Acute pain management in children

The Maxillary Nerve Block in Cleft Palate Care: A Review of the Literature and Expert's Opinion on the Preferred Technique of Administration

INTRODUCTION

Although the maxillary nerve block (MNB) provides adequate pain relief in cleft palate surgery, it is not routinely used globally, and reported techniques are heterogeneous. This study aims to describe relevant anatomy and to present the preferred technique of MNB administration based on the current literature and the expert opinion of the authors.

METHOD AND MATERIALS

First, a survey was sent to 432 registrants of the International Cleft Palate Master Course Amsterdam 2023. Second, MEDLINE (PubMed interface) was searched for relevant literature on maxillary artery (MA) anatomy and MNB administration in pediatric patients.

RESULTS

Survey response rate was 18% (n=78). Thirty-five respondents (44.9%) used MNB for cleft palate surgery before the course. A suprazygomatic approach with needle reorientation towards the ipsilateral commissure before incision was most frequently reported, mostly without the use of ultrasound. Ten and 20 articles were included on, respectively, MA anatomy and MNB administration. A 47.5% to 69.4% of the MA's run superficial to the lateral pterygoid muscle and 32% to 52.5% medially. The most frequently described technique for MNB administration is the suprazygomatic approach. Reorientation of the needle towards the anterior aspect of the contralateral tragus appears optimal. Needle reorientation angles do not have to be adjusted for age, unlike needle depth. The preferred anesthetics are either ropivacaine or (levo)bupivacaine, with dexmedetomidine as an adjuvant.

CONCLUSION

Described MNB techniques are heterogeneous throughout the literature and among survey respondents and not routinely used. Further research is required comparing different techniques regarding efficacy and safety.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Regional anesthesia for pain control in children with solid tumors-a review of case reports

Introduction

Around seventy percent of all childhood cancer patients suffer from severe pain. This pain can arise from various sources, including tumors themselves, pain caused by metastasizing tumor cells or as the outcome of therapy meant to deal with tumors. If managed inadequately, such pain can lead to many hazardous sequelae. However, there are extreme cases when pain does not respond to standard treatment. For such cases, regional anesthesia or nerve blocks are utilized as the utmost pain control measure. Blocks are used to treat pain in patients who no longer respond to conventional opioid-based treatment or whose worsened condition makes it impossible to receive any other therapy. The data regarding the use of regional anesthesia for such cases in the children population is limited.

Methods

For this review we searched for case reports in Scopus and PubMed from inception to 2023. The descriptive search items included terms related to childhood cancer and the description of each block. The inclusion criteria for review include children (0-18 years old) receiving oncology-related surgical procedures or palliative care. The data collection was limited to solid tumor-related cases only. We analyzed a total of 38 studies that included case reports and one retrospective study.

Results and discussion

It was concluded that nerve blocks, although rarely performed, are a safe and efficient way of pain control in children with solid tumors. The major settings for block performance are postoperative pain control and palliative care. We observed that block indication and its outcomes depend on unique health circumstances in which they should be performed. Patients with similar diagnoses had differing outcomes while receiving the same block treatment.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Diclofenac for acute postoperative pain in children

BACKGROUND

Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain.

OBJECTIVES

To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled').

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI).

MAIN RESULTS

We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results.

AUTHORS' CONCLUSIONS

We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.

Assessment of pain management adequacy among hospitalized pediatric patients: institutional-based cross-sectional study

Background

As the evidence showed, despite the magnitude of the effects that pain can have on a child, it is often inadequately assessed and treated. However, whether pain is adequately treated or not, evidence is lacking in the study setting.

Objectives

This study assessed pain management adequacy among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.

Methods

An institution-based cross-sectional study was conducted among pediatric patients admitted to the University of Gondar Comprehensive and Specialized Hospital between June and August 2021. Eligible patients were enrolled in the study using consecutive sampling techniques. Data were collected using a structured interview-based questionnaire and a review of the patient's medical records that were prepared after reviewing earlier studies. Pain management adequacy was determined using the pain management index (PMI) score. Statistical Software for Social Sciences (SPSS) version 22 was used for data entry and analysis. Descriptive statistics such as frequencies, percentages, and means with standard deviation were used to describe the respective variables. Logistic regression was used to assess predictor variables of pain management adequacy. A p-value <0.05 at a 95% CI was considered statistically significant.

Results

Of the 422 participants enrolled in the study, most (58.1%) were males, with a mean age of 3.9 ± 0.8 years. Pain medication was prescribed to 62.8% (95% CI: 57.3-68.2) of the participants. About 63.3% (95% CI: 58.8%-68%) received inadequate analgesics. The type of painkillers administered also did not match the severity of the pain. Pediatric patients less than 1 month and between 1 month and 1 year (AOR = 2.891, 95% CI: 1.274-12.899 and AOR = 2.657, 95% CI: 1.350-5.175), respectively, and patients with severe and moderate levels of pain (AOR = 3.448, 95% CI: 1.902-6.251 and AOR = 5.345, 95% CI: 1.956-9.828), respectively, were found to have inadequate pain medication compared with their counterparts.

Conclusion

This study revealed that pain was hardly managed based on its severity. Overall, two-thirds of pediatric patients received inadequate pain medication. This indicates majority of patients experienced pain did not manage appropriately.

Analgesic efficacy of bupivacaine with or without magnesium adjunct in bilateral ilioinguinal and iliohypogastric nerve blocks following cesarean section under subarachnoid block: A randomized controlled trial

Background

Pain relief is a basic aspect of anesthesia care. Optimal post-cesarean section analgesia should minimize postoperative complications, facilitate infant care, and prevent postoperative morbidity. Bilateral ilioinguinal-iliohypogastric (IIIH) nerve block has been considered as a part of the multimodal approach. This study was designed to explore the efficacy of adding magnesium sulfate as an adjunct to bupivacaine to provide analgesia following cesarean delivery, using bilateral IIIH nerve block.

Materials And Methods

Seventy-two parturients who were scheduled for elective cesarean section were randomized into two groups of 36 patients each. Group MB patients were given bilateral IIIH nerve block with 250 mg of magnesium sulfate and 95 mg of 0.25% plain bupivacaine. Group B patients were given bilateral IIIH nerve block with 0.9% normal saline and 95 mg of 0.25% plain bupivacaine. Postoperative visual analog scale (VAS) pain scores at post-anesthesia care unit (PACU), 2, 4, 6, 12, and 24 h, both at rest and with activity were measured. Rescue doses of opioid (intravenous [IV] tramadol 50 mg) at each time point of assessment, total tramadol consumption, time to patients' first request for rescue analgesic agent, and patients' satisfaction score were recorded.

Results

The demographic and social parameters of patients in both the groups were comparable. The mean postoperative VAS pain score in group MB was significantly lesser both at rest and with movement than in group B at 12 and 24 h after surgery (P < 0.05). Total postoperative tramadol consumed over 24 h was significantly lesser in the magnesium group than in the control group (125.55 ± 20.76 vs. 160.24 ± 25.82 mg), with a P value of 0.026. The time to patient's first analgesic request was significantly prolonged in group MB compared to group B (505.2 ± 41.4 vs. 372.6 ± 88.8 min, respectively), with a P value of 0.040. However, patients in both groups expressed good satisfaction scores.

Conclusion

Magnesium sulfate as an adjunct to bupivacaine in bilateral IIIH nerve block reduced VAS pain scores, total tramadol consumption, and prolonged post-cesarean section analgesia.

Short-acting versus long-acting opioids for pediatric postoperative pain management

INTRODUCTION

Opioids are potent analgesics commonly used to manage children's moderate to severe perioperative pain in children. A wide range of short and long-acting opioids are used to treat surgical pain and will be reviewed in this article.

AREAS COVERED

Both short- and long-acting opioids contain unique therapeutic benefits and adverse effects; however, due to the side effect profile and safety concerns, lack of familiarity, and evidence with long-acting opioids to treat surgical pain, shorter-acting opioids have traditionally been used in children. Almost all opioids work by binding to the mu receptor. Methadone, a long-acting opioid, is an exception because it also has beneficial N-methyl-D-aspartate antagonist properties. Clinically methadone's properties could translate to improved analgesic outcomes, reduced risk of adverse events, less risk for acute hyperalgesia, tolerance and abuse potential, faster recovery, and reduced risk for chronic persistent surgical pain. This review article summarizes and compares the evidence of commonly used short and long-acting opioids for perioperative pain control in the pediatric population.

EXPERT OPINION

Individualized methadone therapy using pharmacogenomics has the potential to transform opioid use in pain management by improving patient safety and analgesic outcomes, thereby addressing the gaps in current standardized ERAS protocols.

Analgesic Efficacy of Erector Spinae Plane Block in Pediatric Abdominal Surgery: Guidance with Conventional Method and NOL: Case Series

Background

Erector spinae plane (ESP) block is a regional anesthesia technique that blocks both somatic and visceral nerve fibers. Despite its high analgesic potential, its mechanism of action is not yet fully understood. The ultrasound-guided ESP block, which can be easily performed, makes important contributions to the control of intraoperative pain in pediatric patients undergoing abdominal surgery. The follow-up of pain in the intraoperative period is usually done by evaluating the changes in hemodynamic parameters. Due to physiological differences in pediatric patients, it is more difficult to do this with only hemodynamic changes than in adult patients. Aim: The NOL® (Nociception Level) monitor calculates the nociception/pain score by evaluating many parameters through a proprietary algorithm. Our primary aim was to demonstrate the effectiveness of ESP block with an advanced pain monitor in this patient group; our secondary aim was to investigate the necessity of pain monitors in the pediatric patient group.

Methods

In this case series, we applied intraoperative NOL® monitoring in addition to standard monitoring (ECG, SpO2, heart rate, EtCO₂) in pediatric patients (16 cases) who were scheduled for abdominal surgery and underwent ESP block.

Results

Considering the hemodynamic data, NOL values, postoperative pain scores, side effects, and complications, it was concluded that ESP block can be used safely in this patient group. Although the hemodynamic data and the NOL® index were compatible with each other after a nociceptive stimulus, the NOL index was less affected by other variables and gave the clinician clearer information about pain.

Evaluation of age-banded dosing of oral paracetamol in hospitalised children: a retrospective analysis using clinical data in a tertiary paediatric hospital

OBJECTIVE

To evaluate age-banded dosing in paediatric inpatients by determining the proportion of patients whose dose would fall outside the therapeutic range (by weight).

DESIGN

A retrospective observational study. Weight and height measurements and details of hospital admissions were matched from the electronic patient record of a single, tertiary paediatric hospital. Dosage which would be given according to age-banded dosing was then compared with their weight.

PARTICIPANTS

All children admitted to a single tertiary children's hospital aged 3 months to 16 years over a 5-year period. Data were cleaned to remove values likely to be erroneous and filtered to reduce bias due to patients who were admitted on multiple occasions.

OUTCOMES

The main outcome was the proportion of patients who would receive a subtherapeutic or supratherapeutic paracetamol dose if given a dose based on their age. Secondary outcomes were to examine this in children of different ages and to examine the impact of alternative size-based dosing strategies.

RESULTS

100 047 admissions (in 68 310 patients) had a weight documented. If age-banded dosing had been used, a subtherapeutic dose (less than 10 mg/kg) would be given during 19 829 (20%) of the admissions and a supratherapeutic dose (over 18.75 mg/kg, 75 mg/kg/day in four doses) in 4289 (4.3%). The highest risk of a subtherapeutic dose occurred in infants just prior to reaching 6 months of age (83%) and in children just prior to reaching 8 years (66%). The highest risk of a supratherapeutic dose was at 12 years of age (35%).

CONCLUSION

Age-banded dosing is not suitable for an inpatient paediatric population as approximately a quarter of patients receive a dose outside the recommended range of 10.0-18.75 mg/kg.

What influences physician opioid prescribing for children with acute pain?

Background

Pain is one of the most common symptoms encountered in the healthcare system, and opioids are among the top three medications used to treat it. Understanding the reasoning behind physicians' opioid prescribing practices is vital to safe practice. The primary objective of our study was to describe pediatric emergency physicians' decision-making process when prescribing opioids for children's acute pain management.

Methods

This study employed qualitative methodology, using one-on-one semi-structured interviews within a grounded theory analytic framework. We employed purposeful sampling to recruit pediatric emergency physicians from across Canada. Interviews were conducted by telephone (December 2019-January 2021). Transcript analysis occurred concurrently with data collection, supporting data saturation and theory development considerations.

Results

Eleven interviews were completed with participants representing each of Canada's geographic regions. Nine major themes emerged: (1) practice setting and outpatient opioid use, (2) condition-specific considerations, (3) physician confidence in medical evidence, (4) pain assessment challenges, (5) patient and family perspectives, (6) opioid safety concerns, (7) personal biases and experiences, (8) personal practice context, and (9) the Opioid Crisis/media influence. Most clinicians felt that they limited opioid use to those who needed it most; all participants described challenges managing acute pain, emphasizing the need for accurate pain measurement and better guidelines, evidence-based data, and knowledge translation. Clinicians were more comfortable treating pain in the emergency department, compared to discharge prescribing. They recognized the importance of co-therapy with non-opioids and the need for opioid risk assessment when prescribing. A family centered approach was recognized as the goal of practice.

Conclusion

Clinicians are less comfortable prescribing opioids to children for at-home use and find pain assessment and lack of clear guidelines to be barriers to pain care. Knowledge translation strategies for safer practice and optimal acute pain management could support responsible and judicious opioid use.

Risk of Neurotoxicity with Multiple General Anaesthetics for Examination Under Anaesthesia in Paediatric Ophthalmology - A Cause for Concern?

Purpose

To evaluate the impact of clinical protocol change via active minimisation on the number of general anaesthetic (GA)/sedation episodes for diagnostic ophthalmic purposes at Children's Health Ireland at Temple Street (CHI-TS), Dublin, Ireland, from 2016 to 2019, inclusive. Change was implemented following published cautionary principles in 2016 by the FDA regarding the potential neurotoxic risk from multiple GA exposure in children.

Methods

Retrospective analysis of electronic operating theatre records was completed using procedure codes "Ophthalmological examination" and "Examination of fundi". Available records for patients undergoing multiple examination under anaesthesia (EUA) procedures were assessed for demographics, indication. Comparison was made regarding overall EUA numbers and breakdown for each year, before and after the new departmental approach. From 2018 onward, a patient-centred, departmental strategy of active minimisation of EUA was adopted, using strategies of "training, technology and patience". A literature review was conducted using online databases.

Results

A total of 450 EUAs were performed over the 4 years investigated. In the former 2 years of the study period, prior to departmental policy change, EUAs represented 32% (304 of 948 total theatre episodes) of the ophthalmic theatre caseload. In the latter 2 years of this study period, this proportion fell to 19% (146 EUAs of 783 theatre episodes). Total theatre case numbers were comparable in both time periods. Eighteen children had multiple EUAs (ie, ≥2 EUAs, mean 6.5, SD 2.9) for life/sight threatening indications, totalling 116 EUAs (25.7%).

Conclusion

A significant reduction in diagnostic EUA volume was accomplished resulting in reduced individual patient risk and increased capacity for surgical interventions. A detailed description of this methodology is included for the purposes of replication at comparable units. EUA will continue to play a crucial role in the management of life/sight threatening conditions but the application of a cautionary principle to reduce EUA, where possible, is appropriate to reduce potential for neurotoxicity.

Memojis Pain Scale: A novel pain assessment tool

BACKGROUND

Dental pain exerts a considerable impact on the psychosocial well-being of children; reliable management of pain depends on the ability to assess pain intensity.

AIM

To validate and compare a new memojis pain assessment scale with the Faces Pain Scale-Revised (FPS-R) and Wong-Baker FACES Pain Rating Scale (WBFPS) in assessing dental pain experienced by children.

DESIGN

Two hundred and fifty healthy children aged 5-9 years without any past dental experience and requiring local anaesthesia (LA) administration were recruited. Three different scales [FPS-R, WBFPS and Memojis Pain Scale (MPS)] were applied to assess the children's pain during LA administration. The preferences of each child based on the ease of understanding the faces were recorded.

RESULTS

Pearson correlation test was performed to determine the correlation between MPS with WBFPS and MPS with FPS-R. A strong correlation was seen when comparing MPS with WBFPS (r = .966; p < .001) and MPS with FPS-R (r = .969; p < .001), and 81.6% of the children preferred MPS.

CONCLUSION

The Memojis Pain Scale was an effective pain assessment tool. It can be employed as an alternative scale for pain assessment in children.

Diclofenac for acute postoperative pain in children

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by either different routes (e.g. oral, rectal, etc.) or strategies (e.g. as needed versus as scheduled).

The effectiveness and safety of paediatric prehospital pain management: a systematic review

BACKGROUND

Clinically meaningful pain reduction with respect to severity and the adverse events of drugs used in prehospital pain management for children are areas that have not received sufficient attention. The present systematic review therefore aims to perform a comprehensive search of databases to examine the preferable drugs for prehospital pain relief in paediatric patients with acute pain, irrespective of aetiology.

METHODS

The systematic review includes studies from 2000 and up to 2020 that focus on children's prehospital pain management. The study protocol is registered in PROSPERO with registration no. CRD42019126699. Pharmacological pain management using any type of analgesic drug and in all routes of administration was included. The main outcomes were (1) measurable pain reduction (effectiveness) and (2) no occurrence of any serious adverse events. Searches were conducted in PubMed, Medline, Embase, CINAHL, Epistemonikos and Cochrane library. Finally, the risk of bias was assessed using the Joanna Briggs Institute (JBI) checklist and a textual narrative analysis was performed due to the heterogeneity of the results.

RESULTS

The present systematic review on the effectiveness and safety of analgesic drugs in prehospital pain relief in children identified a total of eight articles. Most of the articles reviewed identified analgesic drugs such as fentanyl (intranasal/IV), morphine (IV), methoxyflurane (inhalational) and ketamine (IV/IM). The effects of fentanyl, morphine and methoxyflurane were examined and all of the included analgesic drugs were evaluated as effective. Adverse events of fentanyl, methoxyflurane and ketamine were also reported, although none of these were considered serious.

CONCLUSION

The systematic review revealed that fentanyl, morphine, methoxyflurane and combination drugs are effective analgesic drugs for children in prehospital settings. No serious adverse events were reported following the administration of fentanyl, methoxyflurane and ketamine. Intranasal fentanyl and inhalational methoxyflurane seem to be the preferred drugs for children in pre-hospital settings due to their ease of administration, similar effect and safety profile when compared to other analgesic drugs. However, the level of evidence (LOE) in the included studies was only three or four, and further studies are therefore necessary.

Sub-anesthetic intravenous ketamine vs. caudal bupivacaine for postoperative analgesia in children undergoing infra-umbilical surgeries: a non-inferiority randomized single-blind controlled trial

Background

Sub-anesthetic iv ketamine acts as an analgesic and has opioid-sparing effects, particularly for acute postoperative pain. Primary aim of this study was to evaluate the non-inferiority of sub-anesthetic iv ketamine vs caudal bupivacaine for postoperative analgesia in children.

Methods

Children below six years were enrolled in this single-blind study and randomized to receive either sub-anesthetic iv ketamine (0.3 mg/kg) or 1 ml/kg of caudal 0.125% bupivacaine, along with general anesthesia. Postoperative pain was assessed with the FLACC scale at 30 minutes, and at one, two, three, and six hours. Intra and postoperative opioid consumption, time to extubation, postoperative vomiting (POV), postoperative agitation, sedation, and inflammatory markers (serum IL-6 and TNF-α) were also assessed.

Results

One hundred and forty-one children completed the study, 71 in the ketamine and 70 in the caudal group. The cumulative proportion of children without significant postoperative pain (FLACC score < 4) until six hours post-surgery was 45.1% in the ketamine group vs 72.9% in the caudal group (P < 0.001). More children required an additional dose of intraoperative fentanyl (33.8% vs 5.7%; P < 0.001) and postoperative tramadol (54.9% vs. 27.1%; P < 0.001) in the ketamine group. Postoperative agitation, (4.3% vs. 9.9%; P = 0.19) and sedation (32.8% vs 22.5%; P = 0.17) were similar in the groups. Time to extubation, POV, baseline and post-surgical inflammatory markers were comparable.

Conclusions

Sub-anesthetic ketamine is inferior to caudal bupivacaine for postoperative analgesia in children below six years undergoing infra-umbilical surgeries but results in similar postoperative outcomes.

Researchers' choice of pain scales in trials of children undergoing surgery: A cross-sectional analysis of systematically searched randomized controlled trials and survey of authors

BACKGROUND

Many pain scales are used post-operatively in pediatric trials, making the comparison of trials, and the pooling of data for meta-analyses difficult. The Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) statement, published in 2008, attempted to address this issue. We aimed to investigate the reasons for authors' choice of pain scales and the potential impact of PedIMMPACT.

METHODS

We performed a cross-sectional analysis of systematically searched randomized controlled trials testing tramadol in children (up to 16 years) undergoing surgery, published between 2000 and 2020 (9 years prior to and 12 years following the publication of PedIMMPACT).

RESULTS

Among 76 trials (6211 children), 49 unique pain scales were used. The choice of the scales was explained in 18 trials (24%); in 13 of them, authors at least partly justified their choice by the fact that the pain scale was validated. In 52 trials (68%), the pain scales were referenced, with a total of 59 unique references, most often to prior studies using the same scale (36%) or to studies validating the chosen scale (31%). Twenty-three trials (30%) provided no explanation nor reference. One single trial referenced PedIMMPACT. There was no evidence of a change in the choice of pain scales after the publication of PedIMMPACT.

CONCLUSIONS

A large variety of pain scales are still used in pediatric post-operative pain trials 12 years after the publication of PedIMMPACT. Only a minority of trials provided an explanation for their choice of pain scale. The reasons given most often included that the scale was validated or it was justified by a reference to a prior study using that scale. The impact of the publication of the PedIMMPACT seems limited. The ethics of the ongoing usage of large numbers of pain scales in pediatric pain trials must be challenged.

Cross-sectional study of pediatric pain prevalence, assessment, and treatment at a Canadian tertiary hospital

Background

Painful experiences are common among hospitalized children. Long-term negative biopsychosocial consequences of undertreated pain are recognized.

Aims

The study benchmarks pain prevalence, assessment, and treatment as first steps to improve pain care in a Canadian tertiary hospital.

Methods

Single-day audits were undertaken on the pediatric ward (PW), pediatric emergency department (ED), and maternal services (MS). Participants (child or caregiver proxy) reported hospital pain experiences in the preceding 24 h; medical records were reviewed for assessment and treatment.

Results

Among 84 participants, pain prevalence ranged from 75% to 88%; mean pain intensity ranged from 5.7 to 6.5/10. Prevalence of moderate to severe pain was 78% on PW, 65% in ED, and 55% on MS; needle pokes were the most frequent cause of worst pain. Documentation of pain assessment varied by setting (PW, 93%; ED, 13%; MS, 0%). Documented maximum pain scores were significantly lower compared to participant report (mean difference 4.5/10, SD 3.1, P < 0.0001). A total 29% (6/21) of infants with heel lance or injection received breastfeeding or sucrose, and 29% (7/24) of participants receiving other needle procedures had documented or reported topical lidocaine use. All participants on MS underwent needle procedures.

Conclusions

Pain is experienced commonly by infants and children in PW, ED, and MS. Pain assessment documentation is not routine and underestimates participant report. Evidence-based pain management strategies are underutilized. An institution-wide quality improvement approach is required to address pain care. Pain assessment and needle pain prevention and treatment should be prioritized in these pediatric acute care and newborn care settings.

A Systematic Review of Assessments and Interventions for Chronic Pain in Young Children With or at High Risk for Cerebral Palsy

BACKGROUND

Pain is common in children with cerebral palsy. The purpose of this systematic review was to evaluate the evidence regarding assessments and interventions for chronic pain in children aged ≤2 years with or at high risk for cerebral palsy.

METHODS

A comprehensive literature search was performed. Included articles were screened using PRISMA guidelines and quality of evidence was reviewed using best-evidence tools by independent reviewers. Using social media channels, an online survey was conducted to elicit parent preferences.

RESULTS

Six articles met criteria. Parent perception was an assessment option. Three pharmacologic interventions (gabapentin, medical cannabis, botulinum toxin type A) and 1 nonpharmacologic intervention were identified. Parent survey report parent-comfort and other nonpharmacologic interventions ranked as most preferable.

CONCLUSION

A conditional GRADE recommendation was in favor of parent report for pain assessment. Clinical trials are sorely needed because of the lack of evidence for safety and efficacy of pharmacologic interventions.

Subcutaneous Bupivacaine Infiltration Is Not Effective to Support Control of Postoperative Pain in Paediatric Patients Undergoing Spinal Surgery

Spinal deformity corrections in paediatric patients are long-lasting procedures involving damage to many tissues and long pain exposure; therefore, effective pain management after surgical treatment is an important issue. In this study, the effect of inclusion of local infiltration analgesia, as an integral part of the scheme in postoperative pain control, in children and adolescents, subjected to the spinal deformity correction procedure, was assessed. Thirty patients, aged 8 to 17 years, undergoing spinal deformity correction were divided into a study group, receiving a 0.25% bupivacaine solution before wound closure, and a control group (no local analgesic agent). Morphine, at the doses of 0.10 mg/kg of body weight, was administered to the patients when pain occurred. Pain scores, morphine administration, and bleeding were observed during 48 postoperative hours. The pain scores were slightly lower in a 0–4 h period in patients who received bupivacaine compared with those in the control group. However, no differences were observed in a longer period of time and in the total opioid consumption. Moreover, increasing bleeding was observed in the bupivacaine-treated patients (study group) vs. the control. Bupivacaine only modestly affects analgesia and, due to the increased bleeding observed, it should not to be part of pain control management in young patients after spinal deformity correction.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Development of a Structured Regional Analgesia Program for Postoperative Pain Management

OBJECTIVES

We pursued the use of regional analgesia (RA) to minimize the use of postoperative opioids. Our aim was to increase the use of postoperative RA for eligible surgical procedures in the NICU from 0% to 80% by June 30, 2019.

METHODS

A multidisciplinary team determined the eligibility criteria, developed an extensive process map, implemented comprehensive education, and a structured process for communication of postoperative pain management plans. Daily pain team rounds provided an opportunity for collaborative comanagement. An additional 30 minutes for catheter placement was added in operating room (OR) scheduling so that it would not affect the surgeon OR time.

RESULTS

There were 21 eligible surgeries in the baseline period and 34 in the intervention period. In total, 30 of 34 infants in eligible surgeries (88%) received RA. The average total opioid exposure in intravenous morphine milligram equivalents decreased from 5.0 to 1.1 mg/kg in the intervention group. The average time to extubation was 45 hours in the baseline period and 19.9 hours in the intervention group. After interventions, 75% of infants were extubated in the OR, as compared with 10.5% in the baseline period. No difference was seen in postoperative pain scores or postoperative hypothermia between the baseline and intervention groups.

CONCLUSIONS

We used quality improvement methodology to develop a structured RA program. We demonstrated a significant reduction in opioid requirements and need for mechanical ventilation postoperatively for those infants who received RA. Our findings support safe and effective use of RA, and provide a framework for implementation of a similar program.

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.

Caudal block with rectal diclofenac and paracetamol for pediatrics infra umbilical surgery at a comprehensive specialized teaching hospital in Ethiopia

Background

Caudal block is a common regional technique performed for infra umbilical surgery in pediatrics. Its limited duration of analgesia remains a gap in routine clinical practice. This study aimed to assess the analgesic effectiveness of caudal block with rectal diclofenac or rectal paracetamol among pediatric patients who underwent infra umbilical surgery.

Methods

A prospective cohort study was conducted on patients aged 1–10 years that underwent elective infra umbilical surgery. Patients were allocated into the Caudal block with rectal Diclofenac, Caudal block with rectal Paracetamol, and Caudal block alone groups based on a postoperative pain management plan. Analysis of variance was used for normally distributed data and the Kruskal Wallis H test was used for non-normally distributed. The Tukey for post hoc test was used to compare the difference between groups one with the others. Categorical data were analyzed by using Pearson Chi-squared or Fisher's exact test as appropriate. A p-value < 0.05 considered as statistically significant.

Results

The postoperative median pain score was lower in CD compared to CP and CA group (p-value < 0.001) at the 4th and 8th hour. Time to first analgesic request was significantly longer within CD 735 (540–1200 min) compared to CP 445 (240–840 min p = 0.029) and CA 315 (240–720 min p < 0.001).

Conclusion

The pain score and total postoperative analgesic consumption were significantly reduced in addition to prolonged-time to request the first analgesia in the CD group compared to CA and CP group.

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Caudal block with rectal diclofenac might reduce analgesic request.

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Caudal block with rectal diclofenac might prolong analgesia duration.

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Caudal block with rectal diclofenac might reduce pain severity score.

Postoperative Opioid Analgesia Impacts Resource Utilization in Infants Undergoing Pyloromyotomy

BACKGROUND

Opioid analgesia is often avoided in infants undergoing pyloromyotomy. Previous studies highlight an association between opioid use and prolonged hospitalization after pyloromyotomy. However, the impact of opioid use on healthcare resource utilization and cost is unknown. We hypothesized that use of opioids after pyloromyotomy is associated with increased resource utilization and costs.

METHODS

A retrospective cohort study was conducted identifying healthy infants aged <6 mo with a diagnosis of pyloric stenosis who underwent pyloromyotomy from 2005 to 2015 among 47 children's hospitals using the Pediatric Health Information System database. Time of opioid exposure was categorized as day of surgery (DOS) alone, postoperative use alone, or combined DOS and postoperative use. Primary outcomes were the standardized unit cost, a proxy for resource utilization, billed charges to the patient/insurer, and hospital costs. A multivariable log-linear mixed-effects model was used to adjust for patient and hospital level factors.

RESULTS

Overall, 11,008 infants underwent pyloromyotomy with 2842 (26%) receiving perioperative opioids. Most opioid use was confined to the DOS alone (n = 2,158, 19.6%). Infants who received opioids on DOS and postoperatively exhibited 13% (95% confidence interval [CI]: 7%-20%, P-value <0.001) higher total resource utilization compared with infants who did not receive any opioids. Billed charges were 3% higher (95% CI: 0%-5%, P-value = 0.034) for infants receiving opioids isolated to the postoperative period alone and 6% higher (95% CI: 2%-11%, P-value = 0.004) for infants receiving opioids on the DOS and postoperatively.

CONCLUSIONS

Postoperative opioid use among infants who underwent pyloromyotomy was associated with increased resource utilization and costs.

The Predictors of Postoperative Pain Among Children Based on the Theory of Unpleasant Symptoms: A Descriptive-Correlational Study

PURPOSE

Postoperative pain (POP) is a common outcome of surgical interventions among children. Identifying POP contributing factors can help identify children who are at risk for POP and facilitate POP management. The aim of the study was to determine the predictors of POP based on the Theory of Unpleasant Symptoms.

DESIGN AND METHODS

This descriptive-correlational study was conducted in 2018-2019 on 153 children purposively recruited. Data were collected using a personal characteristics questionnaire, the Coping Strategies Questionnaire, the Child Pain Anxiety Symptoms Scale, and a Visual Analogue Scale for Pain. The SPSS software (v. 21.0) was used for data analysis.

RESULTS

Twelve participants were excluded and final data analysis was done on the data obtained from 141 participants. Most of participants were male (65.2%), underwent abdominal surgery (53.2%), and experienced POP (86.5%). Their age mean was 8.58±2.23. Linear regression analysis revealed that the physiological factors of heart rate, preoperative pain, and surgery duration as well as the psychological factors of anxiety and coping strategies were significant predictors of POP among children. All these factors collectively explained 34% of the total variance of POP. Situational factors (such as age, gender, and ethnicity) had no significant effects on POP.

CONCLUSIONS

Heart rate, preoperative pain, surgery duration, anxiety and coping as predictive factors of POP can be considered when designing effective POP management strategies.

PRACTICE IMPLICATIONS

The findings provide a better understanding about the predictors of POP and can be used to develop pain management among children.

Knowledge, Attitude, and Practice amongst General Dentists Regarding Dental Pain Perception in Children

Aim

The objective of this study was to evaluate the knowledge, attitude, and practice among general dentists regarding perception of dental pain in children.

Materials and methods

A cross-sectional study was conducted among 208 general dentists in a dental hospital in Chennai. A self-constructed questionnaire was distributed to the dental practitioners, which comprised 23 closed-ended questions. The data were entered and analyzed for frequency and percentages by using Statistical Package for the Social Sciences (SPSS), version 21.

Results

Results showed that most of the dentists (46%) treated less than five children per week and were having less than 2 years of experience (47%). Seventy one percent of the dentists felt that they did not feel prepared to identify a child with dental pain, and 57% of the dentists had less than two years of experience

Conclusion

Most of the dentists did not feel prepared to identify the children with dental pain. Measures should be introduced to train the general dental practitioners in identifying pain perception in children so as to achieve effective behavior management of children.

How to cite this article

Subramanyam D, Gurunathan D. Knowledge, Attitude, and Practice amongst General Dentists Regarding Dental Pain Perception in Children. Int J Clin Pediatr Dent 2020;13(3):207–210.

Quality improvement assessment of a bianchi-technique pediatric orchiopexy perioperative pain management pathway

BACKGROUND

Surgical correction of undescended testes is a common surgical procedure which can be performed via a two-incision technique or a single high scrotal incision (Bianchi technique). The Bianchi technique requires less surgical time and may be associated with less pain in the initial postoperative period, however it has been adopted slowly due to a lack of familiarity and perceived technical challenges of the technique. Traditionally postoperative orchiopexy pain is managed with a caudal or ilioinguinal/iliohypogastric nerve block. As urologists at our site adopted the Bianchi technique, the anesthesiologists stopped performing caudals or ilioinguinal/iliohypogastric nerve blocks as local infiltration appeared sufficient. Therefore, this quality improvement (QI) project endeavoured to assess Alberta Children's Hospital's care pathway in its effectiveness to control pain in the first 24 h following pediatric orchiopexy using the Bianchi technique.

METHODS

We completed a prospective QI project examining a care pathway for patients undergoing orchiopexy using the Bianchi technique. Eligible patients were healthy and aged 6 months to 12 years. A multimodal analgesic approach including local anesthetic surgical infiltration was used. Pain scores (FLACC) were recorded for up to 2 h postoperatively and a PPPM was completed at 24 h postoperatively.

RESULTS

Sixty-four patients were included in the final analysis. The median discharge FLACC score was 0 (range 0-2) (Table 2). Median intraoperative morphine administered was 0.09 mg/kg with no significant correlations between the amount of morphine administered and postoperative pain measures. Median PPPM scores were 4 and 3.5 for unilateral and bilateral procedures, respectively.

CONCLUSIONS

We have demonstrated that orchiopexies repaired using the Bianchi technique following the care pathway established at Alberta Children's Hospital are associated with minimal pain scores. Our QI project suggests that combining a Bianchi technique with a simple multimodal analgesic approach including local infiltration, negates the need for regional anesthesia techniques, yet still provides adequate analgesia.

Pain management in children has significantly improved in the Italian emergency departments

AIM

Pain in children is often poorly assessed and treated in Italian emergency departments (EDs) as found in a survey conducted among the centres of the "Pain in Pediatric Emergency Room (PIPER)" Study Group in 2010. Our aim was to evaluate the changes in pain management in Italian EDs in the last years.

METHOD

A structured questionnaire about pain assessment, protocols, use of local anaesthetics before venipuncture, opioids and adjuvants was mailed to 46 Italian EDs between November 2017 and April 2018.

RESULTS

Pain was always assessed at triage in 34 centres (73.9%). Algometric scales were used in over 90% of EDs. Triage protocols were available in 37 centres (80.4%). Local anaesthetics before venipuncture were always used in six centres (13.0%). Protocols included opioids and adjuvants in 73.0% and 47.2%, respectively. Triage pain assessment was always done in 91.0% of the centres joining the PIPER Study Group up to 2015 and 56.5% in ones that joined the Group after 2015 (P = .017). Local anaesthetics before venipuncture were given in 39.1% of the centres joining until up to 2015 and 13.0% in ones that joined the Group after 2015 (P = .003).

CONCLUSION

Paediatric pain management has significantly improved in Italian EDs in the last 8 years. The centres joining the PIPER Study Group for longer time have shown better results for the indicators considered in the survey.

Recognizing Risks and Optimizing Perioperative Care to Reduce Respiratory Complications in the Pediatric Patient

There have been significant advancements in the safe delivery of anesthesia as well as improvements in surgical technique; however, the perioperative period can still be high risk for the pediatric patient. Perioperative respiratory complications (PRCs) are some of the most common critical events that can occur in pediatric surgical patients and they can lead to increased length of hospitalization, worsened patient outcomes, and higher hospital and postoperative costs. It is important to determine the various factors that put pediatric patients at increased risk of PRCs. This will allow for more detailed and accurate informed consent, optimized perioperative management strategy, improved allocation of clinical resources, and, hopefully, better patient experience. There are only a few risk prediction models/scoring tools developed for and validated in the pediatric patient population, but they have been useful in helping identify the key factors associated with a high likelihood of developing PRCs. Some of these factors are patient factors, while others are procedure-related factors. Some of these factors may be modified such that the patient’s clinical status is optimized preoperatively to decrease the risk of PRCs occurring perioperatively. Fore knowledge of the factors that are not able to be modified can help guide allocation of perioperative clinical resources such that the negative impact of these non-modifiable factors is buffered. Additional training in pediatric anesthesia or focused expertise in pediatric airway management, vascular access and management of massive hemorrhage should be considered for the perioperative management of the less than 3 age group. Intraoperative ventilation strategy plays a key role in determining respiratory outcomes for both adult and pediatric surgical patients. Key components of lung protective mechanical ventilation strategy such as low tidal volume and moderate PEEP used in the management of acute respiratory distress syndrome (ARDS) in pediatric intensive care units have been adopted in pediatric operating rooms. Adequate post-operative analgesia that balances pain control with appropriate mental status and respiratory drive is important in reducing PRCs.

A practical guide to acute pain management in children

In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact the management of pain in children. The purpose of this review is to provide a practical clinical approach to the management of acute pain in the pediatric inpatient population. This will include an overview of commonly used pain management modalities and their potential pitfalls. For institutions that have a pediatric acute pain service or are considering initiating one, it is our hope to provide a useful tool to aid clinicians in the safe and effective treatment of pain in children.

Contextual risk among adolescents receiving opioid prescriptions for acute pain in pediatric ambulatory care settings

Many adults with opioid use disorder (OUD) report that their first exposure to opioids was in the course of routine pain treatment in medical care settings. Adolescents receive opioid prescriptions with frequency, but are susceptible to a constellation of unique risks in the context of pain management. This empirical study presents the first cohort of adolescents recruited from ambulatory medical care within 72 h of their receipt of opioids to treat acute pain. The primary aim was to capture a time-sensitive report of the intersection of prescription opioid receipt and contextual risks for opioid misuse related to pain experience, mental health symptoms, and substance use at the adolescent and parental levels. Data were collected from 70 14-19-year-old adolescents and their accompanying parent. Results reflected that 90% of this sample of adolescents reported 2 or more risks and 35% reported 5 or more risks for future opioid misuse. Pain catastrophizing (46%) and alcohol use (40%) and were the most common adolescent-level risk factors; mother history of chronic pain (32%) and parent anxiety (21%) were the most common parent-level risk factors. Past-week parent pain intensity showed the strongest association with adolescent past-week pain intensity; neither was associated with adolescent OUD symptoms. Adolescent pain catastrophizing most reliably predicted OUD symptoms; parent pain interference was also associated. Seventy-one percent of parents reported keeping opioids at home, a relevant risk factor for future misuse. These findings illuminate the intersection between adolescent and parental risks in the context of pediatric opioid prescribing for acute pain management, and provide initial insight into potential points of prevention early in adolescent pain treatment, including avenues by which to inform and enhance prescriber decision-making regarding factors to be weighed in adolescent candidacy for opioid therapy.

Malignant cerebellar edema in three-year-old girl following accidental opioid ingestion and fentanyl administration

A three-year-old girl was found altered with an unknown timeline. Gas chromatography mass spectrometry was positive for hydromorphone, dihydrocodeine, and hydrocodone. Initial computed tomography and magnetic resonance imaging suggested a malignant cerebellar edema not confined to a vascular distribution. She received fentanyl boluses on hospital days 0 and 1 before receiving a continuous infusion on day 1. On day 3, she had an episode of acute hypertension and bradycardia. Emergent computed tomography showed an evolving hydrocephalus and similar diffuse edema throughout both cerebellar hemispheres. External ventricular drain was placed to relieve the increased intracranial pressure. Following drain placement and fentanyl discontinuation, the patient recovered, though not without fine- and gross-motor deficits at the four-month follow-up. Our case adds to a handful of case reports of opioid toxicity in pediatric patients that present as toxic leukoencephalopathy. Though the mechanism is poorly understood, it has been suggested to be a consequence of the neurotoxic effects of the drug, which has particular affinity for µ opioid receptors-the primary opioid receptor found in the cerebellum. Clinicians would do well to recognize that this syndrome is primarily caused by direct toxicity rather than ischemia. This case adds insight by suggesting that lipophilic opioid analgesics may worsen this neurotoxicity. When intervening with mechanical ventilation, clinicians should consider avoiding lipophilic opioid drugs for analgesia until the pathogenesis of cerebellar edema is better understood.

The Association Between Opioid Use and Outcomes in Infants Undergoing Pyloromyotomy

PURPOSE

The purpose of this study was to describe the frequency and variation of opioid use across hospitals in infants undergoing pyloromyotomy and to determine the impact of opioid use on postoperative outcomes.

METHODS

A retrospective cohort study (2005-2015) was conducted by using the Pediatric Health Information System (PHIS) database, including infants (aged <6 months) with pyloric stenosis who underwent pyloromyotomy. Infants with significant comorbidities were excluded. Opioid use was classified as a patient receiving at least 1 opioid medication during his or her hospital stay and categorized as preoperative, day of surgery, or postoperative (≥1 day after surgery). Outcomes included prolonged hospital length of stay (LOS; ≥3 days) and readmission within 30 days.

FINDINGS

Overall, 25,724 infants who underwent pyloromyotomy were analyzed. Opioids were administered to 6865 (26.7%) infants, with 1385 (5.4%) receiving opioids postoperatively. In 2015, there was significant variation in frequency of opioid use by hospital, with 0%-81% of infants within an individual hospital receiving opioids (P < 0.001). Infants only receiving opioids on the day of surgery exhibited decreased odds of prolonged hospital LOS (odds ratio [OR], 0.85; 95% CI, 0.78-0.92). Infants who received an opioid on both the day of surgery and postoperatively exhibited increased odds of a prolonged hospital LOS (OR, 1.71; 95% CI, 1.33-2.20). Thirty-day readmission was not associated with opioid use (OR, 1.03; 95% CI, 0.93-1.14).

IMPLICATIONS

There is national variability in opioid use for infants undergoing pyloromyotomy, and postoperative opioid use is associated with prolonged hospital stay. Nonopioid analgesic protocols may warrant future investigation.

Reducing Time to Pain Medication Administration for Pediatric Patients with Long Bone Fractures in the Emergency Department

Introduction

Pain management is a critical aspect of effective long bone fracture treatment. Pediatric patients frequently report suboptimal pain management, which is an area of growing public concern. The purpose of this quality improvement project was to develop a protocol with the goal to administer pain medication to children presenting with suspected long bone fractures ≤47 minutes of emergency department arrival.

Methods

A multidisciplinary team developed a standardized protocol for pain management of patients presenting with musculoskeletal pain utilizing acetaminophen as the first-line agent under a nurse-initiated order. Following education and implementation, weekly reports generated using the International Classification of Diseases codes of fractures were reviewed to assess compliance with the protocol. This study evaluates the frequency of a second pain medication administration and reduction in vital signs and pain scores.

Results

Implementation of a pain management protocol reduced median time to pain medication administration to 26 minutes. Overall, 63% (n = 638) of patients required a second pain medication. Of these, 66.5% (348/523) who initially received acetaminophen and 59.7% (286/479) who initially received an opioid required a second pain medication. No significant changes in pre and posttreatment vital signs were found between groups. Patients who initially received opioids experienced a greater reduction in posttreatment pain scores.

Conclusions

Using a standardized pain management protocol in combination with comprehensive education effectively reduces median time to pain medication administration in pediatric patients with long bone fractures. Acetaminophen is a rapid and effective first-line agent for managing pain in this population.

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.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

Patient- and Nurse-Controlled Analgesia: 22-Year Experience in a Pediatric Hospital

OBJECTIVES

Pediatric pain management has rapidly changed over the last 2 decades. In this study, we describe the changing practices and adverse events (AEs) related to patient-controlled analgesia (PCA) and/or nurse-controlled analgesia (NCA) over a 22-year period.

METHODS

After institutional review board approval, retrospective data from a single tertiary-care pediatric hospital were collected between 1994 and 2016. Subgroup analyses were done for surgical and medical case patients. We reported the number of times that PCA and/or NCA was ordered annually, the median and interquartile ranges for age, PCA and/or NCA duration and length of stay, and AE frequencies.

RESULTS

Over 22 years, 32 338 PCAs and/or NCAs were ordered in this institution. Morphine and hydromorphone were used most commonly. Between 1994 and 2006, initial orders for PCA and/or NCA increased 2.5-fold. After 2007, initial orders for PCA and/or NCA rapidly decreased; after 2013, the decrease continued at a slower rate, with a total of 1007 orders in 2016. This decrease occurred despite increased hospital admissions and surgeries. Between 2007 and 2012, peripheral nerve blocks rapidly increased (10-fold). After 2002, 146 AEs were reported (1.0%). Of those, 50.5% were nonintercepted, and 20.6% were intercepted AEs; 5.5% and 6.2% were preventable and nonpreventable AEs, respectively.

CONCLUSIONS

PCA and/or NCA usage continues to be common in pediatric patients, although usage has declined and stabilized in the setting of other emerging methods of analgesia and increases in the number of minimally invasive surgical procedures. The overall rate of AEs was extremely low. However, improvements to eliminate all errors are needed, especially with medications with a great risk of harm (such as opioids).

Tokenism or true partnership: Parental involvement in a child's acute pain care

AIMS AND OBJECTIVES

To explore parental involvement in the child's acute pain care and establish ways in which parental preferences for involvement in their child's care can be identified, facilitated and enhanced by nurses.

BACKGROUND

Despite growing evidence supporting effective acute pain management in children and the availability of national and international practice guidelines, children still experience acute pain. Involving parents in their child's pain care has been identified as being a central tenet of pain management in children.

DESIGN AND METHODS

A qualitative study using an ethnographical approach with nonparticipant observation and follow-up semi-structured interviews was undertaken. Nurses (n = 14), parents (n = 41), grandparents (n = 2), other relative (n = 1) and children (n = 30) participated. The framework approach underpinned data analysis. Consolidated criteria for reporting qualitative research (COREQ) enabled comprehensive reporting of the study.

RESULTS

Three concepts emerged from the data: "parents as advocates for their child," "nurses promoting involvement and partnership" and "nurses unintentionally preventing involvement and partnership." Variations in the way parents were involved in their child's pain care were identified. Despite family-centred care being the dominant model of involving families in their child's care, evidence of this being implemented was limited. Parents attempted to advocate effective pain care for their child, whether or not they were supported by nurses.

CONCLUSIONS

Parental involvement in their child's acute pain care can improve the child's pain experience, reduce parental anxiety and increase parents' satisfaction in care. Nurses aspired to involve parents in pain care, but did not always enact this in practice.

RELEVANCE FOR PRACTICE

Children deserve optimum pain care, which includes parental involvement. Parental involvement underpinned by the principles of family-centred care was poorly implemented. Parents attempted to be involved and advocate for their child's pain care whether or not they were supported by nurses. An alternative approach for supporting parents to advocate in their child's acute pain care is offered, the "Partnership in Pain Care Model."

Opioid Use in Children

Limited guidance on opioid use exists in the pediatric population, causing medication safety concerns for pain management in children and adolescents. Opioid misuse and use disorder continue to greatly affect adolescents and young adults in the United States, furthering the apprehension of their use. Pediatric Pharmacy Advocacy Group (PPAG) recommends pharmacists contribute their knowledge to pain management in children, including the discussion of appropriate use of non-opioid alternatives for pain and when to recommend coprescribing of naloxone. PPAG also supports the review of electronic prescription drug-monitoring programs prior to opioid prescribing and dispensing by both prescribers and pharmacists. Education by pharmacists of children and their families regarding proper administration, storage, and disposal, as well as the awareness of opioid misuse and use disorder among adolescents and young adults, is key to prevention. If opioid use disorder is diagnosed, PPAG encourages improved access among adolescents to evidence-based medications including methadone, buprenorphine, and naltrexone. Furthermore, pharmacists should assist in screening and referral to evidence-based treatment.