Anne Haddad
Two expert panels-one in the United Kingdom and one in the United States-published significant articles in late 2020 to address pediatric pain management.
One of the panels, a Lancet Child and Adolescent Health Commission, focused on comprehensive improvement and advocacy for better pain management in pediatrics.
Meanwhile, an American Pediatric Surgical Association (APvSA) committee published guidelines focused on avoiding unnecessary opioid prescribing in pediatric patients and other measures to prevent opioid use disorders and diversion in this population. APSA conducted a review of relevant literature that included all English-language articles published from January 1, 1988, to February 28, 2019, in prominent databases.1
"These are the first opioid-prescribing guidelines to address the unique needs of children who require surgery," the authors wrote. "Health care professionals caring for children and adolescents in the perioperative period should optimize pain management and minimize risks associated with opioid use by engaging patients and families in opioid stewardship efforts."
The new APSA guidelines steer surgeons away from excessive postoperative opioid prescribing. The guidelines were published online first in JAMA Surgery on November 11, 2020. The lead author is Lorraine I. Kelley-Quon, MD, MSHS, of Children's Hospital of Los Angeles.
The recommendations, from the APSA Outcomes and Evidence-Based Practice Committee, are that providers recognize the risk of misuse and abuse in pediatric populations. The committee also recommends surgeons educate families on expectations and methods of pain management before surgery, and about safely disposing of any unused opioids after the postoperative period.
Instead of opioids, nonopioid analgesics are recommended for certain procedures, including inguinal hernia repair, myringotomy, and meatotomy, for which there is strong evidence of the likelihood of opioid-free recovery, the authors wrote.
The authors screened thousands of articles, selecting 217 for qualitative synthesis. The panel of APSA experts generated the 20 guideline statements.
Lancet Article Addresses Undertreatment of Pediatric Pain
The Lancet article, which is 41 pages long, advocates for better diagnosis and treatment of pediatric pain, opening with the statement that pain is undertreated in young patients.2
"This undertreatment of pain should not continue, as there are available tools, expertise, and evidence to provide better treatment for childhood pain. In this Commission, we present four transformative goals that will improve the lives of children and adolescents with pain and their families. These goals, taken at face value, might seem simple and obvious. However, if the goals were easy to achieve, there would be few, if any, young people reporting poorly managed acute pain, pain after surgery or procedures, or ongoing chronic pain."2
The four goals-not meant to be sequential but rather simultaneously addressed-are to make pain matter, make pain understood, make pain visible, and make pain better.
Related to making pain "matter," the authors write: "Despite some good examples of knowledge translation, investment in a strong social science research base for paediatric pain is needed to catapult us into a new era in which the social and cultural context of pain can be understood and addressed."
Regarding making pain "visible," the authors wrote, "Although subjective pain report is the primary and desirable method when this is possible, many of the methods and measures that are in common use can and should be improved. There have been developments in our understanding of the biological correlates of pain, and in broader patient-reported outcome variables that can provide a more holistic understanding of patients' pain status. Finally, a greater focus should be placed on assessing outcomes that are important to patients, rather than those that are central to researchers and clinicians."
References