Pain after discharge following head and neck surgery in children

Efficacy of the Subtenon Block in Children Undergoing Strabismus Surgery: A Systematic Review and Meta-Analysis

PURPOSE

To investigate the efficacy of the subtenon block in preventing postoperative complications in children undergoing strabismus surgery.

DESIGN

Systematic review and meta-analysis.

METHODS

We searched the Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, Scopus, Web of Science, and clinicaltrials.gov. All randomized controlled trials investigating the efficacy of the subtenon block in children undergoing strabismus surgery were included. Outcomes included severity of pain after surgery, number of children requiring postoperative opioid and nonopioid analgesia, and the incidences of postoperative nausea and vomiting, oculocardiac events, and block-related complications. We pooled continuous outcomes using a random-effects model to calculate the mean difference (MD) and/or standardized MD and corresponding 95% confidence intervals (CI). Dichotomous outcomes were pooled using a random-effect model to calculate the relative risk (RR) and corresponding 95% CI. Risk of bias was assessed using the Cochrane Risk of Bias instrument and quality of evidence was assessed using a Grading of Recommendations Assessment, Development, and Evaluation approach.

RESULTS

Nine randomized controlled trials (607 participants) were included. We found evidence for an effect of the subtenon block in reducing pain at 20 to 40 minutes after surgery (MD -1.9, 95% CI -2.2 to -1.5; high-quality evidence) and on admission to PACU (MD -1.8, 95% CI -2.2 to -1.4; moderate-quality evidence); however, there was no difference in pain scores at 6 hours after surgery. In addition, evidence was found that the subtenon block decreased the number of children requiring postoperative opioid (RR 0.59, 95% CI 0.37-0.92; high-quality evidence) and nonopioid (RR 0.52, 95% CI 0.27-0.98; moderate-quality evidence) analgesia, and the incidences of postoperative vomiting (RR 0.31, 95% CI 0.12-0.7; high-quality evidence) and intraoperative oculocardiac events (RR 0.40, 95% CI 0.26-0.60; high-quality evidence). Other secondary outcomes had low or moderate-quality evidence. Risk of bias was low in six trials and high in three. There were no reports of block-related complications.

CONCLUSIONS

Our findings suggest that the subtenon block reduces the severity of early postoperative pain and the incidences of postoperative vomiting and intraoperative oculocardiac events compared with controls in children undergoing strabismus surgery.

REVIEW REGISTRATION

PROSPERO (CRD42015025443).

The use of honey in the perioperative care of tonsillectomy patients-A narrative review

Tonsillectomy is one of the most common surgical procedures in childhood. While generally safe, it often is associated with a difficult early recovery phase with poor oral intake, dehydration, difficult or painful swallowing, postoperative bleeding, infection and/or otalgia. Better pain management and the availability of more child friendly medications are within the top consumer priorities in perioperative medicine, highlighting the importance of alternative pain treatments. This review focuses on the potential role of honey in the postoperative setting, its effects, and mechanisms of action. While the application of honey post-tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. A systematic search was carried out using the search terms honey, tonsillectomy. Filters were applied to human studies and English. No other search terms were used or age filters applied to yield a broader range of results. Seven pediatric, four adult, and two studies of mixed pediatric and adult patients with sample sizes ranging from 8 to 52 patients were included in this review. Effect sizes ranged from small to huge across the studies. While the application of honey post-tonsillectomy may offer analgesic and healing benefits, it may also reduce postoperative bleeding. However, while there are potential benefits based on the chemical composition of honey, the current literature is of variable quality and there is need for high quality clinical trials.

Updating Clinical Practice: Improving Perioperative Pain Management for Adeno-Tonsillectomy in Children

BACKGROUND/OBJECTIVE

Perioperative acute pain management in pediatric patients is essential to reduce complications. Adenoidectomy-Tonsillectomy are surgical procedures requiring pain control, and risk minimization for postoperative bleeding, nausea, and vomiting. Despite their known secondary effects, the use of opioid analgesics is still preponderant in pediatric perioperative management. We performed a comprehensive review on adeno-tonsillectomy perioperative pain management in children. We developed and implemented a multimodal analgesia protocol aimed to improve patients' pain management while consistently reducing opioids use.

METHODS/RESULTS

relevant Information was summarized, then compared to our clinical needs. Learnings were used to create and implement a multimodal analgesia protocol that we use in patients 3-9 years-old undergoing adenoidectomy/tonsillectomy. The full protocol is presented. Analgesic strategies have emerged to reduce or avoid the use of opioids. Among these strategies, combining different non-opioid analgesics (Ibuprofen, Paracetamol, Metamizole) has been shown to be an effective and safe pharmacological strategy when implemented as part of perioperative multimodal analgesia protocols. Considerable evidence associating the use of NSAIDs with a bigger risk of postoperative bleeding does not exist.

CONCLUSIONS

Perioperative management of adenotonsillectomy pain should include preventive and multimodal analgesia, which have shown to provide significantly more effective analgesia than some opioid regimens. Ibuprofen offers highly effective analgesia for postoperative pain, particularly when combined with acetaminophen.

Jelly snakes to reduce early postoperative vomiting in children after adenotonsillectomy: The randomized controlled snakes trial

BACKGROUND

Despite the use of dual antiemetic agents, postoperative nausea and vomiting (PONV) occurs in an unacceptably large number of patients post-tonsillectomy. There has been increased interest in alternative and non-pharmacological treatments for PONV e.g., chewing gum. We investigated if chewing a large confectionary jelly snake had prophylactic antiemetic effects postoperatively in young children.

METHODS

Prospective, open-label randomised controlled trial of 240 patients, 2-16 years. Patients administered a confectionary jelly snake to chew postoperatively were compared with a control group. The primary outcome was the number of episodes of vomiting within 6 h of the operation on an intention-to-treat basis.

SECONDARY OUTCOMES

incidence of nausea, vomiting at 6 and 24 h, rescue antiemetic use, acceptability, delayed discharge.

RESULTS

233 patients were randomised to receive the confectionary snake (snake group, 118) or standard care (control group, 115). The number of vomiting episodes in 6 h was similar between groups on an intention-to-treat basis, with 39 episodes across 22 (19%) patients in the control group and 31 across 19 (16%) patients in the snake group (p = 0.666). From post anaesthetic care unit until 24 h there was no difference in doses of antiemetics or delayed discharge due to PONV. A secondary as per protocol analysis did not change this result.

CONCLUSIONS

Chewing of confectionery jelly snakes within one hour of waking following adenotonsillectomy with vapour-maintained anaesthesia and two prophylactic antiemetics did not further reduce the incidence of early vomiting.

REGISTRATION

prospective registration at the Australia and New Zealand Clinical Trials Registry (ACTRN12618000637246).

Paediatric post-discharge pain and parent perceptions of support from an Australian nurse practitioner led acute pain service

Poorly managed post-operative pain remains an issue for paediatric patients. Post-discharge telephone follow-up is used by an Australian Nurse Practitioner Acute Pain Service (NpAPS) to provide access to effective pain management post-discharge from hospital. This cross-sectional survey design study aimed to determine the pain levels of children following discharge and parent views on participation in their child's pain management and perceptions of support from the NpAPS. Parents completed the Parents' Postoperative Pain Measure-Short Form (PPPM-SF) and factors affecting parents' participation in children's pain management questionnaire (FPMQ). Results indicated that pain score was high, especially on the day of discharge and 24 hours post-discharge. Parents, despite feeling supported by the NpAPS, experienced uncertainty, emotional responses and expressed concerns about communication and coordination of care. The clinically significant pain levels of the majority of children on the day of discharge and day post-discharge from hospital are a concern. Worry and uncertainty among parents, particularly on the day and first night of discharge, suggest this transition period where responsibility of clinical management of pain is handed over to parents may require greater focus for parental support.

Effect of post-operative oral steroids on bleeding rate after pediatric tonsillectomy

PURPOSE

In 2013, the FDA placed a black box warning on the usage of opioid pain medications in the post-operative setting after pediatric adenotonsillectomy. Since then, alternative pain management regimens have been employed. Some have advocated for post-operative oral steroids, in part due to the effectiveness of intraoperative intravenous steroids in reducing post-operative pain and nausea. The evidence regarding the efficacy and safety of post-operative oral steroids is not as clear. The purpose of this study was to examine whether post-tonsillectomy hemorrhage rates in pediatric patients were affected by post-operative oral steroid usage.

MATERIALS AND METHODS

Case-control retrospective chart review using a deidentified data set of patients undergoing tonsillectomy with or without adenoidectomy at a single academic medical center between June 2012 and November 2015.

RESULTS

A total of 1416 patients were included in the study, with 704 in the no post-operative oral steroids group and 712 in the group who did receive post-operative oral steroids. The rate of post-tonsillectomy hemorrhage in the post-operative oral steroid group was 3.1 % compared to 1.8 % in the group who did not receive post-operative oral steroids, however, this was not a statistically significant difference (P = .132).

CONCLUSIONS

Our study suggests that post-operative oral steroids are safe and do not increase the risk of post-operative hemorrhage after pediatric tonsillectomy.

Remote after-care using smartphones: A feasibility study of monitoring children's pain with automated SMS messaging

BACKGROUND

Monitoring children's recovery postoperatively is important for routine care, research, and quality improvement. Although telephone follow-up is common, it is also time-consuming and intrusive for families. Using SMS messaging to communicate with families regarding their child's recovery has the potential to address these concerns. While a previous survey at our institution indicated that parents were willing to communicate with the hospital by SMS, data on response rates for SMS-based postoperative data collection is limited, particularly in pediatric populations.

AIMS

We conducted a feasibility study with 50 completed pain profiles obtained from patients at Perth Children's Hospital to examine response rates.

METHODS

We collected and classified daily average pain (0-10 parent proxy score) on each day after tonsillectomy until pain-free for two consecutive days.

RESULTS

We enrolled 62 participants and recorded 50 (81%) completed pain profiles, with 711 (97.9%) of 726 requests for a pain score receiving a response. Two families (3%) opted out of the trial, and 10 (16%) were lost to follow-up. Responses received were classified automatically in 92% of cases. No negative feedback was received, with a median (range) satisfaction score of 5 on a 5-point Likert scale (1 = very unhappy, 5 = very happy).

CONCLUSIONS

This methodology is likely to generalize well to other simple clinical questions and produce good response rates in further similar studies. We expect SMS messaging to permit expanded longitudinal data collection and broader investigation into patient recovery than previously feasible using telephone follow-up at our institution.

Impact of a revised postoperative care plan on pain and recovery trajectory following pediatric tonsillectomy

BACKGROUND

A previous cohort of adenotonsillectomy patients at our institution demonstrated moderate-severe post-tonsillectomy pain scores lasting a median (range) duration of 6 (0-23) days and postdischarge nausea and vomiting affecting 8% of children on day 1 following surgery. In this subsequent cohort, we evaluate the impact of changes to our discharge medication and parental education on post-tonsillectomy pain and recovery profile.

METHODS

In this follow-on, prospective observational cohort study, all patients undergoing tonsillectomy at our institution during the study period were discharged with standardized analgesia. Parents received a revised education package and a medication diary which were not provided to the previous cohort. Pain scores, rates of nausea and vomiting, medication usage and unplanned representation rates were collected by telephone from parents.

RESULTS

Sixty-nine patients were recruited. Moderate-severe pain lasted a median (range) of 5 (0-12) days. Twenty-nine (42%) had pain scores ≥4/10 beyond postoperative day 7. By postoperative day 5, only 37 (53%) parents continued to administer regular analgesia. The median number of oxycodone doses used was 5 (0-22), and only 28 (41%) parents had disposed of leftover oxycodone within 1 month of surgery. Twenty-four (35%) patients experienced nausea or vomiting postdischarge. The median (range) time for return to normal activities was 6 (0-14) days. Thirty-two/sixty-nine (46%) patients had unplanned medical representations. Most occurred between postoperative day 5 and 7. Pain contributed to 16 (35%) representations.

CONCLUSIONS

Despite extensive changes to our discharge protocols parents continued to report a prolonged period of pain, post operative nausea and vomiting, and behavioral changes. Further work is required to examine barriers to compliance with simple analgesia and education in appropriate methods of opioid disposal.

Recovery After Adenotonsillectomy-Do Steroids Help? Outcomes From a Randomized Controlled Trial

OBJECTIVES

The primary objective was to compare pain control following adenotonsillectomy (AT) in children with and without a single postoperative dose of oral dexamethasone in addition to standard analgesic medication. The secondary objective was to compare changes in caregiver-reported snoring, return to normal diet and baseline function, and the number of phone calls and emergency department (ED) visits.

STUDY DESIGN

Prospective randomized controlled trial.

SETTING

Tertiary care university hospital.

METHODS

Children aged 3 to 10 years with sleep-disordered breathing who were scheduled to undergo AT were randomized to receive standard analgesia with or without dexamethasone (0.6 mg/kg) administered on the third postoperative day. Standard analgesia was defined as alternating weight-based doses of ibuprofen and acetaminophen. A nurse practitioner blinded to the study condition performed telephone surveys postoperatively, and the electronic medical record was reviewed.

RESULTS

Enrollment comprised 149 children, of whom 119 were included. When compared with the control group (n = 61, 51%), children who received dexamethasone (n = 58, 49%) had a greater decrease in reported pain score on day 4 (mean ± SD, 2.5 ± 3.1 vs 1.1 ± 3.5, P < .001). Additionally, steroid use was associated with fewer caregiver phone calls (18 [29.5%] vs 6 [10%]) and ED visits (6 [10%] vs 1 [2%]).

CONCLUSION

A single dose of dexamethasone administered on day 3 after adenotonsillectomy significantly improved pain control. There were fewer phone calls and ED visits in the steroid arm. These results support the use of oral steroids as an adjunct for postoperative pain control in children undergoing AT.

Parents' management of adolescent patients' postoperative pain after discharge: A qualitative study

Background: Short hospital admission periods following pediatric inpatient surgery leave parents responsible for managing their child’s postoperative pain in the community following discharge. Little is known about the experiences of parents caring for their child’s postoperative pain after discharge home following inpatient surgery. Research examining parental postoperative pain management following their child’s day surgery has found that parents are challenged in their pain management knowledge and practices.

Aims: This interpretative phenomenological analysis study sought to understand parents’ experiences caring for their child’s postoperative pain at home.

Methods: Semistructured telephone interviews were conducted with seven parents between 2 weeks and 6 months after their child’s discharge from hospital.

Results: Identified themes were coming home without support, managing significant pain at home, and changes in the parent–child relationship.

Conclusions: Parents could potentially benefit from nurses optimizing educational interventions, from receiving ongoing support of transitional pain teams, and from assistance with return to school planning.

Perioperative Analgesia in Pediatric Patients Undergoing Otolaryngologic Surgery

This article reviews the evidence regarding current perioperative pain management strategies in pediatric patients undergoing otolaryngologic surgery. Pediatric otolaryngology is a broad field with a wide variety of surgical procedures that each requires careful consideration for optimal perioperative pain management. Adequate pain control is vital to ensuring patient safety and achieving successful postoperative care, but many young children are limited in their capacity to communicate their pain experience. Current literature holds a disproportionate amount of focus on pain management for certain procedures, whereas there is a paucity of evidence-based literature informing most other procedures within the field.

Adolescent Patients' Management of Postoperative Pain after Discharge: A Qualitative Study

BACKGROUND

Adolescents are typically admitted for a short period of time after inpatient surgery, leaving much of their recovery to occur at home. Pain, and thus pain management, is a major component of recovery at home. Research among pediatric outpatient surgical patients has found that pain experienced in the community setting after discharge is often severe and is related to knowledge deficits resulting in inadequate pain management. However, there is little research on community pain management after inpatient surgery.

AIM

This study aimed to explore the pain experiences of seven adolescents who underwent inpatient surgery.

DESIGN

This study used Interpretative Phenomenological Analysis as a methodology.

SETTING

This study took place at a pediatric tertiary care hospital in Canada.

PARTICIPANTS

7 adolescents participated, all of whom underwent inpatient surgery with admission between 2-14 days in length.

METHODS

Semi-structured interviews were conducted 2 to 6 weeks post-discharge.

RESULTS

Three themes were identified that described their experiences, including managing severe pain at home with minimal preparation, changes in the parent-child relationship, and difficulties returning to school and regular activities.

CONCLUSIONS

Involving adolescents directly in discharge education, particularly with the use of novel interventions and coaching, may improve outcomes.

KEY PRACTICE POINTS

Adolescent patients experience significant pain after discharge from hospital after inpatient surgical procedures. Adolescents are in need of adolescent-specific pain management education to increase skill and knowledge and address pain management-related misconceptions. Greater emphasis on involving adolescents in their own pain care and novel intervention could prove useful in improving outcomes.

The Comparison between Microdebrider Assisted Adenoidectomy and Coblation Adenoidectomy: Analyzing the Intraoperative Parameters and Post-operative Recovery

Microdebrider adenoidectomy and Coblation adenoidectomy are the two new techniques available for adenoidectomy these days. The advantages of endoscopic power assisted adenoidectomy over cold steel adenoidectomy has been well established in the literature. As adenoidectomy is one of the most common paediatric surgical procedure there is always a concern to improve the outcomes and make postoperative experience more pleasant for the paediatric population. Cost difference between a coblator wand and microdebrider blade is always a confounding factor in decision making. The present study was conducted to compare both the techniques of adenoidectomy in terms of certain intraoperative and post operative parameters. The present study was a prospective randomized single blind study conducted in a university hospital on 140 subjects. The patients diagnosed with chronic adenoiditis grade 3-4 were randomly allocated in two groups after following the exclusion and inclusion criteria. the adenoidectomy in two groups; Microdebrider group and Coblation group were compared in terms of intraoperative time, post operative pain score; intraoperative bleeding, surgical field and some common complications. The data was analysed for significance by various statistical tests. The average adenoid size operated in both groups was Grade 3. The intraoperative time taken to complete the procedure in group A was 12.78 ± 3.8 min and in group B was 22 ± 3.3 min with p value < 0.05. There was statistically significant difference in grade of Intraoperative Bleeding in both groups with mean grade of intraoperative bleeding being 1.4 ± 1.04 in group B and 3.5 ± 0.9 in Group A. The surgical field was poor to average in 33 cases (n = 70) in group A as compared to only 1 case (n = 70) in group B; the difference being statistically significant. The average post-operative pain score was 2.69 ± 0.99 and 1.17 ± 1.1 after post-operatively 24 h and 72 h respectively in group B; 7.14 ± 0.99 and 4.08 ± 1.42 respectively in group A. The p value for the same was < 0.05. However there was no statistically significant difference between two groups in terms of any complications or completeness of removal. Though both the techniques are highly efficacious in adenoid removal and low complication rate in our study but still more studies with large sample size are encouraged to validate these results and establish the comparative efficacy of both the techniques in terms of the intraoperative parameters as well as post-operative recovery along with recurrence rates.

Psychometric evaluation of the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery and postoperative behavior and recovery in children undergoing tonsil surgery

The study comprised a prospective, comparative cross-sectional survey in 143 (of 390) children undergoing tonsil surgery. Parents answered the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery (PHBQ-AS), and children answered the questionnaire Postoperative Recovery in Children (PRiC). The PHBQ-AS had positive correlation with the PRiC and with general health. On day 10 after surgery, up to one-third of the children still reported physical symptoms (PRiC). No gender or age differences concerning the items of behavior (PHBQ-AS) were found. The quality of postoperative recovery (PRiC) in girls was lower, with higher levels of nausea, dizziness, coldness, and headache compared to the boys. Children <6 years of age reported higher levels of dizziness and lower sleep quality and lower general health.

Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative)

The main remit of the European Society for Paediatric Anaesthesiology (ESPA) Pain Committee is to improve the quality of pain management in children. The ESPA Pain Management Ladder is a clinical practice advisory based upon expert consensus to help to ensure a basic standard of perioperative pain management for all children. Further steps are suggested to improve pain management once a basic standard has been achieved. The guidance is grouped by the type of surgical procedure and layered to suggest basic, intermediate, and advanced pain management methods. The committee members are aware that there are marked differences in financial and personal resources in different institutions and countries and also considerable variations in the availability of analgesic drugs across Europe. We recommend that the guidance should be used as a framework to guide best practice.

Coblation versus microdebrider in pediatric adenoidectomy

OBJECTIVE

To compare and contrast coblation and microdebrider with touch-up electrocautery (ME) for adenoidectomy in children.

METHODS

Patients <18 years old undergoing adenoidectomy without tonsillectomy were selected for this prospective, single-blinded, randomized controlled trial. Participants were enrolled into one of two groups based on birth date: coblation or ME. The surgeons completed a standard survey about intraoperative factors for each method. Recovery nurses filled out a standardized survey postoperatively. A third standardized survey was completed via a phone interview with the parent or patient caregiver on postoperative day 3 to assess procedure outcomes. The survey results were then compared using ANOVA statistical analysis.

RESULTS

50 patients were enrolled in the coblation group and 51 were enrolled in the ME group. There was no significant difference in mean age between the coblation (4.96 years) and ME groups (4.58 years) (p = 0.525). The mean time (in minutes) for coblation (5.50) was significantly lower than ME (9.47) when controlling for the confounder: surgical site exposure (p < 0.001). The surgical time was significantly influenced by the quality of exposure/visualization (p = 0.037). The coblator method had significantly less intraoperative blood loss compared to ME (p < 0.001). There was a statistically significant difference between coblation (1.53) and ME (2.05) for days of pain (p = 0.045) when controlling for the confounder adenoid size.

CONCLUSION

In our study we found that coblation demonstrated significantly less intraoperative time and less blood loss, as well as a shorter duration of postoperative pain, when compared to ME for adenoidectomy.

A prospective audit of pain profiles following general and urological surgery in children

BACKGROUND

Postoperative pain is frequently undertreated in children both in hospital and at home following discharge. Pain has both short- and long-term consequences for children, their families, and the healthcare system. A greater understanding of procedure-specific postoperative pain trajectories is required to improve pain management.

AIM

To determine the duration and severity of acute postoperative pain experienced by children undergoing 8 different general and urological procedures (primary outcomes). Behavioral disturbance rates, nausea and vomiting scores, and parental satisfaction were also examined during the follow-up period (secondary outcomes).

METHOD

Families of children (0-18 years) undergoing common general and urological procedures were invited to enroll in the study. Children's pain scores, measured using a parental proxy 0-10 numerical rating scale, were collected by telephone interview until pain was resolved. Analgesia prescribed and given, behavioral disturbance, nausea and vomiting scores, the method of medication education communication, and parental satisfaction were also measured.

RESULTS

Of 360 patients recruited, 326 complete datasets were available. Patients underwent laparoscopic appendicectomy (57), open appendicectomy (19), circumcision (50), cystoscopy (52), hypospadias repair (22), inguinal hernia repair (51), orchidopexy (51), or umbilical hernia repair (24). Postoperative pain peaked on the day of or the day after surgery in all groups, and decreased over time. Pain lasted a median duration of 5 postoperative days following open appendicectomy, and 0-2 postoperative days for other procedures. Behavioral disturbance rates closely followed pain scores. Analgesia administration at home varied widely between and within groups.

CONCLUSION

Pain management was inadequate in most of the groups studied, particularly after appendicectomy or umbilical hernia repair, with most children experiencing at least moderate pain on the day of and day after surgery. There was a need for a standardized management, with increased dual analgesia prescribing, to ensure that children receive adequate postoperative analgesia in hospital and at home.

Ambulatory anesthetic care in children undergoing myringotomy and tube placement: current perspectives

PURPOSE

Myringotomy and tube placement is one of the most frequently performed ear, nose and throat (ENT) surgeries in the pediatric population. Effective anesthetic management is vital to ensuring successful ambulatory care and ensuring child and parental satisfaction.

RECENT FINDINGS

This review summarizes recently published studies about the long-term effects of general anesthesia in young children, novel approaches to preoperative fasting and simplified approaches to the assessment and management of emergence delirium (ED) and emergence agitation (EA). New developments in perioperative ambulatory care, including management of comorbidities and day care unit logistics, are discussed.

SUMMARY

Long-term follow-up of children exposed to general anesthesia before the age of 4 years has limited impact on academic achievement or cognitive performance and should not delay the treatment of common ENT pathology, which can impair speech and language development. A more liberal approach to fasting, employing a 6-4-0 regime allowing children fluids up until theater, may become an accepted practice in future. ED and EA should be discriminated from pain in recovery and, where the child is at risk of harm, should be treated promptly. Postoperative pain at home remains problematic in ambulatory surgery and better parental education is needed. Effective ambulatory care ultimately requires a well-coordinated team approach from effective preassessment to postoperative follow-up.