Treatment Of Pain In Children Research Articles

Interim guidelines for the assessment and treatment of pain in children with multiple sclerosis.

Pain in multiple sclerosis (MS) is common, but literature on pain in children with MS remains scarce. Pain has physical, psychological, and social implications in MS, and both comprehensive assessment and interdisciplinary management approaches are needed. We sought to develop an interdisciplinary interim guideline for the assessment and management of pain in children with MS. We convened a modified Delphi panel composed of 13 experts in pediatric and adult MS neurology, physiotherapy, pain, patient lived-experience, advanced practice nursing, psychology, physiatry, and MS research. A survey was sent to panelists for anonymous completion. The panel discussed survey themes extracted by the panel chair. The process was repeated twice. Thirteen assessment and treatment recommendations were produced regarding pain in children with MS. Future studies will assess implementation of these pain assessment and treatment guidelines in the clinical setting.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review.

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Intranasal Fentanyl for Acute Pain Management in Children, Adults and Elderly Patients in the Prehospital Emergency Service and in the Emergency Department: A Systematic Review.

This systematic review examined the efficacy and safety of intranasal fentanyl (INF) for acute pain treatment in children, adults, and the elderly in prehospital emergency services (PHES) and emergency departments (ED). ClinicalTrials.gov, LILACS, PubMed, SCOPUS, EMBASE, Google Scholar and Cochrane databases were consulted until 31 December 2022. A total of 23 studies were included: 18 in children (1 PHES, 17 ED), 5 in adults (1 PHES, 4 ED) and 1 in older people (1 PHES subgroup analysis). In children, INF was effective in both settings and as effective as the comparator drugs, with no differences in adverse events (AEs); one randomised controlled trial (RCT) showed that INF was more effective than the comparator drugs. In adults, one study demonstrated the efficacy of INF in the PHES setting, one study demonstrated the efficacy of INF in the ED setting, two RCTs showed INF to be less effective than the comparator drugs and one RCT showed INF to be as effective as the comparator, with no difference in AEs reported. In older people, one study showed effective pain relief and no AEs. In summary, INF appears to be effective and safe in children and adults in PHES and ED. More high-quality studies are needed, especially in PHES and older people.

Postoperative analgesia in children - a comprehensive assessment and management

Introduction. Pain is the most common cause of complaints in hospitalized pediatric patients. Pain continues to be underestimated and undertreated in childhood. The European Society of Pediatric Anesthetists has published guidelines for pain management in children. Pain assessment. Pain assessment is very important in the treatment of pain in children. Basic pain management. Administration of basic analgesics is crucial for pain management. Paracetamol and non-steroidal anti-inflammatory drugs. Generally, basic or simple analgesia includes the use of paracetamol and non-steroidal anti-inflammatory drugs. Systemic opioids. Opioids are reserved for early postoperative and intraoperative use when adequate monitoring and specially trained personnel are available around the clock. Regional anesthesia and local anesthetics. Regional anesthesia in children has been increasingly used in recent decades, particularly against the background of multimodal analgesia. Conclusion. Basic analgesics are crucial, and opioids are added only when needed. Regional anesthesia and local anesthetics play a superior role in pain management compared to systemic analgesics in such cases in pediatric patients.

The impact of education on the knowledge and attitudes of Ghanaian nurse tutors towards the assessment and management of pain in children: A quantitative study

BackgroundUndertreatment of pain in children is an international problem as many children reports unresolved moderate to severe pain. One key factor which may contribute to under treatment of pain in children by nurses is lack of knowledge. In Ghana opportunities for nurses to learn about pediatric pain have been limited due to gaps in the undergraduate curriculum and inadequate continuing professional education post qualification. ObjectiveTo assess tutors' knowledge and attitudes to pediatric pain management before and after an educational workshop. DesignSingle group pre-test-post-test design. SettingOne Ghanaian Nursing Training College. ParticipantsAll (37) nursing tutors in the college. MethodTotal population sampling was used to access 37 tutors, data were collected using the Knowledge and Attitude Survey Regarding Pain at 3 stages; pre-intervention, immediately after the train-the-trainer based Pediatric Pain Educational Workshop and at 3-months follow-up. Data from the survey were analyzed using descriptive and inferential statistics. ResultsResults at pre-intervention showed low scores in the survey. However, post-intervention results at both the immediate and 3-months follow-up stages revealed a significant increase from pre-intervention: Mean (SD) of 20.35 (4.56), to immediate follow-up Mean (SD) 26.93 (5.02), and 3-months follow-up Mean (SD) 25.19 (5.80) and a p-value of <0.001. ConclusionThe results suggest tutors' knowledge and attitudes regarding pediatric pain management can be directly improved through a nurse tutor focused educational program. However, knowledge declines with time and as such there is the need for regular update through Continuing Professional Development activities.

Optimisation of acute pain treatment in children in abdominal surgery at the stages of the perioperative period

The aim of the study. To improve the quality of perioperative analgesia by combined multimodal use of paracetamol and ketorolac tromethamine in children after abdominal surgery.&#x0D; Materials and methods. 48 children (6-17 years old) with choledochal, pancreatic cysts, hepatic echinococcosis, and abdominal trauma. The study period was from January 2021 to January 2022. Group 1 (main group, n=28): baseline analgesia - 15 min before surgery, intravenous paracetamol administration at 25-30 mg/kg. In order to prevent postoperative pain syndrome 15 minutes before the end of the surgery, we administered ketorolac and tromethamine in a dose of 0.5 mg/kg. Pain relief was repeated 6-8 h later with ketorolac at a dose of 0.5 mg/kg. Group 2 (comparison, n=20), who received 0.2 – 0.3 mg/kg promedol (trimeperidin) in the postoperative period. Both groups received standard endotracheal anaesthesia (propofol + fentanyl + arduan against the background of Low-flow anaesthesia with sevoflurane MAK=1). Systemic haemodynamics, C-reactive protein, and glucose were investigated, and a visual analogue scale was applied at the main stages of the study.&#x0D; Results: Analysis of the parameters of central hemodynamics, parameters of the operational stress response and clinical data showed that in the postoperative period, sufficient analgesic effect was established only in children in group 1 with the preventive combined administration of paracetamol and ketorolac on the operating table, which allows recommending them in the practice of perioperative analgesia during abdominal surgical interventions.&#x0D; Conclusions. Optimised method of preventive (preoperative) use of paracetamol in children at a dose of 25-30 mg/kg during abdominal surgery followed by administration of ketorolac tromethamine (15 minutes before the end of the surgery) increases the degree of nociceptive protection. It ensures high efficiency of postoperative pain relief, which allows to recommend it in the practice of perioperative analgesia for the above abdominal surgical interventions in children

Lumbosacral DREZotomy for oncologic pain treatment: a case-based review.

To present 3 cases of oncologic pain treated by DREZotomy in the pediatric population and to review the literature published about this procedure. The permanent literature about oncologic pain treatment in children and the applicability of DREZotomy was reviewed. Three cases treated at our institution were reviewed and presented. In the pediatric population, the DREZotomy has been extensively applied for the treatment of spasticity and spasticity-related pain. Currently, there are no reports of oncologic pain treated by means of a DREZotomy in children. We presented 3 cases coursing the terminal stage of illness, presenting predominantly neuropathic, oncologic pain that were successfully managed after a DREZotomy was performed. In well-selected patients, with a good general condition and life expectancy to withstand an open neurosurgical procedure, DREZotomy is an excellent tool to treat neuropathic oncologic pain.

Comparison of Side Effects of Nalbuphine and Morphine in the Treatment of Pain in children with Cancer: A Prospective Study.

Simple SummaryIn the 2012 WHO guidelines for the treatment of chronic pain in children, the recommendation for the use of the weak opioids tramadol and codeine was removed, and in 2017 the indication for the use of these drugs for the treatment of postoperative pain in the paediatric population was also withdrawn. For the treatment of pain associated with cancer treatment, the recommendations of non-opioid analgesics and, in cases of insufficient analgesia, the use of strong opioids remained. Nalbuphine, a weak opioid commonly used in the treatment of perioperative pain in children, can also be used effectively in the treatment of cancer-related pain. Our study is the first to evaluate the quality of analgesia, side effects, and withdrawal syndrome in children receiving nalbuphine for the treatment of cancer pain. The results indicate that nalbuphine is an effective and safe analgesic that is less likely than morphine to cause adverse side effects when used to treat cancer-related pain in children.Contemporary pain management regimens in children do not include the use of the middle step of the analgesic ladder, i.e., weak opioids. The aim of this study was to analyse the comparison of side effects and the therapeutic efficacy of morphine and nalbuphine in pain management in children with cancer. We conducted an observational, prospective study and analysed medical records of patients treated at the Clinic of Paediatric Haematology and Oncology of the University Hospital in Wroclaw (Poland), who developed mucositis during treatment. The efficacy and safety of both drugs were analysed, and the efficacy of pain relief and the incidence of adverse effects characteristic of opioid drugs were compared. The cases of 96 of children treated with opioid drugs nalbuphine or morphine were analysed. Nalbuphine therapy was accompanied by a statistically significantly lower incidence of side effects such as skin pruritus, constipation, and micturition disorders compared to morphine (p < 0.05). After the discontinuation of nalbuphine, signs of withdrawal syndrome were much less frequent than after morphine (p < 0.05). In Conclusion, nalbuphine used as a pain killer in children with oncological disorder is a safe drug. It provides stable analgesia in most children. Compared to morphine, the side effects typical of opioid use are less common, and the incidence decreases over time.

Non-pharmacological and non-surgical treatment of pain in children and adolescents with cerebral palsy: A scoping review.

To explore the existing literature on non-pharmacological and non-surgical pain management in children and adolescents with cerebral palsy (CP). Databases (Cochrane Library, PubMed MEDLINE, Ovid Embase, and PsycINFO) were systematically searched to identify literature on non-pharmacological and non-surgical interventions for relieving pain in children with CP or similar conditions. Thirteen publications met the inclusion criteria. Based on study designs, the overall level of evidence of the included studies was low, justifying the use of a scoping review. Only three were randomized controlled trials. Pain reduction was reported in 8 of the 13 studies from following interventions: physiotherapy/rehabilitation, massage, cranial osteopathy, swimming and aquatics, and assistive devices. These complementary strategies should not omit conventional treatment, and a multidisciplinary approach using multifaceted treatment of pharmacological and non-pharmacological therapy is recommended to increase the pain-relieving effect. The results indicate that physiotherapy, massage, swimming exercise, and various assistive devices can have pain-relieving effects. We found limited evidence on the topic of non-pharmacological and non-surgical treatment of pain in children with CP. Due to the lack of power in the included studies, no true evidence-based recommendations can be made from the collected articles; thus, further studies with larger cohorts and more power are needed to substantiate evidence-based treatment of pain in children and adolescents with CP.

STOP Pain Project-Opioid Response in Pediatric Cancer Patients and Gene Polymorphisms of Cytokine Pathways.

Moderate to severe cancer pain treatment in children is based on the use of weak and strong opioids. Pharmacogenetics play a central role in developing personalized pain therapies, as well as avoiding treatment failure and/or intolerable adverse drug reactions. This observational study aimed to investigate the association between IL-6, IL-8, and TNFα genetic single nucleotide polymorphisms (SNPs) and response to opioid therapy in a cohort of pediatric cancer patients. Pain intensity before treatment (PIt0) significantly differed according to IL-6 rs1800797 SNP, with a higher PI for A/G and G/G individuals (p = 0.017), who required a higher dose of opioids (p = 0.047). Moreover, compared to G/G subjects, heterozygous or homozygous individuals for the A allele of IL-6 rs1800797 SNP had a lower risk of having a PIt0 > 4. Dose24h and Dosetot were both higher in G/G individuals for TNFα rs1800629 (p = 0.010 and p = 0.031, respectively), while risk of having a PIt0 > 4 and a ∆VAS > 2 was higher for G/G subjects for IL-6 rs1800795 SNP compared to carriers of the C allele. No statistically significant association between genotypes and safety outcomes was found. Thus, IL-6 and TNFα SNPs could be potential markers of baseline pain intensity and opioid dose requirements in pediatric cancer patients.

Outpatient Pain Management in Children With Chronic Pancreatitis: A Scoping Systematic Review.

Although pain management is central to pediatric chronic pancreatitis (CP) care, no evidence-based guidelines exist. In this scoping systematic review, we sought promising strategies for CP pain treatment in children. We systematically reviewed literature on pain management in children and adults with CP, and 2 conditions with similar pain courses: juvenile idiopathic arthritis and sickle cell disease. Of 8997 studies identified, 287 met inclusion criteria. There are no published studies of analgesic medications, antioxidants, dietary modification, integrative medicine, or regional nerve blocks in children with CP. In adults with CP, studies of nonopioid analgesics, pancreatic enzymes, and dietary interventions have mixed results. Retrospective studies suggest that endoscopic retrograde cholangiopancreatography and surgical procedures, most durably total pancreatectomy with islet autotransplant, improve pain for children with CP. Follow-up was short relative to a child's life. Large studies in adults also suggest benefit from endoscopic therapy and surgery, but lack conclusive evidence about optimal procedure or timing. Studies on other painful pediatric chronic illnesses revealed little generalizable to children with CP. No therapy had sufficient high-quality studies to warrant untempered, evidence-based support for use in children with CP. Multicenter studies are needed to identify pain management "best practices."

Функциональная абдоминальная боль у детей

Абдоминальная боль является одной из самых распространенных жалоб детей в практике педиатра и семейного врача. В большинстве случаев причиной хронической боли в животе является неорганическая, функциональная абдоминальная боль (ФАБ) без объективных признаков основного органического расстройства. В настоящее время среди различных групп спазмолитиков при лечении функциональных расстройств пищеварительного тракта отдают предпочтение селективным миотропным спазмолитикам — блокаторам быстрых натриевых каналов клеточной мембраны миоцита (мебеверин). В клинической практике при лечении пациентов с абдоминальной болью заслуживает внимания мебеверина гидрохлорид (СПАРК®, ПАО «Фармак»). Изучение эффективности применения мебеверина СПАРК® при ФАБ у детей проводилось на базе гастроэнтерологического отделения детской клинической больницы № 19 г. Харькова. Под наблюдением находилось 44 ребенка в возрасте от 10 до 18 лет с ФАБ. В структуре функциональной патологии зарегистрированы: функциональная диспепсия (ФД) — 54,1 %, синдром раздраженного кишечника (СРК) — 20,8 %, функциональные расстройства билиарного тракта (ФРБТ) — 79,2 %; ФД + ФРБТ — 34,1 %, ФД + СРК — 16 %, ФРБТ + СРК — 8,3 %. Диагноз был верифицирован согласно унифицированным протоколам лечения. Пациенты получали комплексную патогенетическую терапию и селективный спазмолитик СПАРК® по 1 капсуле два раза в день на протяжении семи дней. Оценка болевого синдрома проводилась на момент обращения и ежедневно в течение периода наблюдения. Для оценки интенсивности боли использовалась цифровая рейтинговая шкала боли. При наблюдаемой тенденции к купированию абдоминальной боли у всех пациентов из группы наблюдения уже с 5-го дня от начала терапии не отмечали абдоминальной боли дети с незначительно выраженной болью, а с 6-го дня — с умеренно выраженной болью. Более длительно, до 7 суток, сохранялась боль у детей с выраженной болью. Таким образом, абдоминальная боль — одна из наиболее часто встречаемых и сложных проблем в практике врача. Наиболее часто она возникает при функциональных расстройствах желудочно-кишечного тракта. Применение селективных миотропных спазмолитиков (мебеверин) для купирования абдоминальной боли патогенетически обосновано. Полученные результаты показали эффективность препарата СПАРК® при лечении функциональной абдоминальной боли у детей. Побочных эффектов и аллергических реакций при приеме препарата не отмечалось. Мебеверин (СПАРК®) может быть препаратом выбора и рекомендован при абдоминальной боли у взрослых и детей в возрасте от 10 лет.

General dental practitioners' knowledge and attitudes on children's pain and pain management-A questionnaire survey.

The aim was to study general dental practitioners’ knowledge and attitudes on pain and pain management in children and adolescents, using a multidimensional questionnaire. There is little information on dentists’ views on pain in children. The research question was how attitudes and knowledge may correlate to the dentists’ age, sex, years of professional experience, the proportion of working time devoted to treating children and adolescents, as well as being a parent. At the time of the study, 387 general dentists working for the Public Dental Service participated in a web‐based, multidimensional validated questionnaire holding the categories (A) views on the care of children in pain, (B) physiology, (C) pain alleviation, (D) medication, (E) sociology/psychology, (F) Pain assessment instruments and methods, (G) non‐medication methods of pain alleviation, and (H) documentation of pain management. The age categories were given as; below 25, 25‐35, 36‐45, 46‐55 years, and older than 55 years of age. 71% of the responders were female. The dentists’ age cohort, as well as the years of professional experience, tended to make a difference as to the pain interventions in children and adolescents (P < 0.03). The female dentists, in comparison to the male dentists, conveyed different pain treatment strategies (P < 0.03). The proportion of working time devoted to treating children and adolescents, as well as being a parent, did not show significant differences regarding pain strategies. Associations were observed between the age of the dentists studied, the number of years as professionals and the knowledge and attitudes that benefit children's pain treatment. Being a parent was not significant. In this studied group, female dentists displayed significantly more care regarding pain management, than did their male colleagues. Furthermore, the study highlighted the need for a short questionnaire, user‐friendly yet with retained multidimensionality.

Guideline for the Assessment and Treatment of Pain in Children with Multiple Sclerosis (MS): A Delphi Panel (4328)

Guideline for the Assessment and Treatment of Pain in Children with Multiple Sclerosis (MS): A Delphi Panel (4328)

Children's Opioid Use at Home After Laparoscopic Appendectomy

BackgroundTo combat the opioid epidemic, prescribers need accurate information about pediatric home opioid requirements to manage acute pain after surgery. Current opioid use estimates come from retrospective surveys; this study used medication adherence technology (eCAP) to track home opioid use. PurposeTo describe children's pain treatment at home after laparoscopic appendectomy, and to compare self-reported opioid analgesic use to eCAP data and counts of returned pills. DesignProspective exploratory and descriptive study MethodsA convenience sample of 96 patients, 10-17 years of age, from a single urban nonprofit children's hospital consented to self-report pain treatment in 14-day diaries and use eCAP to monitor prescribed opioid use at home after laparoscopic appendectomy. ResultsPatients were prescribed 5-45 opioid-containing pills (mean ± standard deviation 15 ± 7.2). Of 749 opioid-containing pills prescribed to 49 patients who returned data, 689 pills were dispensed, 167.5 were used for the reason prescribed, 488 were returned to families for disposal, and 53.5 were missing. The majority of the 49 patients were opioid naïve (72%), Caucasian (64%), and male (56%), with a mean age of 14 years. Patients used 6.6 ± 6.3 opioid-containing pills by pill count and 5.6 ± 5.1 by self-report, a significant difference (p = .004). Unreported eCAP-enabled pill bottle openings typically occurred on weekends. ConclusionMedication adherence technology (eCAP) is a more rigorous method than self-report to estimate opioid needs and detect early opioid misuse. Additional rigorously designed studies of postoperative opioid use are needed to guide opioid prescribing.

Outcomes of the Pediatric Development Plan of Tapentadol.

The opioid analgesic tapentadol was the first pain medication to be developed for the treatment of pain in children under a formal process established by the regulatory authorities. This article summarizes the outcomes of the pediatric development program for tapentadol across the entire age range from birth (including neonates) to adolescents <18 years of age. In addition, the challenges experienced when designing and conducting the pediatric tapentadol clinical trials as well as the interactions with the regulatory authorities are discussed. As a first outcome, the oral solution of tapentadol was authorized in the EU in 2018 as a new treatment option in the hospital setting for moderate to severe acute pain in children from 2 to <18 years of age.

Tapentadol Prolonged Release for Long-Term Treatment of Pain in Children.

PurposeInvestigation of the efficacy and safety of tapentadol prolonged release (PR) compared with morphine PR for long-term treatment of pain in children.Patients and MethodsChildren aged 6 to <18 years requiring long-term treatment with opioids were studied in a 12-month, 2-part, multi-center trial: Part 1, 14-day open-label, randomized, active-controlled, parallel group non-inferiority trial comparing twice daily tapentadol PR with morphine PR; Part 2, open-label treatment with tapentadol PR for up to 12 months or no treatment “safety observation period”. Pain intensity was rated with visual analogue scale or Faces Pain Scale-Revised, and non-inferiority was assessed by comparison of “treatment responders” (those completing the 14-day treatment period and showing pre-defined changes in pain rating) in each group.ResultsTwenty-three of 48 centers enrolled 73 patients. In Part 1, 45 and 24 patients received tapentadol or morphine, respectively, of which 40 and 22 completed 14-day treatment. In Part 2, thirty-six and 58 patients entered the tapentadol PR or observation periods, respectively, with 20/36 completing at least 12 weeks of treatment; 10 of the 36 had received morphine in Part 1. Forty-four of the 58 patients in the safety observation period had received tapentadol. Tapentadol PR was non-inferior to morphine PR (lower limit of confidence interval above negative non-inferiority margin of −0.2) in Part 1. Rates of adverse events were as expected with nausea (22.2%) and constipation (15.6%) in the tapentadol PR group, and with vomiting (33.3%), nausea and constipation (each 16.7%) in the morphine PR group. No new safety issues were identified; the safety profile of tapentadol over the 12 months treatment and observation periods was comparable to that established in subjects >18 years old.ConclusionTapentadol PR was well tolerated and equivalent to morphine PR for both efficacy and safety in children (6 to <18 years old) requiring long-term treatment with opioids.

Commitment to Comfort QI Collaborative: Improving the treatment of children’s pain in Alberta’s emergency departments

Background and Goal: Pediatric pain is often under-treated in emergency departments (EDs), which is known to cause short and long-term harm. A recent quality improvement collaborative (QIC) led by our team was successful in improving treatment of children's pain across 4 EDs in Calgary, Alberta. We then formed a new QIC among general EDs across the province of Alberta to improve treatment of children's presenting and procedural pain. Aims were to improve the proportion of children <12 years of age who receive topical anesthetic before needle procedures from 13% to 50%; and for children <17 years …

Comparison of single shot caudal Ropivacaine and Bupivacaine in paediatric patients undergoing herniotomy

Background: Inguinal hernia repair is a common surgical procedure in children. Caudal block is an appropriate technique for the treatment of post operative pain in children undergoing herniotomy. This study compared the effects of Ropivacaine and Bupivacaine in caudal block in children undergoing herniotomy.&#x0D; Methodology: A total of 74 patients between 5-16 yrs undergoing herniotomy were randomized in two groups. In Group B, 0.75ml/kg of 0.25% caudal Bupivacaine was administered whereas Group R received 0.75 ml/kg of 0.25% caudal Ropivacaine. Pain score was assessed using Wong Baker pain scale in post operative period and motor power was assessed using modified Bromage scale till 6 hours.&#x0D; Results: The mean duration of post operative analgesia was found to be 253.51 ± 11.48 minutes in Bupivacaine and 258.1 ± 12.10 minutes in Ropivacaine group. The median duration of motor block was 180 (Q1 60- Q3 180) minutes in Bupivacaine and 30 (Q1 22.5- Q3 45) minutes in Ropivacaine group which was statistically significant. There was complete recovery of motor block by 2 hour in Ropivacaine and by 4 hour in Bupivacaine group. (p value&lt; 0.001).&#x0D; Conclusion: From the current study, it is concluded that caudal Ropivacaine at 0.25% concentration and 0.75ml/ kg provides similar duration of post operative analgesia with less motor block in comparison to Bupivacaine.

Potential treatment effect modifiers for manipulative therapy for children complaining of spinal pain.Secondary analyses of a randomised controlled trial

BackgroundIn children, spinal pain is transitory for most, but up to 20% experience recurrent and bothersome complaints. It is generally acknowledged that interventions may be more effective for subgroups of those affected with low back pain. In this secondary analysis of data from a randomized clinical trial, we tested whether five indicators of a potential increased need for treatment might act as effect modifiers for manipulative therapy in the treatment of spinal pain in children. We hypothesized that the most severely affected children would benefit more from manipulative therapy.MethodThis study was a secondary analysis of data from a randomised controlled trial comparing advice, exercises and soft tissue treatment with and without the addition of manipulative therapy in 238 Danish school children aged 9–15 years complaining of spinal pain. A text message system (SMS) and clinical examinations were used for data collection (February 2012 to April 2014).Five pre-specified potential effect modifiers were explored: Number of weeks with spinal pain 6 months prior to inclusion, number of weeks with co-occurring musculoskeletal pain 6 months prior to inclusion, expectations of the clinical course, pain intensity, and quality of life.Outcomes were number of recurrences of spinal pain, number of weeks with pain, length of episodes, global perceived effect, and change in pain intensity. To explore potential effect modification, various types of regression models were used depending on the type of outcome, including interaction tests.ResultsWe found that children with long duration of spinal pain or co-occurring musculoskeletal pain prior to inclusion as well as low quality of life at baseline tended to benefit from manipulative therapy over non-manipulative therapy, whereas the opposite was seen for children reporting high intensity of pain. However, most results were statistically insignificant.ConclusionsThis secondary analysis indicates that children more effected by certain baseline characteristics, but not pain intensity, have a greater chance to benefit from treatment that include manipulative therapy. However, these analyses were both secondary and underpowered, and therefore merely exploratory. The results underline the need for a careful choice of inclusion criteria in future investigations of manipulative therapy in children.Trial registrationNCT01504698; results