at home and thus improve children's experiences.

Structured intervention for management of pain following day surgery in children

BACKGROUND

Ambulatory surgery forms a large part of pediatric surgical practice. Several studies indicate that postoperative pain is poorly managed with more than 30% of children having moderate to severe pain. In a busy outpatient clinic contact between healthcare professionals and the family is increasingly limited calling for a global and efficient pain management regime.

OBJECTIVE

The aim of this prospective observational cohort study was to determine postoperative pain intensity following day surgery in children after our structured intervention for pain management.

METHODS

A number of interventions in an effort to address barriers to effective postoperative pain management after day surgery were identified in the literature. By introducing our concept structured intervention, we aimed to address the majority if not all these barriers. Accordingly, we adapted postoperative pain management to each child using a multimodal approach consisting of surgery-specific analgesia with weight appropriate doses of acetaminophen and ibuprofen. Analgesics were handed out to the parents in formulations accepted by child and parent and after thorough information to the parents.

RESULTS

Two hundred and forty-five children were scheduled for surgery during the 3-month period of which 149 children were available for analysis. The postoperative pain as assessed by the parents with a the Short Form of the Parents' Postoperative Pain Measure (PPPM-SF) was well managed exhibiting a median pain score of 4 on postoperative day 0 (POD0) and median 1 on postoperative day 1 (POD1) and a numeric rating scale (NRS) median pain score of 2 on POD0 and median 1 on POD1. We found a highly significant correlation between the PPPM-SF and the NRS scores.

CONCLUSION

After thorough information of the parents we have successfully implemented a surgery-specific regime of primarily around-the-clock dosing of drug formulations acceptable for the specific child with dispensed medication ready available for the family.

The prevalence of pain at home and its consequences in children following two types of short stay surgery: a multicenter observational cohort study

BACKGROUND

The potential for pain at home in children following day case surgery has long been recognized. Pain has also been associated with behavioral disturbances and sleep disruption in children following surgery and may also impact negatively on recovery, parental and patient satisfaction, family life, healthcare use, and have an economic cost.

AIM

To investigate the prevalence of pain at home, and its consequences, in children following two types of short stay surgery across eight pediatric centers in the UK in an observational cohort study. Reporting of the study was done in adherence with STROBE guidelines.

METHOD

Two hundred and forty-one children undergoing either Tonsillectomy with or without Adenoidectomy (T's ± A's) or Orchidopexy surgery (either by Open or Laparoscopic) were recruited. Data collection was via three structured telephone interviews [Day (D) 2, 7 and 14] conducted from a clinical research facility. The normal clinical practices of the centers involved in the study were not altered in any way. Outcomes studied were (i) Pain incidence and severity; (ii) Associated consequences-incidence of psychological disturbances, unplanned use of healthcare services, and social/economic cost to families; and (iii) Comparative pain and associated outcomes for two types of surgery (T's ± A's vs Orchidopexy).

RESULTS

The incidence of pain following both operative models was high though it differed between the two groups. In the T's ± A's group, the incidence of pain was high throughout the study period (D2 90.1%, D3-7 88.1%, D8-14 61.8%). The Orchidopexy group demonstrated a similar pattern, though with decreased rates (D2 70.4%, D3-7 34.7%, D8-14 17.1%). Both groups showed similar patterns for the rates of behavioral disturbances (T's & A's: D2 76%, D3-7 73%, D8-14 30% and Orchidopexy: D2 37%, D3-7 20%, D8-14 10%). Seventy percent of the families reported unplanned healthcare use with pain the primary reason in 79% of these.

CONCLUSIONS

The prevalence of pain at home, and its potential associated consequences, is high following short stay surgery in children in the UK. In both groups, high incidences were seen for longer periods than is commonly perceived. These findings were consistent between the centers involved suggesting that this is a significant national healthcare issue with potential short- and long-term consequences for the child, their family, and health services.

Parental attitudes to children's pain and analgesic drugs in the United Kingdom

Many children experience treatable moderate to severe pain following surgery. Increasingly, children undergo surgery as day cases, and, as such, parents are more likely to be responsible for managing pain post-operatively. Research in the United States and Finland has found parents fear the side effects of analgesics; think they are addictive; and that children should receive as little analgesia as possible. Little is known about parental attitudes in this context in the United Kingdom. This study set out to explore parental attitudes towards children's pain and analgesic drugs to contribute to existing knowledge about parental attitudes elsewhere so that the information provided to parents can be tailored effectively. A convenience sample of parents (n = 108) at one hospital in South West London completed the Parental Pain Expression Perceptions and the Medication Attitudes Questionnaires. Although many parents have a good understanding of the ways in which children express pain, a substantial proportion of parents hold misconceptions regarding how children express pain and concerns in relation to analgesic drugs. This may impact on the quality of the pain management provided to children post-operatively and needs taking into account when preparing parents in this context.

[Validation of the Spanish version of Parent's Postoperative Pain Management pain scale]

INTRODUCTION

Assessment of postoperative pain is a fundamental aspect of post-surgical care. When surgery is performed as an outpatient, the parents are mainly responsible for the assessment of pain, but they may not always correctly evaluate their children's pain. This makes it necessary to have tools that help them to assess postoperative pain reliably. The Parent's Postoperative Pain Measurement (PPPM) is a behavioral measurement tool of post-operative pain developed to help parents to assess their children's post-operative pain. The purpose of this work was to translate this scale into Spanish, and validate the psychometric properties of the Spanish version of the scale.

METHOD

Participants were 111 children aged 2 to 12 years, who had undergone surgery, and one of their parents. After the operation, the children's level of pain was assessed, and the parents completed the PPPM scale in Spanish.

RESULTS

The PPPM items in Spanish showed good internal consistency (Cronbach alpha between 0.784 and 0.900) and the scale scores were closely related to the global pain assessment (Spearman's rho correlation between 0.626 and 0.431). The score on the scale decreased between the day of the operation and the next day, and discriminated well between children undergoing surgery qualified as low/moderate pain and high pain.

CONCLUSIONS

We conclude that the Spanish version of the PPPM scale evaluated in this study, has good psychometric properties to assess postoperative pain by parents at home.

Improving postoperative tonsillectomy pain management in children--a double blinded randomised control trial of a patient analgesia information sheet

OBJECTIVES

To evaluate paediatric post-tonsillectomy pain management using oxycodone when a specific analgesia information sheet is included with standard postoperative information.

METHODS

Oxycodone information sheets were randomly allocated to half the study children's post-tonsillectomy information pack. The trial was double-blinded to the surgeon, anaesthetist, nursing and administrative staff. Parents and children completed the pain assessment on day 3, 5 and 7. On day 10 the parents completed a questionnaire.

RESULTS

A postoperative analgesia information sheet provides for higher satisfaction and knowledge for parents using oxycodone (p<0.001) and children have improved postoperative pain control, most significantly at day 5 (p<0.05). Parent assessment of the child's analgesia was superior with the oxycodone information sheet, most significantly at day 3 and 7 post operatively (p<0.05). There is also a positive correlation between the parents' observed pain score and children's self reported pain score, with a low correlation efficient level observed (p<0.001).

CONCLUSIONS

Information sheets are useful in education and use of postoperative analgesia. The primary objective to explore the efficacy of the information sheet has proved to be successful in this setting. Given risks of opioid analgesia, it is recommended that postoperative information sheets be given to all parents, to provide for improved analgesia control and safe management of children in the postoperative period.

Cancer-Related Pain and Pain Management: Sources, Prevalence, and the Experiences of Children and Parents

Advances in treatment mean children are increasingly cared for by their parents at home, leading to a shift in responsibility from health care professionals to parents. Little is known about parents' pain management experiences and the etiology of pain experienced by children with cancer especially when at home. A rapid review of the literature was undertaken investigating children's cancer-related pain, with emphasis on the management of pain outside the health care setting. Electronic databases were searched and a quality assessment was conducted. Forty-two articles were included. Despite advances in pain management techniques, children with cancer regularly cite pain as the most prevalent symptom throughout the cancer trajectory. The source of pain is usually treatment side effects or painful procedures. Parents find dealing with their child's pain distressing and demanding and may hold misconceptions about pain management. Findings indicate a need for more robust research into parental pain management leading to the development of effective pain management resources for parents.

Confronting the challenges of effective pain management in children following tonsillectomy

Tonsillectomy is an extremely common surgical procedure associated with significant morbidity and mortality. The post-operative challenges include: respiratory complications, post-tonsillectomy hemorrhage, nausea, vomiting and significant pain. The present model of care demands that most of these children are managed in an ambulatory setting. The recent Federal Drug Agency (FDA) warning contraindicating the use of codeine after tonsillectomy in children represents a significant change of practice for many pediatric otolaryngological surgeons. This introduces a number of other safety concerns when deciding on a safe alternative to codeine, especially since most tonsillectomy patients are managed by lay primary caregiver's at home. This review outlines the safety issues and proposes, based on currently available evidence, a preventative multi-modal strategy to manage pain, nausea and vomiting without increasing the risk of post-tonsillectomy bleeding.

Nurses' report of in-hospital pediatric pain assessment: examining challenges and perspectives

Pain is a symptom pediatric nurses commonly encounter in the hospital setting. Untreated pain can lead to adverse physiologic and psychological effects. This study examines in-hospital pain assessment methods nurses report using and assesses challenges, difficulties, and barriers nurses report to assessing pain in hospitalized children. Cross-sectional study of 82 pediatric nurses from all pediatric departments of a tertiary hospital in Israel. A self-report questionnaire was developed to examine how nurses assess children's in-hospital pain and barriers to in-hospital pain assessment. Nearly all nurses (90%) reported having enough knowledge to assess children's pain in the hospital, relying on child's self-report (86%) and being familiar with commonly used validated pain scales (90%). However, a majority (75%) reported not using pain scales recently and only half (58%) reported using an alternative method involving the child. Most nurses (86%) reported relying on their own overall impression of the child's pain and only a third (34%) reported involving the parents in their pain assessments. Nurses included comments stressing the importance of pain assessments and their frustration with the current validated measures available. This study adds to a growing body of literature demonstrating a gap between recommended pediatric pain assessment guidelines and reported practice, with nurses showing a resistance to relying on single-item or unidimensional measures to assess and evaluate the rich and complex pain experience. A multidimensional approach involving child self-report, parent report, and nurses' own overall impression based on clinical assessment skills of pain is discussed.

Can we improve parents' management of their children's postoperative pain at home?

BACKGROUND

Thousands of children undergo surgery each year, and a shift toward same-day surgeries and decreased lengths of hospital stay results in parents being increasingly responsible for their child's postoperative care. Recent studies have tested interventions designed to improve parent management of their children's postoperative pain at home, but progress in this area has been limited by a lack of synthesis of these findings.

OBJECTIVE

To conduct a systematic review of interventions to improve parent management of children's postoperative pain at home.

METHODS

Articles evaluating interventions to improve management of their children's postoperative pain were identified using a library scientist-designed search strategy applied in EMBASE, PubMed, CINAHL and PsycINFO. Two independent raters assessed each study for eligibility and extracted data.

RESULTS

Of the 147 articles identified for the review, eight met the inclusion criteria. Interventions included pain education, training in pain assessment, education on distraction, instruction in around-the-clock dosing and nurse coaching. Overall, results of comparisons of pain intensity and analgesic administration were modest. The intervention with the largest effect size was instruction in around-the-clock dosing, either alone or in combination with nurse coaching. Results of studies investigating pain assessment, pain education and distraction trials revealed small to medium effect sizes.

CONCLUSIONS

Results of trials investigating interventions to improve parent management of their children's postoperative pain at home were modest. Future studies should further examine barriers and facilitators to pain management to design more effective interventions.

Pain management at home in children with cancer: a daily diary study

BACKGROUND

With the transition of care of cancer patients from the hospital to the home setting, parents are largely responsible for children's pain management. Children's cancer pain is undermanaged, yet, there is little empirical data on the occurrence and management of cancer pain in the home setting. The purpose of the present study, therefore, was to employ a daily diary protocol to examine barriers to pain management of children's cancer pain by parents at home.

PROCEDURE

Parent-child dyads were recruited from the Cancer Institute at a major children's hospital in Southern California. A total of 45 patient/parent pairs completed baseline data on demographic and personality characteristics, children's quality of life, and parental beliefs regarding analgesic use for children and then completed daily diaries of pain and analgesic administration for 14 consecutive days.

RESULTS

Most children were reported to experience chronic pain while undergoing treatment for cancer, yet overall analgesic administration at home was low. Parents who reported misconceptions regarding analgesic use for children were less likely to administer pain medication to children. Children who were less shy, more social, or had lower quality of life were more likely to receive analgesics.

CONCLUSIONS

A significant proportion of children receiving outpatient treatment for cancer were rated as experiencing chronic pain and pain was not optimally managed in the home setting. Further understanding and addressing barriers to children's cancer pain management in the home setting will aid in alleviating unnecessary pain in this vulnerable patient population.