Michelle A. Fortier

Pediatric Pain After Ambulatory Surgery: Where's the Medication?

OBJECTIVE: The purpose of this controlled study was to provide a description of childrens postoperative pain, including pain intensity and analgesic consumption. METHODS: Participants included 261 children, 2 to 12 years of age, undergoing routine tonsillectomy and adenoidectomy surgery. Baseline and demographic data were collected before surgery, and a standardized approach to anesthesia and surgical procedures was used. Pain and analgesic consumption were recorded for 2 weeks at home. RESULTS: On the first day at home, although parents rated 86% of children as experiencing significant overall pain, 24% of children received 0 or just 1 medication dose throughout the entire day. On day 3 after surgery, although 67% of children were rated by parents as experiencing significant overall pain, 41% received 0 or 1 medication dose throughout the entire day. CONCLUSIONS: We conclude that a large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Perioperative anxiety in children

Objectives & Aim:  The purpose of this investigation was to examine children’s anxiety across the perioperative setting.

Acute to chronic postoperative pain in children: preliminary findings

BACKGROUND/PURPOSE Chronic postoperative pain is a well-established clinical phenomenon that is associated with adverse outcomes. The incidence of this clinical phenomenon in children, however, is not well established. The purpose of this study was to identify the incidence of chronic pain in children after surgery. METHODS Following a screening process, a total of 113 children and their parents were enrolled in this cross-sectional study. Data regarding persistence and characteristics of pain after surgery were obtained. RESULTS Approximately 13% of the children, most of whom underwent orthopedic procedures, reported the existence of symptoms of chronic postoperative pain. Most of the children indicated that the pain started immediately after surgery, was localized to the surgery site, and was intermittent. Children reported a median duration of pain of 4.1 months, and approximately half of the children experienced pain most days of the week. Up to 30% of the children reported interference of pain in functioning in areas such as extracurricular activities and sleep. DISCUSSION Given the large number of children at risk for experiencing chronic postoperative pain, preventative efforts are necessary. Large-scale cohort prospective studies are needed to confirm the results of this cross-sectional study.

Children's desire for perioperative information.

BACKGROUND: The purpose of this investigation was to identify what perioperative information children want to receive from the medical staff. METHODS: As a first step, we developed an instrument based on a qualitative study conducted with children in Great Britain, input from a focus group, and input from school children. On the day of surgery, 143 children aged 7–17 yr completed a 40-item assessment of desired surgical information and a measure of anxiety (State-Trait Anxiety Inventory for Children). Parents completed a measure assessing their child’s temperament (Emotionality, Activity, Sociability, and Impulsivity Survey) and a measure of their own anxiety (State-Trait Anxiety Inventory). RESULTS: Results indicated that the vast majority of children had a desire for comprehensive information about their surgery, including information about pain and anesthesia, and procedural information and information about potential complications. The most highly endorsed items by children involved information about pain. Children who were more anxious endorsed a stronger desire for pain information and lesser tendency to avoid information. Younger children wanted to know what the perioperative environment would look like more than adolescent children. CONCLUSIONS: We conclude that the majority of children aged 7–17 yr who undergo surgery want to be given comprehensive perioperative information and health care providers should ensure adequate information regarding postoperative pain is provided.

Beyond pain: predictors of postoperative maladaptive behavior change in children

Objectives & Aim:  Using well‐validated measures and controlling for potential confounding variables such as pain and surgical and anesthetic technique, the goal of this project was to identify the incidence of and risk factors for the development of behavior change in children after surgery.

Analysing a family-centred preoperative intervention programme: a dismantling approach

BACKGROUND The goal of this project was to identify key effective components of ADVANCE, a family-centred preoperative intervention programme, through the use of a dismantling approach. ADVANCE was previously demonstrated to be more effective than parental presence and just as effective as midazolam in reducing childrens preoperative anxiety. The total programme, however, may be difficult to implement in hospitals across the country. METHODS Subjects in this follow-up dismantling report were 96 children aged 2-10 who were part of the original study and who underwent anaesthesia and surgery. Baseline characteristics, parental adherence to the components of ADVANCE, and child and parent anxiety were assessed. RESULTS We found that greater parental adherence to the ADVANCE intervention was associated with lower child anxiety before surgery. The two components of ADVANCE that emerged as having a significant impact on childrens anxiety were practising with the anaesthesia mask at home and parental planning and use of distraction in the preoperative holding area. In fact, not only did children experience significantly less preoperative anxiety when their parents were adherent to mask practise and use of distraction, their anxiety tended to remain stable and relatively low throughout the preoperative period. CONCLUSIONS Shaping and exposure (i.e. practise with the anaesthesia mask) and parental use of distraction in the surgical setting are two beneficial components that could be included in preoperative preparation programmes that will be designed in the future.

Prediction of preoperative anxiety in children: who is most accurate?

BACKGROUND: In this investigation, we sought to assess the ability of pediatric attending anesthesiologists, resident anesthesiologists, and mothers to predict anxiety during induction of anesthesia in 2 to 16-yr-old children (n = 125). METHODS: Anesthesiologists and mothers provided predictions using a visual analog scale and children’s anxiety was assessed using a valid behavior observation tool the Modified Yale Preoperative Anxiety Scale. All mothers were present during anesthetic induction and no child received sedative premedication. Correlational analyses were conducted. RESULTS: A total of 125 children aged 2–16 yr, their mothers, and their attending pediatric anesthesiologists and resident anesthesiologists were studied. Correlational analyses revealed significant associations between attending predictions and child anxiety at induction (rs = 0.38, P < 0.001). Resident anesthesiologist and mother predictions were not significantly related to children’s anxiety during induction (rs = 0.01 and 0.001, respectively). In terms of accuracy of prediction, 47.2% of predictions made by attending anesthesiologists were within one standard deviation of the observed anxiety exhibited by the child, and 70.4% of predictions were within two standard deviations. CONCLUSIONS: We conclude that attending anesthesiologists who practice in pediatric settings are better than mothers in predicting the anxiety of children during induction of anesthesia. Although this finding has significant clinical implications, it is unclear if it can be extended to attending anesthesiologists whose practice is not mostly pediatric anesthesia.

Preoperative anxiety in adolescents undergoing surgery: a pilot study

Objectives:  The purpose of this study was to conduct a prospective assessment of preoperative anxiety in adolescents undergoing surgery.

Web-Based Tailored Intervention for Preparation of Parents and Children for Outpatient Surgery (WebTIPS): Formative Evaluation and Randomized Controlled Trial

BACKGROUND:The purpose of this 2-phase project was to conduct a formative evaluation and to test the preliminary efficacy of a newly developed Web-based Tailored Intervention for Preparation of parents and children undergoing Surgery (WebTIPS). METHODS:Phase 1 enrolled 13 children 2 to 7 years of age undergoing outpatient elective surgery and their parents for formative evaluation of WebTIPS. Parent participation focus groups are common in qualitative research and are a method of asking research participants about their perceptions and attitudes regarding a product or concept. In phase 2, children 2 to 7 years of age in 2 medical centers were assigned randomly to receive the WebTIPS program (n = 38) compared with children receiving the standard of care (n = 44). The primary outcome of phase II was child and parent preoperative anxiety. RESULTS:In phase 2, parents reported WebTIPS to be both helpful (P < 0.001) and easy to use (P < 0.001). In phase 2, children in the WebTIPS group (36.2 ± 14.1) were less anxious than children in the standard of care group (46.0 ± 19.0) at entrance to the operating room (P = 0.02; Cohen d = 0.59) and introduction of the anesthesia mask (43.5 ± 21.7 vs 57.0 ± 21.2, respectively, P = 0.01; Cohen d = 0.63). Parents in the WebTIPS group (32.1 ± 7.4) also experienced less anxiety compared with parents in the control group (36.8 ± 7.1) in the preoperative holding area (P = 0.004; Cohen d = 0.65). CONCLUSIONS:WebTIPS was well received by parents and children and led to reductions in preoperative anxiety.

Ethnicity Matters in the Assessment and Treatment of Children's Pain

One of the most challenging treatment dilemmas facing a practicing pediatrician is the management of a child with chronic pain, because it is well established that pain is a highly complex phenomenon that involves biological, psychological, and social variables such as culture, race, and ethnicity.1,2 Understanding the role of culture in the experience of pain is of particular importance when one considers that nearly 25% of children under the age of 5 in the United States are Latino and 17% of children in this age group are black.3 Consequently, it is important for pediatricians to consider the impact of race and ethnicity on the management of pain in children. In adults, there is substantial literature focused on the role of ethnicity and race in the experience of pain.4–16 Although there have been some contradictory findings, as a whole this literature suggests ethnic differences in perception, assessment, and treatment across settings and types of pain,11 differences that persist even after controlling for potential confounding variables such as socioeconomic status, gender, age, education, marital status, and psychological variables such as emotional state.4,7–10 Survey research suggests that Hispanic individuals may be less likely than white and black individuals to seek treatment by a physician for pain and black individuals may be more likely than white and Hispanic adults to use prescription medication for the treatment of pain.13 … Address correspondence to Michelle A. Fortier, PhD, Childrens Hospital of Orange County, 505 S Main St, Suite 940, Orange, CA 92868. E-mail: mfortier{at}choc.org