Pediatric Pain Medicine Research Articles

Pediatric pain physician workforce: an assessment of supply and demand.

Many youth with pain lack access to pediatric pain expertise. There is a critical shortage of pediatric pain physicians, due partly to a paucity of training programs in Pediatric Pain Medicine. Pain fellowships are Anesthesiology-based and there is no pathway to fellowship training or Pain Medicine board certification for pediatricians. This workforce assessment sought to examine the current state of Pediatric Pain Medicine in the United States and future interest in pursuing Pain Medicine among pediatricians. A multidisciplinary working group of Pain Medicine clinicians designed three surveys to examine pediatric comprehensive pain programs in the US, practice patterns of pediatricians and their motivations and opinions regarding Pain Medicine board certification, and current residents' exposure to and interest in Pediatric Pain Medicine. Wait times for initial evaluations are two months or longer for two-thirds of responding centers, and barriers to increase staff size and resources were reported, including an inadequate number of trained or available physicians. Pediatricians expressed interest in earning board certification in Pain Medicine, given the opportunity. Additionally, there is interest among pediatric residents in pursuing Pediatric Pain Medicine, and qualitative data highlight information residents perceived needing in order to pursue a career in the field. Results demonstrate the need for increased training opportunities in pediatric pain medicine. A formal pathway to Pain Medicine for Pediatricians should be developed to increase the potential workforce and to address the lack of trained pediatric pain specialists, thereby improving access to care for youth with pain.

A Call to Action: Shaping the Future of Pediatric Pain Medicine

A Call to Action: Shaping the Future of Pediatric Pain Medicine

Substance Use Disorders in Adolescents and Young Adults: History and Perioperative Considerations From the Society for Pediatric Pain Medicine.

Substance use disorders (SUDs) are on the rise in children and young adults in the United States. According to reports, over 40 million people aged 12 and older had a diagnosed SUD in 2020.1 A recent report from the Centers for Disease Control and Prevention (CDC) found that overdose death in children aged 10 to 19 years old increased 109% from 2019 to 2021.2 Given the rapidly increasing prevalence of SUD, anesthesiologists will almost certainly encounter children, adolescents, and young adults with a history of recreational drug use or nonmedical use of prescription opioids in the perioperative period. Since the perioperative period can be a particularly challenging time for patients with SUD, anesthesiologists can tailor their perioperative care to reduce rates of relapse and can serve as both advocates and educators for this vulnerable patient population. This article examines the history of SUD and physiology of substance use in children, adolescents, and young adults, including reasons why young people are more susceptible to the addictive effects of many substances. The coronavirus disease 2019 (COVID-19) pandemic impacted many aspects of life, including increased social isolation and shifted dynamics at home, both thought to impact substance use.3 Substance use patterns in the wake of the COVID-19 pandemic are explored. Although current literature is mostly on adults, the evidence-based medical treatments for patients with SUD are reviewed, and recommendations for perioperative considerations are suggested. The emphasis of this review is on opioid use disorder, cannabis, and vaping particularly because these have disproportionately affected the younger population. The article provides recommendations and resources for recognizing and treating adolescents and young adults at risk for SUD in the perioperative period. It also provides suggestions to reduce new persistent postoperative opioid use.

Palliative Sedation Therapy Practice Comparison - A Survey of Pediatric Palliative Care and Pain Management Specialists.

Context: Palliative sedation therapy (PST) can relieve suffering at end-of-life (EOL) in children with intolerable and refractory symptoms. However, updated and consistent guidance on PST practices are imperative. Objectives: We investigate current variations in clinical practice and PST implementation among pediatric palliative care (PPC) and pain management (PM) specialists. Methods: We distributed an IRB-exempt electronic anonymous survey via email through the Society of Pediatric Pain Medicine, and the American Academy of Hospice and Palliative Medicine. Survey responses were collated and descriptively reported. Results: Of 83 survey responses, the majority (75%) represented large academic children's hospitals. The distribution between PPC and pediatric pain management specialists' responses was 60% and 40%, respectively. Most respondents reported having designated pain management and/or palliative care teams (70% and 90%, respectively). Approximately half (48%) reported following an institutional PST protocol, most not requiring formal ethics consult (69%). Only 54% of respondents noted that the Do Not Resuscitate (DNR) order was required prior to PST initiation. PST was primarily utilized for children with oncologic diagnoses (76%). The primary and secondary medications of choice for PST implementation were reported to be opioids (39%) and benzodiazepines (36%) by pain management specialists, and benzodiazepines (52%) and barbiturates (28%) by palliative care specialists. Conclusions: Our study highlights the variability in the practice and implementation of PST. Further educational efforts are key for establishing PST practices and efficient protocol development.

The overlap of medical child abuse and central sensitization in adolescents: An exploratory qualitative study

BackgroundBoth medical child abuse (MCA) and central sensitization (CS) may present in adolescents with chronic pain, disability, high healthcare utilization, and unremarkable medical evaluations. ObjectiveThis study aimed to identify themes in the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS. Participants and settingParticipants were 28 adolescents (ages 13–18 years) with chronic pain referred to either the Child Abuse Pediatrics team or the Pediatric Pain Medicine team at a tertiary children's hospital between 2011 and 2019, and diagnosed with MCA or CS, respectively. MethodsThis was a qualitative, retrospective study. Qualitative themes were derived through a process of inductive content analysis utilizing open coding, grouping, and secondary review by an interdisciplinary panel of experts. The relative prevalence of each code, theme, and overarching category was examined between groups to identify areas of convergence and divergence. ResultsSeveral themes appeared to be more prevalent in the MCA group (n = 9) compared to the CS group (n = 19). These included sick identity, homeschooling, caregiver with mental health disorder, maternal catastrophizing, maternal misrepresentation, persistence in healthcare-seeking, mandated reports made, medical neglect, and unnecessary and harmful medical care. ConclusionsThis exploratory work identified themes from the clinical narratives of adolescents with chronic pain that may help differentiate MCA from CS. A visual reference, two illness scripts, and management recommendations are presented to aid pediatric providers in facilitating appropriate referrals for adolescents with chronic pain and disability out of proportion to diagnostic workup.

An interview with Dr. Anne Marie Lynn, a pioneering woman in medicine.

Dr. Anne Marie Lynn (1949-present), Professor Emeritus of Anesthesiology, Pain Medicine, and Pediatrics at the University of Washington, Seattle, was one of the most influential women in pediatric anesthesiology of her generation. Dr. Lynn embodies the spirit of discovery and advancement that have created the practice of pediatric anesthesiology as we know it today. A pioneer in pain medicine pharmacology, particularly morphine and ketorolac, her research transformed pediatric anesthesia, pediatric pain medicine, and pediatric intensive care medicine. Through her journal articles, book chapters, national and international lectures, mentoring of residents, fellows, and faculty, and leadership in the Society for Pediatric Anesthesia, she inspired a generation of women and men physicians by demonstrating that gender should not be a barrier to undertaking roles once only held only by men. In 2017, for her many contributions, she was awarded the Society for Pediatric Anesthesia's Myron Yaster lifetime achievement award.

The randomised prospective comparative study to see the duration of analgesia following intravenous or rectal acetaminophen after adenotonsillectomy in children

Background: The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Author compared the analgesic efficacy and duration of analgesia of rectal acetaminophen and I.V. acetaminophen.Methods: A total of 80 children in the age group of 2-5 years were randomly selected and divided into 2 groups. Group I received 15 mg/kg I.V. paracetamol and group II received 40 mg/kg rectal acetaminophen. Post-operative pain scores were measured using Face, Legs, Activity, Cry and Consolability scale and duration of analgesia were recorded and compared.Results: The pain scores in group I was lower immediately after extubation and at 30 minutes post extubations but at one, two and four hours the pains score were comparable in both the groups. At 6 hours, the pain score was significantly more in I.V. group and also the duration of analgesia was 9-10 hours in rectal acetaminophen group where as in I.V. group, it was 5-6 hours.Conclusions: Rectal acetaminophen 40 mg/kg produces prolonged analgesia as compared to I.V. paracetamol 15 mg/kg and also is more convenient and cost effective and is devoid of side effects of I.V. cannulation.

Physical Therapy Outcome Measures for Assessment of Lower Extremity Chronic Pain-Related Function in Pediatrics

To assess the clinical utility of 5 physical therapy (PT) outcome measures in quantifying functional changes in pediatric lower extremity chronic pain treated at a hospital-based interdisciplinary rehabilitation center. This was a cross-sectional study with retrospective review of 173 individuals, 8 to 18 years old, treated from June 2008 to 2013. The measures used were the Timed Up and Go, Timed Up and Down Stairs, Bruininks-Oseretsky Test of Motor Proficiency, Second Edition, 6-minute walk test, and Lower Extremity Functional Scale. Participant performance was correlated with demographic characteristics, the Functional Disability Index, Multidimensional Anxiety Scale for Children, Child Depression Inventory, and Canadian Occupational Performance Measure. Scores from all 5 PT measures showed significant improvement following treatment. Functional Disability Index correlated to every PT measure except the 6-minute walk test. This study supports the clinical use of these PT measures to track functional progress after rehabilitative treatment of lower extremity chronic pain-related disability.

Chronic Pediatric Pain Management: a Review of Multidisciplinary Care and Emerging Topics

Chronic pain is a prevalent, disabling, and expensive pediatric condition. Specific treatment options have limited evidence and are often extrapolated from adult care. This review evaluates pain outcome measures, psychological treatment, pharmacologic management, multidisciplinary treatment models, and emerging topics in pediatric pain medicine. Multimodal cognitive behavioral therapy and intensive interdisciplinary pain treatment have the strongest evidence for improving pain and function while decreasing healthcare utilization. There is emerging evidence that parental involvement in care is an important factor in pediatric outcomes. While there is increased interest in emerging topics such as use of marijuana-derived products, acupuncture, and virtual reality, the evidence behind such interventions remains limited. Pediatric chronic pain treatment centers on the biopsychosocial model of pain and multidisciplinary treatment. Recent research shows that intensive interdisciplinary pain treatment can improve pain, function, and healthcare utilization. Long-term benefits and risks of emerging treatments in pediatric chronic pain remain poorly understood.

An advanced second year fellowship in pediatric pain medicine: development, implementation, and challenges

This article was migrated. The article was marked as recommended. BackgroundThere is a growing need for advanced fellowship training in pediatric pain medicine and other subspecialties of pediatric anesthesia. Increasing clinical and educational demands have necessitated the development of a novel pediatric anesthesia pain fellowship at our institution. Principal findingsFollowing an iterative process with a workgroup, we have developed and implemented a novel one-year advanced fellowship program in pediatric pain medicine. We describe our experience developing and challenges faced implementing the program. The fellowship has clinical, education, research and administration components. Elective periods are offered for additional specialized training. To date four fellows have been recruited to the fellowship program.Conclusion We present an overview of a novel pediatric medicine pain fellowship. Initial feedback and reviews suggest the fellowship is meeting the needs of fellows and patients in various pediatric settings. It is hoped that continued work to improve the fellowship will enhance patient care by educating physicians in effective methods of pain management in an increasingly complex subspecialty. By enhancing clinical care, education, research and leadership in pain the ultimate aim of the fellowship program is to alleviate pain and improve outcomes in children.

Pediatric Anesthesiology 2013 Meeting Review

Pediatric Anesthesiology 2013 Meeting Review

The Making of a Pediatric Pain Psychologist: Education, Training and Career Trajectories

Currently, there are no standard guidelines for the training of pediatric pain psychologists. This article is intended for pediatric pain medicine trainees and faculty in the USA and Canada, and includes discussion of the professional roles and responsibilities of pediatric pain psychologists, a historical perspective on the role of psychologists in the field of pediatric pain medicine, and career trajectories and recommendations for training of pediatric pain psychologists. The primary aim of this commentary is to provide a starting point for the standardization of training of pediatric pain psychologists in the future.

Improvement In Acute Management of Vaso-Occlusive Pain In Pediatric Sickle Cell Disease with Use of a Clinical Pathway

AbstractAbstract 2660 Background:Sickle cell disease causes considerable morbidity and mortality. Three guidelines exist for the management of vaso-occlusive pain, although studies have shown that these guidelines are not well followed and that there is considerable variation in care. Investigations of clinical pathways for pediatric sickle cell pain have not been published to our knowledge, but research in other pediatric conditions has shown that the implementation of clinical pathways can improve medical care. We initiated an investigation of the effects of a pain management pathway for sickle cell vaso-occlusive crisis in the emergency department (ED) with the hypothesis that the introduction of a clinical pathway would improve the efficiency and efficacy of acute pain management. Methods:We conducted a prospective, cohort study from February 2009 to March 2010 in an urban, tertiary care ED. We collected data from patients aged 3–18 years old with sickle cell disease who presented to the ED with vaso-occlusive crisis (VOC) pain. Baseline data was collected for five months prior to the introduction of the clinical pathway, followed by a four-week time interval in which the ED physicians and nurses were in-serviced on the pathway, followed by six months in which data was collected with the clinical pathway in place. Our pathway, which is in checklist format with instructions for triage, monitoring, medication administration, and timing of assessments and interventions, was developed by representatives from the divisions of Pediatric Hematology, Pediatric Emergency Medicine, and Pediatric Pain Medicine, Symptom Management and Palliative Care and based upon current standard-of-care guidelines. Results:Over the eleven month study period, 68 patients were enrolled. Random chart audits revealed a 75% capture rate. Significant improvement was demonstrated in time interval to first analgesic from 74 minutes to 42 minutes (p value 0.02), time interval to first opioid from 94 minutes to 46 minutes (p value < 0.01), and time interval to subsequent assessment of pain score from 110 minutes to 72 minutes (p value 0.02). The percentage of patients who received ketorolac also increased from 57% to 82% (p value 0.03). Change in pain scores was not significantly different, nor was admission rate. Conclusions:Implementation of a pain management pathway for sickle cell VOC led to an improvement in the time interval to administration of first analgesic and time interval to pain re-assessment, bringing these aspects of patient management closer to accepted guidelines. Whether improvement can be made in admission rates, change in pain ratings, and patient satisfaction will require further study. Disclosures:No relevant conflicts of interest to declare.

Acute pain management in children.

The greatest advance in pediatric pain medicine is the recognition that untreated pain is a significant cause of morbidity and even mortality after surgical trauma. Accurate assessment of pain in different age groups and the effective treatment of postoperative pain is constantly being refined; with newer drugs being used alone or in combination with other drugs continues to be explored. Several advances in developmental neurobiology and pharmacology, knowledge of new analgesics and newer applications of old analgesics in the last two decades have helped the pediatric anesthesiologist in managing pain in children more efficiently. The latter include administering opioids via the skin and nasal mucosa and their addition into the neuraxial local anesthetics. Systemic opioids, nonsteroidal anti-inflammatory agents and regional analgesics alone or combined with additives are currently used to provide effective postoperative analgesia. These modalities are best utilized when combined as a multimodal approach to treat acute pain in the perioperative setting. The development of receptor specific drugs that can produce pain relief without the untoward side effects of respiratory depression will hasten the recovery and discharge of children after surgery. This review focuses on the overview of acute pain management in children, with an emphasis on pharmacological and regional anesthesia in achieving this goal.