Society for Pediatric Pain Medicine
Better Care for Children in Pain

Written by: Deepa Kattail, MD MHS FAAP
McMaster University, Hamilton, Ontario, Canada

A 15 year old girl presents to the pediatric chronic pain clinic as referral from the family doctor. She complains of widespread musculoskeletal pain in her back, neck, shoulders, arms. Her mother is quite tearful and describes how much the pain has disrupted her daughter's life. She was previously a straight A student but now is struggling in school and misses at least one day of school per a week for the last one year. The patients also reports feelings of sadness and crying. Review of the chart reveals normal MRI of the spine, xray of bilateral arms also normal. On examination, she was tender in the areas of pain complaints but was otherwise grossly normally neurologically and had no issues with radicular pain symptoms. She has been prescribed NSAIDs by her family doctor. She is asking for help with pain management. What would be the best next step in managing this patient's pain?

Written by:
  Sam Nia, MD
UMass Memorial Medical Center, Worcester, MA

You are covering the pediatric acute pain/ regional service and are called to the bedside in the holding area to evaluate a 7 month old female who is scheduled to undergo a right cleft lip and cleft palate repair. The patient’s parents are extremely concerned about perioperative opiate use for this patient and would prefer the patient receive the least amount of opiates possible. The patient has no other significant medical and prenatal history. You are asked if there are any regional anesthesia options available for their child. Which regional technique, if any, could be used in this case?

Written by:

 Bob Wilder, MD

The Mayo Clinic, Rochester, MN

A 15-year-old girl developed an acute viral intestinal illness several months ago with nausea, vomiting and diarrhea.  These symptoms resolved in 7 – 10 days, but she has had postprandial right upper quadrant abdominal pain since.  She notes that she also hurts with exercise.  A pediatric gastroenterologist has seen her and has completed a workup consisting of a normal abdominal ultrasound, an EGD that was normal both visually and by pathology.  Disaccharidase levels are normal.  Gastric emptying studies were also normal.  Fructose breath test was normal.  Abdominal radiograph shows “non-obstructive pattern with mild to moderate stool in the colon.” She may have increased pain with bearing down to have a bowel movement, but it returns to baseline thereafter.   On exam the gastroenterologist states she has a “positive Carnett’s sign” in the right upper quadrant. 

What is a Carnett’s sign? 

Submitted by:
Michelle S. Kars, MD, FAAP
North American Partners in Anesthesia

A 3 day-old full-term infant weighing 3.7 kg presents for thoracotomy for repair of esophageal atresia.  Echocardiogram reveals a small PFO.  Currently the infant is on nasal O2 with no pulmonary distress. Laboratory data is significant for INR of 1.4, and platelets of 60,000.  On discussion with the surgical and NICU teams, they would like to avoid prolonged intubation after surgery. Which of the following will provide thoracic dermatomal coverage and the longest duration block in order to minimize opioids and expedite extubation following surgery?

This question submitted by Timothy Casias, MD

A 15-year-old, 50-kilogram female has history of Complex Regional Pain Syndrome in her right lower extremity for the last 5 years. She presents to the operative room for an open reduction and internal fixation of a displaced distal tibial shaft fracture after falling on ice and hitting her right lower leg on the curb during the winter.  She previously is quite disabled from CRPS and spends most of the time in a wheelchair.  The decision is to place a popliteal catheter for post-operative pain control.  The operation was uneventful, and she has good analgesia with the catheter running 0.2% ropivacaine at 6 ml/hr.   Approximately 36 hours after the operation, she has increasing, severe pain.  What is your biggest concern for this patient?