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

BACKGROUND: The risk of developing chronic postsurgical pain (CPSP) in youth is related to psychological factors, including preoperative anxiety, depression, patient/caregiver pain catastrophizing, and poor self-efficacy in managing pain. While interventions exist to address these factors, they are generally brief and educational in nature. The current paper details patient partner feedback on the development of a psychologist-delivered perioperative psychological program (PPP) designed to identify and target psychological risk factors for CPSP and improve self-efficacy in managing pain. METHODS: Qualitative interviews were conducted with two patients and their caregivers to discuss their surgical and pain management experience and to advise on components of the PPP. RESULTS: Reflexive thematic analysis of interviews generated the following themes, which were incorporated into the content and implementation of the PPP: caregiver involvement, psychological and physical strategies for pain management, biopsychosocial pain education, intervention structure, and supporting materials. CONCLUSIONS: The development of a novel psychologist-led PPP is a promising approach to mitigate mental health risks associated with pediatric CPSP and potentially boost postoperative outcomes and family wellbeing. Integrating patient partner feedback ensures that the PPP is relevant, acceptable, and aligned with the needs and preferences of the patients it is designed to serve.

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain.

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Development of a five point enhanced recovery protocol for pectus excavatum surgery.

PURPOSE: We implemented and evaluated an Enhanced Recovery after Surgery (ERAS) protocol for Nuss procedures consisting of patient education, bowel management, pre/post-operative transitional pain service involvement, serratus anterior plane blocks and intercostal nerve cryoablation. METHODS: A 5-point ERAS protocol was implemented using multiple plan-do-study-act (PDSA) cycles. Data was collected prospectively for patients in the full ERAS protocol and retrospectively for previous patients. The primary outcome was length of stay (LOS). Secondary outcomes were opioid consumption, pain scores, protocol compliance and patient satisfaction. The impact of PDSA cycles and the ERAS protocol was quantified using statistical process control charts and Mann Whitney U test. RESULTS: A total of 53 patients were identified, 13 within the ERAS protocol and 40 prior to introduction. There was no difference in age, sex, or Haller index between the two cohorts. The median LOS was decreased by 3 days in the ERAS cohort (P = 0.00001). There was decreased opioid consumption on post-operative day 1 (1.47 vs 1.96 MME/kg, p = 0.009) and overall (3.12 vs 6.35 MME/kg, p = 0.0042) in the ERAS cohort. Median pain scores did not differ between cohorts. ERAS bundle element compliance was: education 92%, bowel management 100%, transitional pain involvement 100%, serratus block 100% and cryoablation 100%. The 1-month survey revealed that 92% of patients were satisfied with their experience. CONCLUSION: Our results demonstrate significant reduction in LOS and a trend to decreasing opioid consumption in hospital following ERAS protocol implementation and support the further application of ERAS protocols in pediatrics. LEVEL OF EVIDENCE: III - Retrospective comparative study.

Don't judge a book by its cover: Exploring low self-reported distress and repressive coping in a pediatric chronic pain population.

Repression has been linked to greater illness, somatic symptoms, and poorer physical health, both in adult and pediatric populations. The current study examined psychological and pain profiles of children with chronic pain who may under-report levels of psychological distress at a first interdisciplinary chronic pain assessment. Children and their caregiver completed measures of psychopathology and pain intensity, while clinicians rated their levels of disability. Based on self-report measures, children were classified as "repressors" (low anxiety/high social desirability) or as "true low anxious" (low anxiety/low social desirability). Groups were then compared on psychological and pain characteristics. Compared to children with true low anxiety, repressors reported lower levels of depressive and somatic symptoms but provided higher ratings on pain intensity, pain-unpleasantness, and self-oriented perfectionism. Caregivers of repressors rated their children as having higher levels of adaptability compared to caregivers of children in the true low anxious group. Groups did not differ on clinician-rated level of disability. Children classified as repressors exhibited different profiles than children classified as having true low anxiety on both psychological outcomes and pain characteristics. Repression may be an important factor to consider for those assessing and treating children with chronic pain.

The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic.

BACKGROUND: Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement. METHODS: This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™). STUDY: Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS). RESULTS: Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size. CONCLUSION: Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.

Mapping the current state of pediatric surgical pain care across Canada and assessing readiness for change.

Background: Preventing pediatric chronic postsurgical pain is a patient, parent/caregiver, health care professional, and policymaker priority. Poorly managed presurgical and acute postsurgical pain are established risk factors for pediatric chronic postsurgical pain. Effective perioperative pain management is essential to prevent the transition from acute to chronic pain after surgery. Aims: The aim of this study was to identify current pediatric surgical pain management practices and assess health system readiness for change at health care institutions conducting pediatric surgery in Canada. Methods: An online survey was completed by 85 multidisciplinary health care professionals (nurses, surgeons, anesthesiologists, allied health) from 20 health institutions in Canada regarding institutional pre- and postsurgical pediatric pain care, specialty pain services, and Organizational Readiness for Implementing Change (ORIC). Results: Of all specialty pain services, acute and chronic/complex pain services were most common, primarily with physician and nursing involvement. Alignment to recommended practices for pediatric pre- and postsurgical pain care varied (38.1%-79.8% reported "yes, for every child"), with tertiary/quaternary children's hospitals reporting less alignment than other institutions (community/regional or rehabilitation hospitals, community treatment centers). No significant differences were reported between health care institutions serving pediatric populations only versus those also serving adults. Health care professional experience/practice was the most reported strength in pediatric surgical pain care, with inconsistent standard of care the most common gap. Participants "somewhat agreed" that their institutions were committed and capable of change in pediatric surgical pain care. Conclusions: There is a continued need to improve pediatric pain care during the perioperative period at Canadian health care institutions to effectively prevent the development of pediatric postsurgical pain.

Contexte: La prévention de la douleur post-chirurgicale chronique pédiatrique est une priorité des patients, des parents/prestataires de soins, des professionnels de la santé et des décideurs. La douleur pré-chirurgicale et post-chirurgicale aiguë mal prises en charge constituent des facteurs de risque connus de la douleur post-chirurgicale chronique pédiatrique. La prise en charge efficace de la douleur périopératoire est essentielle pour prévenir la transition de la douleur aiguë à la douleur chronique aprés une chirurgie.Buts: Le but de cette étude était de recenser les pratiques actuelles en matiére de prise en charge de la douleur chirurgicale pédiatrique et d'évaluer l'état de préparation au changement du systéme de santé dans les établissements de soins de santé menant des chirurgies pédiatriques au Canada.Méthodes: 85 professionnels de la santé multidisciplinaires (infirmiéres, chirurgiens, anesthésistes, auxiliaires médicaux) ont répondu à un sondage en ligne de 20 établissements de santé au Canada concernant les soins pédiatriques pré et post-chirurgicaux en établissement, les services spécialisés de traitement de la douleur, les services de la douleur spécialisés et la préparation organisationnelle à la mise en œuvre du changement.Résultats: De tous les services de la douleur spécialisés, les services de la douleur aiguë et chronique/complexe étaient les plus fréquents, principalement avec la participation d'un médecin et d'une infirmiére. L'adéquation avec les pratiques recommandées pour les soins pédiatriques pré et post-chirurgicaux était variable (38,1 %-79,8 % ont déclaré « oui, pour chaque enfant ¼), alors que les hôpitaux pour enfants tertiaires/quaternaires ont déclaré moins d'adéquation que les autres institutions (hôpitaux communautaires/régionaux ou de réadaptation, centres de traitement communautaires). Aucune différence significative n'a été rapportée entre les établissements de soins de santé desservant uniquement les populations pédiatriques et ceux desservant aussi les adultes. L'expérience professionnelle/la pratique en matière de soins de santé a été la force la plus rapportée dans les soins de la douleur chirurgicale pédiatrique, tandis que les normes de soins incoh'rentes constituaient la lacune la plus courante. Les participants ont « quelque peu convenu ¼ que leurs institutions étaient engagées et capables de changer les soins chirurgicaux pédiatriques.Conclusions: ll y a un besoin continu déaméliorer les soins de la douleur pédiatrique pendant la période périopératoire dans les établissements de soins de santé canadiens afin de prévenir efficacement le développement de la douleur postopératoire.

Maternal and iatrogenic neonatal opioid withdrawal syndrome: Differences and similarities in recognition, management, and consequences.

Opioids are potent analgesics used to manage pain in both young and old, but the increased use in the pregnant population has significant individual and societal implications. Infants dependent on opioids, either through maternal or iatrogenic exposure, undergo neonatal opioid withdrawal syndrome (NOWS), where they may experience withdrawal symptoms ranging from mild to severe. We present a detailed and original review of NOWS caused by maternal opioid exposure (mNOWS) and iatrogenic opioid intake (iNOWS). While these two entities have been assessed entirely separately, recognition and treatment of the clinical manifestations of NOWS overlap. Neonatal risk factors such as age, genetic predisposition, drug type, and clinical factors like type of opioid, cumulative dose of opioid exposure, and disease status affect the incidence of both mNOWS and iNOWS, as well as their severity. Recognition of withdrawal is dependent on clinical assessment of symptoms, and the use of clinical assessment tools designed to determine the need for pharmacotherapy. Treatment of NOWS relies on a combination of non-pharmacological therapies and pharmacological options. Long-term consequences of opioids and NOWS continue to generate controversy, with some evidence of anatomic brain changes, but conflicting animal and human clinical evidence of significant cognitive or behavioral impacts on school-age children. We highlight the current knowledge on clinically relevant recognition, treatment, and consequences of NOWS, and identify new advances in clinical management of the neonate. This review brings a unique clinical perspective and critically analyzes gaps between the clinical problem and our preclinical understanding of NOWS.

Variability in discharge opioid prescribing practices for children: a historical cohort study.

PURPOSE: Legitimate opioid prescriptions can increase the risk of misuse, addiction, and overdose of opioids in children and adolescents. This study aimed to describe the prescribing patterns of discharge opioid analgesics following inpatient visits and to determine patient and prescriber characteristics that are associated with prolonged opioid prescription. METHODS: In a historical cohort study, we identified patients discharged from hospital with an opioid analgesic prescription in a tertiary pediatric hospital from 1 January 2016 to 30 June 2017. The primary outcome was the duration of opioid prescription in number of days. We assessed the association between patient and prescriber characteristics and an opioid prescription duration > five days using a generalized estimating equation to account for clustering due to repeated admissions of the same patient. RESULTS: During the 18-month study period, 15.4% of all admitted patients (3,787/24,571) were given a total of 3,870 opioid prescriptions at discharge. The median [interquartile range] prescribed duration of outpatient opioid therapy was 3.75 [3.00-5.00] days. Seventy-seven percent of the opioid prescriptions were for five days or less. Generalized estimating equation analysis revealed that hospital stay > four days, oxycodone prescription, and prescription by clinical fellows and the orthopedics service were all independently associated with a discharge opioid prescription of > five days. CONCLUSIONS: Most discharge opioids for children were prescribed for less than five days, consistent with current guidelines for adults. Nevertheless, the dosage and duration of opioids prescribed at discharge varied widely.

RéSUMé: OBJECTIF: Les ordonnances légales d'opioïdes peuvent augmenter le risque d'abus, de dépendance et de surdose d'opioïdes chez les enfants et les adolescents. Cette étude avait pour objectif de décrire les schémas de prescription d'analgésiques opioïdes au congé des séjours hospitaliers et à déterminer les caractéristiques des patients et des prescripteurs qui sont associées à la prescription prolongée d'opioïdes. MéTHODE: Dans une étude de cohorte historique, nous avons identifié les patients ayant reçu leur congé de l'hôpital avec une ordonnance d'analgésiques opioïdes dans un hôpital pédiatrique de soins tertiaires entre le 1er janvier 2016 et le 30 juin 2017. Le critère d'évaluation principal était la durée de la prescription d'opioïdes en nombre de jours. Nous avons évalué l'association entre les caractéristiques des patients et des prescripteurs et la durée d'une ordonnance d'opioïdes > cinq jours à l'aide d'une équation d'estimation généralisée pour tenir compte du regroupement dû aux admissions répétées d'un même patient. RéSULTATS: Au cours de la période d'étude de 18 mois, 15,4 % de tous les patients admis (3787/24 571) ont reçu un total de 3870 ordonnances d'opioïdes à leur congé. La durée de prescription médiane [écart interquartile] du traitement d'opioïdes hors hôpital était de 3,75 [3,00-5,00] jours. Soixante-dix-sept pour cent des ordonnances d'opioïdes étaient de cinq jours ou moins. L'analyse de l'équation d'estimation généralisée a révélé qu'un séjour à l'hôpital > quatre jours, une prescription d'oxycodone et la prescription par des fellows cliniques et le service d'orthopédie ont tous été indépendamment associés à une ordonnance d'opioïdes au congé > cinq jours. CONCLUSION: La plupart des opioïdes prescrits au congé pour les enfants ont été prescrits pour moins de cinq jours, conformément aux lignes directrices actuelles pour les adultes. Néanmoins, la posologie et la durée des opioïdes prescrits au congé variaient considérablement.

Differential Risk Factor Profiles in the Prediction of General and Pain-Specific Functional Limitations 12 Months after Major Pediatric Surgery.

Pediatric chronic post-surgical pain is a surgical complication associated with various levels of functional limitation. Two commonly used measures of functional limitations in youth are the Functional Disability Inventory (FDI) and the PROMIS Pediatric Pain Interference Scale (PPIS), where the former is general, and the latter, pain specific. The aim of the present study was to prospectively compare pre-surgical youth and parent risk factors for youth functional limitations, assessed by the FDI and PPIS, 12 months after major pediatric surgery. Risk factors for the FDI and PPIS were compared in 79 dyads consisting of youth (58% female, M = 14.56 years; SD = 2.31) undergoing major surgery and one of their parents. The FDI and PPIS were highly correlated prior to surgery (r = 0.698, p < 0.001) and even more so 12 months after surgery (r = 0.807, p < 0.001). Parent pre-surgical anxiety sensitivity and youth pre-surgical functional disability significantly predicted 12-month FDI (F(6,56) = 4.443, p = 0.001, Adjusted R2 = 0.25), whereas parent pre-surgical anxiety sensitivity, trait anxiety, pain anxiety, as well as youth pain-related anxiety and worry significantly predicted 12-month PPIS (F(6,45) = 4.104, p = 0.002, Adjusted R2 = 0.27). Risk factors for 12-month general and pain-specific functional limitations differ by dyad member and type. Functional limitations in youth after surgery are predicted by youth and parent factors, however the risk factors differ between the FDI and the PPIS.

Fear of movement in children and adolescents undergoing major surgery: A psychometric evaluation of the Tampa Scale for Kinesiophobia.

BACKGROUND: The objective of this study was to evaluate the psychometric properties of the 17-item Tampa Scale for Kinesiophobia (TSK) in youth. METHODS: Participants were 264 children and adolescents (58.7% female, Mage  = 14.1 years, SDage  = 2.51) scheduled for major surgery who were assessed before surgery, while in hospital postoperatively, and at 6 and 12 months after surgery. Exploratory factor analyses (EFA) were conducted to determine the factor structure of pre-operative TSK scores. Reliability, and convergent, discriminant, and predictive validity were examined. RESULTS: EFA on the 17-item TSK revealed a two-factor model distinguishing the 13 positively scored items from the 4 reverse scored items, but the fit was poor. A second EFA was conducted on the 13 positively scored items (TSK-13) revealing a three-factor model: Fear of injury, bodily vulnerability, and activity avoidance. The TSK-13 showed adequate internal consistency (Ω = 0.82) and weak convergent validity. The TSK-13 was not correlated with postoperative, in-hospital physical activity (actigraphy; r (179) = -0.10, p = 0.18) and showed adequate discriminant validity, that is correlations less than 0.70, with measures of depression (r (225) = 0.41, p < 0.001) and general anxiety (r (224)=0.35, p < 0.001). Predictive validity for pain-related disability at 12 months (r (70) = 0.34, p < 0.001) was adequate. CONCLUSIONS: The original TSK-17 does not appear to be a meaningful measure of kinesiophobia in youth after surgery possibly because of the syntactic structure of the reverse scored items. In contrast, a modified TSK-13, comprised of only the positively scored items, revealed a 3-factor structure that is reliable and demonstrates adequate convergent, discriminant, and predictive validity. SIGNIFICANCE: Kinesiophobia is an important construct to evaluate in the transition from acute to chronic pain among children and adolescents. The 17 item Tampa Scale for Kinesiophobia (TSK) does not show adequate validity or reliability in youth undergoing major surgery, however, the psychometric properties of a 13-item modified scale (TSK-13) are promising.

Pediatric Chronic Postsurgical Pain And Functional Disability: A Prospective Study Of Risk Factors Up To One Year After Major Surgery.

BACKGROUND: Chronic postsurgical pain (CPSP) is a surgical complication associated with increased functional disability, psychological distress, and economic costs. The aims of this paper were to prospectively: (1) examine the incidence of CPSP 6 and 12 months after pediatric major surgery; (2) identify pain intensity and pain unpleasantness trajectories before, and up to 12 months after, surgery; (3) identify pre-operative factors that predict pain trajectory group membership; and (4) identify predictors of 12-month functional disability. METHODS: This study followed 265 children aged 8-17 years at four time points (pre-surgical [T0], in-hospital [T1], 6 [T2] and 12 [T3] months after surgery). Children and parents completed pain and psychological questionnaires. In-hospital physical activity was monitored using actigraphy. RESULTS AND DISCUSSION: The incidence of moderate-to-severe CPSP at 6 and 12 months was 35% (95% CI 29.1% to 41.9%) and 38% (95% CI 32.4% to 45.1%), respectively. Three percent (95% CI 1.17% to 6.23%) and 4% (95% CI 1.45% to 6.55%) of children reported using opioids to manage pain at 6 and 12 months, respectively. Growth mixture modeling revealed a two-class trajectory model with a quadratic slope best fit the data for both pain intensity (Bayesian information criterion [BIC] = 3977.03) and pain unpleasantness (BIC = 3644.45) over the 12 months. Preoperative functional disability and cumulative in-hospital opioid consumption predicted pain intensity trajectories. Preoperative functional disability predicted pain unpleasantness trajectories. Preoperative functional disability (OR: 1.05, 95% CI: 1.01 to 1.09) and pain unpleasantness trajectories (OR: 2.59, 95% CI: 1.05 to 6.37) predicted 12-month moderate-to-severe functional disability. CONCLUSION: Pre-surgical functional disability is the only factor that predicts both 12-month functional disability and the course of pain intensity and pain unpleasantness ratings over the 12-month period.

Remembering the pain of surgery 1 year later: a longitudinal examination of anxiety in children's pain memory development.

Children who develop greater negatively-biased recall of pain (ie, recalled pain is higher than the initial pain report) following surgery are at risk for developing chronic pain; therefore, identifying risk factors for the development of biased pain memories is important. Higher anxiety has been implicated in the development of greater negatively-biased recall of pain; however, studies have not examined anxiety at multiple time points before and after a surgery and its relationship to children's postsurgical pain memories after 1 year. This prospective study examined a cohort of 237 children and adolescents undergoing major surgery. Anxiety sensitivity, pain catastrophizing, and pain anxiety were assessed at baseline, 48 to 72 hours after surgery, and at 6- and 12-month follow-ups. Pain intensity at rest, movement-evoked pain intensity, and pain unpleasantness were assessed daily in hospital. Memories for pain were elicited via telephone 1-year post surgery. Findings revealed that children who had higher levels of anxiety at baseline and 48 to 72 hours after surgery developed greater negatively-biased recall of pain intensity 12 months after surgery. Specifically, higher anxiety sensitivity at baseline and greater tendencies to catastrophize about pain at baseline and in the immediate acute recovery phase were most strongly linked to greater negatively-biased recall of pain. Greater negatively-biased recall of pain was related to higher pain intensity at 6 and 12 months post surgery. Findings support conceptual models of anxiety and pain memory biases and can inform intervention efforts to reduce anxiety in the pre- and post-op periods to minimize negative biases in pain memories.

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.

Understanding the use of over-the-counter pain treatments in adolescents with chronic pain.

Background: The prevalence of chronic pain in children and adolescents is well established. What is not well understood is how over-the-counter (OTC) oral and topical pain treatments are being used by adolescents with chronic pain, their decision making around use of these products, and how they communicate with their health care providers about their use. Aims: The aim of this study was to explore the use, decision-making process, and communication about the use of OTC pain medications with health care professionals among adolescents living with chronic pain and their primary caregiver. Methods: A qualitative descriptive design with semistructured, audiotaped individual interviews was undertaken with adolescents with chronic pain (n = 15, aged 12-18 years, mean age = 16, SD = 1.79) and their caregivers (n = 16). A convenience sample of patient-caregiver dyads was recruited from a tertiary care pediatric chronic pain clinic in Ontario. Results: Interview questions focused on four topics: (1) experience with chronic pain and medication; (2) perceptions of medications and concerns with long-term consumption; (3) decision making for use of OTC medications guided mainly by a trusted source or health care professional; and (4) topical OTC medications perceived as harmless. Content analysis within these four topics uncovered two to four subthemes, which are described in detail. Conclusions: An improved understanding of the prevalence of use, decision-making process around use, and how patients and their families communicate about the use of OTC pain medications with health care providers can help clinicians better personalize treatments and help adolescents with chronic pain to make sound self-care decisions.

Contexte: La prévalence de la douleur chronique chez les enfants et les adolescents est bien établie. Toutefois, on ne comprend pas bien comment les traitements antidouleur en vente libre administrés par voie topique ou orale sont utilisés par les adolescents souffrant de douleur chronique, leur prise de décision concernant ces produits et la façon dont ils communiquent avec les prestataires de soins de santé au sujet de leur utilisation.But: Étudier l'utilisation des médicaments antidouleur en vente libre, ainsi que la prise de décision et la communication avec les professionnels de la santé au sujet de l'utilisation de ces médicaments chez les adolescents souffrant de douleur chronique et leur principal prestataire de soins.Méthodes: Un devis de recherche axé sur la description qualitative à l'aide d'entrevues semi-structurées individuelles a été utilisé auprès d'adolescents souffrant de douleur chronique (n = 15, âgés de 12 à 18 ans, âge moyen de 16 ans, ÉT = 1,79) et leurs prestataires de soins (n = 16). Un échantillon de commodité de dyades patient-prestataire de soins a été recruté dans une clinique de soins tertiaires en douleur chronique pédiatrique de l'Ontario.Résultats: Les questions d'entrevue portaient sur quatre sujets: (1) l'expérience de la douleur chronique et la médication; (2) la perception des médicaments et les préoccupations concernant leur consommation à long terme; (3) la prise de décision concernant l'utilisation de médication en vente libre, principalement guidée par une personne de confiance ou un professionnel de la santé et (4) les médicaments en vente libre appliqués par voie topique qui sont perçus comme étant sans danger. L'analyse de contenu pour ces quatre sujets a révélé de 2 à 4 sous-thèmes, qui sont décrits en détail.Conclusions: Une meilleure compréhension de la prévalence de l'utilisation des médicaments antidouleur en vente libre, ainsi que du processus de décision entourant leur utilisation et de la façon dont les patients et leur famille communiquent avec les professionnels de la santé peut aider les cliniciens à mieux personnaliser les traitements et aider les adolescents qui souffrent de douleur chronique à prendre des décisions judicieuses en matière de soins auto-administrés.

iCanCope with Pain™: User-centred design of a web- and mobile-based self-management program for youth with chronic pain based on identified health care needs.

BACKGROUND: While there are emerging web-based self-management programs for children and adolescents with chronic pain, there is currently not an integrated web- and smartphone-based app that specifically addresses the needs of adolescents with chronic pain. OBJECTIVES: To conduct a needs assessment to inform the development of an online chronic pain self-management program for adolescents, called iCanCope with Pain™. METHODS: A purposive sample of adolescents (n=23; 14 to 18 years of age) was recruited from two pediatric chronic pain clinics in Ontario. Interdisciplinary health care providers were also recruited from these sites. Three focus groups were conducted with adolescents (n=16) and one with pediatric health care providers (n=7). Individual adolescent interviews were also conducted (n=7). RESULTS: Qualitative analysis uncovered four major themes: pain impact; barriers to care; pain management strategies; and transition to adult care. Pain impacted social, emotional, physical and role functioning, as well as future goals. Barriers to care were revealed at the health care system, patient and societal levels. Pain management strategies included support systems, and pharmacological, physical and psychological approaches. Transition subthemes were: disconnect between pediatric and adult systems; skills development; parental role; and fear/anxiety. Based on these identified needs, the iCanCope with Pain™ architecture will include the core theory-based functionalities of: symptom self-monitoring; personalized goal setting; pain coping skills training; peer-based social support; and chronic pain education. CONCLUSIONS: The proposed iCanCope with Pain™ program aims to address the self-management needs of adolescents with chronic pain by improving access to disease information, strategies to manage symptoms and social support.

Unusual presentation of postdural puncture headache requiring repeat epidural blood patch in a 4-year-old child.

We present the case of a 4-year-old child who required two epidural blood patches (EBPs) to treat a delayed onset postdural puncture headache (PDPH) caused by lumbar cerebrospinal fluid drain. The first EBP was unsuccessful with 0.41 ml·kg(-1) of blood injected. A second EBP with 0.76 ml·kg(-1) of blood was performed 2 days later with the complete resolution of symptoms. The volume of blood necessary for effective treatment for symptomatic cerebrospinal fluid leaks in children remains controversial, and a repeat EBP may be required for resolution of symptoms.

Pain-QuILT: assessing clinical feasibility of a Web-based tool for the visual self-report of pain in an interdisciplinary pediatric chronic pain clinic.

OBJECTIVES: To evaluate clinical feasibility of the Pain-QuILT (previously known as the Iconic Pain Assessment Tool) from the perspective of adolescents with chronic pain and members of their interdisciplinary health team. The Pain-QuILT (PQ), a web-based tool that records the visual self-report of sensory pain in the form of time-stamped records, was directly compared with standard interview questions that were transformed to a paper-based tool. METHODS: Qualitative, semi-structured interviews were used to refine the PQ. Adolescents with chronic pain aged 12 to 18 years used the PQ and comparator tool (randomized order) to self-report pain before a scheduled clinic appointment, and then took part in a semi-structured interview. The health team used these pain reports (PQ and comparator) during patient appointments, and later participated in focus group interviews. Interview audio recordings were transcribed verbatim and underwent a simple line-by-line content analysis to identify key concepts. RESULTS: A total of 17 adolescents and 9 health team members completed the study. All adolescents felt that the PQ was easy to use and understand. The median time required for completion of the PQ and comparator tool was 3.3 and 3.6 minutes, respectively. Overall, 15/17 (88%) of adolescents preferred the PQ to self-report their pain versus the comparator. The health team indicated that the PQ was a clinically useful tool and identified minor barriers to implementation. DISCUSSION: Consultations with adolescents and their health team indicate that the PQ is a clinically feasible tool for eliciting detailed self-report records of the sensory experience of chronic pain.

Parental risk factors for the development of pediatric acute and chronic postsurgical pain: a longitudinal study.

BACKGROUND: The goal of this longitudinal study was to examine the associations among psychological factors and pain reports of children and their parents over the 12 month period after pediatric surgery. MATERIALS AND METHODS: Included in the study were 83 children aged 8-18 years undergoing major surgery. In each case, the child and one of their parents completed measures of pain intensity and unpleasantness, psychological function, and functional disability at 48-72 hours, 2 weeks (child only), 6 months, and 12 months after surgery. RESULTS: The strength of the correlation coefficients between the psychological measures of the parent and their child increased significantly over time. There was a fair level of agreement between parent ratings of child acute and chronic pain (6 months after surgery) and the child's actual ratings. Parent and child pain anxiety scores 48-72 hours after surgery interacted significantly to predict pain intensity, pain unpleasantness, and functional disability levels 2 weeks after discharge from hospital. Parent pain catastrophizing scores 48-72 hours after surgery predicted child pain intensity reports 12 months later. CONCLUSION: These results raise the possibility that as time from surgery increases, parents exert greater and greater influence over the pain response of their children, so that by 12 months postsurgery mark, parent pain catastrophizing (measured in the days after surgery) is the main risk factor for the development of postsurgical pain chronicity.

Identification of pain-related psychological risk factors for the development and maintenance of pediatric chronic postsurgical pain.

BACKGROUND: The goals of this study were to examine the trajectory of pediatric chronic postsurgical pain (CPSP) over the first year after surgery and to identify acute postsurgical predictors of CPSP. METHODS: Eighty-three children aged 8-18 years (mean 13.8, standard deviation 2.4) who underwent major orthopedic or general surgery completed pain and pain-related psychological measures at 48-72 hours, 2 weeks (pain anxiety and pain measures only), and 6 and 12 months after surgery. RESULTS: Results showed that 1 year after surgery, 22% of children developed moderate to severe CPSP with minimal functional disability. Children who reported a Numeric Rating Scale pain-intensity score ≥ 3 out of 10 two weeks after discharge were more than three times as likely to develop moderate/severe CPSP at 6 months and more than twice as likely to develop moderate/severe CPSP at 12 months than those who reported a Numeric Rating Scale pain score < 3 (6-month relative risk 3.3, 95% confidence interval 1.2-9.0 and 12-month relative risk 2.5, 95% confidence interval 0.9-7.5). Pain unpleasantness predicted the transition from acute to moderate/severe CPSP, whereas anxiety sensitivity predicted the maintenance of moderate/severe CPSP from 6 to 12 months after surgery. CONCLUSIONS: This study highlights the prevalence of pediatric CPSP and the role played by psychological variables in its development/maintenance. Risk factors that are associated with the development of CPSP are different from those that maintain it.