Epidemiology of paediatric pain-related visits to emergency departments in the USA: a cross-sectional study

Opioid Prescribing for Acute Pain Management in Children and Adolescents in Outpatient Settings: Clinical Practice Guideline

This is the first clinical practice guideline (CPG) from the American Academy of Pediatrics outlining evidence-based approaches to safely prescribing opioids for acute pain in outpatient settings. The central goal is to aid clinicians in understanding when opioids may be indicated to treat acute pain in children and adolescents and how to minimize risks (including opioid use disorder, poisoning, and overdose). The document also seeks to alleviate disparate pain treatment of Black, Hispanic, and American Indian/Alaska Native children and adolescents, who receive pain management that is less adequate and less timely than that provided to white individuals. There may also be disparities in pain treatment based on language, socioeconomic status, geographic location, and other factors, which are discussed. The document recommends that clinicians treat acute pain using a multimodal approach that includes the appropriate use of nonpharmacologic therapies, nonopioid medications, and, when needed, opioid medications. Opioids should not be prescribed as monotherapy for children or adolescents who have acute pain. When using opioids for acute pain management, clinicians should prescribe immediate-release opioid formulations, start with the lowest age- and weight-appropriate doses, and provide an initial supply of 5 or fewer days, unless the pain is related to trauma or surgery with expected duration of pain longer than 5 days. Clinicians should not prescribe codeine or tramadol for patients younger than 12 years; adolescents 12 to 18 years of age who have obesity, obstructive sleep apnea, or severe lung disease; to treat postsurgical pain after tonsillectomy or adenoidectomy in patients younger than 18 years; or for any breastfeeding patient. The CPG recommends providing opioids when appropriate for treating acutely worsened pain in children and adolescents who have a history of chronic pain; clinicians should partner with other opioid-prescribing clinicians involved in the patient's care and/or a specialist in chronic pain or palliative care to determine an appropriate treatment plan. Caution should be used when treating acute pain in those who are taking sedating medications. The CPG describes potential harms of discontinuing or rapidly tapering opioids in individuals who have been on stable, long-term opioids to treat chronic pain. The guideline also recommends providing naloxone and information on naloxone, safe storage and disposal of opioids, and direct observation of medication administration. Clinicians are encouraged to help caregivers develop a plan for safe disposal. The CPG contains 12 key action statements based on evidence from randomized controlled trials, high-quality observational studies, and, when studies are lacking or could not feasibly or ethically be conducted, from expert opinion. Each key action statement includes a level of evidence, the benefit-harm relationship, and the strength of recommendation.

Prevalence of pain-related presentations in Canadian pediatric emergency departments

OBJECTIVE

Pain is a common reason for attendance to the emergency department; however, pediatric specific data on the prevalence, location, and etiology of painful presentations are limited in the literature. Therefore, the objective of this study was to determine the prevalence of pain-related presentations to pediatric emergency departments during the triage process and characterize the anatomical locations and organ systems most affected by pain in a modern cohort.

METHODS

A two-center health record review of triage documentation was conducted at Canadian pediatric emergency departments. All children (< 18 years) were eligible for inclusion. Data were extracted from administrative sources with one week of consecutive patients included every 3 months over a one-year timeframe. Regression analyses were completed to identify variables associated with painful presentations and analgesia provision during the triage process.

RESULTS

A total of 7208 emergency department presentations were included. Median [IQR] child age was 5.2 [1.9, 11.8] years and 53.2% were male. 58.8% of children were found to have pain as a component of their triage presentation. Of those with pain (n = 4237), 24.1% had a pain score documented and 13.8% had analgesia provided at triage. Location of pain (n = 4523) was predominantly in the head (38.0%), extremities (27.8%), and abdomen (22.8%). Primary organ systems most affected (n = 4237) included the musculoskeletal (31.1%), gastrointestinal (18.3%), and cutaneous (including lacerations) (14.4%) systems.

CONCLUSIONS

In this study, pain was identified in almost 60% of all pediatric emergency department presentations at the time of triage. Suboptimal documentation of pain scores and provision of analgesia at triage were found for children with pain. These results support early assessment and implementation of pain management strategies at triage. Results can also focus further research efforts to the management of the most commonly presenting types of pediatric pain.

Efficacy of Buzzy Device Versus EMLA Cream for Reducing Pain During Needle-Related Procedures in Children: A Randomized Controlled Trial

OBJECTIVES

Several pain management tools exist but with limitations in their efficacy or applicability. The EMLA (eutectic mixture of local anesthetics) cream is currently used for pain relief for needle-related procedures; however, it needs a minimum of 30 to 45 minutes to be effective. The Buzzy is a device that generates vibrations with cold leading to quicker pain relief. Our aim was to evaluate the effect of the Buzzy device in pain and anxiety reduction compared with EMLA cream in children requiring intravenous cannulation or venepuncture.

METHODS

This was a randomized clinical trial comparing pain and anxiety reduction by Buzzy device with the standard care (EMLA cream) in children aged 2 to 14 years who required blood extraction or intravenous cannulation based on their clinical needs. Eligible patients were randomized to either Buzzy device as the intervention or EMLA cream as the control. The outcome measures were the degree of pain scores and anxiety ratings at different stages of the needle-related procedures.

RESULTS

A total of 300 patients with a mean age of 6.5 ± 3.1 years were enrolled. Baseline characteristics were similar between the Buzzy device and EMLA cream groups. The observed pain scores by research nurses and a parent were significantly lower in the EMLA group compared with the Buzzy device group; however, the pain scores by the self-assessment scale were not statistically significant with mean difference of -0.332, 95% confidence interval, -0.635 to -0.028 ( P = 0.062). The level of anxiety was significantly lower in EMLA compared with Buzzy device ( P = 0. 0.0001). Both staff and parents' satisfaction, success rate of cannulation, type of blood tests, and comment on the physician on the results were similar in both groups.

CONCLUSIONS

Pain and anxiety relief using the Buzzy device is not as effective as EMLA cream in children requiring venepuncture. However, rapid onset of action of the Buzzy device is valuable in decreasing waiting time in a busy emergency department.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT05354739.

Analgesia Administration by Sex Among Pediatric Emergency Department Patients with Abdominal Pain

Background

There is conflicting data about sex-based differences in the treatment of acute pain in the ED. Little is known about sex-based disparities in analgesia in pediatric ED patients.

Objectives

Our objective was to determine whether analgesic administration rates differ between female and male pediatric patients presenting to the ED with abdominal pain.

Methods

We conducted a retrospective cohort study of ED patients 5-21 years old with abdominal pain between 6/1/19 and 6/30/21. The primary outcome was receipt of any analgesia, and secondary outcomes were receipt of opioid analgesia and time to receipt of analgesia. Multivariable regression models were fitted for each outcome.

Results

We studied 1,087 patients; 681 (63%) were female with a median age of 17 years (IQR 13, 19) and 406 (37%) were male with a median age of 14 years (IQR 9, 18). 371 female patients (55%) and 180 male patients (44%) received any analgesia. 132 female patients (19%) and 83 male patients (20%) received opioid analgesia. In multivariate analyses, female patients were equally likely to receive any analgesia (OR 1.30, 95% CI 0.97 - 1.74, p = 0.07), but time to analgesia was 14% longer (GMR 1.14, 95% CI 1.00 - 1.29, p = 0.04). Non-White patients were 32% less likely to receive opioids (OR 0.68, 95% CI 0.47 - 0.97, p = 0.04).

Conclusions

Female pediatric ED patients were equally likely to receive any analgesia as male patients, but their time to analgesia was longer. Non-White patients were less likely to receive opioid analgesia than White patients.

Predictors of triage pain assessment and subsequent pain management among pediatric patients presenting to the emergency department

BACKGROUND

Pediatric patients with pain of various causes present to the emergency department. Appropriate assessment and management of pain are important aspects of emergency department treatment. However, only a few studies have identified the predictors of both outcomes. This study aimed to evaluate the rate of pain assessment at triage and subsequent management and to identify the predictors of each outcome.

METHODS

This was a multi-center retrospective study based at five community emergency departments. Pediatric patients (< 18 years) with pain or injury who presented to the emergency department between February 2018 and May 2018 were included. In addition to patient demographics, the initial pain assessment at triage, reason for visit, and time to analgesia were determined. Further, the type and route of analgesia were identified in patients who received analgesia. Univariate and multivariable regression models were used to identify predictors of pain assessment and management.

RESULTS

There were 4,128 patients with an average age of 9.6 years, and 49.1% of them were female. Only 74.2% of the patients underwent assessment for pain at triage, and 18.3% received analgesia. The median time to analgesia was 95 (IQR: 49-154) min. Most patients presented with head/neck (36.1%), upper limb (21.6%), and lower limb (19.9%) pain. The oral route was the most common analgesia delivery method (67.4%), and ibuprofen and acetaminophen were the primary agents used. Younger age, higher acuity, and presenting with head or neck pain were independent predictors of pain assessment at triage, while children 3-5 years and those with lower extremity pain were more likely to receive analgesia.

CONCLUSION

Although pain assessment at triage has improved in pediatric patients, there is still a major deficiency in adequate pain management. Our study highlights predictors of pain assessment and management that can be considered for improved pediatric care.

Kiwifruit and Kiwifruit Extracts for Treatment of Constipation: A Systematic Review and Meta-Analysis

INTRODUCTION

This systematic review aimed to summarize evidence to determine the effectiveness of kiwifruit or kiwifruit extracts in the treatment of constipation.

METHODS

Electronic databases were searched from inception to May 2022 without any age or language limitations. Eligible studies enrolled participants with constipation who were randomized to receive kiwifruit or kiwifruit extracts vs. any nonkiwifruit control. Standardized mean difference (SMD) and mean difference (MD) with confidence intervals (CI) were determined for the following outcomes: frequency of spontaneous bowel movements (SBM), abdominal pain and straining, as well as stool type as determined by the Bristol Stool Scale (BSS). The Grading of Recommendations, Assessment, Development and Evaluations (GRADE) approach was used to rate the certainty of evidence. Our review was registered on PROSPERO (CRD42021239397).

RESULTS

Seven RCTs, including 399 participants (82% female; mean age: 42 years (SD 14.6)), were included. Compared with placebo (n = 95), kiwifruit extracts might increase the weekly frequency of SBM (MD: 1.36; 95% CI: -0.44, 3.16) with low certainty of evidence; moreover, it had an uncertain effect on BSS (SMD: 1.54; 95% CI: -1.33, 4.41) with very low certainty of evidence. Additionally, compared with placebo (n = 119), kiwifruit or its extracts reduced abdominal pain (SMD: -1.44, 95% CI -2.83, -1.66) with moderate certainty of the evidence and improved frequency of straining (SMD: -0.29; 95% CI: -1.03, 0.47). Compared with psyllium, kiwifruit may increase the weekly frequency of SBM (MD: 1.01; 95% CI: -0.02, 2.04) with moderate certainty evidence, and may increase the value on the BSS (indicating softer stools) (MD: 0.63; 95% CI: 0.01, 1.25)with low certainty of evidence. Compared to placebo, kiwifruit-encapsulated extracts may result in an increase in minor adverse events (relative risk: 4.58; 95% CI: 0.79, 26.4).

CONCLUSIONS

Among individuals with constipation, there is an overall low certainty of evidence indicating that kiwifruit may increase SBM when compared to placebo or psyllium. Although overall results are promising, establishing the role of kiwifruit in constipation requires large, methodologically rigorous trials. Protocol Registration: PROSPERO registration number CRD42021239397.