Society for Pediatric Pain Medicine
Better Care for Children in Pain

April's question submitted by:


Caitlin Thompson, PhD
Pediatric Psychology Consultation Program
Kennedy Krieger Institute


Chris Joseph, DPT
Pediatric Chronic Pain and Connective Tissue Disorders Clinic
Kennedy Krieger Institute

A 15-year-old female presents to the multidisciplinary chronic pain clinic for evaluation of widespread body pain, primarily in the back and knees.  Her rheumatological testing and imaging were normal.  During the physical exam, all orthopedic testing indicated no acute injury.  She reports that she has more pain when sitting for a long period of time and after doing a lot of activity. She feels her sleep is nonrestorative and has difficulty initiating sleep. She has little to no pain during an activity she really enjoys, but pays for it the next day.  She scores a 9/9 on the Beighton scale for hypermobility and shows mild proximal weakness in the core and hip extensors.  Her numeric self-rating of pain is 9/10 at the worst, with an average of 6-7/10.  She previously participated in field hockey and volleyball, but discontinued due to pain. She is typically very social but has avoided doing activities with friends because she worries that doing so will lead to increased pain.  Psychologically, she describes anxiety about schoolwork, worries that her pain will not get better, and feelings of hopelessness.  Standardized measures showed clinical elevation of anxiety and depression. 

What course of treatment should be recommended?

March's question is written by:


Clarice Nguyen, MD
Combined Pediatrics and Anesthesiology Resident
Department of Anesthesiology
Department of Pediatrics
Stanford University

AND


Viviana F. Ruiz, MD
Pediatric Anesthesiology Fellow
Lucile Packard Children's Hospital
Stanford University

An 11-year-old female with a history of precursor B cell acute lymphoblastic leukemia (ALL) is admitted to your pediatric hospital after she was found to have a medullary relapse. The patient has already undergone two rounds of chemotherapy and is now undergoing Chimeric Antigen Receptor (CAR) T-cell therapy.  The patient also has a history of chronic peripheral neuropathy and low back pain and is on scheduled hydromorphone. Four days after starting CAR T-cell therapy the patient develops flu-like symptoms, including fever, headache, and severe muscle and joint pain. Blood cultures have been negative to date. You are consulted to help manage the patient’s acute on chronic pain during CAR T-Cell treatment. Which of the following would BEST address this patient’s current pain symptoms?

January's Question of the Month is written by:    

Elizabeth O'Brien, MD
Pediatric Anesthesiology Fellow
Department of Anesthesiology and Critical Care
Children’s Hospital of Philadelphia


An 8-year-old female with a history of a cleft lip and palate status post staged primary repairs of both defects presents for an alveolar cleft graft. The surgical team intends to use a pyramidal bone block from the anterior iliac crest for the graft site. The patient reports hives with morphine and a history of postoperative nausea/vomiting. As part of an opioid-sparing multimodal analgesic plan, you offer to place a transversalis fascia plane block for post-op pain control. Identify the location for local anesthetic deposition for a successful block:

Figure 1

December's question is written by:  

Ashlee Holman, MD
Assistant Professor of Anesthesiology
University of Michigan Health System

A 16-year old male with sickle cell disease presents to the hospital in acute pain crisis. His sickle cell disease has worsened over the last few years, and optimal pain control during acute crises has been difficult to achieve. His analgesic regimen is complex and includes non-pharmacological methods (e.g. distraction techniques, behavioral modification therapy) as well as acetaminophen, NSAIDs, hydromorphone, methadone, and most recently, initiation of a lidocaine infusion. He reports low pain scores on the intravenous lidocaine and wonders if he can continue lidocaine in some form as an outpatient. The patient’s care team suggests transition to oral mexiletine as a replacement for intravenous lidocaine. Which of the following is false?

This month’s question was jointly written by a team from the Lucile Salter Packard Children's Hospital at Stanford University, Palo Alto, CA. Catherine A. Dietrich, MD is currently a pediatric anesthesiology fellow who completed both her medical training and residency in anesthesiology at the University of Florida College of Medicine in Gainesville, FL. Christina M. Almgren, MS, RN, CPNP, is a pediatric nurse practitioner, practicing in the hospital’s pediatric pain management service since 2000 following her graduation from the University of California, San Francisco.    

Christina Almgren, RN, CPNP (Pediatric Nurse Practitioner)

Catherine Dietrich, MD (Pediatric Anesthesiology Fellow) 

A 9-year-old male is scheduled for staged washout and internal fixation of a severe right tibia/fibula compound fracture. The trauma occurred initially 3 days ago and involved degloving of the lower extremity followed by lake water contamination.  He was transferred to your tertiary care facility for definitive management. His surgeons plan for a flap for delayed closure of his lower extremity wound, to occur at least 5-7 days from the currently planned procedure. While in the ICU, pain control has only been moderately successful, with severe opioid dose-limiting side effects (opioid-induced myoclonus, nausea, and somnolence). The surgeons request a plan for postoperative pain control, concerned especially about pain with daily dressing changes for at least the next two weeks.  What would your primary plan for postop pain management entail?