Society for Pediatric Pain Medicine
Better Care for Children in Pain

Written by:
Genevieve D’Souza, MD
Stanford University

A 16 year old boy presents to the pediatric chronic pain clinic with 5 month history of daily headaches. Onset of headaches correlated with the start of 9^th grade in a new high school. His headache is in the occipital area radiating to the top of his head bilaterally. His grades have dropped significantly as he is absent 2-3 days/week and comes home early from school the other days. He reports being stressed from missing all the school work and now having to make up all the work. He reports difficulties in falling asleep and is playing videogames for 2-4 hrs at night as he can’t fall asleep. He was trialed on triptans and gabapentin but had to discontinue them due to side effects.  Review of the chart reveals a normal MRI of the head. On examination, he has a normal neurological exam with positive bilateral occipital neuralgia. He has been taking acetaminophen every 4 hours and ibuprofen every 6 hours, in scheduled fashion.  

Which option would not be the recommended next step in management?

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?