Trajectories of postsurgical pain in children: risk factors and impact of late pain recovery on long-term health outcomes after major surgery

Parental anxiety and catastrophizing in pediatric tonsillectomy pain control: A multivariate analysis

OBJECTIVE

Parental anxiety and/or catastrophizing may bias the interpretation of children's pain and administration of analgesia post-tonsillectomy. We aimed to determine whether high levels of parental anxiety and/or catastrophizing impact child pain intensity interpretation and administration of analgesia.

METHODS

Child-parent dyads were recruited from a tertiary care institution between July 2017-December 2019. Preoperative parental anxiety and catastrophizing were assessed using self-report measures. Postoperative data on child and parent pain intensity, as well as analgesia use, were collected up to 2 weeks post-surgery. Multivariable logistic regression models were created to assess predictors of postoperative child pain intensity and analgesia use.

RESULTS

Our cohort included 234 child-parent dyads. Median child age was 5 years (IQR, 4-6), and 9.0 % of children (n = 21) had a medical comorbidity. Both child- and parent-reported pain intensity were highest on postoperative day 2 (3.65 [SD = 3.08] and 3.67 [SD = 2.51], respectively). Parental catastrophizing did not predict analgesia use at home, although a minimal significant decrease in the odds of analgesia administration was observed on postoperative day 7 (OR 0.932, p = 0.017). Maximal parental anxiety did not predict higher odds of increased child postoperative pain intensity on any postoperative day.

CONCLUSION

Parental catastrophizing prior to tonsillectomy has minimal predictive value for analgesia use postoperatively. Children may be successfully advocating for their own pain control as parental anxiety and catastrophizing do not appear to be unduly influencing analgesia administration. Future studies should explore the impact of parental anxiety on vulnerable pediatric populations who may be unable to self-advocate for pain management.

Interpersonal dyadic influences on transitions between pain states: a narrative review and synthesis

ABSTRACT

Pain is not experienced in isolation; it is affected by and affects other people. Interactions between parents and partners and people living with pain affect beliefs, emotions and behaviours, and pain progress and change. We searched systematically for longitudinal studies of associations between specific familial, dyadic, interpersonal factors and quantitative pain transitions. We coded studies for risk of bias. For the narrative synthesis, we grouped findings by dyads-parents and children, and people with pain and their partners (usually spouses), and then by the psychosocial mechanism/s. We described certainty of evidence for each pain transition and each mechanism. Patient and public contributors were involved throughout. Of 52 studies, 38 were of parents and children (27,814 dyads) and 14 of partners (4904 dyads). Three groups of predictive factors were identified for parent and child studies: parent mental health, parent cognitions, and parent behaviours. Parental anxiety (but not depression) predicted children's onset of pain and worsening; the evidence was of moderate certainty and almost exclusively involved mothers. Evidence that some parental behaviours, such as protective behaviours, were associated with worse child pain was of very low certainty. The evidence for partners was of poor quality, precluding synthesis. The review highlights that most interpersonal pain research fails to capture the complex dynamics of longstanding relationships and highlights the difficulty of doing so using simple models.

A high fat, high sugar diet exacerbates persistent post-surgical pain and modifies the brain-microbiota-gut axis in adolescent rats

Persistent post-surgical pain (PPSP) occurs in a proportion of patients following surgical interventions. Research suggests that specific microbiome components are important for brain development and function, with recent studies demonstrating that chronic pain results in changes to the microbiome. Consumption of a high fat, high sugar (HFHS) diet can drastically alter composition of the microbiome and is a modifiable risk factor for many neuroinflammatory conditions. Therefore, we investigated how daily consumption of a HFHS diet modified the development of PPSP, brain structure and function, and the microbiome. In addition, we identified significant correlations between the microbiome and brain in animals with PPSP. Male and female rats were maintained on a control or HFHS diet. Animals were further allocated to a sham or surgery on postnatal day (p) p35. The von Frey task measured mechanical nociceptive sensitivity at a chronic timepoint (p65-67). Between p68-72 rats underwent in-vivo MRI to examine brain volume and diffusivity. At p73 fecal samples were used for downstream 16 s rRNA sequencing. Spearman correlation analyses were performed between individual microbial abundance and MRI diffusivity to determine if specific bacterial species were associated with PPSP-induced brain changes. We found that consumption of a HFHS diet exacerbated PPSP in adolescents. The HFHS diet reduced overall brain volume and increased white and grey matter density. The HFHS diet interacted with the surgical intervention to modify diffusivity in numerous brain regions which were associated with specific changes to the microbiome. These findings demonstrate that premorbid characteristics can influence the development of PPSP and advance our understanding of the contribution that the microbiome has on function of the brain-microbiota-gut axis.

Prognostic factors of chronic postsurgical pain in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Approximately 28% of children and adolescents undergoing major surgery develop chronic postsurgical pain (CPSP; pain persisting>3 months). A previous review attempted to investigate biopsychosocial prognostic factors for pediatric CPSP; however, due to lack of data, no meta-analytic techniques were employed. Since that review, numerous studies have investigated risk/protective factors that fall within an Interpersonal Fear Avoidance Model for CPSP, thus warranting a reinvestigation of prognostic factors.

OBJECTIVE

This systematic review and meta-analysis aimed to examine prognostic factors, measurement tools applied, and their effect on the development of CPSP.

EVIDENCE REVIEW

Prospective, observational studies examining prognostic factors of pediatric CPSP using validated self-report measures were included. 4884 unique publications were screened and 15 met inclusion criteria.

FINDINGS

The pooled effect size for the association between presurgical child pain intensity and the presence of child CPSP was significant, OR=0.540 (95% CI=0.184 to 0.894). Child anxiety, child pain-related anxiety, and parent pain catastrophizing were not significant prognostic factors for child CPSP. Using Grading of Recommendations, Assessment, Development, and Evaluation, the certainty in prognostic estimates was moderate. Risk of bias using Quality in Prognostic Study tool ranged from low to moderate.

CONCLUSIONS

Presurgical pain was the only presurgical risk factor at the meta-analytic level that significantly predicted pediatric CPSP, highlighting the importance of prioritizing pain management throughout the perioperative experience, starting before surgery. Depressive symptoms and sleep disturbance were the two potential risk/protective factors that were unable to be assessed due to insufficient data or use of an unvalidated measure indicating a critical need for future research.

PROSPERO REGISTRATION NUMBER

CRD42022306340.

Chronic postsurgical pain and transitional pain services: a narrative review highlighting European perspectives

BACKGROUND/IMPORTANCE

Chronic postsurgical pain (CPSP) is a significant, often debilitating outcome of surgery, impacting patients' quality of life and placing a substantial burden on healthcare systems worldwide. CPSP (pain persisting for more than 3 months postsurgery) leads to both physical and psychological distress. Recognized as a distinct chronic pain entity in International Classification of Diseases, 11th Revision, CPSP enables better reporting and improved management strategies. Despite advancements in surgical care, CPSP remains prevalent, affecting 5%-85% of patients, with higher rates following thoracotomies, amputations, mastectomies and joint replacements.

OBJECTIVE

The acute to chronic pain transition involves complex interactions between peripheral and central mechanisms, with central sensitization playing a key role. Identifying high-risk patients is crucial for prevention, with factors such as surgical type, nerve injury, neuropathic elements in acute postoperative pain, and psychosocial conditions being significant contributors.

EVIDENCE REVIEW

Current pain management strategies, including multimodal therapy and regional anesthesia, show limited effectiveness in preventing CPSP. Neuromodulation interventions, though promising, are not yet established as preventive modalities.

FINDINGS

Transitional pain services (TPSs) offer a comprehensive, multidisciplinary approach to managing CPSP and reducing opioid dependence, addressing both physical and psychosocial aspects of functional recovery. While promising results have been seen in Canada and Finland, TPSs are not yet widely implemented in Europe. There is also growing interest in pain biomarkers, through initiatives such as the A2CPS program, aiming to improve CPSP prediction and develop targeted interventions.

CONCLUSIONS

Future research should focus on large-scale studies integrating various factors to facilitate CPSP prediction, refine prevention strategies and reduce its long-term impact.

Prevalence of and recommendation for measuring chronic postsurgical pain in children: an updated systematic review and meta-analysis

BACKGROUND

According to the prior 2017 review (Rabbitts et al), approximately 20% of children and adolescents develop chronic postsurgical pain (CPSP; ie, pain persisting >3 months after surgery) after major surgeries, which is associated with adverse functional and psychological consequences. A major barrier was that definitions of CPSP applied were highly variable. Since that prior review was conducted (n=4 studies in meta-analysis), numerous relevant studies have been published warranting an update.

OBJECTIVE

The aims of this current review were to: (1) provide an updated prevalence estimate for pediatric CPSP and (2) examine definitions of pediatric CPSP applied in current research.

EVIDENCE REVIEW

Prospective, observational studies examining CPSP using a validated self-report pain intensity measure in children were included. 4884 unique publications were screened with 20 articles meeting inclusion criteria. Risk of bias using Quality in Prognostic Study tool ranged from low to high.

FINDINGS

The pooled prevalence of CPSP among mostly major surgeries was 28.2% (95% CI 21.4% to 36.1%). Subgroup analysis of spinal fusion surgeries identified a prevalence of 31% (95% CI 21.4% to 43.5%). Using Grading of Recommendations, Assessment, Development, and Evaluation, the certainty in prevalence estimates was moderate. Studies used a range of valid pain intensity measures to classify CPSP (eg, Numeric Rating Scale), often without pain interference or quality of life measures.

CONCLUSIONS

The overall prevalence of pediatric CPSP is higher than estimated in the prior review, and quality of studies generally improved though with some heterogeneity. Standardizing the measurement of CPSP will facilitate future efforts to combine and compare data across studies.

PROSPERO REGISTRATION NUMBER

CRD42022306340.

Preoperative Psychological Factors, Postoperative Pain Scores, and Development of Posttraumatic Stress Disorder Symptoms After Pediatric Anterior Cruciate Ligament Reconstruction

BACKGROUND

Acute orthopedic injuries and subsequent surgical repair can be challenging for children and adolescents and result in posttraumatic stress reactions that can be problematic after the acute perioperative period. In a cohort of patients undergoing anterior cruciate ligament reconstruction (ACLR), we investigated the incidence and explored risk factors associated with the development of posttraumatic stress disorder (PTSD) symptoms after surgery.

METHODS

We analyzed data from a multicenter, prospective, observational registry of pediatric patients undergoing ACLR. Patient data included demographic, psychological assessments, postoperative pain measures, and a posttraumatic stress disorder assessment (Child PTSD Symptom Scale [CPSS]) collected after the operation. An analysis of patients who provided survey data at 6 months was used to determine the incidence of posttraumatic stress reactions and to explore associated risk factors.

RESULTS

A total of 519 patients were enrolled in a prospective observational study of outcomes after ACLR. A cohort of 226 patients (44%) provided completed data collection and CPSS follow-up surveys at 6 months. We found that 17 of the patients (7.5%) met the criteria for PTSD at 6 months which represents 3.3% of our total study population (17/519). A univariate analysis suggested that a negative (P = .017), excitable (P = .039), or inhibitory (P = .043) temperament compared to a positive temperament, high preoperative scores for anxiety (P = .001) or depression (P = .019) and high pain scores on postoperative day (POD)1 (P = .02) increased the odds of PTSD at 6 months. A multivariable model revealed that patients self-reporting symptoms consistent with clinical anxiety/depression preoperatively and patients with a max pain score ≥7 on POD1 were 29 times (P = .018) and 9.8 times (P = .018) more likely to develop PTSD at 6 months.

CONCLUSIONS

A portion of patients undergoing ACLR are at risk for the development of symptoms consistent with PTSD. Risk factors include preoperative anxiety or depression and high postoperative pain scores. Interventions designed to address preoperative risk factors and optimization of postoperative pain may represent opportunities to improve outcomes in this patient population.

Parental Perspectives on Pediatric Surgical Recovery: Narrative Analysis of Free-Text Comments From a Postoperative Survey

BACKGROUND

Qualitative experience data can inform health care providers how to best support families during pediatric postoperative recovery. Patient experience data can also provide actionable information to guide health care quality improvement; positive feedback can confirm the efficacy of current practices and systems, while negative comments can identify areas for improvement.

OBJECTIVE

This study aimed to understand families' perspectives regarding their children's surgical recovery using qualitative patient experience data (free-text comments) from a prospective cohort study conducted within a larger study developing a postoperative-outcome risk stratification model.

METHODS

Participants were parents or guardians of children aged 0-18 years who underwent surgery at a pediatric tertiary care facility; children undergoing either outpatient or inpatient procedures were eligible to be enrolled. Participants with English as a second language were offered translational services during the consent process and were included if any family member could translate the surveys into their preferred language. Participants were ineligible if they and their families could not understand English or the child had a neurodevelopmental disability. Perioperative data were collected from families using web-based surveys, including 1 preoperative survey and follow-up surveys sent on postoperative days 1, 2, 3, 7, 15, 30, and 90. Surveys were completed until the family indicated the child was fully recovered or until postoperative day 90 was reached. Follow-up surveys included opportunities to leave free-text comments on the child's surgical experience.

RESULTS

In total, 91% (453/500) of enrolled families completed at least 1 postoperative survey; 53% (242/453) provided at least 1 free-text comment and were included in the presented analysis, based on a total of 485 comments. The patient's age distribution was bimodal (modes at 2-3 and 14-15 years), with 66% (160/242) being male. Patients underwent orthopedic (60/242, 25%), urological (39/242, 16%), general (36/242,15%), otolaryngological (31/242, 13%), ophthalmological (32/242, 13%), dental (27/242, 11%), and plastic (17/242, 7%) surgeries. Largely positive comments (398/485, 82%) were made on the recovery and clinical care experience. A key theme for improvement included "communication," with subthemes highlighting parental concerns regarding the "preoperative discussions," "clarity of discharge instructions," and "continuity of care." Other themes included "length of stay" and "recovery experience." Feedback also suggested survey design amendments for future iterations of this instrument.

CONCLUSIONS

Collecting parental recovery feedback is feasible and valued by families. Findings underscored the significance of enhancing communication strategies between health care providers and parents to align expectations and support proactive family-centered care. Our postoperative surveys allowed families to provide actionable suggestions for improving their experience, which may not have been considered during their hospital encounter. Our longitudinal survey protocol may be expanded to support continuous quality improvement initiatives involving near-real-time patient feedback to improve the health care experience of patients and families.

The associations between adverse childhood experiences and body pain among middle-aged and older adults: findings from China

BACKGROUND

Adverse Childhood Experiences (ACEs) have been implicated in the development of body pain, yet research on their impact on body pain and its progression remains scarce. This study aimed to examine the associations between ACEs and the presence and areas of body pain, as well as their developmental trajectories among middle-aged and older Chinese adults.

METHODS

We included participants aged 45 years and above from the China Health and Retirement Longitudinal Study (CHARLS) conducted between 2011 and 2018. Retrospective data on ACEs and pain sites were collected with questionnaires. The presence of pain at different body sites was categorized into three areas: head & neck, trunk, and limbs. ACEs consisted of ten types of adverse experiences and were cumulatively scored. For the cross-sectional analysis (2011), logistic regressions were performed to estimate the associations between ACEs and pain presence in specific areas. In the longitudinal analysis (2011-2018), we further applied group-based trajectory modelling (GBTM) to determine the developmental trajectories of body pain. Multinomial logistic regressions were then conducted to estimate the associations between ACEs and pain trajectories.

RESULTS

In the cross-sectional analysis (n = 8157), ACEs were positively associated with the presence of pain in the head & neck (odds ratio [OR] = 3.55, 95% confidence intervals [CI] = 2.37-4.74), trunk (OR = 3.28, 95% CI = 2.47-4.34), and limbs areas (OR = 2.30, 95% CI = 1.77-3.00) compared to no ACEs. These associations varied by sex and residence. In the longitudinal analysis (n = 5188), GBTM identified three developmental trajectories of body pain (n = 9521): high-increasing (7.44%), low-moderate (33.67%) and maintained-low trajectories (58.89%) trajectories. Compared to participants without ACEs, individuals had three ACEs and 4 or more ACEs were consistently associated with low-moderate (three ACEs: OR = 2.26, 95% CI = 1.81-2.83, four or more ACEs: OR = 3.11, 95% CI = 2.51-3.87) and high-increasing (three ACEs: OR = 3.28, 95% CI = 2.03-5.30, four or more ACEs: OR = 6.78, 95% CI = 4.30-10.68) body pain trajectories across sexes and residence.

CONCLUSION

This study highlighted the significant association between ACEs and body pain among middle-aged and older Chinese, emphasizing the importance of preventing or mitigating ACEs as a strategy for the prevention and management of body pain.

When thinking about pain contributes to suffering: the example of pain catastrophizing

ABSTRACT

The extensive literature on the potent role negative thoughts about pain have on the experience of pain and pain-related suffering has documented associations with important neurobiological processes involved in amplifying nociceptive signals. We focus this review on pain catastrophizing (pCAT)- appraisals of pain as threatening, overwhelming, and unmanageable- and review the evidence that these thoughts are learned in childhood through experience and observation of others, particularly caretakers and parents. For children who have learned pCAT, repeated exposures to pain over time activate pCAT and likely contribute to further amplification of pain through changes in the neurobiological pain regulatory systems, which overlap with those regulating the stress response. We propose that repeated pain and stress exposures throughout childhood, adolescence, and into adulthood alter the neurobiology of pain via a repetitive positive feedback loop that increases risk for heightened pain sensitivity over time with repeated exposures. At some point, often precipitated by an acute episode of pain and possibly influenced by allostatic load, pCAT contributes to persistence of episodic or acute pain and exacerbates pain-related suffering. This developmental trajectory is not inevitable, as the impact of pCAT on pain and pain-related suffering can be influenced by various factors. We also present future directions for work in this area.

The relationship of pain catastrophizing in principal caregivers of postoperative children with malignant bone tumors and children's kinesiophobia and pain perception: A cross-sectional survey

OBJECTIVE

To examine the phenomenon of pain catastrophizing among the principal caregivers of postoperative children with malignant bone tumors and explore its impact on pain perception and kinesiophobia in children.

DESIGN

A cross-sectional study design.

METHODS

Using a cross-sectional study design, a questionnaire-based survey was conducted among 140 children with malignant bone tumors and their principal caregivers, who were admitted to a tertiary hospital in Shanghai from 2020 to 2023. Pearson's univariate and multiple regression analyses were conducted. The questionnaire included general data, the Parental Pain Catastrophizing Scale, the Short-Form McGill Pain Questionnaire, and the Tampa Scale of Kinesiophobia.

RESULTS

The frequency of pain catastrophizing for the principal caregivers was 16.8%. The frequency of kinesiophobia in children was 93.1%. The level of pain catastrophizing was positively correlated with the level of kinesiophobia and pain perception (r = 0.556, 0.614, p < 0.05). Multiple logistic regression analysis showed that the level of pain catastrophizing in principal caregivers was an important factor of kinesiophobia in children (B = 0.370, Std. = 0.119, Wald = 9.687, Ex (P) = 1.448, p = 0.002). Multiple linear regression analysis showed that the incidence of pain catastrophizing and the level of kinesiophobia were important influencing factors in pain perception (p < 0.05), with R2 = 0.272, adjusted R2 = 0.249, F = 11.579, and p < 0.001.

CONCLUSIONS

The level of pain catastrophizing in the principal caregivers was an important factor in postoperative kinesiophobia and pain perception in children with a malignant bone tumor.

PRACTICE IMPLICATIONS

It is important to evaluate the patients' and their families' emotional changes and psychological needs during the perioperative period. Nurses play a crucial role in providing appropriate interventions for patients or families to reduce the negative pain experience and improve patients' prognosis.

Use of Biofeedback-Based Virtual Reality in Pediatric Perioperative and Postoperative Settings: Observational Study

BACKGROUND

Biofeedback-based virtual reality (VR-BF) is a novel, nonpharmacologic method for teaching patients how to control their breathing, which in turn increases heart rate variability (HRV) and may reduce pain. Unlike traditional forms of biofeedback, VR-BF is delivered through a gamified virtual reality environment, increasing the accessibility of biofeedback. This is the first study to systematically integrate VR-BF use in the pediatric perioperative setting, with the ultimate goal of evaluating the efficacy of VR-BF to reduce pain, anxiety, and opioid consumption once feasibility and acceptability have been established.

OBJECTIVES

The primary objective was to develop a clinical trial protocol for VR-BF use in the pediatric perioperative setting, including preoperative education and training, and postoperative application of VR-BF in children undergoing surgery. A secondary objective was to evaluate the patient and parent experience with VR-BF.

METHODS

A total of 23 patients (12-18 years of age) scheduled for surgery at Nationwide Children's Hospital were recruited using purposive sampling. Following training, participants independently completed a daily, 10-minute VR-BF session for 7 days before surgery and during their inpatient stay. Participants could use VR-BF up to 2 weeks after hospital discharge. Patient- and session-level data of VR-BF usage and achievement of target HRV parameters were measured to identify the optimal frequency and duration of sessions before and after surgery for this population. Standardized questionnaires and semistructured interviews were conducted to obtain qualitative information about patients' experiences with VR-BF.

RESULTS

Patient-level data indicated that the highest odds of achieving 1 session under target HRV parameters was after 4 sessions (odds ratio [OR] 5.1 for 4 vs 3 sessions, 95% CI 1.3-20.6; OR 16.6 for 3 vs 2 sessions, 95% CI 1.2-217.0). Session-level data showed that a session duration of 9 to 10 minutes provided the greatest odds of achieving 1 session under target HRV parameters (OR 1.3 for 9 vs 8 min, 95% CI 1.1-1.7; OR 1.4 for 8 vs 7 min, 95% CI 1.1-1.8; OR 1 for 10 vs 9 min, 95% CI 0.9-1.2). Qualitative data revealed patient satisfaction with the VR-BF technology, particularly in managing perioperative stress (17/20, 85%). Few patients reported VR-BF as beneficial for pain (8/20, 40%).

CONCLUSIONS

Children and adolescents undergoing surgery successfully learned behavioral strategies with VR-BF with 10-minute sessions once daily for 5 days. To integrate VR-BF as a therapeutic intervention in a subsequent clinical trial, patients will be instructed to complete three 10-minute sessions a day for 7 days after surgery.

TRIAL REGISTRATION

ClinicalTrials NCT04943874; https://clinicaltrials.gov/ct2/show/NCT04943874.

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.

Longitudinal Associations Between Pain, Risk for Posttraumatic Stress Disorder, Posttraumatic Stress Symptoms, and Pain Characteristics in Children After Unintentional Injury

OBJECTIVES

Approximately 20% of children demonstrate persistent posttraumatic stress symptoms (PTSS) after unintentional injury, with more severe pain intensity predicting concurrent and later PTSS. Examining additional pain characteristics like pain behaviors, impairment related to pain, and subjective experiences of pain might provide additional insight into the mechanisms that reinforce relationships between risk for posttraumatic stress disorder (PTSD), PTSS, and pain.

METHODS

During hospitalization for unintentional injury, the Screening Tool for Predictors of PTSD (STEPP) was administered and the highest pain score was collected. One month later, the Child PTSD Symptom Scale and PROMIS questionnaires assessed PTSS and pain characteristics respectively, including intensity, interference, behaviors, and quality.

RESULTS

Correlations between PTSS and PROMIS questionnaires were significant. STEPP predicted future PTSS and all PROMIS questionnaires. The highest pain score predicted future PTSS, as well as pain interference and pain behavior, and did not predict pain intensity and pain quality. When STEPP and highest pain score were combined into a single regression, STEPP and highest pain score predicted future PTSS but only STEPP continued to predict all PROMIS questionnaires.

DISCUSSION

PTSD risk significantly predicted PTSS and pain characteristics 1 month later. The highest pain score predicted future PTSS and several pain characteristics but no longer had predictive value for pain-related outcomes when combined with PTSD risk. These results indicate that risk factors for PTSD are stronger predictors than pain-related risk factors in predicting pain outcomes. Addressing PTSD risk, as well as pain intensity during hospitalization, may result in improved outcomes for children with unintentional injury.

Chronic Postsurgical Pain in Children and Adolescents: A Call for Action

Chronic postsurgical pain (CPSP) affects a significant proportion of children and adolescents after major surgery and is a detriment to both short- and long-term recovery outcomes. While clinical characteristics and psychosocial risk factors for developing CPSP in children and adults are well established in the literature, there has been little progress on the prevention and management of CPSP after pediatric surgery. Limited evidence to support current pharmacologic approaches suggests a fundamentally new paradigm must be considered by clinicians to both conceptualize and address this adverse complication. This narrative review provides a comprehensive evaluation of both the known and emerging mechanisms that support our current understanding of CPSP. Additionally, we discuss the importance of optimizing perioperative analgesic strategies to mitigate CPSP based on individual patient risks. We highlight the importance of postoperative pain trajectories to identify those most at risk for developing CPSP, the early referral to multi-disciplinary pain clinics for comprehensive evaluation and treatment of CPSP, and additional work needed to differentiate CPSP characteristics from other chronic pain syndromes in children. Finally, we recognize ongoing challenges associated with the universal implementation of available knowledge about pediatric CPSP into practically useful care plans for clinicians.

Trajectory Analysis for Identifying Classes of Attention Deficit Hyperactivity Disorder (ADHD) in Children of the United States

BACKGROUND

Attention Deficit Hyperactivity Disorder (ADHD) is a mental health disorder that affects attention and behavior. People with ADHD frequently encounter challenges in social interactions, facing issues, like social rejection and difficulties in interpersonal relationships, due to their inattention, impulsivity, and hyperactivity.

METHODS

A National Longitudinal Survey of Youth (NLSY) database was employed to identify patterns of ADHD symptoms. The children who were born to women in the NLSY study between 1986 and 2014 were included. A total of 1,847 children in the NLSY 1979 cohort whose hyperactivity/inattention score was calculated when they were four years old were eligible for this study. A trajectory modeling method was used to evaluate the trajectory classes. Sex, baseline antisocial score, baseline anxiety score, and baseline depression score were adjusted to build the trajectory model. We used stepwise multivariate logistic regression models to select the risk factors for the identified trajectories.

RESULTS

The trajectory analysis identified six classes for ADHD, including (1) no sign class, (2) few signs since preschool being persistent class, (3) few signs in preschool but no signs later class, (4) few signs in preschool that magnified in elementary school class, (5) few signs in preschool that diminished later class, and (6) many signs since preschool being persistent class. The sensitivity analysis resulted in a similar trajectory pattern, except for the few signs since preschool that magnified later class. Children's race, breastfeeding status, headstrong score, immature dependent score, peer conflict score, educational level of the mother, baseline antisocial score, baseline anxious/depressed score, and smoking status 12 months prior to the birth of the child were found to be risk factors in the ADHD trajectory classes.

CONCLUSION

The trajectory classes findings obtained in the current study can (a) assist a researcher in evaluating an intervention (or combination of interventions) that best decreases the long-term impact of ADHD symptoms and (b) allow clinicians to better assess as to which class a child with ADHD belongs so that appropriate intervention can be employed.

Perioperative methadone for posterior spinal fusion in adolescents: Results from a double-blind randomized-controlled trial

BACKGROUND

Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature.

AIMS

We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion.

METHODS

A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain.

RESULTS

Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects.

CONCLUSIONS

A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion.

Child and Parent Risk and Resilience Factors as Predictors of Long-term Recovery in Youth Undergoing Spinal Fusion Surgery

OBJECTIVES

Undertreated pediatric postsurgical pain negatively affects health-related quality of life (HRQOL) and functioning and may lead to chronic postsurgical pain (CPSP). Predictors of recovery have been identified but more research is needed, particularly regarding resilience, social factors, and long-term effects. The aim of the present study was to investigate child and parent risk and resilience factors as predictors of long-term postsurgical recovery for adolescents.

METHODS

Participants were patients with Adolescent Idiopathic Scoliosis (AIS), 12 to 18 years old, undergoing spinal fusion, and their parents. Recruitment occurred at the orthopedic units at 4 hospitals in Belgium. Data were collected before surgery (T0), at 3 (T1) and 6 weeks (T2), 6 months (T3), and 1 year (T4) post surgery. Multiple regression models were used to evaluate the predictive effect of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance on long-term functioning, HRQOL, and pain.

RESULTS

The sample comprised 100 adolescents and 61 parents. Pain at T0, T1, and T3 and adolescent pain catastrophizing (T0) predicted health-related quality of life, functioning, and pain at T4 (while pain at T2 predicted HRQOL and pain). Parent pain catastrophizing predicted pain at T4. Adolescent and parental psychological flexibility predicted HRQOL, and parent psychological flexibility also predicted pain at T4. Adolescent acceptance at T1 predicted pain, and acceptance at T2 predicted HRQOL, at T4.

DISCUSSION

The study identified pain and adolescent pain catastrophizing as risk factors, and adolescent and parental psychological flexibility and adolescent pain acceptance as resilience factors, for long-term recovery in youths undergoing spinal fusion. Postsurgical pain management targeting these factors may therefore promote recovery for these adolescents.

Predicting Health-Related Quality of Life Outcomes Following Major Scoliosis Surgery in Adolescents: A Latent Class Growth Analysis

STUDY DESIGN

Prospective cohort study.

OBJECTIVES

To identify patient trajectories of recovery defined by change in health-related quality of life (HRQOL) following surgery for adolescent idiopathic scoliosis (AIS). To explore possible predictors of trajectory membership.

METHODS

Adolescent patients scheduled to undergo spinal fusion for AIS were enrolled in the Post-Operative Recovery following Spinal Correction: Home Experience (PORSCHE) study. Responses to the Pediatric Quality of Life Inventory-version 4 (PedsQL-4.0) were collected prior to surgery and 4 to 6 weeks, 3, 6, and 12 months post-operatively. Latent class growth analyses identified patient subgroups based on their unique trajectories of physical health (PH) and psychosocial health (PSH) outcomes using the PedsQL-4.0 subscale scores. Predictors included demographic, clinical, and psychosocial factors.

RESULTS

Data from up to 190 patients were included (87.4% female; mean±SD age = 14.6 ± 1.9 years). Three trajectory subgroups were identified for PH and 4 trajectories were found for PSH, with a majority of patients scoring within the established range of healthy adolescents 12 months post-surgery. Increased child and parent pain catastrophizing, child trait anxiety and previous hospitalizations were associated with poorer PH outcomes, whereas increased child and parent pain catastrophizing, child state and trait anxiety, and parent state and trait anxiety were associated with poorer PSH trajectories.

CONCLUSIONS

The PH and PSH trajectories identified in this study and the factors associated with their membership may inform surgical decision-making for AIS while facilitating patient and family counselling regarding peri-operative recovery and expectations.

Longitudinal Resilience and Risk Factors in Pediatric Postoperative Pain (LORRIS): Protocol for a Prospective Longitudinal Swiss University Children's Hospitals-Based Study

INTRODUCTION

Chronic postsurgical pain (CPSP) is defined as pain that persists after a surgical procedure and has a significant impact on quality of life. Previous studies show the importance of psychological factors in CPSP, yet the majority of studies focused solely on negative emotions. This longitudinal observational study aims to broaden this knowledge base by examining the role of emotional state, emotion variability, emotion regulation and emotion differentiation on the child and the parent level for the development CPSP, and to describe pain and emotion-related trajectories following surgery.

METHODS AND ANALYSIS

We intend to include 280 children and adolescents aged 8-18 years with a planned orthopaedic surgery and their parents. A total of five assessment time points is planned: 3 weeks before surgery (baseline), 2 weeks after surgery (post) and 3 months (follow-up (FU) 1), 6 months and 12 months after surgery. At baseline and post only, children and parents are asked to complete a daily diary thrice a day for a week where they rate their current emotional state and their pain severity (children only). Emotional state ratings will be used to calculate indices of emotion variability, emotion regulation and emotion differentiation. Children and parents will complete questionnaires at each time point, including measures on quality of life, social support, sleep, and symptoms of anxiety and depression.To predict development of CPSP, generalised linear regression models will be used, resulting in ORs and 95% CIs. Pearson product-moment correlations between predictors and outcomes will be evaluated at each time point. The primary outcome of the prediction model is CPSP at FU1. For the trajectory analysis, the classification method K-means for longitudinal data will be used to determine clusters in the data.

ETHICS AND DISSEMINATION

The Ethics Committee of the Canton of Zurich, Switzerland, has approved the study (ID: 2023-01475). Participants will be compensated, and a dissemination workshop will be held.

TRIAL REGISTRATION NUMBER

NCT05816174.

"Seeing the light in the shade of it": primary caregiver and youth perspectives on using an inpatient portal for pain care during hospitalization

ABSTRACT

Studies from multiple countries report that most hospitalized children, especially the youngest and sickest, experience pain that is often severe yet inadequately treated. Evidence suggests this can lead to immediate and lifelong consequences affecting children, families, and communities. Partnership and shared decision-making by children, families, and clinicians is the ideal pediatric healthcare model and can improve care quality and safety, including pain care. A growing evidence base demonstrates that inpatient portals (electronic personal health record applications linked to hospital electronic medical or health records) can improve child and family engagement, outcomes, and satisfaction during hospitalization. This study examined the perspectives of caregivers of hospitalized children and of hospitalized youth about using an inpatient portal to support their engagement in pain care while in hospital. A qualitative descriptive study design was used and 20 participants (15 caregivers and 5 youth) with various painful conditions in one pediatric hospital participated in semistructured interviews. The authors applied a reflexive content analysis to the data and developed 3 broad categories: (1) connecting and sharing knowledge about pain, (2) user-centred designs, and (3) preserving roles. These findings outlined caregiver and youth recommendations for portal configurations that deeply engage and empower children and families in pain care through multidirectional knowledge sharing, supporting caregiver and clinicians' roles without burdening, or replacing human interaction implicit in family-centered pain care. Further research should measure the impact of portals on pain-related outcomes and explore the perspectives of clinicians.

Daily Pain Experiences in Chronic Pancreatitis: Identifying Pain Phenotypes

OBJECTIVES

Pain, the hallmark symptom of chronic pancreatitis (CP), remains difficult to assess. To capture the variability of pain that patients can experience day to day, this study used pain diaries to describe daily pain experiences and identify pain phenotypes.

METHODS

This study is a secondary data analysis from a pilot trial examining cognitive behavioral therapy for pain treatment in CP. Before treatment, patients completed an online daily pain diary using the Brief Pain Inventory for 7 days. Using indicators of pain magnitude, pain variability, pain synchrony along with least, worst, and average pain intensity levels, we identified pain patterns using K-means clustering.

RESULTS

Of 30 patients in the pilot trial, a total of 27 patients (mean age of 49.8 years, 80% women) had complete data to include in this report. Four clusters were identified: cluster 1, lowest pain magnitude (n = 3); cluster 2, moderate pain magnitude and high pain variability (n = 4); cluster 3, moderate pain magnitude and low pain variability (n = 9); and cluster 4, highest pain magnitude and lowest pain variability (n = 11).

CONCLUSIONS

Daily pain diaries offer a novel way of evaluating the dynamic pain experiences in CP. Although 4 distinct pain patterns were identified, further studies are needed to validate these findings.

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.

Virtual psychoeducation for improvement of pain catastrophizing in pediatric presurgical patients and caregivers: a proof-of-concept study

PURPOSE

Pain catastrophizing (PC) is the tendency to magnify the threat value of pain sensations and is associated with greater postsurgical pain intensity, functional disability, and pain chronicity. Higher parental PC predicts higher chronic postsurgical pain in youth. Treating PC in caregivers and youth prior to surgery may improve recovery and surgical outcomes. We developed and evaluated a psychoeducational workshop addressing PC for presurgical youth and their parents/caregivers. We hypothesized that parent/caregiver and youth PC scores would decrease over time. We also explored preintervention levels of youth anxiety and depression as moderators of outcome.

METHODS

Youth (n = 43) and caregivers (n = 41) attended a virtual, group-based single-session intervention (SSI). Single-session intervention content addressed pain neuroscience, PC, and adaptive coping strategies for managing pain and PC drawn from cognitive-behavioural, acceptance and commitment, and dialectical behaviour therapy approaches. Participants completed questionnaires assessing PC at preintervention, postintervention, and two weeks postsurgery. Youth mood and anxiety were assessed at preintervention.

RESULTS

Caregiver PC scores decreased from pre- to postintervention (P = 0.006), and this was maintained at postsurgery (P = 0.002). Youth PC scores decreased from preintervention to postsurgery, but only for those with higher preintervention anxiety (P = 0.01).

CONCLUSION

Our results provide proof-of-concept support for a virtual SSI targeting caregivers and youth PC during the perioperative period. The present findings highlight the possible need to screen presurgical candidates for symptoms of anxiety. Replication with larger and more diverse samples, and a more robust design are warranted.

Is Pain Perception Communicated through Mothers? Maternal Pain Catastrophizing Scores Are Associated with Children's Postoperative Circumcision Pain

The aim of this study was to evaluate the relation of maternal pain catastrophizing score with children who underwent circumcision postoperative pain. This prospective cohort study was performed between March 2022 and March 2023 at Samsun University, Turkey. Demographic characteristics of mothers and children, mothers' education level, presence of chronic pain, and Beck Depression Inventory scores were recorded preoperatively. Pain catastrophizing was assessed by applying the pain catastrophizing scale (PCS) to the mothers of children who experienced postoperative circumcision pain. The mothers were divided into low-pain catastrophizing (Group 1) and high-pain catastrophizing (Group 2) group. A total of 197 mothers and sons participated in the study, with 86 (43.6%) in Group 1 and 111 (56.4%) in Group 2. Significant differences were found between the two groups in terms of the mothers' PCS scores (p < 0.001), education levels (p = 0.004), chronic pain scores (p = 0.022), and Beck Depression Inventory scores (p < 0.001). Our findings showed that children with high pain catastrophizing mothers experience greater postoperative pain than those with low pain catastrophizing mothers. This may be attributable to a mother's specific cognitive style for coping with pain, which is associated with the child's responses to painful experiences.

Dataset used to refine a treatment protocol of a biofeedback-based virtual reality intervention for pain and anxiety in children and adolescents undergoing surgery

There is a great need for nonpharmacologic pain management strategies, given the catastrophic effects of the opioid epidemic and the role of opioid prescription in precipitating addiction [1], particularly in children and adolescents at risk of chronic pain and opioid use after surgery [2], [3], [4]. Biofeedback-based virtual reality (VR-BF) is an innovative approach to managing pain that compliments and may even increase accessibility [5] and acceptability [6] of existing mind-body therapies for pain management, like biofeedback (BF). BF teaches patients behavioral modification techniques that impact involuntary processes [7,8]. For example, slow breathing increases heart rate variability (HRV) [9] to reduce pain through the downregulation of the sympathetic nervous system [10,11]. However, barriers to widespread use, such as the need for trained personnel and high costs of direct intervention, have hindered its widespread clinical use and access to this therapy [5,12]. VR-BF has not yet been integrated into perioperative care, and as such, no defined treatment protocols for preoperative training and postoperative application of VR-BF exist, particularly in children. The dataset presented in this article may help fill the unmet, critical need for accessible, effective, alternative therapeutic options for reducing postoperative pain and opioid exposure in children. This investigation aimed to establish measurable outcomes impacting a perioperative treatment protocol of VR-BF, a novel VR-based therapy that teaches patients relaxation techniques and monitors the sensitivity of heart rate variability (HRV) to different frequencies and durations of VR-BF sessions. Achievement of target physiological parameters, including HRV, was measured in children and adolescents undergoing surgery anticipated to cause moderate to severe pain (e.g., orthopedic, chest) requiring postoperative pain management by the Acute Pain Services at Nationwide Children's Hospital (NCH). This dataset included 23 surgical patients evaluated quantitatively and qualitatively to refine a treatment protocol for the feasibility and acceptability of (a) preoperative education and training in relaxation, and (b) postoperative application of a VR-BF intervention for pain management [13]. Qualitative data was collected using an investigator-derived questionnaire to obtain feedback and understand the patient and family experience using VR-BF. Descriptive statistics (mean±SD or median with interquartile range [IQR] for continuous variables; frequencies and percentages for categorical variables) and exploratory spline regression analyses were generated to define measurable outcomes for a future pilot, randomized clinical trial protocol.

Monitoring the initial recovery after fusion surgery using activity trackers in adolescent idiopathic scoliosis: going in the lumbar spine decreases the daily step count

PURPOSE

Although the functional outcome (e.g. the return to daily activities) plays an important role in the evaluation of treatment success for the paediatric patient, clinicians currently cannot make accurate and objective predictions regarding the very early (≤ 6 weeks) functional outcome and its recovery over time. The purpose of the present study is to objectively measure initial postoperative physical activity levels and examine the relationship with patient characteristics, fusion levels and pain.

METHODS

Step count (SC) was obtained pre- (Pre-Op) and postoperatively (Post-3W: 3 weeks after surgery; Post-6W: 6 weeks after surgery) using an accelerometer. Patients were grouped based on LIV (thoracic (T-group) and lumbar (L-group)) and fusion length (FL ≤ 10 levels = SF-group and FL ≥ 11 levels = LF-group). Differences in the daily SC between groups (LIV and FL) and the three timepoints was investigated using a two-way ANOVA.

RESULTS

The SC was significantly lower at both Post-3W (p < 0.001) and Post-6W (p < 0.001) compared to the preoperative SC, and significantly (p < 0.001) increased from Post-3W to Post-6W (Pre-Op = 13,049 ± 3214 steps/day; Post-3W = 6486 ± 2925 steps/day; Post-6W = 8723 ± 3020 steps/day). At both post-op timepoints the T-group had a higher SC compared to the L-group.

CONCLUSION

A fusion surgery with the LIV at L2 or below has a negative impact on the very early postoperative activity levels. The initial functional outcome level of AIS patients was not related to the presently collected patient characteristics. This suggests that objective activity trackers provide novel information and could have an added value in very early rehabilitation programs.

Quantitative Sensory Changes Following Posterior Spinal Fusion to Treat Adolescent Idiopathic Scoliosis

BACKGROUND

Sensory changes surrounding the incision frequently develop after posterior spinal fusion (PSF) to treat adolescent idiopathic scoliosis (AIS). Anecdotally, patients may experience sensory changes on the chest wall. Such postsurgical sensory changes are not well described quantitatively. This study aims to evaluate the presence, intensity, and duration of mechanical sensory changes in AIS patients postoperatively.

METHODS

A prospective cohort of AIS patients, 10 to 21 years old, was followed. Quantitative sensory testing (QST) included touch detection threshold [mechanical detection threshold (MDT)] and pain detection threshold (MPT), using VonFrey monofilaments and pinprick stimulators. QST was performed at 3 sites at T6: the right and left chest at the nipple line and adjacent to the incision below the inferior angle of the scapula. QST at the thenar eminence was the control. QST was collected at baseline, 3 days, 1, and 6 months postoperative.

RESULTS

Thirty-four patients (21% males; mean age: 14.9 years old; median preoperative curve: 58 degrees) completed all testing. Mean deformity correction was 64% (SD: 10.4). Adjacent to the incision site, MDT was significantly higher compared with baseline at 3 days and 1 month ( P < 0.001) but not at 6 months ( P = 0.19), whereas MPT was significantly higher at 3 days, ( P < 0.001), 1 month ( P < 0.001), and 6 months ( P = 0.001). For the chest wall in all patients, MPT was higher on the left chest at 3 days ( P = 0.04) and on the right chest at 3 days ( P = 0.022) and 1 month ( P = 0.05). For patients with right-sided curves, MDT ( P = 0.01) and MPT ( P = 0.015) overall were significantly higher on the concave side (left) chest postoperatively.

CONCLUSIONS

PSF is associated with sensory disturbances that are detectable within days, persist at 1 month, and improve at 6 months postoperatively adjacent to the incision and on the chest wall. We suspect that these sensory changes are transient. Describing postoperative sensory changes will help us better set postoperative expectations for patients undergoing PSF.

LEVEL OF EVIDENCE

Level I.

Pilot Investigation of Somatosensory Functioning and Pain Catastrophizing in Pediatric Spinal Fusion Surgery

PURPOSE

Chronic post-surgical pain (CPSP) is a significant concern and contributes to the opioid epidemic; however, little is known about CPSP in young people.

DESIGN

This prospective study aimed to identify sensory, psychological, and demographic factors that may increase the risk of CPSP after spinal fusion surgery for children and adolescents with idiopathic scoliosis.

METHODS

32 children and adolescents from two children's hospitals completed quantitative sensory testing (QST) and the Pain Catastrophizing Scale Child (PCS-C) pre-and 4-6 months post spinal fusion surgery. Between-group differences were assessed using an independent samples t-test. Pearson's correlations and stepwise linear regression were used to assess the relationship between variables at both time points.

RESULTS

56% of patients endorsed pain post-surgery. They were more sensitive tomechanical detection on both a control non-pain site (r = -2.87, p = .004) and the back (r = -1.83, p = .04), as well as pressure pain (r=-2.37, p = .01) on the back. This group also reported worse pain scores pre-surgery. Pre-surgery helplessness positively correlated with preoperative pain (r = .67 p < .001), and age was negatively correlated with the post-surgical catastrophizing total score (r =-.39, p = .05), suggesting that younger patients endorsed more pain-related worry after surgery.

CONCLUSIONS

Patients who present with pain during their preoperative appointment may need to be monitored with increased vigilance throughout the perioperative period, possibly with bedside QST and psychological questionnaires, which nurses could administer. Biobehavioral interventions targeting pain intensity and feelings of helplessness and anxiety during the preoperative period may alleviate the transition to CPSP.

Association of Common Pediatric Surgeries With New Onset Chronic Pain in Patients 0-21 Years of Age in the United States

Chronic pain (CP) is a major public health issue. While new onset CP is known to occur frequently after some pediatric surgeries, its incidence after the most common pediatric surgeries is unknown. This retrospective cohort study used insurance claims data from 2002 to 2017 for patients 0 to 21 years of age. The primary outcome was CP 90 to 365 days after each of the 20 most frequent surgeries in 5 age categories (identified using CP ICD codes). Multivariable logistic regression identified surgeries and risk factors associated with CP after surgery. A total of 424,590 surgical patients aged 0 to 21 were included, 22,361 of whom developed CP in the 90 to 365 days after surgery. The incidences of CP after surgery were: 1.1% in age group 0 to 1 years; 3.0% in 2 to 5 years; 5.6% in 6 to 11 years; 10.1% in 12 to 18 years; 9.9% in 19 to 21 years. Some surgeries and patient variables were associated with CP. Approximately 1 in 10 adolescents who underwent the most common surgeries developed CP, as did a striking percentage of children in other age groups. Given the long-term consequences of CP, resources should be allocated toward identification of high-risk pediatric patients and strategies to prevent CP after surgery. PERSPECTIVE: This study identifies the incidences of and risk factors for chronic pain after common surgeries in patients 0 to 21 years of age. Our findings suggest that resources should be allocated toward the identification of high-risk pediatric patients and strategies to prevent CP after surgery.

An Analysis of Prehospital Pediatric Medication Dosing Errors after Implementation of a State-Wide EMS Pediatric Drug Dosing Reference

BACKGROUND

Medication dosing errors are common in prehospital pediatric patients. Prior work has shown the overall medication error rate by emergency medical services (EMS) in Michigan was 34.7%. To reduce these errors, the state of Michigan implemented a pediatric dosing reference in 2014 listing medication doses and volume to be administered.

OBJECTIVE

To examine changes in pediatric dosing errors by EMS in Michigan after implementation of the pediatric dosing reference.

METHODS

We conducted a retrospective review of the Michigan Emergency Medical Services Information System of children ≤ 12 years of age from June 2016-May 2017 treated by 16 EMS agencies. Agencies were a mix of public, private, third-service, and fire-based. A dosing error was defined as >20% deviation from the weight-appropriate dose listed on the pediatric dosing reference. Descriptive statistics with confidence intervals and standard deviations are reported.

RESULTS

During the study period, there were 9,247 pediatric encounters, of whom 727 (7.9%) received medications and are included in the study. There were 1078 medication administrations, with 380 dosing errors (35.2% [95% CI 25.3-48.4]). The highest error rates were for dextrose 50% (3/4 or 75% [95% CI 32.57-100.0]) and glucagon (3/4 or 75% [95% CI 32.57-100.0]). The next highest proportions of incorrect doses were opioids: intranasal fentanyl (11/16 or 68.8% [95% CI 46.04-91.46]) and intravenous fentanyl (89/130 or 68.5% [95% CI 60.47-76.45]). Morphine had a much lower error rate (24/51 or 47.1% [95% CI 33.36-60.76]). Midazolam had the third highest error rate, for intravenous (27/50 or 54.0% [95% CI (40.19-67.81]) and intramuscular (25/68 or 36.8% [95% CI 40.19-67.81]) routes. Epinephrine 1 mg/10 ml had an incorrect dosage rate of 35/119 (29.4% [95% CI 20.64-36.99]). Asthma medications had the lowest rate of incorrect dosing (albuterol sulfate 9/247 or 3.6% [95% CI 1.31-5.98]).

CONCLUSIONS

Medications administered to prehospital pediatric patients continue to demonstrate dosing errors despite pediatric dosing reference implementation. Although there have been improvements in error rates in asthma medications, the overall error rate has increased. Continued work to build patient safety strategies to reduce pediatric medication dosing errors by EMS is needed.

Feasibility and acceptability of perioperative application of biofeedback-based virtual reality versus active control for pain and anxiety in children and adolescents undergoing surgery: protocol for a pilot randomised controlled trial

INTRODUCTION

Current clinical applications of virtual reality (VR) provide patients with transient pain relief during acutely painful events by redirecting attention. Biofeedback (BF) is a mind-body therapy that effectively produces sustained pain reduction, but there are obstacles to its routine use. Combined, BF-based VR (VR-BF) may increase accessibility while enhancing the benefits of BF. VR-BF has yet to be employed in perioperative care, and as such, no defined treatment protocol for VR-BF exists. The primary aim of this study is to assess the feasibility of the perioperative use of VR-BF in children and adolescents. The secondary aims are to assess the acceptability of VR-BF and to collect pilot efficacy data.

METHODS AND ANALYSIS

This is a single-centre, randomised controlled pilot clinical trial. A total of 70 patients (12-18 years) scheduled for surgery anticipated to cause moderate to severe pain with ≥1 night of hospital admission will be randomised to one of two study arms (VR-BF or control). Participants randomised to VR-BF (n=35) will use the ForeVR VR platform to engage their breathing in gamified VR applications. Participants randomised to control (n=35) will interact with a pain reflection app, Manage My Pain. The primary outcome is feasibility of VR-BF use in adolescents undergoing surgery as assessed through recruitment, enrolment, retention and adherence to the protocol. Secondary outcomes are acceptability of VR-BF and pilot efficacy measures, including pain, anxiety and opioid consumption.

ETHICS AND DISSEMINATION

The protocol was approved by the Nationwide Children's Hospital Institutional Review Board (IRB #STUDY00002080). Patient recruitment begins in March 2023. Written informed consent is obtained for all participants. All information acquired will be disseminated via scientific meetings and published in peer-reviewed journals. Data will be available per request and results will be posted on ClinicalTrials.gov.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT04943874).

"Persistent Post-Operative Pain in Children - An Argument for a Transitional Pain Service in Pediatrics"

BACKGROUND

Persistent post-operative pain continues to occur in pediatric patients. Despite the growing amount of literature on causes, there is little discussion on treatment and prevention with a majority of studies focusing on specific surgeries.

AIM

The aim of this retrospective chart study is to identify risk factors and clinical features of persistent post-operative pain after any surgery in a pediatric quaternary complex pain service, describe the pharmacologic and non-pharmacologic management in children, and explore options to improve outcomes, in particular, the introduction of a transitional pain service.

METHODS

A retrospective chart review recorded demographics, gender, age, pain location and surgery type, treatment, and outcomes of 31 children identified through relevant registers over a 2-year period.

RESULTS

A total of 31 children were positively identified as having persistent post-operative pain and were seen in the complex pain clinic. Consistent with the literature, most cases represented neuropathic pain and persistent post-operative pain was most commonly seen after orthopedic surgery. All but four children had resolution of their pain after implementing the pain management plan. Management was characterized by early intervention, emphasis on non-pharmacologic strategies, and conservative use of opioids.

CONCLUSIONS

Identifying risk factors is useful, however putting strategies into place for prevention is necessary. Early intervention and the implementation of strategies before and immediately after are best provided by a transitional pain service.

Pain Quality After Pediatric Pectus Excavatum Repair

BACKGROUND

Neuropathic pain medications are included in multimodal postoperative analgesic strategies, but quality of perioperative pain is rarely assessed.

AIMS

The purpose of this study was to describe adolescents' pain experiences after thoracoscopic pectus excavatum repair (Nuss procedure) using the Adolescent Pediatric Pain Tool.

DESIGN

This prospective descriptive longitudinal study was designed to test the hypothesis that pain quality descriptors reported are consistent with neuropathic pain.

METHODS

A convenience sample of 23 adolescents aged 12 to 17 years from a single urban, university affiliated, nonprofit children's hospital consented to self-report pain using the Adolescent Pediatric Pain Tool before and during hospitalization, and up to 14 months after Nuss procedure. Visual analytic techniques were used to analyze reported pain intensity, location, and affective, evaluative, sensory, and temporal qualities.

RESULTS

Postoperative pain quality, intensity, number of sites, and surface area decreased over time. Word clouds illustrated that neuropathic sensory and temporal pain quality descriptors increased in frequency 2 to 6 weeks after surgery and were the predominant descriptors 2 to 4 months after surgery. Dot matrix charts illustrated an inconsistent relationship of pain quality and intensity with pain surface area.

CONCLUSIONS

Pain quality should be assessed with valid, reliable, and developmentally appropriate tools. Visual analytics help illustrate pain quality at single points in time and longitudinally and may be helpful in guiding postoperative pain treatment.

Trajectories, Risk Factors, and Impact of Persistent Pain After Major Musculoskeletal Surgery in Adolescents: A Replication Study

Studies have identified high rates of chronic postsurgical pain in adolescents. Characterizing patterns of pain in the transition from acute to chronic following major surgery may pinpoint critical periods of recovery. This observational study modelled pain trajectories over 1-year following surgery to attempt replication of prior work and evaluate baseline psychosocial factors and 12-month health outcomes. Adolescents 10 to 18 years completed electronic daily pain reporting for 7 days and self-reported health outcomes, at 5 assessment timepoints. Group-based trajectory modelling identified two trajectories with similar starting points in-hospital but distinct recovery courses at home. Pain declined steadily in one group across the study period ("Declining Pain"; estimated probability,18.9%), but pain increased after hospital discharge and remained high through 12-months in the other group ("High and Persistent Pain"; estimated probability,81.1%). Pre-surgery pain (Aor = 1.86, P = .001) and sleep quality (Aor = 0.49, P = .029) were associated with the High and Persistent pain trajectory in multivariate regressions. This trajectory was associated with lower total quality of life (B=-9.79, P = .002), physical health (B = -15.93, P < .001), psychosocial health (B = -6.73, P = .06), and greater fatigue (B = -13.61, P = .001). This study replicated prior findings identifying two post-surgical pain trajectories with diverging pain in the first two weeks. Clinical detection of those with increasing pain and early intervention may interrupt persistence of pain. PERSPECTIVE: This article replicates a prior study identifying distinct post-surgical pain trajectories, Declining Pain and High and Persistent Pain. The High and Persistent pain trajectory is associated with pre-surgery pain, pre-surgery sleep quality, and lower quality of life (total, physical, and psychosocial health as well as fatigue) at 12-month follow-up.

Extending the Biopsychosocial Conceptualisation of Chronic Post Surgical Pain in Children and Adolescents: The Family Systems Perspective

A substantial number of children and adolescents undergoing surgical procedures, as many as 40% in some estimates, will go on to develop chronic postsurgical pain (CPSP). Because of the significant negative impact of CPSP on social and emotional milestones, as well as the child's quality of life, it is important to identify modifiable factors that are associated with the onset and maintenance of the condition. Research has demonstrated that parent factors can play a role in pediatric chronic pain; however, there has been little examination of parent and family influences on the transition to CPSP. Family systems theories, which consider the influence of the family unit overall on the behavior of individuals members, have been applied to the eating disorders literature for decades. This narrative review proposes a novel application of family systems theory to pediatric CPSP and, in particular, highlights the role that parental dyadic factors may play in the development and maintenance of persistent pain following surgery in children and adolescents.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Modeling the transition from acute to chronic postsurgical pain in youth: A narrative review of epidemiologic, perioperative and psychosocial factors

A growing number of studies have identified high rates of pediatric chronic postsurgical pain (CPSP) after major surgery. Pediatric CPSP is associated with pain-related distress and comorbid mental health outcomes, such as anxiety and depression. From a biopsychosocial perspective, youth factors, such as genetics, epigenetics, sex, presurgical pain, sleep, anxiety, and pain catastrophizing, as well as parent factors, such as cognitive appraisals of their child’s pain expression and pain catastrophizing, converge and lead to chronic pain disability. A comprehensive and testable psychosocial model of the transition from acute to chronic pediatric postsurgical pain has not been developed. This narrative review begins by evaluating the epidemiology and trajectories of pediatric CPSP and moves on to examine the more influential psychosocial models that have been proposed to understand the development of pediatric CPSP. Much of the literature to date has been conducted on adolescents undergoing spinal fusion. To conceptualize the transition from acute to chronic pain in youth, a combined diathesis-stress and interpersonal fear avoidance model is presented. Novel areas of future research include the potential influence that siblings and peers have on a youth’s development of CPSP as well as the influence of gender.

Pediatric Pain Screening Tool: A Simple 9-Item Questionnaire Predicts Functional and Chronic Postsurgical Pain Outcomes After Major Musculoskeletal Surgeries

Reliable, clinic-friendly screening for Chronic postsurgical pain (CPSP) risk is unavailable. Within a prospective, observational study, we evaluated Pediatric Pain Screening Tool (PPST), a concise 9-item questionnaire, as a preoperative screening tool to identify those at higher risk for CPSP (Numerical Rating Scale > 3/10 beyond 3 months post-surgery) and poor function (disability/Functional Disability Inventory [FDI]/quality of life/ Pediatric Quality of Life) after spine fusion and Nuss procedures. Incidence of CPSP was 34.86% (38/109). We confirmed PPST scale stability, test re-test reliability (ICC = 0.68; P< .001); PPST measures were positively correlated with known CPSP risk factors (P< .001) preoperative pain (Pearson or Spearman Correlation Coefficient [SCC]:0.672), Child anxiety sensitivity index (SCC:0.357), Patient Related Outcome Measures Information System pain interference (SCC:0.569), Patient Related Outcome Measures Information System depression (SCC:0.501), Pediatric Quality of Life (SCC:-0.460) and insomnia severity index (SCC0.567). Preoperative PPST and PPST physical sub-scores (median(IQR) were higher in CPSP (2[0.5,4], 1[0,2]) compared to non-CPSP (1[0,3], 0[0,1.5]) groups (P= .026, P= .029) respectively. PPST scores/sub-scores positively correlated with higher FDI at 6 months but only PPST total and PPST psychosocial subscore correlated with higher FDI at 12 months. Based on ROC, optimal PPST cutoff for CPSP was 2 (63.9% sensitivity, 64.7% specificity). CPSP risk was high (48.94% risk) if PPST ≥ 2 (n = 47) and medium (22.81%) if PPST < 2 (n = 57) after spine/pectus surgery. General and risk-strata specific, targeted psychosocial non-pharmacological interventions, need to be studied. Findings need validation in diverse, larger cohorts. CLINICALTRIALS.GOV IDENTIFIER: NCT02998138. PERSPECTIVE: The article supports Pediatric Pain Screening Tool, a simple 9-item questionnaire, as a preoperative screening tool for CPSP and function 6-12 months after spine/pectus surgeries. PPST measures correlate with known risk factors for CPSP. Risk stratification and targeted preventive interventions in high-risk subjects are proposed.

ICD-11 Classification of Pediatric Chronic Pain Referrals in Ireland, with Secondary Analysis of Primary vs Secondary Pain Conditions

Objective

To classify pediatric chronic pain referrals in Ireland according to the classification system of the 11^th version of the International Classification of Diseases (ICD-11). In addition, differences between primary and secondary pain groups were assessed.

Methods

Retrospective review of complex pain assessment forms completed at the time of initial attendance at pediatric chronic pain clinics in Dublin, Ireland. Patients were classified as having a chronic primary (CPP) or chronic secondary (CSP) pain condition as per ICD-11 classification. Secondary analysis of between-group and within-group differences between primary and secondary pain conditions was undertaken.

Results

Of 285 patients coded, 123 patients were designated as having a CPP condition (77% of whom were assigned an adjunct parent code) and 162 patients as having a CSP condition (61% of whom were assigned an adjunct parent code). Between-group comparisons found that the lowest reported pain scores were higher in CPP than in CSP conditions. There were stronger correlations between parental pain catastrophizing and pain intensity, school attendance, and pain interference with social activities in the CSP group than in the CPP group.

Conclusions

The majority of children with both CPP and CSP were assigned multiple parent codes. There appears to be a gradient in the differences in biopsychosocial profile between CPP and CSP conditions. Additional field testing of the ICD-11 classification in pediatric chronic pain will be required.

Risk and Resilience Predictors of Recovery After Spinal Fusion Surgery in Adolescents

OBJECTIVE

This prospective study examined risk and resilience predictors of pain and functional recovery in the first 6 months after spinal fusion surgery in adolescents.

METHODS

Adolescents with adolescent idiopathic scoliosis undergoing spinal fusion surgery (n=100, aged 12 to 18 y, 77% girls) completed assessments before surgery and at 3 weeks, 6 weeks, and 6 months after surgery. Recovery trajectories in pain, health-related quality of life (HRQOL), and objectively registered physical activity were identified. Presurgical pain catastrophizing and pain intensity (risk), and psychological flexibility, and postsurgical pain acceptance (resilience) were examined as predictors of recovery.

RESULTS

Latent growth class analyses revealed 4 distinct pain recovery trajectories (ie, Severe-Moderate [11%, n=9], Mild-No [58%, n=49], Moderate-Mild [24%, n=20], and Moderate-Severe [7%, n=6] pain trajectory), 2 HRQOL recovery trajectories; 2 trajectories characterizing recovery in average daily physical activity at moderate-to-vigorous intensity (MVPA); and 3 trajectories characterizing recovery in total physical activity volume characterized by the average daily number of steps. Subsequent multivariate analyses of variance revealed that presurgical pain intensity (partial η2=0.21, P<0.001) and pain catastrophizing (partial η2=0.13, P<0.01) were both predictive of poorer recovery in HRQOL, and pain catastrophizing additionally predicted poorer pain recovery (partial η2=0.15, P<0.05). Psychological flexibility (partial η2=0.25, P<0.001) and postsurgical pain acceptance (partial η2=0.07, P<0.05) were predictive of more favorable recovery trajectories in HRQOL, and psychological flexibility additionally predicted more favorable recovery trajectories in postsurgical pain (partial η2=0.15, P<0.05). Daily MVPA trajectories were not significantly predicted by any of the hypothesized factors, while presurgical pain catastrophizing levels were predictive of a delayed recovery trajectory in the daily amount of steps (partial η2=0.17 P<0.01).

CONCLUSIONS

Presurgical screening could include assessment of pain intensity, pain catastrophizing, psychological flexibility, and pain acceptance to identify adolescents who are at risk for poorer recovery. These are potentially modifiable factors that can be targeted in presurgical interventions to prevent poor and foster adaptive outcomes after major surgery in adolescents.

Predictors and Consequences of Pediatric Pain Symptom Trajectories: A 14-Year Longitudinal Study

OBJECTIVE

The present study had three primary objectives. First, pain trajectory from early childhood to early adolescence were modeled. Second, we examined how early childhood individual-, parental-, and family-level factors predict pain trajectories. Third, we evaluated consequences of pain trajectories in terms of anxiety and depressive symptoms, and substance use at age 16 years.

DESIGN

The current paper is a secondary data analysis of a multisite longitudinal study. A total of 731 children and their families were followed from ages 2 to 16 years.

METHODS

A growth mixture model (GMM) was used to identify pain trajectories from ages 2 to 14 years.

RESULTS

The GMM revealed three distinct pain trajectories: (1) Low Pain Symptom (n = 572); (2) Increasing Pain Symptom (n = 106); and (3) U-shaped Pain Symptom (n = 53). Children who experienced greater harsh parenting and sleep disturbances in early childhood were more likely to belong to the Increasing Pain Symptom group, and those with greater anxious-depressed symptoms at age 2 years were more likely to belong to the U-shaped Pain Symptom group than the Low Pain Symptom group. Additionally, those youth in the Increasing Pain Symptom group, compared to the Low and U-shaped Pain Symptom groups, showed elevated anxiety symptoms at age 16 years.

CONCLUSIONS

Reducing harsh parenting and children's sleep disturbances could be important targets for preventing pediatric pain problems. Children with increasing pain symptoms may also benefit from learning adaptive pain management skills to lower the risk of developing anxiety problems in late adolescence.

A multicenter study to evaluate the pharmacokinetics and safety of liposomal bupivacaine for postsurgical analgesia in pediatric patients aged 6 to less than 17 years (PLAY)

STUDY OBJECTIVE

To evaluate the pharmacokinetics and safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery.

DESIGN

Multicenter, open-label, phase 3, randomized trial (PLAY; NCT03682302).

SETTING

Operating room.

PATIENTS

Two separate age groups were evaluated (age group 1: patients 12 to <17 years undergoing spine surgery; age group 2: patients 6 to <12 years undergoing spine or cardiac surgery).

INTERVENTION

Randomized allocation of liposomal bupivacaine 4 mg/kg or bupivacaine hydrochloride (HCl) 2 mg/kg via local infiltration at the end of spine surgery (age group 1); liposomal bupivacaine 4 mg/kg via local infiltration at the end of spine or cardiac surgery (age group 2).

MEASUREMENTS

The primary and secondary objectives were to evaluate the pharmacokinetics (eg, maximum plasma bupivacaine concentrations [C_max], time to C_max) and safety of liposomal bupivacaine, respectively.

MAIN RESULTS

Baseline characteristics were comparable across groups. Mean C_max after liposomal bupivacaine administration was lower versus bupivacaine HCl in age group 1 (357 vs 564 ng/mL); mean C_max in age group 2 was 320 and 447 ng/mL for spine and cardiac surgery, respectively. Median time to C_max of liposomal bupivacaine occurred later with cardiac surgery versus spine surgery (22.7 vs 7.4 h). In age group 1, the incidence of adverse events (AEs) was comparable between liposomal bupivacaine (61% [19/31]) and bupivacaine HCl (73% [22/30]). In age group 2, 100% (5/5) and 31% (9/29) of patients undergoing spine and cardiac surgery experienced AEs, respectively. AEs were generally mild or moderate, with no discontinuations due to AEs or deaths.

CONCLUSIONS

Plasma bupivacaine levels following local infiltration with liposomal bupivacaine remained below the toxic threshold in adults (~2000-4000 ng/mL) across age groups and procedures. AEs were mild to moderate, supporting the safety of liposomal bupivacaine in pediatric patients undergoing spine or cardiac surgery. Clinical trial number and registry URL: ClinicalTrials.gov identifier: NCT03682302.

Perceived Injustice Is Associated With Pain-related Function and Mood in Youth With Acute Musculoskeletal Pain

OBJECTIVES

Perceived injustice (PI), which is one's appraisal of justice or fairness regarding the pain experience, is an emerging area of interest in pediatric pain research. No previous studies have investigated PI in youth with acute pain. To fill this gap, this study examined (1) associations among PI, pain-related function, and psychological function in treatment-seeking youth with acute musculoskeletal (MSK) pain, and (2) the impact of parent-child PI discordance on children's pain and psychosocial function.

MATERIALS AND METHODS

Participants were youth (aged 11 to 17, 55% male) with acute pain (onset <1 mo) recruited from emergency departments or outpatient clinics and participating parents (102 parent-child dyads). Dyads completed study questionnaires within 1 month of the child's pain onset.

RESULTS

Youth-reported PI was significantly correlated with poorer physical and psychosocial quality of life, higher pain catastrophizing, higher fear of pain, increased pain-related disability, and greater depression and anxiety. Furthermore, PI was significantly associated with the physical quality of life, psychosocial quality of life, and pain-related disability. Moreover, discordance in youth and parent ratings of PI was associated with children's psychological and pain-related function. Specifically, compared with Concordant dyads, youth in the Discordant dyads (youth high PI/parent low PI) reported significantly poorer physical quality of life, psychosocial quality of life, higher pain-related disability, depression, anxiety, and pain catastrophizing.

DISCUSSION

These findings reveal that PI in youth with acute MSK pain is associated with quality of life and pain-related disability. Furthermore, results highlight the importance of discordance between youth and parent reports of PI on pain-related functioning.

A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPalTM): study protocol for a multisite randomized controlled trial

BACKGROUND

Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPalTM) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery.

METHODS

Adolescents 12-18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPalTM or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery.

DISCUSSION

Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery.

TRIAL REGISTRATION

NCT04637802 ClinicalTrials.gov. Registered on November 20, 2020.

Parental Psychosocial Factors Moderate Opioid Administration Following Children's Surgery

BACKGROUND

This investigation aimed to examine the impact of parental psychosocial variables on the administration of opioids to young children experiencing postoperative pain.

METHODS

Participants in this longitudinal analysis were children ages 2-12 undergoing tonsillectomy with or without adenoidectomy and their parents. Parents completed validated instruments assessing trait anxiety, perceived stress, and coping style before surgery, and children and parents completed instruments assessing pain and administration of opioids and acetaminophen on days 1, 2, 3, and 7 at home after surgery. The structure of the data was such that parents and children completed multiple data assessments making the data multilevel (ie, days of data within dyads). To address this issue of data structure, multilevel modeling was used to analyze the dataset.

RESULTS

Participants included 173 parent-child dyads (mean child age = 5.99 ± 2.51) recruited between 2012 and 2017. We found that parent-related psychosocial variables, such as trait anxiety, stress, and coping style, moderated the relationship between the child's pain and postoperative medication administration. Specifically, when predicting hydrocodone, the interactions between anxiety and pain and stress and pain were significant; when child pain was high, high-anxiety and high-stressed parents gave their children 19% and 12% more hydrocodone, respectively, compared to low-anxiety and low-stressed parents. When predicting acetaminophen, the interactions between anxiety and pain, a blunting coping style and pain, and a monitoring coping style and pain were significant.

CONCLUSIONS

These results suggest the need to identify parents who experience high levels of perceived stress and trait anxiety and use appropriate interventions to manage stress and anxiety. This may ensure children receive optimal amounts of pain medication following surgery.