Psychological interventions in managing postoperative pain in children: a systematic review

Gaining Insight into Teenagers' Experiences of Pain after Laparoscopic Surgeries: A Prospective Study

There is an anecdotal impression that teenage patients report exaggerated postoperative pain scores that do not correlate with their actual level of pain. Nurse and parental perception of teenagers' pain can be complemented by knowledge of patient pain behavior, catastrophizing thoughts about pain, anxiety, and mood level. Two hundred and two patients completed the study-56.4% were female, 89.6% White, 5.4% Black, and 5% were of other races. Patient ages ranged from 11 to 17 years (mean = 13.8; SD = 1.9). The patient, the parent, and the nurse completed multiple questionnaires on day one after laparoscopic surgery to assess patient pain. Teenagers and parents (r = 0.56) have a high level of agreement, and teenagers and nurses (r = 0.47) have a moderate level of agreement on pain scores (p < 0.05). The correlation between patient APBQ (adolescent pain behavior questionnaire) and teenager VAS (visual analog scale) and between nurse APBQ and teenager VAS, while statistically significant (p < 0.05), is weaker (r range = 0.14-0.17). There is a moderate correlation between teenagers' pain scores and their psychological assessments of anxiety, catastrophic thoughts, and mood (r range = 0.26-0.39; p < 0.05). A multi-modal evaluation of postoperative pain can be more informative than only assessing self-reported pain scores.

Photos Sculpt the Stories of Youth: Using Photovoice to Holistically Capture the Lived Experiences and Pain of Youth Who Underwent Spinal Fusion Surgery

Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

Innovative Program to Prevent Pediatric Chronic Postsurgical Pain: Patient Partner Feedback on Intervention Development

BACKGROUND

The risk of developing chronic postsurgical pain (CPSP) in youth is related to psychological factors, including preoperative anxiety, depression, patient/caregiver pain catastrophizing, and poor self-efficacy in managing pain. While interventions exist to address these factors, they are generally brief and educational in nature. The current paper details patient partner feedback on the development of a psychologist-delivered perioperative psychological program (PPP) designed to identify and target psychological risk factors for CPSP and improve self-efficacy in managing pain.

METHODS

Qualitative interviews were conducted with two patients and their caregivers to discuss their surgical and pain management experience and to advise on components of the PPP.

RESULTS

Reflexive thematic analysis of interviews generated the following themes, which were incorporated into the content and implementation of the PPP: caregiver involvement, psychological and physical strategies for pain management, biopsychosocial pain education, intervention structure, and supporting materials.

CONCLUSIONS

The development of a novel psychologist-led PPP is a promising approach to mitigate mental health risks associated with pediatric CPSP and potentially boost postoperative outcomes and family wellbeing. Integrating patient partner feedback ensures that the PPP is relevant, acceptable, and aligned with the needs and preferences of the patients it is designed to serve.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

Differences in the child, mother, and nurses' pain score measurements during pediatric venipuncture

BACKGROUND

Self-reporting is the gold standard for measuring pain in adult pain management; however, this issue is unique and different in children. Accurate pain assessment for the appropriate management of children's pain is important.

PURPOSE

This study was conducted to assess the pain level by the child, mother, and nurse during intravenous line insertion in preschool children, candidates for surgery in Tabriz Children's Hospital.

DESIGN AND METHODS

This is descriptive observational study. A total of 140 eligible children were included in the study using convenience and sequential methods. The intravenous line was inserted by an experienced nurse and pain assessment was performed by the child, mother, and nurse immediately after procedure, using the Wong-Baker face scale (WBFS). The data were analyzed through descriptive statistics and repeated measures ANOVA test using SPSS version 13 software.

RESULTS

The difference between child-mother and nurse-mother mean scores was not statistically significant; however, there was a statistically significant difference between the score measured by the child and the nurse (P = 0.017).

CONCLUSION

The children's pain assessment score during venipuncture was higher than that of mothers and nurses. The mothers' score was more closely related to the children's score. As a result, a mother's assessment can be considered a reliable estimation of proper pain management in young children and mothers can act as a moderator and actualize the nurses' score. Consequently, establishing a three-way communication between mother, child, and nurses is necessary to precisely estimate the child's actual pain and take appropriate measures to reduce it.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery

INTRODUCTION

Our aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs).

METHODS

Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models.

RESULTS

Among 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11-0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10-0.70), and both in combination (RRR:0.08, 95% CI:0.02-0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL.

CONCLUSION

Use of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children.

LEVEL OF EVIDENCE

III.

Expanding Neuroprotective Care: A Trauma-Informed Approach to Delivery of Services within Pediatric Inpatient Units

Children with a history of trauma or adverse childhood experiences may be at higher risk for poor psychological and physical responses to medical experiences aimed at enhancing their well-being. Health care institutions are aware of the need for integration of trauma-informed care (TIC) practices yet struggle to find frameworks that promote resiliency to medical stress. An approach called neuroprotective care buffers the effects of toxic stress negatively affecting child health and well-being. Although often used in neonatal and cardiac intensive care units, the development and broad implementation of universal neuroprotective care measures across age groups and hospital settings has not been previously explored. An expanded neuroprotective care protocol takes a prevention approach to TIC. It fits a TIC framework, accounts for children's ecological, biological, and developmental needs, protects them against medical traumatic stress and retraumatization, and provides a tailored, measurable approach that systematically preserves child well-being within hospital settings.

"Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics"

BACKGROUND

Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries.

AIM

The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service.

METHODS

A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period.

RESULTS

A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids.

CONCLUSIONS

Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.

Bibliometric and Visual Analysis of the Current Status and Trends of Postoperative Pain in Children from 1950-2021

Background

Postoperative pain in children has been overlooked for a long time. The knowledge structure, research hotspots and trends related to postoperative pain in children are unclear and have not been systematically summarized.

Purpose

We aimed to analyze the current state of research on postoperative pain in children and to conduct in-depth mining of the knowledge structure.

Methods

The PubMed database for publications on postoperative pain in children between 1950 and 2021 was searched. Bibliographic Item Co-Occurrence Matrix Builder (BICOMB) was performed to obtain the co-word matrix and co-occurrence matrix. The H-index method was used to extract high-frequency main Medical Subject Headings (MeSH) terms/subheadings.

Results

The high-frequency MeSH terms were analyzed by biclustering, strategic diagram and social network analyses. Totally, 4022 publications were retrieved. The analysis showed that 60 countries or regions published relevant documents, with the United States publishing the most significant number of papers. Totally, 811 journals published relevant papers, with Pediatric Anesthesia ranking first. Moreover, we extracted 43 high-frequency main MeSH terms/subheadings and clustered them into five categories: overview, aetiology and epidemiology, pharmacotherapy, opioid administration and dosing, and prevention and control of postoperative pain in children.

Conclusion

Pharmacological treatments, pain prevention and control are the focus of research and are becoming increasingly mature. Opioid stewardship and regional anesthesia is the trend and focus of future research. Our study offers a better understanding of the current status and knowledge structure of postoperative pain in children and provides a reference for improving postoperative pain management in children in the future.

Exploring the Necessity of Psychological Rounds and Psychological Interventions in General Hospitals in the Post-COVID-19 Period

Objective

To explore the necessity of psychological rounds and psychological intervention in the post-COVID-19 period in a general hospital.

Methods

Based on the current pandemic influence on Chinese people's psychology, the medical experience, and environment were analyzed, and the feasibility of psychological evaluation and intervention were appraised with the psychological changes that might be brought by the medical behaviors, especially for surgical operations.

Results

Nowadays, the pandemic is under full control in China, although the pandemic is rampant abroad. In China, the "Normalized pandemic prevention" phase has begun. In the post-COVID-19 period, the prolonged pandemic has made numerous people pessimistic, angry, and other negative emotions. Several general hospitals are facing huge influences: under the influence of anxiety, such as "higher hospital-acquired infection rate," the patient attendance rate is reduced, and the hospital income is sharply reduced. Doctor-patient conflicts are more likely to occur during the medical procedures, affecting the medical experience, and reducing the rate of re-visit and referral.

Conclusion

After analyzing a series of "endogenous" and "exogenous" factors of medical procedures in a general hospital in the post-pandemic period, it suggests that anxiety and depression caused by uncertainties in the medical procedures may be more obvious. Also, it is necessary to pay attention to the psychological status of patients and carry out psychological rounds and psychological interventions in general hospitals. The service quality can be improved, the medical experience can be ameliorated, and it can help general hospitals to turn "crisis" into "opportunity," which also brings better development.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

A pilot feasibility and acceptability study of an internet-delivered psychosocial intervention to reduce postoperative pain in adolescents undergoing spinal fusion

Background

Spinal fusion surgery is a common and painful musculoskeletal surgery performed in the adolescent population. Despite the known risk for developing chronic postsurgical pain, few perioperative psychosocial interventions have been evaluated in this population, and none have been delivered remotely (via the Internet) to improve accessibility.

Aims

The aim of this single-arm pilot study was to evaluate the feasibility and acceptability of the first Internet-based psychological intervention delivered during the perioperative period to adolescents undergoing major spinal fusion surgery and their parents.

Methods

Thirteen adolescents (M age = 14.3; 69.2% female) scheduled for spine fusion surgery and their parents were provided access to the online psychosocial intervention program. The program included six lessons delivering cognitive-behavioral therapy skills targeting anxiety, sleep, and acute pain management during the month prior to and the month following surgery. Feasibility indicators included recruitment rate, intervention engagement, and measure completion. Acceptability was assessed via quantitative ratings and qualitative interviews.

Results

Our recruitment rate was 81.2% of families approached for screening. Among participating adolescent–parent dyads, high levels of engagement were demonstrated (100% completed all six lessons). All participants completed outcome measures. High treatment acceptability was demonstrated via survey ratings and qualitative feedback, with families highlighting numerous strengths of the program as well as areas for improvement.

Conclusions

These findings suggest that this online psychosocial intervention delivered during the perioperative period is feasible and acceptable to adolescents and their parents. Given favorable feasibility outcomes, an important next step is to evaluate the intervention in a full-scale randomized controlled trial.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

BACKGROUND

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

METHODS

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

DISCUSSION

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

TRIAL REGISTRATION

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

Parental Psychosocial Factors Moderate Opioid Administration Following Children's Surgery

BACKGROUND

This investigation aimed to examine the impact of parental psychosocial variables on the administration of opioids to young children experiencing postoperative pain.

METHODS

Participants in this longitudinal analysis were children ages 2-12 undergoing tonsillectomy with or without adenoidectomy and their parents. Parents completed validated instruments assessing trait anxiety, perceived stress, and coping style before surgery, and children and parents completed instruments assessing pain and administration of opioids and acetaminophen on days 1, 2, 3, and 7 at home after surgery. The structure of the data was such that parents and children completed multiple data assessments making the data multilevel (ie, days of data within dyads). To address this issue of data structure, multilevel modeling was used to analyze the dataset.

RESULTS

Participants included 173 parent-child dyads (mean child age = 5.99 ± 2.51) recruited between 2012 and 2017. We found that parent-related psychosocial variables, such as trait anxiety, stress, and coping style, moderated the relationship between the child's pain and postoperative medication administration. Specifically, when predicting hydrocodone, the interactions between anxiety and pain and stress and pain were significant; when child pain was high, high-anxiety and high-stressed parents gave their children 19% and 12% more hydrocodone, respectively, compared to low-anxiety and low-stressed parents. When predicting acetaminophen, the interactions between anxiety and pain, a blunting coping style and pain, and a monitoring coping style and pain were significant.

CONCLUSIONS

These results suggest the need to identify parents who experience high levels of perceived stress and trait anxiety and use appropriate interventions to manage stress and anxiety. This may ensure children receive optimal amounts of pain medication following surgery.

Guidelines for Opioid Prescribing in Children and Adolescents After Surgery: An Expert Panel Opinion

IMPORTANCE

Opioids are frequently prescribed to children and adolescents after surgery. Prescription opioid misuse is associated with high-risk behavior in youth. Evidence-based guidelines for opioid prescribing practices in children are lacking.

OBJECTIVE

To assemble a multidisciplinary team of health care experts and leaders in opioid stewardship, review current literature regarding opioid use and risks unique to pediatric populations, and develop a broad framework for evidence-based opioid prescribing guidelines for children who require surgery.

EVIDENCE REVIEW

Reviews of relevant literature were performed including all English-language articles published from January 1, 1988, to February 28, 2019, found via searches of the PubMed (MEDLINE), CINAHL, Embase, and Cochrane databases. Pediatric was defined as children younger than 18 years. Animal and experimental studies, case reports, review articles, and editorials were excluded. Selected articles were graded using tools from the Oxford Centre for Evidence-based Medicine 2011 levels of evidence. The Appraisal of Guidelines for Research & Evaluation (AGREE) II instrument was applied throughout guideline creation. Consensus was determined using a modified Delphi technique.

FINDINGS

Overall, 14 574 articles were screened for inclusion, with 217 unique articles included for qualitative synthesis. Twenty guideline statements were generated from a 2-day in-person meeting and subsequently reviewed, edited, and endorsed externally by pediatric surgical specialists, the American Pediatric Surgery Association Board of Governors, the American Academy of Pediatrics Section on Surgery Executive Committee, and the American College of Surgeons Board of Regents. Review of the literature and guideline statements underscored 3 primary themes: (1) health care professionals caring for children who require surgery must recognize the risks of opioid misuse associated with prescription opioids, (2) nonopioid analgesic use should be optimized in the perioperative period, and (3) patient and family education regarding perioperative pain management and safe opioid use practices must occur both before and after surgery.

CONCLUSIONS AND RELEVANCE

These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery. Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts.

The role of anxiety and related states in pediatric postsurgical pain

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

Psychosocial Factors and Psychological Interventions: Implications for Chronic Post-Surgical Pain in Pediatric Patients with Osteosarcoma

This study retrospectively investigated psychological factors contributing to chronic post-surgical pain (CPSP) in pediatric patients after limb-sparing or amputation surgery for extremity osteosarcoma. Psychological factors were identified and analyzed by the Wilcoxon rank-sum and median two-sample tests. Univariate and multivariate Cox regressions were performed using gender, age, psychological factors, and psychological interventions related to CPSP duration as covariates. Duration of pain treatment was significantly longer in patients resistant to psychological interventions (p = 0.01) than those receptive to interventions. Shorter duration of pain treatment was associated with older age (p = 0.03) and receptiveness to psychological interventions (HR = 4.19, 95% CI [1.22, 14.35]). Older age and receptiveness to psychological interventions as part of pain management care are associated with needing a shorter duration of pain treatment. Our results highlight the importance of prospective investigations evaluating motivation to engage in psychotherapy and psychological interventions and identify risk factors for CPSP in pediatric oncology.

The Effect of Caregiver-Facilitated Pain Management Interventions in Hospitalized Patients on Patient, Caregiver, Provider, and Health System Outcomes: A Systematic Review

CONTEXT

Alternative pain management interventions involving caregivers may be valuable adjuncts to conventional pain management interventions.

OBJECTIVES

Use systematic review methodology to examine caregiver-facilitated pain management interventions in a hospital setting and whether they improve patient, caregiver, provider, or health system outcomes.

METHODS

We searched MEDLINE, EMBASE, PsycINFO, CINAHL, and Scopus databases from inception to April 2020. Original research on caregiver-facilitated pain management interventions in hospitalized settings (i.e., any age) were included and categorized into three caregiver engagement strategies: inform (e.g., pain education), activate (e.g., prompt caregiver action), and collaborate (encourage caregiver's interaction with providers).

RESULTS

Of 61 included studies, most investigated premature (n = 27 of 61; 44.3%) and full-term neonates (n = 19 of 61; 31.1%). Interventions were classified as activate (n = 46 of 61; 75.4%), inform-activate-collaborate (n = 6 of 61; 9.8%), inform-activate (n = 5 of 61; 8.2%), activate-collaborate (n = 3 of 61; 4.9%), or inform (n = 1 of 61; 1.6%) caregiver engagement strategies. Interventions that included an activate engagement strategy improved pain outcomes in adults (18-64 years) (e.g., self-reported pain, n = 4 of 5; 80%) and neonates (e.g., crying, n = 32 of 41; 73.0%) but not children or older adults (65 years and older). Caregiver outcomes (e.g., pain knowledge) were improved by inform-activate engagement strategies (n = 3 of 3). Interventions did not improve provider (e.g., satisfaction) or health system (e.g., hospital length of stay) outcomes. Most studies were of low (n = 36 of 61; 59.0%) risk of bias.

CONCLUSION

Caregiver-facilitated pain management interventions using an activate engagement strategy may be effective in reducing pain of hospitalized neonates. Caregiver-facilitated pain management interventions improved pain outcomes in most adult studies; however, the number of studies of adults is small warranting caution pending further studies.

Complementary and Alternative Medicine for Postoperative Pain: A Systematic Review

BACKGROUND

The treatment of postoperative pain is an ongoing challenge for orthopaedic surgeons. Poorly controlled pain is associated with poorer patient outcomes, and the prescription of opioids may lead to prolonged, nonmedical use. Complementary and alternative medicine is widely adopted by the general public, and its use in chronic musculoskeletal pain conditions has been studied; however, its efficacy in a postoperative context has not yet been established.

METHODS

We conducted a systematic literature review of 10 databases to identify all relevant publications. We extracted variables related to pain measurement and postoperative opioid prescriptions.

RESULTS

We identified 8 relevant publications from an initial pool of 2,517 items. Of these, 5 were randomized studies and 3 were nonrandomized studies. All 8 studies addressed postoperative pain, with 5 showing significant decreases (p < 0.05) in postoperative pain. Also, 5 studies addressed postoperative opioid use, with 2 showing significant differences (p < 0.05) in opioid consumption. Substantial heterogeneity among the studies precluded meta-analysis. No articles were found to be free of potential bias.

CONCLUSIONS

Currently, there is insufficient evidence to determine the efficacy of complementary and alternative medicines for postoperative pain management or as an alternative to opioid use following orthopaedic surgery.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Implications of a Retrospective Study on Weight-Based Risk for Post-Tonsillectomy Pain in Children

PURPOSE

The purpose was to examine if children experience weight-based risks for post-tonsillectomy pain (PTP) in the postanesthesia care unit (PACU).

DESIGN

This retrospective correlational cohort design included a sample of 180 children between the ages of 4 to 12 years who had tonsillectomy and adenoidectomy or tonsillectomy before August 2016; half were obese (OB) or overweight (OW).

METHODS

The sample was obtained from children who had surgery at a large pediatric hospital with an attached outpatient surgical center in North Texas. Children were defined as either OB and OW or non-OB and non-OW based on a cutoff of standardized body mass index z scores of 85th percentile and greater per the National Center for Health Statistics. Pain scores were obtained in the PACU after surgery. Early PTP was defined as the most severe pain experienced by a child in the first 15 minutes after extubation. Prolonged PTP was sustained and uncontrolled pain in the PACU.

FINDINGS

OB and OW status did not increase the likelihood of experiencing early PTP when examined by multiple logistic regression controlling for covariates (adjusted odds ratio, 1.391; P = .369). OB and OW status was associated with longer episodes of prolonged PTP (r_s[178] = 0.16; P = .03). OB and OW children were more likely to experience prolonged PTP in the PACU (χ²[1] = 8.353; P = .004), with these children experiencing an average PTP period twice as long as their peers.

CONCLUSIONS

OB and OW children did experience risk for prolonged PTP, averaging sustained pain for approximately twice as long as other children. The increased risk for prolonged PTP in OB and OW children occurred despite well-managed early PTP with rates that matched those of their peers. No weight-based risk for early PTP was observed. Further research is needed in the area of PTP management in OB and OW children.

Painapple®. Validation and evaluation of an electronic application for the management of acute pain in pediatric patients

INTRODUCTION

The digital version of the assessment scales recommended for the pediatric patient could contribute to its improvement and to implement the quality indicators described for the management of acute pain.

MATERIAL AND METHODS

Psychometric validation (validity and reliability) of pain assessment and treatment side effects scales incorporated in the electronic application PainAPPle. For this, both formats (paper and electronic) of all the scales were applied in two measurements with 30minutes of difference in 44 patients from 4 to 18years of the Acute Pain Unit in the immediate postoperative period. In addition, the data collected by PainAPPle was evaluated by retrospectively applying the quality indicators described for the management of acute postoperative pain.

RESULTS

Reliability was studied analyzing the high correlation (Spearman greater than 0.5, P<.001) that we obtained for the values of each scale in two moments with 30minutes of difference, in the same patients. For validity, the high correlation (Spearman greater than 0.5, P<.001) between the values of the paper scales (gold rule) and PainAPPle at both minute 0 and 30 was analyzed. Concordance obtained taking into account the cut-off point of the scales that would force a treatment were also statistically significant (P<.005).

CONCLUSIONS

PainAPPle is a validated instrument for the management of acute pain in pediatric patients. The collected data allow to apply the quality indicators described for the management of acute postoperative pain.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

Framework to Explain the Progression of Pain in Obese or Overweight Children Undergoing Tonsillectomy

An estimated 100,000 obese (OB) and overweight (OW) children undergo tonsillectomy each year in the United States. Pain management in this population is particularly challenging because of weight-based dosing, clinician fears, potential for airway obstruction, and genetic differences. A framework is proposed to explain factors involved in the post-tonsillectomy pain (PTP) experience in OB and OW children. The tonsillectomy, the body's inflammatory state, and mechanical stressors comprise influencing factors in PTP progression. Clinician-delivered medication doses, genetic variants of drug metabolism, and soothing factors serve as mediating factors in the progression of PTP. Postanesthesia care unit (PACU) nurses may use this framework to better understand PTP progression in OB and OW children. PACU nurses may manipulate certain mediating factors discussed in this framework to moderate PTP progression in OB and OW children. Researchers may use this framework to support future research to improve PTP management in OB and OW children.

Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study

Several studies have shown the efficacy of psychological interventions in reducing preoperative anxiety in children undergoing surgery. This study aims to investigate the effectiveness of a specific non-pharmacological technique, the relaxation-guided imagery, in reducing both preoperative anxiety and postoperative pain in a sample of 60 children (6-12 years old) undergoing minor surgery who were randomly assigned to the experimental group (N = 30) or the control group (N = 30). The first group received the relaxation-guided imagery, before the induction of general anesthesia; the second group received standard care. The levels of preoperative anxiety and postoperative pain were assessed using, respectively, the modified Yale Preoperative Anxiety Scale and the Face, Legs, Activity, Cry, and Consolability Scale. The results showed a statistically significant difference between groups, with less anxiety and less pain for children included in the experimental group (p < .001; p < .001).Conclusion: Results suggest that relaxation-guided imagery reduces preoperative anxiety and postoperative pain in children. Future studies should focus on developing protocols and studying the eventual reduction of administered drugs for anesthesia and pain. What is Known: • Literature suggests the usefulness of relaxation-guided imagery in reducing anxiety and pain in the perioperative period. • Stronger evidences are needed to support the application of relaxation-guided imagery as routine care in pediatric surgery. What is New: • To our knowledge, this is the first randomized study to investigate the efficacy of relaxation-guided imagery in reducing preoperative anxiety and postoperative pain within a single pediatric sample. • The present study provides stronger evidence in an area that is lacking in research.

iCanCope PostOp: User-Centered Design of a Smartphone-Based App for Self-Management of Postoperative Pain in Children and Adolescents

Background

Moderate to severe postoperative pain in children is common. Increased pediatric day surgeries have shifted postoperative pain management predominantly to the home setting. Mobile health technology has the potential to overcome barriers to pain care by improving access to self-management resources. However, pain apps generally lack scientific evidence and are highly underutilized due to lack of involvement of end users in their development. Thus, an evidence-based pain self-management smartphone app that incorporates the needs and perspective of children and adolescents (end users) has potential to improve postoperative pain management.

Objective

This paper aimed to describe how the principles of user-centered design were applied to the development of iCanCope PostOp, a smartphone-based pain self-management app for children and adolescents after surgery. Specifically, it presents 2 completed phases of the user-centered design process (concept generation and ideation) for the iCanCope PostOp app.

Methods

Phase 1 was a multisite needs assessment from the perspective of 19 children and adolescents who had undergone various day surgeries, 19 parents, and 32 multidisciplinary health care providers. Children, adolescents, and parents completed individual semistructured interviews, and health care providers participated in focus groups. Data were summarized using qualitative content analysis. Phase 2 developed a pain care algorithm for the app using Delphi surveys and a 2-day in-person design workshop with 11 multidisciplinary pediatric postoperative pain experts and 2 people with lived experience with postoperative pain.

Results

Phase 1 identified self-management challenges to postoperative pain management and recovery; limited available resources and reliance on medications as a predominant postoperative pain management strategy; and shared responsibility of postoperative pain care by children and adolescents, parents, and health care providers. Key app functions of tracking pain, pain self-management strategies, and goal setting were identified as priorities. Phase 2 led to the successful and efficient generation of a complete preliminary pain care algorithm for the iCanCope PostOp app, including clinically relevant inputs for feasible assessment and reassessment of pain and function (rest or sleep, movement or play, and mood or worry), as well as a catalog of pain management advice to be pushed to end users (psychological, physical, pharmacological, and education).

Conclusions

The concept ideation and generation phases of the user-centered design approach were successfully completed for the iCanCope PostOp app. Next steps will include design finalization, app development (iOS or Android), evaluation through a randomized controlled trial, and subsequent implementation of the iCanCope PostOp app in clinical care.

Approaches to Pediatric Musculoskeletal Pain: Opioids and So Much More

Treatment of musculoskeletal pain in children poses unique challenges, particularly in the context of the ongoing opioid epidemic. In addition to the developmental level of the child, the type of pain he or she is experiencing should influence the team's approach when collaborating with the patient and the family to develop and refine pain management strategies. Understanding the categories of pain that may result from specific types of musculoskeletal injuries or orthopaedic surgeries influences the selection of medication or other most appropriate treatment. Although opioids are an important part of managing acute pain in the pediatric population, many other pharmacological and nonpharmacological therapies can be used in combination with or in place of opioids to optimize pain management. This article will review strategies for collaborating with families and the multidisciplinary team, provide an overview of pediatric pain assessment including assessment of acute musculoskeletal pain in children, and discuss pharmacological and nonpharmacological options for managing pain after acute injury or surgery.

Management of pain in children and adolescents with cerebral palsy: a systematic review

AIM

To determine the efficacy of interventions for the management of pain in children and adolescents with cerebral palsy (CP).

METHOD

Electronic databases were searched from the earliest date possible to April 2018 using a mixture of subject headings and free text. Inclusion criteria comprised of studies with (1) diagnosis of CP, (2) under the age of 18 years, (3) intervention for the management of pain, (4) outcome measure of pain, and (5) studies published in English-language peer-reviewed journals.

RESULTS

Fifty-seven studies met the eligibility criteria. Pain related to (n=number of studies): hypertonia (n=17), spastic hip disease (n=13), procedures for the management of CP (n=7), postoperative (n=18), and other (n=2). Most of the studies were of level III to level V evidence.

INTERPRETATION

There is level II evidence to support intrathecal baclofen therapy for pain secondary to hypertonia in spastic and spastic-dyskinetic CP, and non-pharmacological interventions for procedural pain and pharmacological interventions for postoperative pain. Most studies were restricted by retrospective design and limited use of validated outcome measures. Future research is needed to explore multidisciplinary interventions for chronic pain and pain secondary to dystonia. Clinicians and researchers would benefit from a standardized approach to pain assessment.

WHAT THIS PAPER ADDS

The strongest evidence exists for pharmacological treatments for postoperative pain in children and adolescents with cerebral palsy (CP). There is moderate evidence for the efficacy of intrathecal baclofen for pain related to hypertonia in predominately spastic CP. There is a lack of standardization in the assessment of pain. There is limited evidence for multimodal and non-pharmacological strategies in paediatric CP.

A parent–science partnership to improve postsurgical pain management in young children: Co-development and usability testing of the Achy Penguin smartphone-based app

Background

Young children are at risk for poorly managed pain after surgery, with significant negative consequence to their quality of life and health outcomes. Mobile applications offer a highly accessible, engaging, and interactive medium to improve pain assessment and management; however, they generally lack scientific foundation or support.

Aims

The aims of this study were to describe a successful parent–science partnership in the development and testing of Achy Penguin, a parent-developed iOS app to help assess and manage acute pain in young children, and to evaluate and refine the usability of Achy Penguin in young children with acute postoperative pain.

Methods

Three cycles of iterative usability testing were conducted with 20 4- to 7-year-old children (M = 5.8 years) in hospital who had recently undergone surgery (n = 6–7 children/cycle). Semistructured qualitative interviews were analyzed using simple content analysis.

Results

Feedback from children and further integration of evidence-based pediatric pain knowledge led to refinements in app pain assessment and management content, as well as app flow and functionality. Changes improved children’s ease of use and understanding and satisfaction by simplifying language in app instructions and content, adding audio and pictorial instructions, and increasing the engagement, interactiveness, immersiveness, and general appeal of pain management strategies.

Conclusions

This article showcases the value of collaborative partnerships between various stakeholders (parents, app developers, and researcher/health care providers) to address gaps in pediatric pain care. The Achy Penguin app shows promise for improving pain assessment and management in young children, although further evaluation of app effectiveness and implementation is warranted.

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

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

New Advances in Acute Postoperative Pain Management

PURPOSE OF REVIEW

Postoperative pain remains one of the most common challenges following inpatient and outpatient surgeries. With our advances in modern medicine, pain following surgical procedures still remains a challenge, though significant accomplishments have been made over the past few decades. This article highlights some of the promising new advances and approaches in postoperative pain management.

RECENT FINDINGS

Over the last decade, Enhanced Recovery after Surgery (ERAS) pathways and protocols are becoming the benchmark standards for enhancing postoperative recovery. Multimodal analgesia (MMA) is an essential component of such care. Further, in the wake of serious and persistent concern on the opioid epidemic in the USA, there has been a recent renewal of interest in non-opioid alternatives or adjuncts in controlling postoperative pain, often in the context of MMA. Intravenous (IV) acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs), magnesium, ketamine, dexmedetomidine, liposomal bupivacaine, and newer neuraxial and peripheral regional techniques as well as patient-controlled modalities are gaining importance. Gabapentinoids have become popular but recent meta-analytic reviews have cast doubt on their routine use in perioperative settings. Among opioids, sublingual sufentanil, IV oxycodone, and iontophoretic transdermal fentanyl hold promise. Acupuncture and transcutaneous electrical nerve stimulation may be useful as adjuncts in MMA packages. Genetic testing, derivatives of herbal preparations, and an extended role of acute pain services may emerge as potential areas of importance in the future. There are, however, critical gaps in good quality evidence in many of the practice guideline recommendations. In the era of opioid epidemic, several lines of evidence have emerged to support non-opioid-based drugs and approaches along with a few newer opioid formulations for postoperative pain management, although more research is needed to find the right balance of efficacy and safety.

Commercially Available Smartphone Apps to Support Postoperative Pain Self-Management: Scoping Review

Background

Recently, the use of smartphones to deliver health-related content has experienced rapid growth, with more than 165,000 mobile health (mHealth) apps currently available in the digital marketplace. With 3 out of 4 Canadians currently owning a smartphone, mHealth apps offer opportunities to deliver accessible health-related knowledge and support. Many individuals experience pain after surgery, which can negatively impact their health-related quality of life, including sleep, emotional, and social functioning. Smartphone apps that provide remote real-time monitoring and symptom management have the potential to improve self-management skills in patients experiencing postoperative pain. Increased confidence and practice of self-management skills could contribute to decreased postoperative pain and reduce risk of developing persistent pain. Published reviews of general pain self-management apps demonstrate a lack of evidence-based content, theoretical grounding, and health care professional involvement. However, no review to date has focused on the app marketplace specific for individuals with postoperative pain.

Objective

The aim of this study was to characterize and critically appraise the content and functionality of commercially available postoperative pain self-management apps.

Methods

An electronic search and extraction was conducted between December 2016 and March 2017 of the official Canadian app stores for the three major smartphone operating systems (iPhone operating system [iOS], Android, and Windows). Stores were searched separately using predetermined search terms. Two authors screened apps based on information provided in the public app description. Metadata from all included apps were abstracted into a standard spreadsheet. Two authors verified the data with reference to the apps and downloaded apps themselves. The content and functionality of each app as it pertained to postoperative pain self-management was rated.

Results

A total of 10 apps met the inclusion criteria. All included apps were designed exclusively for the Android platform. Education was the most common self-management feature offered (8/10, 80%), with none of the apps offering features related to goal setting or social support. Overall, no single app was comprehensive in terms of pain self-management content. Five (50%) apps reported the involvement of a health care provider in their development. However, not a single app involved end users in their development, and none of the apps underwent scientific evaluation. Additionally, none of the apps were designed for use in pediatric patients.

Conclusions

Currently available postoperative pain apps for patients lack evidence-based content, goal setting, and social support functions. There is a need to develop and test comprehensive theory-based apps to support patients with pain self-management care following surgery.

Pediatric Perioperative Pain Management

Effective perioperative pain control in pediatric patients undergoing orthopedic surgery remains a challenge. Developing a successful pain control regimen begins preoperatively with assessment of the patient and discussion with the patient and family regarding expectations. Perioperative pain control regimens are customized based on the type of surgery, patient characteristics, and anticipated severity and duration of the postoperative pain. Recent study focuses on multimodal strategies and regional anesthesia options, allowing for decreased opioid use. This article provides an evidence-based overview of preoperative, intraoperative, and postoperative pain control for the pediatric orthopedic patient.

Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens, Parents, and Perioperative Care Providers

Research developing targeted treatment focused on coping with children's long-term pain after surgery is needed because of the high prevalence of chronic pain after surgery. This qualitative study aimed to: 1) understand the child's and family's experiences of pain over the course of their surgical experience, and 2) gather stakeholder input regarding potential barriers and facilitators of perioperative intervention delivery. Fifteen children ages 10 to 18 years who underwent recent major surgery, their primary caregivers, and 17 perioperative health care providers were interviewed. Interviews were coded using semantic thematic analysis. The perioperative period presented emotional challenges for families. Families felt unprepared for surgery and pain. Recovery and regaining physical functioning at home was challenging. Families struggled to return to valued activities. Families reported interest in a perioperative psychosocial intervention. Providers endorsed that families would benefit from enhanced coping skills. They emphasized that families would benefit from more detailed preparatory information. Providers suggested that flexible intervention delivery at home would be ideal. Research developing interventions addressing pain and anxiety in children undergoing major surgery is critically needed. The findings of the present study can inform intervention development with the aim of improving short- as well as long-term recovery in children undergoing major surgery.

PERSPECTIVE

This qualitative study examined children and their parents' experience of long-term pain and recovery after major surgery, identifying barriers and facilitators of perioperative intervention delivery. Families experienced surgery as stressful, and felt underprepared for pain and recovery. Families and health care providers expressed interest in a preoperative intervention teaching coping skills.