Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020.

INTRODUCTION: The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States. METHODS: We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed. RESULTS: Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020). DISCUSSION: Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing. CONCLUSION: The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

Can Use of Default Dispensing Quantities in Electronic Medical Record Lower Opioid Prescribing?

OBJECTIVES: Leftover opioids can contribute to misuse and abuse. Recommended dosing quantities in the electronic medical record can guide prescribing patterns. We hypothesized that decreasing the default from 30 doses to 12 doses would decrease the overall number of opioids prescribed without increasing second opioid prescriptions or additional health utilization. METHODS: We performed a single-center retrospective study of children with forearm and elbow fractures who presented to the emergency department for evaluation and subsequent orthopedic follow-up between January 15, and September 19, 2017. The default dispensing quantity was decreased on June 1, 2016 from 30 doses to 12 doses. Patients were categorized to preintervention and postintervention groups. We compared the number of opioids prescribed, second opioid prescriptions, emergency department visits, and pain-related telephone calls and orthopedic visits with χ2 and logistic regression analyses. RESULTS: There were 1107 patients included. Rates of opioid prescribing were similar preintervention and postintervention (61% vs 56%, P = 0.13). After the change to the default quantity, the median number of doses decreased from 18 to 12 doses, with opioid prescriptions of 30 or more doses dropping from 35% to 11%. No significant association was found between preintervention versus postintervention, opioid prescription at discharge, and having 1 or more pain-related or unexpected follow-up visits. CONCLUSIONS: Lowering the default dispensing quantity of opioids in the electronic medical record decreases the number of opioids prescribed without increasing second prescriptions or additional health care utilization. These findings suggest that a further reduction in the number of opioids prescribed for upper-extremity fractures may be possible.

Prescription Opioid Misuse and Sports-Related Concussion Among High School Students in the United States.

STUDY OBJECTIVE: Concussion is highly prevalent in adolescents and associated with a higher risk of substance use. With the rising use of opioids among adolescents, one form of substance use of concern is the misuse of prescription opioids. This study aimed to examine the association between a history of sports-related concussion in the past year and current prescription opioid misuse among high school students in the United States. SETTING: Secondary data analysis from the 2019 Youth Risk Behavior Survey. PARTICIPANTS: Nationally representative sample of high school students (n = 7314). DESIGN: Cross-sectional study. MAIN MEASURES: Participants were asked whether they experienced any concussions related to sports or being physically active during the past 12 months and whether they had any prescription opioid misuse within the past 30 days. RESULTS: Among this cohort, 14.0% reported sustaining a concussion in the past 12 months and 6% reported current prescription opioid misuse. The prevalence of prescription opioid misuse was higher among those with a history of concussion (9.9%) than among those without concussion (5.5%, P = .002). Controlling for covariates (sex, race/ethnicity, other substance use, depressive symptoms), the odds of prescription opioid misuse was 1.5 times higher for adolescents with concussion than those without (adjusted odds ratios [aOR] = 1.5; 95% CI, 1.0-2.3; P = .029). CONCLUSION: Concussion was associated with prescription opioid misuse among the US youth, even after accounting for depressive symptoms and other substance use. Longitudinal studies are needed to test causal relationships and understand biobehavioral mechanisms that underlie associations between concussion and opioid misuse in adolescents.

Epidemiology of Pediatric Surgery in the United States.

BACKGROUND: The epidemiology of pediatric surgery in the United States and whether disparities in access to surgical care exist on a national level remain inadequately described. AIMS: We determined rates of surgical intervention and associations with sociodemographic factors among children 0-17 years of age in the United States. METHODS: Analysis of the 2005-2018 National Health Interview Survey samples included 155,064 children. Parents reported on whether their child had a surgery or surgical procedure either as an inpatient or outpatient over the past 12 months. Multivariate logistic regression models, adjusted for age, sex, race and ethnicity, income, language, parent education, region, having a usual source of care, and comorbid conditions, examined odds ratios for sociodemographic factors associated with surgery, analyzing the most recent data (2016-2018; 25 544 children). RESULTS: In the most recent data, 4.7% of children had surgical intervention each year, with an average of 3.9 million surgeries performed annually. Rates of surgery were stable between 2005 and 2018. Minority children had lower adjusted odds (aOR) of surgical intervention as compared to white, non-Hispanic children (aOR = 0.6, 95%CI = 0.5-0.8 for black children, and aOR = 0.7, 95%CI = 0.5-0.9 for Hispanic children). Other sociodemographic factors associated with a lower adjusted odd of surgical intervention included uninsured status (aOR = 0.5; 95%CI = 0.3-0.9), and primary language other than English (aOR = 0.5; 95%CI 0.3-0.9). Income was not associated with surgical intervention. CONCLUSIONS: On average, 3.9 million surgeries are performed on children 0-17 years of age in the United States each year. Significant disparities exist in surgical care for children, with black and Hispanic children having lower rates of surgery over and above contribution of other disparity domains. These findings in a nationally representative sample highlight the need for national policies to eliminate disparity of care received by minority children.

Economic Impact of Headache and Psychiatric Comorbidities on Healthcare Expenditures Among Children in the United States: A Retrospective Cross-Sectional Study.

OBJECTIVE: To examine the annual healthcare expenditures associated with childhood headache in the United States, and to evaluate whether psychiatric comorbidities increase the impact of headache on expenditures. BACKGROUND: Headache is prevalent in childhood and co-occurs with anxiety disorders, depressive disorders, and attention deficit/hyperactivity disorder (ADHD), which may increase cost of illness. METHODS: We conducted a secondary data analysis using a nationally representative sample of 34,633 children ages 2-17 from the 2012-2015 Medical Expenditure Panel Surveys (MEPS), of which 779 (weighted 2.6%) were identified as having headache based on health service use associated with headache. Using a comprehensive cost-of-illness approach, we assessed the incremental expenditures associated with headache and determined excess expenditures associated with psychiatric comorbidities using standard adjusted 2-part expenditure models. RESULTS: Annual total healthcare expenditures were estimated to be 24.3% higher, 95% CI [1,55], in our headache group ($3036, 95% CI [2374,3699] vs $2350, 95% CI [2140,2559]). Total national expenditures associated with pediatric headache in the United States were estimated at $1.1 billion annually, 95% CI [.04, 2.2 billion]. Depression and ADHD were associated with higher incremental expenditures for the headache group (depression: $1815, 95% CI[676,2953] vs $1409, 95% CI[697,2112]; ADHD: $4742, 95% CI[1659,7825] vs $2935, 95% CI[1977,3894]); however, interactions between psychiatric comorbidities and headache did not reach statistical significance. CONCLUSION: Youth with headache exert a considerable economic burden on families, healthcare systems, and society. Due to the limitations in methods used to classify youth with headache in MEPS, our findings may underestimate the true prevalence and cost of pediatric headache in the United States. Further research with larger sample sizes is needed to understand the impact of psychiatric comorbidities on healthcare expenditures in this population.

Codeine use among children in the United States: a nationally representative study from 1996 to 2013.

BACKGROUND: Concerns regarding the safety of codeine have been raised. Cases of life-threatening respiratory depression and death in children have been attributed to codeine's polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown. AIMS: Our objective was to examine patterns of codeine use in the US among children. METHODS: A cross-sectional analysis of children of age 0-17 years from 1996 to 2013 in the US was performed. Data were extracted from MEPS, a nationally representative set of health care surveys. Prevalence rates of codeine use between 1996 and 2013 were examined. Multivariable logistic regression examined relationships between codeine use and patient demographics. RESULTS: Codeine use remained largely unchanged from 1996 to 2013 (1.08 vs 1.03 million children, respectively). Odds of codeine use was higher in ages 12-17 (OR, 1.40; [1.21-1.61]), outside of the Northeastern US, and among those with poor physical health status (OR, 3.29 [1.79-6.03]). Codeine use was lower in children whose ethnicity was not white and those uninsured (OR, 0.47 [0.34-0.63]). Codeine was most frequently prescribed by emergency physicians (18%) and dentists (14%). The most common condition associated with codeine use was trauma-related pain. CONCLUSIONS: Pediatric codeine use has declined since 1996; however, more than 1 million children still used codeine in 2013. Health care providers must be made aware of guidelines advising against the use of codeine in children. Codeine is potentially hazardous and safer alternatives to treat children's pain are available.

Association of Neighborhood Characteristics and Chronic Pain in Children and Adolescents in the United States.

OBJECTIVE: To determine the associations between neighborhood characteristics and chronic pain during childhood and adolescence in the United States, 2020-2021. METHODS: Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health. National Survey of Children's Health grouped parents' responses to questions about neighborhood characteristics into 5 categories: neighborhood support, neighborhood safety, school support, neighborhood amenities, and the presence of detracting neighborhood elements. Chronic pain was defined as parents reporting their children had "frequent or chronic difficulty with repeated or chronic physical pain, including headache or other back or body pain during the past 12 months." Multivariable Poisson regression analyses estimated associations between neighborhood characteristics and chronic pain, adjusted for sociodemographic characteristics. RESULTS: The sample contained 55,387 children (6 to 17 years), weighted to represent 44 million nationally. Children had significantly increased rates of chronic pain if they lived in neighborhoods that were unsupportive, unsafe, had unsafe schools, fewer amenities, and greater numbers of detracting elements ( P <0.0001). After adjusting for covariates, children had significantly increased chronic pain if they lived in neighborhoods that were not supportive (adjusted prevalence rate ratio=1.7 (95% CI: 1.5-1.9, P <0.0001), with similar patterns observed for living in neighborhoods characterized as not safe, that did not have safe schools, with fewer amenities, and/or more detracting elements. DISCUSSION: Disadvantageous neighborhood characteristics are associated with pediatric chronic pain prevalence. Future research should investigate the underlying mechanisms of this association and guide neighborhood interventions aimed at preventing and decreasing childhood chronic pain and its associated burdens.

Comparing the prevalence of chronic pain in school-aged children in the United States from 2019 to 2020: a nationally representative study examining differences associated with the COVID-19 pandemic.

ABSTRACT: The coronavirus disease 19 (COVID-19) pandemic negatively affected children's health in the United States (US), with more severe disruption for marginalized groups. However, potential impact on pediatric chronic pain has not been assessed at the population level. This study aimed to (1) estimate differences in the US national prevalence of pediatric chronic pain during the first year of the COVID-19 pandemic (2020), relative to one year earlier (2019); (2) determine whether differences in prevalence varied across sociodemographic groups; and (3) explore changes in child, caregiver, and family factors associated with chronic pain prevalence. Using data of children 6 to 17 years from the National Survey of Children's Health 2019 and 2020 (n = 50,518), we compared weighted percentages of sample characteristics by year and conducted a series of directed-acyclic graph-informed survey-weighted Poisson regressions. The estimated national prevalence (95% CI) of pediatric chronic pain was 10.8% (9.9, 11.9%) in 2019, decreasing to 7.6% (6.9, 8.3%) in 2020. Contrary to hypotheses, the adjusted prevalence of chronic pain was 31% lower in 2020 than in 2019 (aPR = 0.69, 95% CI: 0.61, 0.79), adjusting for child age, sex, race or ethnicity, caregiver education, neighborhood park or playground, and census region. The 2019 to 2020 change in chronic pain prevalence was similar by age ( P = 0.34), sex ( P = 0.94), race or ethnicity ( P = 0.41), caregiver education ( P = 0.49), neighborhood park or playground ( P = 0.22), and census region ( P = 0.20). Exploratory analyses identified 3 potential contributors to the unexpected decrease in the national prevalence of pediatric chronic pain: lower prevalence of bullying, more frequent family meals, and higher family resilience.

Sexual Orientation/Gender Identity Discrimination and Chronic Pain in Children: A National Study.

INTRODUCTION: This study provides national estimates of parental perceived child sexual orientation or gender minority (SGM) discrimination and examines associations between SGM discrimination and chronic pain in children. METHODS: Cross-sectional analysis of the 2020 and 2021 National Survey of Children's Health (N=47,213). Caregivers of children ages 6-17 years old reported whether their child had ever been treated or judged unfairly (i.e., discrimination) because of their SGM identity. Chronic pain in children was defined as frequent or chronic difficulty with repeated or chronic physical pain during the past 12 months, as reported by caregivers. Weighted prevalence estimates for discrimination were calculated for the whole sample and sociodemographic subgroups. Associations between SGM discrimination and chronic pain were estimated using multivariable Poisson regression models adjusting for sociodemographic factors. Analyses were conducted 2022-2023. RESULTS: Within this nationally representative sample, parents reported 1.4% (95% CI 1.2%-1.6%) of children have experienced SGM-related discrimination. The prevalence was higher among adolescents, females at birth, and those living in suburban areas. Children who experienced discrimination had a higher prevalence of chronic pain (20.2%) compared to those who did not (7.0%, p<0.0001), with an adjusted prevalence rate ratio of 2.0 (95% CI 1.5-2.5, p<0.0001). CONCLUSIONS: Based on parent report, about 0.6 million children in the U.S. have experienced SGM-based discrimination; these children are twice as likely to have chronic pain. Findings highlight the importance of assessment and intervention for chronic pain in children who may experience marginalization and discrimination due to their sexual orientation and gender identity.

Prescription Opioid Decision-making and Use Behaviors in Adolescents With Acute Pain: A Qualitative Study.

OBJECTIVES: Understanding adolescent perspectives on prescribed opioids in the context of medical care for acute pain is needed to prevent opioid-related adverse outcomes. We explored factors that may influence opioid decision-making and use behaviors among adolescents prescribed opioids for acute pain. METHODS: We conducted semistructured interviews with 19 adolescents (63% females, ages 12 to 17) prescribed opioids upon discharge from surgery or intensive care unit admission. Interview transcripts were coded using inductive thematic analysis. RESULTS: Five themes were identified: "Opioid use to reduce extreme pain and facilitate acute recovery"; "Familiarity with risks and negative effects of opioids"; "Assessment of opioid risk based on individual characteristics and use behaviors"; "Careful balance of risks, benefits, and symptoms when taking opioids"; "Importance of trusted adults for adolescent opioid management". Adolescents commonly believe opioids are only appropriate for severe pain that cannot be managed with other strategies. Most (but not all) adolescents were aware of addiction and other potential opioid harms and generally disapproved of misuse. However, a few adolescents would consider taking unprescribed opioids for severe pain. Adolescents wanted to be well informed for opioid decision-making, considering guidance from trusted adults. DISCUSSION: Adolescents often demonstrated active and sound participation in shared opioid decision-making, influenced by complex integration of inputs and self-reflection. Conversely, potential factors that could contribute to risky behaviors included low personal risk perceptions, uncertainty about what constitutes opioid misuse, and avoidance of prescribed opioids despite extreme pain. Future studies may explore associations of adolescents' opioid decision-making with longer-term pain and opioid-related outcomes.

An unexpected cause of cardiac arrest during laparoscopy in an infant with supravalvar aortic stenosis.

Patients with congenital supravalvar aortic stenosis (SVAS) with associated biventricular outflow tract obstruction and coronary artery abnormalities have a tenuous myocardial oxygen supply/demand relationship. They are at increased risk of acute myocardial ischemia and sudden death, especially during anesthesia. Furthermore, resuscitation during cardiac arrest is frequently unsuccessful. We report a case of perioperative cardiac arrest due to an unexpected cause in a 2 month old with SVAS during a laparoscopic Nissen fundoplication.

Outcomes of general anesthesia for noncardiac surgery in a series of patients with Fontan palliation.

OBJECTIVES: To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery. BACKGROUND: The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery. METHODS: We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described. RESULTS: Thirty-nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long-term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%). CONCLUSION: It may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of <30%. Intraoperative arterial blood pressure monitoring and overnight admission are likely appropriate for most cases.

Positive Childhood Experiences and Chronic Pain Among Children and Adolescents in the United States.

Positive childhood experiences (PCEs) are associated with better mental and physical health outcomes and moderate the negative effects of adverse childhood experiences (ACEs). However, knowledge of the associations between PCEs and childhood chronic pain is limited. We conducted a cross-sectional analysis of 2019 to 2020 National Survey of Children's Health (NSCH) to evaluate associations between PCEs and childhood chronic pain. Parents of 47,514 children ages 6 to 17 years old reported on their child's exposure to 7 PCEs and 9 ACEs. Associations between PCEs and chronic pain were evaluated using weighted, multivariate logistic regression analyses adjusted for sociodemographic factors. We found that PCEs had dose-dependent associations with pediatric chronic pain; children exposed to higher numbers of PCEs (5-7 PCEs) had the lowest reported rate of chronic pain (7.1%), while children exposed to 2 or fewer PCEs had the highest rate of chronic pain (14.7%). The adjusted analysis confirmed that children experiencing 5 to 7 PCEs had significantly lower odds of chronic pain relative to children experiencing 0 to 2 PCEs (adjusted odds ratio (aOR): .47, 95% confidence interval (CI): .39-.61, P < .0001). PCEs moderated associations between ACEs and chronic pain: among children reporting 2 or more ACEs, those reporting 5 to 7 PCEs were significantly less likely to report chronic pain as compared to children only reporting 0 to 2 PCEs (aOR: .64, 95%CI: .45-.89, P = .009). In conclusion, children with greater PCEs exposure had lower prevalence rates of chronic pain. Furthermore, PCEs was associated with reduced prevalence of chronic pain among children exposed to ACEs. PERSPECTIVE: This article estimates associations between survey-measured PCEs and pediatric chronic pain among children in the United States. Promoting PCEs could improve pediatric pain outcomes.

Household Food Insufficiency and Chronic Pain among Children in the US: A National Study.

This study aimed to determine the prevalence of pediatric chronic pain by household food sufficiency status and examine whether food insufficiency would be associated with greater risk for chronic pain. We analyzed data from the 2019-2020 National Survey of Children's Health of 48,410 children (6-17 years) in the United States. Across the sample, 26.1% (95% CI: 25.2-27.0) experienced mild food insufficiency and 5.1% (95% CI: 4.6-5.7) moderate/severe food insufficiency. The prevalence of chronic pain was higher among children with mild (13.7%) and moderate/severe food insufficiency (20.6%) relative to children in food-sufficient households (6.7%, p < 0.001). After adjusting for a priori covariates (individual: age, sex, race/ethnicity, anxiety, depression, other health conditions, adverse childhood events; household: poverty, parent education, physical and mental health; community: region of residence), multivariable logistic regression revealed that children with mild food insufficiency had 1.6 times greater odds of having chronic pain (95% CI: 1.4-1.9, p < 0.0001) and those with moderate/severe food insufficiency, 1.9 higher odds (95% CI: 1.4-2.7, p < 0.0001) relative to food-sufficient children. The dose-response relationship between food insufficiency and childhood chronic pain highlights the importance of further research to identify underlying mechanisms and evaluate the impact of food insufficiency on the onset and persistence of chronic pain across the lifespan.

We need to talk: The urgent conversation on chronic pain, mental health, prescribing patterns and the opioid crisis.

The opioid crisis' pathways from first exposure onwards to eventual illnesses and fatalities are multiple, intertwined and difficult to dissect. Here, we offer a multidisciplinary appraisal of the relationships among mental health, chronic pain, prescribing patterns worldwide and the opioid crisis. Because the opioid crisis' toll is especially harsh on young people, emphasis is given on data regarding the younger strata of the population. Because analgesic opioid prescription constitute a recognised entry point towards misuse, opioid use disorder, and ultimately overdose, prescribing patterns across different countries are examined as a modifiable hazard factor along these pathways of risk. Psychiatrists are called to play a more compelling role in this urgent conversation, as they are uniquely placed to provide synthesis and lead action among the different fields of knowledge and care that lie at the crossroads of the opioid crisis. Psychiatrists are also ideally positioned to gauge and disseminate the foundations for diagnosis and clinical management of mental conditions associated with chronic pain, including the identification of hazardous and protective factors. It is our hope to spark more interdisciplinary exchanges and encourage psychiatrists worldwide to become leaders in an urgent conversation with interlocutors from the clinical and basic sciences, policy makers and stakeholders including clients and their families.

Geographic differences in perioperative opioid administration in children.

OBJECTIVES: To investigate whether geographic differences exist in perioperative opioid administration to children. AIM: To investigate whether perioperative fentanyl use for cleft lip and palate surgery varies between children of three different geographic regions. BACKGROUND: Differences have been found in perioperative opioid administration to children of differing ethnicity in the USA. Whether similar differences exist in perioperative opioid administration to children residing in different geographic regions is unknown. METHODS/MATERIALS: We retrospectively reviewed the medical records of ASA I children who underwent surgery under standardized general anesthesia between January 2010 and April 2011 during SMILE Network International mission trips to Africa, India and Central and South America. Perioperative administration of fentanyl was compared between these three locations. RESULTS: We analyzed data from 79 children who underwent surgery in Africa, 76 in India and 153 in Central and South America. Children in Central and South America were given <50% of the intraoperative amount of fentanyl (2.0 ± 1.2 mcg·kg(-1) ) administered to children in Africa (4.1 ± 2.4 mcg·kg(-1) ; P < 0.001) and children in India (4.3 ± 2.2 mcg·kg(-1) ; P < 0.001). Postoperatively, fentanyl was administered in equivalent doses to all groups. CONCLUSIONS: Children in Central and South America received less opioid intraoperatively than African and Indian children, under standardized anesthesia for cleft surgeries. Further research is necessary to elucidate the mechanisms underlying these group differences.

Prevalence of moderate-severe pain in hospitalized children.

BACKGROUND: Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown. METHODS: We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed. RESULTS: The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four. CONCLUSIONS: The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

Racial and ethnic differences in pediatric surgery utilization in the United States: A nationally representative cross-sectional analysis.

OBJECTIVES: Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location. MATERIALS AND METHODS: We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child's physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity. RESULTS: The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations. CONCLUSIONS: Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.