A systematic review of the prevalence of chronic postsurgical pain in children.

Two prior reviews highlight the scarcity and conflicting nature of available data on chronic postsurgical pain in children, reporting a wide prevalence range of 3.2% to 64% (at ≥3 months). This updated systematic review aimed to consolidate information on the prevalence of pediatric chronic postsurgical pain. A thorough literature search of full English-text publications from April 2014 to August 2021 was conducted using Ovid MEDLINE, PubMed, and Cochrane Database of Systematic Reviews, with search terms: postoperative pain, child, preschool, pediatrics, adolescent, chronic pain. Seventeen relevant studies were identified. Most assessed chronicity once greater than 3 months duration postoperatively (82%), were predominantly prospective (71%) and conducted in inpatient settings (88%). The surgeries examined included orthopedic (scoliosis and limb), urological, laparotomy, inguinal, and cardiothoracic procedures, involving numbers ranging from 36 to 750, totaling 3137 participants/2792 completers. The studies had wide variations in median age at surgery (6 days to 16 years), the percentage of female participants (unspecified or 12.5% to 90%), and follow-up duration (2.5 months to 9 years). Various pain, functional, psychosocial, and health-related quality of life outcomes were documented. Chronic postsurgical pain prevalence varied widely from 2% to 100%. Despite increased data, challenges persist due to heterogeneity in definitions, patient demographics, mixed versus single surgical populations, diverse perioperative analgesic interventions, follow-up durations and reported outcomes. Interpretation is further complicated by limited information on impact, long-term analgesia and healthcare utilization, and relatively small sample sizes, hindering the assessment of reported associations. In some cases, preoperative pain and deformity may not have been addressed by surgery and persisting pain postoperatively may then be inappropriately termed chronic postsurgical pain. Larger-scale, procedure-specific data to better assess current prevalence, impact, and whether modifiable factors link to negative long-term outcomes, would be more useful and allow targeted perioperative interventions for at-risk pediatric surgical patients.

A pilot feasibility study of gabapentin for managing pain in children with dystonic cerebral palsy.

BACKGROUND: Gabapentin is often used to manage pain in children with dystonic cerebral palsy, however the evidence for its effectiveness in this population is limited. The primary objective of this feasibility pilot study was to assess the factors which might impact on a future randomised controlled trial including the ability to recruit and retain participants, assess adherence/compliance to the prescribed intervention, and ability to complete all outcome assessments. The secondary objective was to gather preliminary evidence for the effectiveness of gabapentin at reducing pain, improving comfort and reducing dystonia in children with dystonic cerebral palsy. METHODS: This open label pilot study recruited children aged 5-18 years with dystonic cerebral palsy and accompanying pain affecting daily activities from four centres around Australia. Children were prescribed gabapentin for 12 weeks and were assessed at baseline, 6 weeks and 12 weeks. The primary outcome was feasibility of the protocol. Secondary outcomes were pain behaviour, pain intensity, care and comfort, individualised goal setting and dystonia severity. RESULTS: Thirteen children (mean age 10.4 years (SD 2.4yrs), 9 females) were recruited from 71 screened over 15 months. Two children withdrew while eight children experienced side effects. There were issues with adherence to medication dosage regimens and data collection. Improvements were seen in pain behaviour, comfort and pain related goals at 12 weeks. Dystonia was not significantly changed. CONCLUSIONS: Whilst gabapentin has potential to improve pain and comfort in children with dystonic CP, the feasibility of implementing a definitive randomised controlled trial is low. Alternative trials designs are required to further examine the effectiveness of gabapentin in this heterogeneous population. TRIAL REGISTRATION: The trial was registered with the Australian Clinical Trial Registry ( ACTRN12616000366459 ) on 22/03/2016 and the Therapeutic Goods Administration (CT-2016-CTN-00500-1) on 22/06/2016.

Is spinal anaesthesia in young infants really safer and better than general anaesthesia?

PURPOSE OF REVIEW: Concerns regarding the potential neurotoxic effects of general anaesthesia have seen resurgence in awake spinal anaesthesia in neonates and infants. This review includes recently published data from a large prospective randomized controlled trial with view to determining if spinal anaesthesia is safer and better than general anaesthesia in this population. RECENT FINDINGS: Compared with general anaesthesia, spinal anaesthesia results in less haemodynamic instability and fewer early (<30 min) apnoeic episodes in neonates and infants undergoing inguinal herniorraphy; the overall incidence of apnoeas in the first 12 h postoperatively was similar. Neurodevelopmental outcome 2 years postoperatively was similar. An appreciable failure rate for spinal anaesthesia was confirmed. SUMMARY: Spinal anaesthesia represents a suitable alternative to general anaesthesia in neonates and infants undergoing minor surgery avoiding the need for endotracheal intubation and ventilation. Spinal anaesthesia has some advantages but a significant failure rat and has not been demonstrated to improve neurodevelopmental outcome.

Comparison of lumbar epidural bupivacaine with fentanyl or clonidine for postoperative analgesia in children with cerebral palsy after single-event multilevel surgery.

AIM: To compare diazepam use, muscle spasm, analgesia, and side effects when clonidine or fentanyl are added to epidural bupivacaine in children with cerebral palsy after multilevel orthopaedic surgery. METHOD: Fifty children were prospectively randomized to receive clonidine (n=24, mean age 10y 10mo [SD 2y 11mo]) or fentanyl (n=26, mean age 10y 11mo [SD 2y 10mo]). RESULTS: There was no difference in primary outcome measures: median diazepam use (fentanyl 0, interquartile range [IQR] 0-0; clonidine 0, IQR 0-0; p=0.46), any muscle spasm (no muscle spasms in: fentanyl, 36%; clonidine, 62%; p=0.11), painful muscle spasm (fentanyl 40%; clonidine 25%; p=0.46), or pain score ≥6 (none: fentanyl 44%; clonidine 42%; p=0.29). There were differences in secondary outcome measures: no vomiting (clonidine 63%; fentanyl 20%); vomiting occurred more frequently with fentanyl (32% vomited more than three times; clonidine none; p=0.001). Fentanyl resulted in more oxygen desaturation (at least two episodes: fentanyl 20%; clonidine 0; p<0.001). Clonidine resulted in lower mean (SD) area under the curve for systolic blood pressure (fentanyl 106.5 [11.0]; clonidine 95.7mmHg [7.9]) and heart rate (fentanyl 104.9 beats per minute [13.6]; clonidine 85.3 [11.5]; p<0.001). INTERPRETATION: Clonidine and fentanyl provide adequate analgesia with low rates of muscle spasm, resulting in low diazepam use. The choice of epidural additive should be based upon the most tolerable side-effect profile.

Post-thoracotomy pain in children and adolescence: a retrospective cross-sectional study.

OBJECTIVE: We sought to determine the prevalence of chronic post-thoracotomy pain, defined as persistent or recurring incisional pain for at least 2 months after thoracotomy, in children. DESIGN: Retrospective cross-sectional study. SETTING: Quaternary pediatric teaching hospital. SUBJECTS: Patients who underwent a lateral thoracotomy from January 2005 to December 2007 at the Royal Children's Hospital, Melbourne, Australia. METHODS: Eligible patients were sent a questionnaire for telephonic completion with a researcher, with assistance from the parents if required. RESULTS: Of the 87 patients eligible to participate, 51 (59%) completed questionnaires. The majority of respondents was male (65%), underwent a single thoracotomy (84%; range 1-3), and were non-elective operations (71%). The median age at first thoracotomy was 5.7 (interquartile range [IQR] 2-14.2) years. The median age at questionnaire completion was 9.0 (IQR 5.4-17.9) years, with 3.6 (IQR 2.8-4.1) years between thoracotomy and time of questionnaire completion. Three patients (6%) scored ≥12 on self-report versions of the Leeds Assessment of Neuropathic Symptoms and Signs pain scale. Of these, only one patient complained of current post-thoracotomy pain. All three patients had a single thoracotomy and were older (mean age 14.2 years) at the time of thoracotomy. The rate of post-thoracotomy pain calculated using the binomial exact method is 1.96% (95% confidence interval 0-10.4%). CONCLUSIONS: Our study reports a low prevalence of post-thoracotomy pain in childhood and adolescence, and stands in contrast to previously published adult data.

Effective postoperative pain management in children after ambulatory surgery, with a focus on tonsillectomy: barriers and possible solutions.

Pain following ambulatory surgery is often poorly managed at home. Certain procedures, such as tonsillectomy, cause high levels of pain for at least 1 week postoperatively. This impacts significantly on recovery and postoperative morbidity with regards to oral intake, sleep, and behavior. Barriers to effective postoperative pain management at home following discharge have been investigated and incorporate: parental factors, such as the ability to recognize and assess their child's pain, and misconceptions about analgesics; child factors, such as refusal to take medication; medication factors, such as ineffective medication or inadequate formulation or dose of analgesics; and system factors, such as poor discharge instructions, difficulty in obtaining medication and lack of information provision. A number of interventions have been suggested and trialled in an effort to address these barriers, which encompass educational strategies, improved information provision, improved medication regimens, and the provision of tools to aid parents in the pain management of their children. All in all, improvements in pain outcomes have been minor, and a more holistic approach, that appreciates the complex and multifaceted nature of pain management at home, is required.

Absorption characteristics of epidural levobupivacaine with adrenaline and clonidine in children.

AIM: To determine if the addition of adrenaline, clonidine, or their combination altered the pharmacokinetic profile of levobupivacaine administered via the caudal epidural route in children. METHODS: Children aged <18 years old scheduled to undergo sub-umbilical surgery were administered caudal levobupivacaine plain 2.5 mg · ml(-1) or with adjuvants adrenaline 5 mcg · ml(-1) or clonidine 2 mcg · ml(-1) or their combination. Covariate analysis included weight and postnatal age (PNA). Time-concentration profile analysis was undertaken using nonlinear mixed effects models. A one-compartment linear disposition model with first-order input and first-order elimination was used to describe the data. The effect of either clonidine or adrenaline on absorption was investigated using a scaling parameter (Fabs(CLON), Fabs(ADR)) applied to the absorption half-life (Tabs). RESULTS: There were 240 children (median weight 11.0, range 1.9-56.1 kg; median postnatal age 16.7, range 0.6-167.6 months). Absorption of levobupivacaine was faster when mixed with clonidine (Fabs(CLON) 0.60; 95%CI 0.44, 0.83) but slower when mixed with adrenaline (Fabs(ADR) 2.12; 95%CI 1.45, 3.08). The addition of adrenaline to levobupivacaine resulted in a bifid absorption pattern. While initial absorption was unchanged (Tabs 0.15 h 95%CI 0.12, 0.18 h), there was a late absorption peak characterized by a Tabs(LATE) 2.34 h (95%CI 1.44, 4.97 h). The additional use of clonidine with adrenaline had minimal effect on the bifid absorption profile observed with adrenaline alone. Neither clonidine nor adrenaline had any effect on clearance. The population parameter estimate for volume of distribution was 157 l 70 kg(-1). Clearance was 6.5 l · h(-1) 70 kg(-1) at 1-month PNA and increased with a maturation half-time of 1.6 months to reach 90% of the mature value (18.5 l · h(-1) 70 kg(-1)) by 5 months PNA. CONCLUSIONS: The addition of adrenaline decreases the rate of levobupivacaine systemic absorption, reducing peak concentration by half. Levobupivacaine concentrations with adrenaline adjuvant were reduced compared to plain levobupivacaine for up to 3.5 hours. Clonidine as an adjuvant results in faster systemic absorption of levobupivacaine and similar concentration time profile to levobupivacaine alone. Adding adrenaline with clonidine does not alter the concentration profile observed with adrenaline alone.

Developing a pediatric pain service.

Pediatric pain services were first established in larger pediatric centers over two decades ago. Children's acute pain was poorly managed at the time owing to misconceptions, safety concerns, and variability in practice. While many larger pediatric centers now have acute pain services, there remains a need for better pain management in facilities and geographic locations with fewer resources. Institutional acknowledgement and desire to change, appropriate staffing, and funding are major obstacles. Better recognition and assessment as well safer and more efficacious treatment of pain are the principal objectives when establishing a pain service. It is important to determine whether the proposed service intends to treat acute, chronic, procedural, and/or cancer and palliative pain as each requires different skills and resources. An ideal and comprehensive pediatric pain service should be equipped to diagnose and treat acute, persistent (chronic), procedural, and cancer/palliative pain. It is not feasible or necessary for every hospital to manage all. Establishing the scope of practice (based on case mix and caseload) in any given hospital will determine which resources are desired. Country-specific standards, local staffing, and fiscal constraints will influence which resources are available.

The severity and duration of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair.

OBJECTIVES: To provide parents of children with accurate information regarding postoperative pain, its management, and functioning following common surgical procedures. BACKGROUND: The increasing prevalence of pediatric day-case procedures demands a more thorough understanding of the recovery profiles associated with these operations. AIM: To document postdischarge pain profiles, analgesia requirements, and functional limitation in children following tonsillectomy, orchidopexy, or inguinal hernia repair (IHR). METHODS: Following hospital discharge, parents were asked to record their children's pain levels, analgesia consumption, and degree of functional limitation each day until complete recovery. Pain and functional limitation were measured using the Parents' Postoperative Pain Measurement (PPPM) scale and Functional Activity Score, respectively. Significant pain was defined as PPPM ≥ 6. RESULTS: One hundred and five patients (50, tonsillectomy; 24, orchidopexy; and 31, IHR) were recruited. Median PPPM was always <6 after IHR, ≥6 only on day 1 after orchidopexy and persisted through to day 8 after tonsillectomy. Mild or severe functional limitation was observed after all surgeries and persisted for 4, 5, and 4 days after median PPPM < 6 after IHR, orchidopexy, and tonsillectomy, respectively. Combination analgesia was commonly administered after orchidopexy and tonsillectomy but less so after IHR. The general practitioner consultation rate following tonsillectomy was 54%. CONCLUSIONS: After tonsillectomy, children experience significant pain and severe functional limitation for 7 days after surgery. For many children, pain and functional limitation persists throughout the second postoperative week. In children undergoing orchidopexy, paracetamol and ibuprofen provide adequate analgesia. Pain begins to subside after the first postoperative day, and normal activity resumes after 7 days. After IHR, children experience mild pain that can be treated with paracetamol and return to normal functioning after 4 days.

A case of sympathetically mediated headache treated with stellate ganglion blockade.

BACKGROUND: Chronic pain following trauma may be mediated in part by the sympathetic nervous system. There is evidence of sympathetic nervous system dysfunction in patients who suffer from posttraumatic headaches. Not all patients will obtain relief from conventional and antineuropathic medications. Furthermore, the development of adverse effects may limit therapeutic dosing or continuation of these medications. CASE REPORT: A pediatric case of posttraumatic headache is described. The patient failed medical therapy, and a single stellate ganglion blockade was performed for possible sympathetic involvement. Following sympathetic blockade, the patient's headaches resolved completely. The analgesia proved to be long lasting as the patient reported no further headaches at monthly follow-up intervals. The patient did not require any further analgesic medication after the single procedure. CONCLUSION: Posttraumatic headache is difficult to treat. Although there is evidence of sympathetic nervous system dysfunction in some patients, the extent to which this influences pain remains to be determined. While most cases are treated with a combination of nonpharmacological and pharmacological measures, sympathetic blockade via the stellate ganglion may be an alternative for those patients not responding to conventional therapy.

Does epidural analgesia delay the diagnosis of lower limb compartment syndrome in children?

One of the cardinal symptoms of compartment syndrome is pain. A literature review was undertaken in order to assess the association of epidural analgesia and compartment syndrome in children, whether epidural analgesia delays the diagnosis, and to identify patients who might be at risk. Evidence was sought to offer recommendations in the use of epidural analgesia in patients at risk of developing compartment syndrome of the lower limb. Increasing analgesic use, increasing/breakthrough pain and pain remote to the surgical site were identified as important early warning signs of impending compartment syndrome in the lower limb of a child with a working epidural. The presence of any should trigger immediate examination of the painful site, and active management of the situation (we have proposed one clinical pathway). Avoidance of dense sensory or motor block and unnecessary sensory blockade of areas remote to the surgical site allows full assessment of the child and may prevent any delay in diagnosis of compartment syndrome. Focusing on excluding the diagnosis of compartment syndrome rather than failure of analgesic modality is vital. In the pediatric cases reviewed there was no clear evidence that the presence of an epidural had delayed the diagnosis.

Sensory Modulation: An Important Piece of the Disability Puzzle for Adolescents With Persistent Pain.

OBJECTIVES: Sensory modulation patterns contribute to altered pain perception and disengagement in activities; atypical sensory modulation patterns have been associated with higher pain sensitivity, catastrophizing, and reduced function. Objectives of this study were to ascertain whether: adolescents with persistent pain had atypical sensory modulation patterns, atypical sensory modulation was associated with reduced functioning and higher pain, and pain catastrophizing mediated the relationship between sensory modulation and functional disability. METHODS: Adolescents (N=70, females=63, males=7) attending tertiary level interdisciplinary team assessment for persistent pain completed sensory modulation (Adolescent/Adult Sensory Profile), pain catastrophizing (Bath Adolescent Pain Questionnaire), pain intensity, functional disability (Functional Disability Index), and quality of life (QOL) (Pediatric QOL Scales) questionnaires. RESULTS: Adolescents with persistent pain had atypical patterns of sensory modulation compared with normative data. Sensory modulation patterns were not associated with pain intensity; however, higher sensitivity was associated with greater disability (r=0.36, P<0.01), and lower registration of sensation was associated with poorer emotional (r=0.31, P<0.01), social (r=0.35, P<0.01), and school-related (r=0.49, P<0.001) QOL. Sensory modulation, pain intensity, and catastrophizing contributed independently to disability; catastrophizing mediated sensory sensitivity and both functional disability and emotional QOL. DISCUSSION: This study is the first to show that atypical sensory modulation patterns are associated with poorer function for adolescents with persistent pain, suggesting that individualized sensory-informed interventions can potentially facilitate participation in daily activities and improve QOL.

Achieving organizational change in pediatric pain management.

BACKGROUND: Pain in hospitalized children is often undertreated. Little information exists to guide the process of organizational change with a view to improving pain management practices. OBJECTIVES: To describe the process and results of a hospital-wide review of pain management practices designed to identify deficiencies in service provision and recommend directions for change in a pediatric hospital. DESIGN: Prospective consultation of the clinical staff of a specialist pediatric hospital, using qualitative research methodology involving semistructured individual and group interviews. Recommendations based on the interview findings were made by a hospital-appointed working party. RESULTS: A total of 454 staff (27% of all clinical staff) from a variety of professional backgrounds, representing almost every hospital unit or department, were interviewed. Procedural and persistent (chronic) pain was identified as the area needing the most improvement. Barriers to improving pain management included variability in practice, outmoded beliefs and inadequate knowledge, factors which were seen to contribute to a culture of slow or no change. Recommendations of the working party and changes achieved after the review are described. CONCLUSION: The review process identified deficiencies in the management of pain in children, and barriers to its effective management. With institutional support, the present review has guided improvement.

Functional disability and depression symptoms in a paediatric persistent pain sample.

BACKGROUND AND AIMS: Clinicians treating paediatric chronic pain conditions understand that persistent pain, functional ability, and symptoms of depression often co-exist, yet these relationships have only been described to a limited extent by research. This paper more closely examines the relationship between symptoms of depression and subtypes of functional disability. METHODS: Participants included a clinical sample of children and adolescents (N=239) referred to a paediatric multidisciplinary pain clinic for treatment of persistent or recurrent (chronic) pain in Australia. The majority of participants were female, (76.6%), and were aged 7-17 years (mean age at the time of presentation was 13.8 years). Data from standardized instruments and interview data were collected from a clinical file audit. The Pediatric Outcomes Data Collection Instrument (PODCI) was used as a measure of functional difficulties performing activities of daily living, and the Children's Depression Inventory (CDI) was used to measure depressive symptoms. RESULTS: High rates of depression and functional disability were observed, but were not associated with one another beyond relatively weak associations. Contrary to prior studies using different measures of physical functioning, depression symptoms were not associated with PODCI functional disability beyond a minor association with anhedonia symptoms (primarily driven by the pain/comfort subscale of the PODCI). CONCLUSIONS AND IMPLICATIONS: We argue that prior research has measured physical functional limitations in paediatric pain sufferers in a way that is heavily influenced by psychosocial factors, in particular by the symptoms of clinical depression. In contrast, using a measure of physical functioning (PODCI) less influenced by psychosocial factors suggests that the relationship between physical functioning during activities of daily living (e.g., use of upper limbs, basic gross and fine motor skills, basic mobility) and depression is weaker, despite both being heightened in this sample. Unlike other functional disability measures, the Pediatric Outcomes Data Collection Instrument (PODCI) may allow researchers to assess functional limitations somewhat independently of depression symptoms. This conclusion requires replication in further studies, but if confirmed, then the PODCI could be advocated as a useful measure to obtain a more 'pure' measure of functional difficulties due to pain, relatively independent of depression.

Child and Family Antecedents of Pain During the Transition to Adolescence: A Longitudinal Population-Based Study.

Pediatric persistent pain is associated with poorer physical and psychosocial functioning in children, as well as immediate and long-term societal costs. Onset typically occurs in early adolescence, suggesting that late childhood is a key window for identifying potential intervention targets before pain symptoms become entrenched. This study used population-based data from the Longitudinal Study of Australian Children (n = 3,812) and adopted a biopsychosocial and ecological systems approach to investigate child, family, and sociodemographic factors associated with pain problems in children transitioning to adolescence. The prevalence of at least weekly parent-reported pain in the study sample was approximately 5% at 10 to 11 years of age, and pain continued at 12 to 13 years of age for 40% of these children. Key factors at 10 to 11 years that uniquely predicted parent-reported pain problems at 12 to 13 years were frequency of previous pain (1-3 times weekly: odds ratio [OR] = 7.49; 95% confidence interval [CI], 4.3-13.0; 4-7 times weekly: OR = 17.8; 95% CI, 8.7-36.5) and sleep difficulties (OR = 1.86; 95% CI, 1.16-2.97). This study highlights the importance of early intervention for persistent pain in childhood, because pain complaints in late childhood tend to persist into early adolescence. PERSPECTIVE: This article used a biopsychosocial and ecological systems approach to understanding predictors of pain problems during the transition to adolescence within a nationally representative community-based cohort. Sleep difficulties at 10 to 11 years uniquely predicted pain at ages 12 to 13 years, suggesting that early intervention using sleep interventions may be a promising direction for future research.