Society for Pediatric Pain Medicine
Better Care for Children in Pain

Ex 34-week infant who was born to a mother with a history of severe Osteogenesis Imperfecta (OI) and chronic pain on chronic opioid therapy. Throughout her pregnancy, the mother was on methadone 15mg TID, and PRN hydrocodone/acetaminophen (dose weaned from 100 mg/day earlier in pregnancy to 30mg/day in an attempt to limit fetal exposure). The inpatient pain service was consulted for evaluation and treatment of NAS and ongoing pain issues.

Which of the following statements is true?

This question was submitted by Deepa Kattail and Anjana Kundu. If you would like to submit a future question, please send it to Franklin Chiao at [email protected].

A previously healthy 16 year old, 60 kg female with a diagnosis of CRPS type I after a right ankle sprain while skiing 6 months ago presents to your pain clinic. Although the edema, purplish discoloration and cold foot and ankle seen 1-2 weeks after the injury have subsided, allodynia and intense pain of the entire right lower extremity persist. She is unable to bear weight on that leg and has been wheelchair bound at this point. All imaging studies were normal after the initial injury. Despite regular physical therapy and compliance with her oral medication regimen (gabapentin, amitriptyline, acetaminophen, ibuprofen and hydromorphone as needed) she continues to have severe excruciating pain interfering with school attendance, sleep, ambulation and is limiting progress with PT. An assessment by the pediatric pain psychologist did not reveal any major mental health concerns except some reactive depression. A lumbar sympathetic block performed during earlier phase, failed to provide any analgesia despite obvious signs of sympathetic blockade. She and her family are desperate to get some pain relief, want help with being able to participate in PT more aggressively and seek other options for pain control.

Which option, supported by current guidelines, would be most appropriate at this time?

This question submitted by Rani Sunder and Franklin Chiao.

A 6-month old boy presents for proximal hypospadias repair. The plan is to perform the surgery under general anesthesia with supplemental regional anesthesia. Which analgesic technique would best manage intraoperative and post-operative pain?

A 2.5 month-old, ex- 31 week premature infant is scheduled for an exploratory laparotomy for adhesiolysis and possible small bowel resection. The infant has a history of necrotizing enterocolitis, and underwent a small bowel resection six weeks prior to the operation. Other history includes grade I IVH. The infant was intubated for 3 weeks after birth, and for one week following her initial operation. She required significant amounts of opioid for sedation during mechanical ventilation, and recently finished weaning opioids. The surgeon requests epidural placement to facilitate immediate postoperative extubation and minimize postoperative opioids.
Preoperative lab results include an INR of 1.3 (normalized values 0.8-1.2), PTT of 45.4 (normal 28-37 seconds), fibrinogen 175 mg/dL (normal 200-400), platelets 375 K/uL.

What strategy would you select for postoperative pain management?

A 9 year old female had an epidural placement for postoperative analgesia after osteosarcoma resection and reconstruction of the left leg. The epidural placement required multiple attempts by resident and attending. Patient reported on POD 1 that she is not able to sit up without 8/10 pain described as in the occipital location, dull, and constant. Orthopedic surgery wants to mobilize her early. What are your treatment options?