Version May 2024
INTRODUCTION — Perioperative pain control is an essential component of the anesthetic plan for infants and children. Inadequately treated pain, even in infants, may have both short-term and long-term deleterious effects [1]. Parents rightfully expect care providers to mitigate their child's experience of pain to the extent that is possible. Establishing an appropriate level of patient and parent expectation that is safely achievable prior to the procedure may help allay anxiety and improve their understanding of contemporary pain management.
This topic will discuss evaluation of perioperative pain and a general approach to management in infants older than one month of age and in children. Pharmacologic options for perioperative pain management in these children are discussed separately. (See "Pharmacologic management of acute perioperative pain in infants and children".)
Evaluation and management of pain in neonates, and the effects of untreated pain in neonates, are discussed separately. (See "Management and prevention of pain in neonates" and "Assessment of pain in neonates".)
ASSESSMENT OF PAIN THROUGHOUT THE DEVELOPMENTAL CONTINUUM — Assessment and management of pain in children is complicated by the developmental changes that occur from the neonatal period through puberty. It may be challenging to distinguish pain from other sources of discomfort, and to measure its intensity, quality, or location. Self-report of pain remains the gold standard, but in children we must often interpret non-verbal signals of discomfort.
●Assessment of pain severity is necessary to determine the intervention that is required and to evaluate its efficacy.
●Pain localization may be aided by having the child point to the site of pain by using a cartoon image or doll, especially if they are not willing or able to communicate verbally. Often the major site of discomfort is a sore throat following intubation, the IV or other catheter, tape or a bandage, and not the surgical site itself.
●Differentiating pain from other causes of distress may be challenging in patients who are not verbally communicative. Other causes of discomfort that should be ruled out include wetness, cold, hunger, poor positioning, or need for caregiver contact. The parent or other caregiver of a non-verbal child may provide valuable insight on the child's usual pain behaviors.
●Importantly, emergence delirium may be difficult to distinguish from pain in a child who is inconsolable in the immediate postoperative period, particularly for preschool-age children who have received a potent inhaled anesthetic (eg, sevoflurane). Emergence delirium is discussed separately. (See "Emergence delirium and agitation in children".)
Examples of tools that may be used to assess pain in children are provided (table 1 and form 1 and figure 1). Assessment of pain in neonates and children is discussed in detail separately. (See "Pain in children: Approach to pain assessment and overview of management principles" and "Management and prevention of pain in neonates".)
GENERAL APPROACH TO ACUTE PEDIATRIC PAIN MANAGEMENT — The approach to acute pain management in children is similar to the approach in adults, and consists of a multimodal opioid-sparing strategy appropriate for the expected degree and duration of pain.
Goals for pain management — Establishing a tolerable degree of pain is mandatory, but the true goal is functional recovery, not a specific pain score. For children, functional recovery may include the ability to mobilize; eat and drink as appropriate; achieve normal bowel and bladder function; participate in physical, occupational and respiratory rehabilitation; engage in play or concentrate on school work; and return to a restorative sleep wake cycle.
Both pain assessment and treatment must be age- and development-specific, and must include the educated involvement of the child's caregivers, with expectations established.
Multimodal pain control — Nonpharmacologic therapies discussed below should be used for all patients when appropriate, and may reduce the need for medications. (See 'Start with nonpharmacologic therapy' below.)
Other therapeutic options, which are often used in combination, may include topical or local anesthetic patches and neuraxial or regional anesthesia techniques in addition to non-opioid and/or opioid systemic medications. (See "Pharmacologic management of acute perioperative pain in infants and children".)
Opioid avoidance — An overarching principle of pain management in both children and adults is to avoid the excessive use of perioperative opioids. Opioids are associated with short-term side effects (ie, respiratory depression, excessive sedation, nausea and vomiting, pruritus, urinary retention, constipation) and long-term adverse effects (ie, tolerance, dependence, opioid induced hyperalgesia or withdrawal upon conclusion of therapy) and in older children and adolescents, possible opioid misuse [2].
CREATING A PLAN FOR PERIOPERATIVE ANALGESIA — The plan for perioperative analgesia must necessarily be based on the procedure and expected degree of postoperative pain. However, individual patient characteristics and surgical procedures vary widely, and the degree of pain after surgery may be difficult to predict. Thus, the plan for analgesia must be flexible, tailored to the patient, and guided by ongoing assessment of treatment effect. Any multimodal analgesic protocol should serve as a checklist only, and should be modified to meet the needs of the individual patient, considering patient comorbidities, staffing and institutional resources, the available medication formulary, and the clinical environment [3-6]. A primary goal of perioperative pain management is to have the child comfortable upon awakening from anesthesia, with a smooth transition from post-anesthesia care to the surgical unit or home [7].
Start with nonpharmacologic therapy — Nonpharmacologic methods of pain control are low risk and may reduce the need for analgesic medication.
Preemptive behavioral therapy — Children with preoperative anxiety may be predisposed to increased postoperative pain and postoperative behavioral problems [8-10]. Preoperative patient and family education as well as psychological preparation may decrease preoperative anxiety and increase patient and caregiver satisfaction, but it is unclear whether such preparation reduces postoperative pain. Prevention of preoperative anxiety, including premedication and parental presence, is discussed separately. (See "General anesthesia in neonates and children: Agents and techniques", section on 'Prevention and treatment of preoperative anxiety'.)
Many centers have preoperative protocols designed to familiarize patients and their families with the perioperative environment and provide realistic information about expected pain and treatment options. In our experience, such accurate expectation management is a key determinant of patient and parent satisfaction as well as compliance with postoperative rehabilitation and pain management programs.
Procedure specific enhanced recovery protocols that include preoperative preparation are increasingly used in adult surgical patients [11,12], and are beginning to be studied in children. The effect of enhanced recovery protocols on postoperative analgesia in children remains to be elucidated. In one single institution retrospective study of 72 children who underwent spinal fusion for scoliosis, perioperative outcomes were evaluated before and after implementation of a multidisciplinary perioperative protocol [13]. Patients who were treated with the protocol used patient-controlled opioid analgesia for a shorter period of time than those who were not enrolled in the protocol. However, the total postoperative opioid consumption (IV and oral) and postoperative pain scores were similar between groups.
Other nonpharmacologic options for pain control — Other nonpharmacologic options include swaddling, skin-to-skin contact, aroma therapy, application of warm or cold compresses, massage, elevation, rest or immobilization of an extremity, and careful positioning. Behavioral options for older children include cognitive techniques, distraction, visualization, and focused breathing. Child life involvement and use of expressive therapies during recovery such as art and music may also decrease anxiety and hence may influence pain perception. Newer modalities such as virtual reality and augmented reality programs are also being investigated.
Pharmacologic therapy based on expected degree of pain — In addition to nonpharmacologic therapy, most children who have surgery will require analgesic medications as well. An approach to the use of medications for perioperative pain management based on the expected degree of pain is described here, with representative examples of our usual strategies. These should not be regarded as the only acceptable approaches, and should be modified based on patient factors. Doses and further information about these therapeutic options are discussed separately. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Systemic analgesics'.)
Mild pain — Mild postoperative pain can usually be managed with multimodal analgesia without the use of postoperative opioids. Mild pain is expected after many ambulatory procedures, including dental extractions, diagnostic procedures (eg, percutaneous biopsy), and myringotomy.
Example: myringotomy — As an example, our usual strategy for analgesia after myringotomy is as follows:
●Preoperative – Oral acetaminophen, distraction to allay anxiety (table 2)
●Intraoperative – Acetaminophen (if not given preoperatively), IV nonsteroidal antiinflammatory drugs (NSAIDs) with or without low dose fentanyl, dexmedetomidine
●Postoperative – Regularly scheduled acetaminophen, ibuprofen as needed
The uses of these medications for perioperative pain are discussed separately:
Moderate pain — Most laparoscopic and soft tissue surgeries are expected to result in at least moderate postoperative pain. In addition to nonpharmacologic analgesic measures and nonopioid analgesic adjuvants, local or regional analgesia may provide adequate analgesia. A short course of postoperative opioids may be required, particularly if regional analgesia is not possible.
Tonsillectomy causes moderate to severe pain for many children. Analgesia for tonsillectomy is discussed separately. (See "Anesthesia for tonsillectomy with or without adenoidectomy in children", section on 'Analgesia' and "Tonsillectomy (with or without adenoidectomy) in children: Postoperative care and complications", section on 'Pain'.)
Example: hernia repair — As an additional example, our strategy for pain control for inguinal hernia repair is as follows:
●Preoperative – Acetaminophen
●Intraoperative
•Local anesthetic wound infiltration and/or ilioinguinal/iliohypogastric nerve blocks
•IV acetaminophen if not given preoperatively, ketorolac, dexmedetomidine
●Postoperative – Regularly scheduled alternating ibuprofen and acetaminophen, each dosed every six hours, so that one or the other drug is administered every three hours for the first 24 hours. After 24 hours, ibuprofen or acetaminophen as needed.
The uses of these medications and nerve blocks for perioperative pain are discussed separately.
Severe pain — Severe pain can be expected after open abdominal surgery, thoracotomy, and most orthopedic procedures. Regional analgesia techniques should be used whenever possible (either single shot techniques or continuous infusions) supplemented by nonopioid analgesics and nonpharmacologic measures. If continuous regional analgesia is not possible or is ineffective, intravenous opioids are usually required postoperatively. Patients may require oral opioids on discharge from the hospital. As examples, our strategy for scoliosis surgery is as follows:
Example: scoliosis surgery (adolescent idiopathic)
●Preoperative – Acetaminophen, gabapentin
●Intraoperative
•Opioid (eg, morphine, fentanyl, hydromorphone, or remifentanil, depending on anesthetic preference and technique) (table 3)
•Acetaminophen IV six hours after preoperative dose; if no preoperative dose was administered, IV dose one hour before the end of surgery
●Postoperative
•Acetaminophen, regularly scheduled for 48 to 72 hours, then as needed.
•NSAIDs – Regularly scheduled ketorolac every six hours starting approximately 12 hours after completion of surgery and after ensuring adequate volume status and control of bleeding, 12 scheduled doses, then as needed ketorolac or ibuprofen, beginning six hours after the last scheduled dose of ketorolac.
•Patient-controlled opioid analgesia (PCA), started in the recovery area, discontinued once the patient tolerates oral liquid and has been mobilized (table 4). (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Patient-controlled analgesia in children'.)
•Oxycodone orally – Once PCA has been discontinued (usually by the afternoon of postoperative day 1), oxycodone on either a scheduled or as needed basis, for breakthrough pain or one half hour prior to physical therapy (table 5). (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Oral opioids'.)
•Diazepam at reduced dose while on opioid, if needed for spasm. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Dosing precautions'.)
•Senna and docusate prophylaxis for opioid-induced constipation as soon as oral medication is tolerated (table 6). (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Prevention and treatment of opioid-related side effects'.)
●After discharge
•Acetaminophen and ibuprofen, regularly scheduled.
•Oxycodone five to seven day course. (See "Pharmacologic management of acute perioperative pain in infants and children", section on 'Postdischarge analgesia with opioids'.)
CHRONIC POST SURGICAL PAIN — Chronic postsurgical pain (CPSP) is increasingly recognized in children. Extensive surgical procedures, such as scoliosis repair or videoscopic pectus excavatum repair, may be [14] associated with significant persistent pain in some children necessitating psychologic and physical therapy intervention. In some cases, longer-term nonopioid analgesics medications may be needed.
Another phenomenon called anterior nerve entrapment syndrome (ACNES), has occasionally been described after minor trauma or abdominal surgery. The pain is highly localized to the anterior abdominal wall and may be a consequence of either inflammation or nerve entrapment during surgical procedures and may respond to local anesthetic nerve blocks [15].
For both of these entities, there may be specific functional and psychosocial factors that can identify patients at risk and guide treatment [16]. CPSP and ACNES are best managed by pediatric pain management specialists.
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Acute pain management".)
SUMMARY AND RECOMMENDATIONS
●Pain assessment and goals
•Assessment of postoperative pain in young children may be challenging. Pain must be distinguished from other causes of discomfort (eg, hunger, wetness, cold, poor positioning, need for caregiver contact) and from emergence delirium. (See 'Assessment of pain throughout the developmental continuum' above.)
•The goal for pain control is functional recovery, rather than a specific pain score, while achieving a tolerable degree of pain. (See 'Goals for pain management' above.)
●Multimodal opioid sparing approach
•The approach to acute pain management in children consists of a multimodal opioid sparing strategy appropriate for the expected degree and duration of pain. An overarching principle of pain management is to avoid the excessive use of opioids. (See 'Opioid avoidance' above and 'Multimodal pain control' above.)
•Age appropriate nonpharmacologic pain control therapy should be used for all patients. (See 'Creating a plan for perioperative analgesia' above.)
●Strategy based on expected degree of pain
•Mild postoperative pain (eg, after dental extraction, percutaneous biopsy, myringotomy) can usually be managed with multimodal analgesia without the use of postoperative opioids. (See 'Mild pain' above.)
•For moderate postoperative pain, in addition to nonpharmacologic analgesic measures and nonopioid analgesic adjuvants, local or regional analgesia may provide adequate analgesia. A short course of postoperative opioids may be required, particularly if regional analgesia is not possible. Moderate pain should be expected after most laparoscopic and soft tissue surgeries (eg, tonsillectomy, hernia repair). (See 'Moderate pain' above.)
•For severe postoperative pain (eg, after open abdominal or orthopedic surgery), regional analgesia techniques should be used whenever possible, supplemented by nonopioid analgesics and nonpharmacologic measures. If continuous regional analgesia is not possible or is ineffective, intravenous opioids are usually required postoperatively, and patients may require oral opioids on discharge from the hospital. (See 'Severe pain' above.)
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