Chronic pain in pediatric patients: epidemiology, pathophysiology, and mitigation strategies.

PURPOSE OF REVIEW: To provide an updated summary on the epidemiology, pathophysiology, and treatment strategies of chronic pain in pediatric patients and its differences with chronic pain in adults. RECENT FINDINGS: Chronic pain in children is common, can be debilitating and can progress into adulthood, thus it requires an interdisciplinary evaluation and management. Targeting interdisciplinary care, including psychology, physical, and/or occupational therapy, has been shown to improve pain and function. Recent decline in mental health post pandemic has correlated with increase in pediatric chronic pain thus the need to identify patients at risk and offer early interdisciplinary treatment. SUMMARY: Chronic pediatric pain should be addressed under the biopsychosocial model, where the biological, psychological, and social factors are evaluated on how they influence the pain perception, pain experience, functional ability, and treatment focus. Pain education to patients and their families is the crucial initial step towards a functional rehabilitation of pain.

Variability and Excess in Opioid Prescribing Patterns After Cleft and Craniosynostosis Repairs.

OBJECTIVE: To critically analyze pediatric opioid prescription patterns after cleft and craniosynostosis repairs. DESIGN: Observational study 1) retrospectively reviewing pediatric opioid prescriptions from July 2018 to June 2019 and 2) prospectively surveying patients about actual opioid use from August 2019 to February 2020. SETTING: Academic tertiary care pediatric hospital. PATIENTS: 133 pediatric patients undergoing cleft lip and/or palate or craniosynostosis repairs. Prospective surveys were offered at postoperative visits; 45 of 69 eligible patients were enrolled. INTERVENTION: None. MAIN OUTCOME MEASURES: Opioid doses prescribed at discharge and actual home opioid use. RESULTS: 90 patients with cleft lip and/or palate and 43 patients with craniosynostosis were included. Median prescribed opioid doses were 10.3 for cleft lip and/or palate procedures (range 0-75), and 14.3 for craniosynostosis repairs (range 0-50). In patients with cleft lip and/or palate, there was a negative correlation between age at surgery and prescribed opioid doses (rs = -0.228, p = 0.031). 45 patients completed surveys of home opioid use. No patients used more than 10 doses. Forty percent used no opioids at home, 33% used 1 to 2 doses, 18% used 3 to 5 doses, and 9% used 6 to 10 doses. CONCLUSIONS: Opioid prescriptions vary widely after common craniofacial procedures. Younger patients with cleft lip and/or palate may be more likely to be prescribed more doses. Actual home opioid use is less than prescribed amounts, with most patients using five or fewer doses. A prescribing guideline is proposed.

Slipping Rib Syndrome in Children: Natural History and Outcomes Following Costal Cartilage Excision.

INTRODUCTION: Slipping rib syndrome (SRS) or subluxation of the medial aspect of the lower rib costal cartilages is an underdiagnosed cause of debilitating pain in otherwise healthy children. Costal cartilage excision may provide definitive symptom relief. However, limited data exist on the natural history, difficulty in diagnosis, and patient-reported outcomes for SRS in children. METHODS: We performed a single-institution descriptive study using chart review and a patient-focused survey for patients who underwent surgery for SRS from 2012 to 2020. Data regarding demographics, symptoms, diagnostic workup, and patient-reported outcomes were collected. RESULTS: Surgical resection was performed in 13 children. The median age at symptom onset was 12.5 y [IQR 9.7, 13.9], with a preponderance of girls (10, 77%). Eight patients participated in competitive athletics at the time of symptom onset. Prior to diagnosis, patients were seen by a median 3 [IQR 2, 5] providers with a median of 4 [IQR 3, 6] non-diagnostic imaging exams performed. The children included in the study underwent surgery for left (8), bilateral (4), and right (1) SRS. Two were lost to follow-up. At median post-op follow-up of 3.5 mo [IQR 1.2, 9.6], 73% (8/11) had returned to full activity. One reported non-limiting persistent pain symptoms. CONCLUSIONS: Lack of knowledge regarding SRS may result in delayed diagnosis, excessive testing, and limitation of physical activity. Operative treatment appears to provide durable relief and should be considered for children with SRS. The challenge remains to decrease the number of non-diagnostic exams and time to diagnosis.

Opioid Prescribing and Use Patterns in Postsurgical Facial Trauma Patients.

BACKGROUND: Facial fractures are painful injuries routinely managed by opioids after surgical repair. Studies have identified patient risk factors and prescribing patterns associated with opioid use in medicine and general surgery; however, little is known about these entities in the facial trauma population. METHODS: A retrospective cohort study of opioid-naive patients undergoing surgical repair of facial fractures was conducted using the Truven Health MarketScan Commercial Claims and Encounters (2006 to 2015) and Medicaid Multi-State Databases (2011 to 2015). Eligible procedures included nasal, nasoorbitoethmoid, orbital, mandible, and Le Fort fracture repair. Opioid type, daily dosage, and prescription duration were analyzed. Multivariable logistic regression was performed to determine independent predictors of prescription refill. RESULTS: A total of 20,191 patients undergoing surgical repair of facial fractures were identified. Of these, 15,861 patients (78.6 percent) filled a perioperative opioid prescription. Refill (58.7 percent) and potentially inappropriate prescribing (39.4 percent) were common among this population. Patient factors including prior substance use (adjusted OR, 1.84; 95 percent CI, 1.63 to 2.07) and history of mental health disorder (adjusted OR, 1.43; 95 percent CI, 1.06 to 1.91) were independent predictors of refill. Increased odds of refill were seen in patients prescribed tramadol (OR, 1.98; 95 percent CI, 1.48 to 2.66) and those who underwent multiple surgical repairs (OR, 3.38; 95 percent CI, 2.54 to 4.50). CONCLUSIONS: Refill and potentially inappropriate prescribing occurred at high rates in facial trauma patients undergoing surgical repair. Additional studies are needed to develop guidelines for proper opioid prescribing in this population. CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.

Early experiences with the use of continuous erector spinae plane blockade for the provision of perioperative analgesia for pediatric liver transplant recipients.

OBJECTIVE: Pediatric liver transplantation presents a number of anesthetic challenges, especially in providing adequate perioperative analgesia. In an effort to reduce opioid consumption and improve functional outcomes following pediatric liver transplantation, we have instituted a novel analgesia protocol centered on the provision of continuous regional analgesia with erector spinae plane (ESP) blockade. CASES: We describe preincisional bilateral ESP catheter placement in two pediatric patients undergoing orthotopic liver transplantation. The first case was a 12-year-old boy with maple syrup urine disease undergoing initial transplantation and the second case was an 8-year-old boy who underwent an 11 hours complex redo liver transplant in the setting of glycogen storage disease type 1A requiring initial liver transplant in 2014. The 8-year-old boy presented to the operating suite with acute Budd-Chiari syndrome with comorbid ascites and a large right pleural effusion. In both cases, ESP blockade resulted in good analgesia, markedly reduced intraoperative and postoperative opioid consumption as compared with institutional data and published rates of consumption and was associated with rapid return of bowel function. CONCLUSIONS: These early experiences suggest a role for continuous ESP blockade to improve analgesia and potentially change the paradigm of treatment in this fragile patient population. The technique should be considered in similar interventions. Further study will be undertaken to validate our observation.