Jennifer A. Rabbitts

Prevalence of moderate-severe pain in hospitalized children

Background:  Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.

Presurgical psychosocial predictors of acute postsurgical pain and quality of life in children undergoing major surgery.

UNLABELLED Limited research has examined presurgical risk factors for poor outcomes in children after major surgery. This longitudinal study examined presurgical psychosocial and behavioral factors as predictors of acute postsurgical pain intensity and health-related quality of life (HRQOL) in children 2 weeks after major surgery. Sixty children aged 10 to 18 years, 66.7% female, and their parent/guardian participated in the study. Children underwent baseline assessment of pain (daily electronic diary), HRQOL, sleep (actigraphy), and psychosocial factors (anxiety, pain catastrophizing). Caregivers reported on parental pain catastrophizing. Longitudinal follow-up assessment of pain and HRQOL was conducted at home 2 weeks after surgery. Regression analyses adjusting for baseline pain revealed that presurgery sleep duration (β = -.26, P < .05) and parental pain catastrophizing (β = .28, P < .05) were significantly associated with mean pain intensity reported by children 2 weeks after surgery, with shorter presurgery sleep duration and greater parental catastrophizing about child pain predicting greater pain intensity. Adjusting for baseline HRQOL, presurgery child state anxiety (β = -.29, P < .05) was significantly associated with HRQOL at 2 weeks, with greater anxiety predicting poorer HRQOL after surgery. In conclusion, child anxiety, parental pain catastrophizing, and sleep patterns are potentially modifiable factors that predict poor outcomes in children after major surgery. PERSPECTIVE This study addresses an important gap in literature, examining presurgical risk factors for poorer acute postsurgical outcomes in children undergoing major surgery. Knowledge of these factors will enable presurgical identification of children at risk for poorer outcomes and guide further research developing prevention and intervention strategies for these children.

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

To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery.

Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012.

Abstract Prescription opioid misuse is a major public health concern in the United States, yet little is known about national prescription patterns. We aimed to assess trends in opioid prescriptions made to children and adolescents, to their families, and to adults in the United States from 1996 to 2012. The sample was drawn from nationally representative data, the Medical Expenditure Panel Surveys. We used survey design methods to examine trends in prescription opioid use over time and a logistic regression analysis to examine predictors associated with opioid use. Findings indicated that from 1996 to 2012 opioid prescriptions to children and adolescents remained stable and low. In 1996, 2.68% of children received an opioid prescription, and in 2012, 2.91% received an opioid prescription. In contrast, opioid prescriptions to family members of children and adolescents and adults in general significantly increased during this period. The most common opioid prescriptions to children and adolescents in 2012 were codeine, hydrocodone, and oxycodone. Using multivariate logistic regression models, the white non-Hispanic race, older age, health insurance, and parent-reported fair to poor general health were associated with higher rates of opioid prescriptions in children and adolescents. Our main finding was that although the rates of opioid prescriptions have increased among adults in the United States, the rates have not changed among children and adolescents. Recent epidemiologic association studies have identified a strong link between increased opioid prescriptions and increased rates of opioid misuse and abuse in adults. Future studies should assess the association between adult opioid prescriptions and children or adolescent opioid misuse.

Bidirectional associations between pain and physical activity in adolescents

Objectives:The objectives were to: (1) examine temporal relationships between pain and activity in youth, specifically, whether physical activity affects pain intensity and whether intensity of pain affects subsequent physical activity levels on a daily basis, and (2) examine clinical predictors of this relationship. Methods:Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12 to 18 years, 71% female. Adolescents completed 10 days of actigraphic monitoring of physical activity and daily electronic diary recordings of pain intensity, medication use, sleep quality, and mood. Linear mixed models assessed daily associations among physical activity and pain. Daily mean (average count/min) and peak (highest daily level) activity were used for analyses. Medication use, sleep quality, and mood ratings were included as covariates, and age, sex, and body mass index percentile were adjusted for. Results:Higher pain intensity was associated with lower peak physical activity levels on the next day (t641=−2.25, P=0.03) and greater medication use predicted lower mean physical activity levels the same day (t641=−2.10, P=0.04). Higher mean physical activity levels predicted lower pain intensity ratings at the end of the day (t705=−2.92, P=0.004), but only in adolescents with chronic pain. Discussion:Youth experiencing high pain intensity limit their physical activity level on a day-to-day basis. Activity was related to subsequent pain intensity, and may represent an important focus in chronic pain treatment. Further study of the effect of medications on subsequent activity is needed.

Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery

UNLABELLED Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on childrens health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a childrens hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13-18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery. PERSPECTIVE This study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.

Geographic differences in perioperative opioid administration in children

Objectives:  To investigate whether geographic differences exist in perioperative opioid administration to children.

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

Concerns regarding the safety of codeine have been raised. Cases of life‐threatening respiratory depression and death in children have been attributed to codeines polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown.

Postsurgical pain in children: unraveling the interplay between child and parent psychosocial factors

Spinal fusion surgery is performed on approximately 10,000 children annually in the United States. A recent systematic review identified the prevalence of chronic postsurgical pain (CPSP) ranging from 11% to 54% after pediatric spinal fusion. Chronic postsurgical pain is associated with significant functional disability and impaired health-related quality of life in youth. Thus, research that can lead to identifying youth at risk for the transition from acute postsurgical pain to CPSP is a critical research question in this field. Currently, there are few highquality research studies investigating this topic, but findings suggest that parent and child psychosocial factors place children at risk of CPSP. In recognition of the importance of family and parent factors in understanding and treating pediatric pain, we suggest here that in the context of surgery, it is also critical to understand how child and parent factors interact to maintain pain over time. In this issue of PAIN, Birnie et al. take an important step in investigating the cross-sectional and longitudinal relationship among child and parent reports of pain catastrophizing and pain intensity related to spinal fusion. The actor–partner interdependence model was used to measure bidirectional effects in the child–parent dyads. The primary results reported by Birnie et al. are (1) significant cross-sectional relationships at baseline and follow-up between child, but not parent, pain catastrophizing and children’s pain intensity, (2) a lack of longitudinal relationships between baseline child and parent pain catastrophizing and children’s postoperative pain intensity, and (3) only moderate stability in child and parent pain catastrophizing from baseline to follow-up, with significantly lower stability of this construct in children than parents. Although other studies have not used the actor–partner interdependence model to analyze data, they have examined parent–child relationships finding significant cross-sectional associations between child and parent pain catastrophizing, and significant longitudinal relationships between baseline child and parent pain catastrophizing and postoperative pain intensity. There are several possible reasons for these contrasting results, including differences in study design and perioperative care models within which studies were conducted. As discussed by Birnie et al., questions have specifically been raised regarding timing of pain catastrophizing assessment in the perioperative setting (ie, presurgery vs postsurgery), when pain catastrophizing might be evolving in response to the experience of intense pain. However, we posit that the inconsistency of findings between studies may rather indicate that psychosocial constructs beyond pain catastrophizing are important and have been overlooked. For example, research in children with chronic pain has found that higher parent protectiveness, distress, and fear of pain are associated with higher child pain-related disability. The relationship of a broader range of parent emotions, behaviors, and cognitions with children’s postoperative pain should be explored. Related, there has been limited application of theory to guide research on child psychosocial factors in the perioperative setting, and an overreliance on constructs deemed relevant for adults. There has been a large focus on pain catastrophizing in the perioperative setting, despite several notable limitations. First, the Pain Catastrophizing Scale, originally developed in adults with chronic pain and then later adapted for children with chronic pain and their parents, has not been validated in the perioperative setting with children or parents and may not be relevant to children during the preoperative or acute postoperative periods. Indeed, Birnie et al. found a lack of stability in pain catastrophizing over time, particularly in children. Second, as Eccleston et al. have argued, pain catastrophizing may not be a developmentally appropriate construct to assess in youth with pain because of the different ways that children think about pain compared with adults which may require other measures of emotional coping. Third, the primary focus on pain catastrophizing may divert us away from other important child cognitive, emotional, and behavioral factors, which may be linked to persistence of pain and disability. Unfortunately, this has likely hindered our progress in addressing this major health issue for children. Although dyadic interactions between parent and child are considered key in the maintenance of pain, very limited methodologies for understanding these interactions have been used in the perioperative setting thus far. Observational methodology may be needed to capture the richness of dyadic interactions, rather than relying on self-report questionnaires. For example, Caes et al. coded parent-child interactions before and after minor procedures in children undergoing cancer treatment to explore parental responses to child procedural pain and their impact on child experiences. They found significant interactions between parent distress and behavioral responses, and children’s distress and pain behaviors. Similar approaches Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article. a Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA, b Center for Clinical and Translational Research, Seattle Children’s Hospital, Seattle, WA c Center for Child Health, Behavior, and Development, Seattle Children’s Hospital, Seattle, WA, USA

A developmental perspective on the impact of chronic pain in late adolescence and early adulthood: implications for assessment and intervention

1. IntroductionThe prevalence and severity of chronic pain is well defined in children and adults. Epidemiological studies estimate that 11% to 38% of children25 and 35% to 51% of adults17 have chronic pain; for 5% to 8% of children21 and 10% to 13% of adults,36 the pain is severe and disabling. Alt