Literature Reviews

By Sabine Kost-Byerly, MD
Former President, Society for Pediatric Pain Medicine
Former Director, Pediatric Pain Management,
Former Director, Multi-disciplinary Pediatric Pain Clinic, Kennedy Krieger Institute
Associate Professor of Anesthesiology and Critical Care Medicine, Emeritus
Johns Hopkins University School of Medicine
Baltimore, Maryland

Variation in pediatric local anesthetic dosing for peripheral nerve blocks: an analysis from the Pediatric Regional Anesthesia Network (PRAN)

Taenzer AH, Herrick M, Hoyt M, et al. Reg Anesth Pain Med 2020;45(12):964-969
doi: 10.1136/rapm-2020-101720.

Higher doses of local anesthetic (LA) administrations can be associated with systemic toxicity. Variation in LA dosing has been reported in adults and infants. This study aimed to evaluate factors associated with LA dose variations.

Methods:
The 10 most common peripheral nerve blocks (PNBs) in the Pediatric Regional Anesthesia Network PRAN (a prospective, observational multi-institutional collaborative) database were evaluated for variation in LA dose. Data included specifics regarding patient (age, weight, ASA status), block (type of block, concentration, and volume of LA) and study institution. All LA doses were converted to bupivacaine equivalents (BEs) and mg/kg (BE/kg). Excluded was data for age 0-1 month and some LA’s (lidocaine, chloroprocaine) due to low numbers.

Results:
The children (N=34,514; age 10.4±5.2 years; weight 45±27 kg; 62% male) received a mean LA dose of 0.9±0.5 BE/kg with concentrations of 0.5%, 0.25% and 0.2% (a third each respectively). Ropivacaine was the LA of choice in 65% of blocks. Most common blocks were femoral (26%), TAP (14%), and IL/IH (11%). LA doses varied independent of age group or block type. The IDR (measure of variation for the central 80% of all doses) exceeded the average dose of LA/kg.  Hospital institution was more important (14%) than block type (6%) or choice of LA for dosing.

Discussion:
There is lack of agreement in the administration of LA volume for PNB in children, not just because of current lack of evidence but also because of institutional traditions and practice. (See one, do one, teach one seems to be alive and well…). Limitations of this study include lack of efficacy data and associated quality metrics.

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Caudal analgesia versus abdominal wall blocks for pediatric genitourinary surgery: systematic review and meta-analysis

Desai N, Chan E, El-Boghdadly K, et al. Reg Anesth Pain Med 2020;45(11):924-933
doi: 10.1136/rapm-2020-101726

Caudal analgesia is an established regional anesthesia technique but in recent years abdominal wall blocks (TAP, IL/IH) have been commonly used.  This study aimed to compare analgesic efficiency, side effects, and functional outcomes of peripheral nerve blocks versus caudal analgesia by conducting a systematic review and meta-analysis.

Methods:
The authors performed a systematic search of databases (Central, CINAHL, Embase, Global Health, LILACs, MEDLINE, Scopus, Web of Science) for RCTs in children with genitourinary surgery comparing IL/IH or TAP block with caudal analgesia. Outcomes assessed were patient and block characteristics, postoperative pain scores within first 24 hours, need for in-hospital rescue analgesia, time needed to perform block, cumulative morphine and paracetamol consumption, adverse events, as well as patient and parent satisfaction.

Results:
The screening process identified 23 RCTs with 24 to 200 participants each (N=1399, IL/IH or TAP N=703; caudal analgesia N=696). Immediate postoperative pain score was equivalent when reported (N=763, 13 trials), as was need for in-hospital rescue analgesia (N=1020, 16 trials), and adverse events. No differences were found in a subgroup analysis of TAP and IL/IH blocks. No study assessed pruritus or urinary retention at 24 hours.

Discussion:
Abdominal wall blocks (somatic analgesia) and caudal blocks (somatic and visceral analgesia) provide comparable analgesia and a similar need for supplemental analgesia rescue. Somatic analgesia may be more important for these procedures. Limitations of this study were the use of landmark modalities in many trials, co-administration of LA adjuncts, potential risk of selection and performance biases, limited outcomes reporting in some trials, and heterogeneity. 

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The relationship between parental factors, child symptom profile, and persistent postoperative pain interference and analgesic use in children

Siemer LC, Foxen-Craft E, Malviya S, et al. Pediatr Anaesth 2020;30(12):1340-1347
doi: 10.1111/pan.14031

Pediatric patients will report persistent postoperative pain in about a fifth of cases on average and in almost two thirds of some, especially painful orthopedic procedures. Patients’ physical, psychological and symptom profile prior to surgery play a role in the development of such pain. This study aimed to evaluate the contribution of parental factors.

Methods:
This study (third one based on a prospective observational study with multiple aims) involved parents and their children (age 10-17 years) undergoing posterior spinal fusion for scoliosis. Measures included: parent pain catastrophizing, parent self-reported pain history, parent pain relief preference (PR Pref scale), child psychologic and somatic symptom profile, pediatric Patient-Reported Outcome Measure System (PROMIS)-short forms (pain interference, fatigue, depression, anxiety), PainDETECT (qualitative descriptors of neuropathic pain), child pain catastrophizing, and longitudinal outcomes including analgesic use.

Results:
One-year follow-up surveys in addition to baseline assessment were completed by 76/95 (80%) of parent/child dyads. The follow-up group was like the baseline group. Parents (79%) and patients (78%) were primarily female. High symptom profile was seen in 28% of the children at baseline. Long-term pain interference score was 5.64 (range 0-30). Analgesics use at one year was reported by 41% (1-2 times/week 29%; daily 2.6%). Except for two children, patients used over the counter non-opioids for pain management. Parent (20%) and patient (23%) factors predicted patient long-term interference scores.  Parent catastrophizing predicted longitudinal outcome, long-term pain interference but not long-term analgesic use. Parents’ pain relief preference scores predicted long-term outcomes and analgesic use. Parent pain history was not associated with long-term outcomes.  Addition of the child baseline symptom profile in the model completely attenuated the association between parent factors and the patients’ long-term outcomes.

Discussion:
Parent catastrophizing and pain relief preferences predicted some of the variance seen in pediatric patients’ long-term outcomes and pain interference.  The association between parent factors and outcome may be dependent on the child’s baseline psychological/somatic symptom profile. Future interventions may need to address the patient’s baseline symptomatology and then indirectly influence parental responses and outcomes.

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Psychosocial predictors of acute and chronic pain in adolescents undergoing major musculoskeletal surgery

Rabbits JA, Palermo TM, Zhou C, et al.  J Pain 2020;21(11-12):1236-1246  doi: 10.1016/j.jpain.2020.02.004

Persistent pain in adolescents after major surgery has been documented but contributing factors are less established. This study aimed to identify patient and caregiver psychosocial predictors of acute and chronic pain after major surgery.

Methods:
This is a prospective longitudinal cohort study in adolescents undergoing major musculoskeletal surgery and their parent/guardian in a single US tertiary pediatric hospital. Data include assessment before surgery (baseline, T1), two weeks post-surgery (acute outcomes, T2) and at four-month follow-up (chronic outcome, T3 [N=114]). Measures for youth were: pain diary for seven days at each time interval, pain intensity (NRS), medication intake, quality of life and pain associated limitations (Peds QL short form-acute version), wide-spread pain index (WPI), pain catastrophizing scale-child version (PCS-C), revised child anxiety and depression scale (RCADS), insomnia severity index (ISI), and the adolescent sleep wake scale (ASWS). Caregiver measures included parent catastrophizing scale (PCS-P), family assessment device – general subscale (FAD), and demographics.

Results:
Adolescents (N=119, N=114 at T3; 75 females, 44 males; 78% white; mean age 15 [range 10-19] years) reported moderate severe pain and impaired HRQOL at two weeks (ASPS) in 27% and at four months (CPSP) in 20% of the cases.  These patients also had significantly higher pain interference with activities and emotional distress at T2 and T3.  The rate of CPSP was significantly higher in those who had also met criteria for ASPS (50% vs. 9%).  At T2, non-opioids were taken on more than 50% and opioids on 21% of the days. At T3, non-opioid use decreased to 7% of days. No opioids were taken.  At T1, clinical depression was apparent in 5% and clinical anxiety in 4% of youth.  Predictor of APSP was pain intensity at T1. Predictors of CPSP were adolescent depressive symptoms and sleep quality at T1.

Discussion:
In adolescents undergoing major surgery, pre-surgical pain intensity was a risk factor for APSP and depressive symptoms and sleep quality were for CPSP. Half the patients with ASPS went on to meet criteria for CPSP, suggesting prolonged postoperative pain can become established early after surgery.

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What do parents value regarding pediatric palliative and hospice care in the home setting?

Boyden JY, Ersek M, Deatrick JA, et al.  J Pain Symptom Manage 2021;61(1):12-23  doi: 10.1016/j.jpainsymman.2020.07.024

Many children with serious life-shortening and complex care requiring illnesses are cared for at home. Although studies have examined parental views of quality of palliative care in the inpatient setting less is known about home care. This study aimed to assess parents’ priorities for such care and begin to develop a parent-report measure.

Methods:
This is a cross-sectional evaluation of parents’ priorities concerning pediatric palliative care and hospice care in the home setting (PPHC@Home). Parents at a tertiary US children’s hospital and a virtual community network (Courage Parents Network – CPN) were recruited by PI phone call after screening for eligibility with the care team (hospital) or by website posted material and parent-imitated phone call (CPN). The investigators employed a discrete choice experiment (DCE) with maximum difference scaling for a quantitative estimate of the importance of certain domains. The examined 20 PPHC@Home domains (including communication, relationships, knowledge and skills, physical, psychological, social care) were based on the National Consensus Project’s (NCP) Clinical Guidelines for Quality Care and a panel of PPC providers and parent advocates.

Results:
Participating parents (N=47, 45 families, age 43±9 years) were mostly white (89%), female (94%), married/partnered (87%) and had at least a college degree (68%). Parents cared for the child at home (70%) or were bereaved (30%). Children (median age about 10 years) received palliative care for neuromuscular, neurologic, or mitochondrial (51%), genetic/congenital (49%), cardiovascular (22%) and metabolic (22%) diseases. Parents rated physical aspects of care: symptom management, psychological/emotional aspects of care, and care coordination as most important. Lowest ratings were for emotional aspects of care for the extended social network, spiritual/religious and cultural aspects of care. There was a 10-fold difference between most and least important domains.

Discussion:
Parents in this study assigned significantly different importance to various domains involving the palliative care of their children at home. (This study is especially limited by the significant homogeneity of the sample, a group of mostly highly educated, married, white women. Clearly, we need to understand a lot more about the needs and preferences of more disadvantaged, minority - or even male parents before deploying a new parent report measure or any ranking of importance of limited health care resources.)

Other Publications of Note

Delivering transformative action in paediatric pain: a Lancet Child & Adolescent Health Commission
Eccleston C, Fisher E, Howard RF, et al. Lancet Child Adolesc Health 2021;5(1):47-87  doi: 10.1016/S2352-4642(20)30277-7
Review. (There are seven other related articles on pediatric pain in the same Lancet issue).

Guidelines for opioid prescribing in children and adolescents after surgery: an expert panel opinion
Kelley-Quon LI, Kirkpatrick MG, Ricca RL, et al. JAMA Surg 2020 Nov 11  doi: 10.1001/jamasurg.2020.5045
Review of literature and guideline statements (This review led to discussions on a pediatric pain listserv regarding appropriate inclusion of experts of various backgrounds in the panel)

Opioid use in children’s surgery: awareness, current state, and advocacy
Bass KD, Heiss KF, Kelley-Quon LI, et al J Pediatr Surg 2020;55(11):2448-2453
doi: 10.1016/j.jpedsurg.2020.02.015
Review article

Pain control and medication use in children following closed reduction and percutaneous pinning of supracondylar humerus fractures: are we still overprescribing opioids?
Stillwagon MR, Feinstein S, Nichols B, et al. J Pediatr Orthop 2020;40(10):543-548 
doi: 10.1097/BPO.0000000000001639
Two-part, retrospective, and prospective, observational study

Evaluation of racial disparities in postoperative opioid prescription filling after common pediatric surgical procedures
Chavez LJ, Cooper JN, Deans KJ, et al.  J Pediatr Surg 2020;55(12):2575-2583  doi: 10.1016/j.jpedsurg.2020.07.024
Retrospective cohort study

Ketorolac after colectomy for ulcerative colitis in children: an analysis of opioid utilization and postoperative complications
Taylor MA, West WB, Guthery SL, et al. J Pediatr Surg 2020;55(11):2393-2396  doi: 10.1016/j.jpedsurg.2020.04.001
Retrospective cohort study including 60 patients

Pain and placebo in pediatrics: a comprehensive review of laboratory and clinical findings
Simmons K, Ortiz R, Kossowsky J, et al. Pain 2020;155(11):2229-2235  doi: 10.1016/j.pain.2014.08.036
Review

Impact of video games on ultrasound-guided regional anesthesia skills
Shafquat A, Mukarram S, Bedforth NM, et al. Reg Anesth Pain Med 2020;45(11):860-865  doi: 10.1136/rapm-2020-101641
Prospective observational study involving 60 medical students, self declared gamers (frequent or daily video game play) and non-gamers (not playing video games at all). (Let the kids play…)

Infant spinal anesthesia reduces postoperative pain scores and pain medication consumption in infants undergoing inguinal herniorrhaphy
Chen FK, Kelleher CM, Liu CA. J Pediatr Surg 2020;55(12):2840-2843  doi: 10.1016/j.jpedsurg.2020.08.011
Letter to the editor with prospective observational cohort study including 20 infants

Management of accidental lumbar epidural catheter breakage in a 5-month-old infant
Smedile F, Giordano G, Pariante R, et al. Pediatr Anaesth 2020;30(11):1278-1279
doi: 10.1111/pan.14022
Case report

Efficacy of caudal vs intravenous administration of α2-adrenoreceptor agonist to prolong analgesia in pediatric caudal block: a systematic review and meta-analysis
Xing M, Liang X, Li Lin, et al. Pediatr Anaesth 2020;30(12):1322-1330
doi: 10.1111/pan.14025

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review
Kars MS, Gomez Morad A, Haskins SC, et al.  Reg Anesth Pain Med 2020;45(12):985-992  doi: 10.1136/rapm-2020-101341

Nurse-implemented goal-directed strategy to improve pain and sedation management in a pediatric cardiac ICU
Lincoln PA, Whelan K, Hartwell LP, et al. Pediatr Crit Care Med 2020;21(12):1064-1070  doi: 10.1097/PCC.0000000000002505
Report of a quality improvement project applying a Cardiac-RESTORE protocol for pain and sedation management in a 31 bed PCICU

Assessment of procedural distress in sedated/intubated children under 3 years old using the Newborn Infant Parasympathetic Evaluation: a diagnostic accuracy pilot study
Recher M, Rousseaux J, Flocteil M, et al. Pediatr Crit Care Med 2020;21(12):e1052-e1060
doi: 10.1097/PCC.0000000000002454
(also see editorial: Another tool to assess distress in sedated children; do we need a better mousetrap?  Parker MM Pediatr Crit Care Med 2020;21(12):1092-1094
doi: 10.1097/PCC.0000000000002503)
Prospective study assessing the usefulness of NIPE compared with the Comfort Behavioral Scale in assessing pain and discomfort in young sedated and ventilated children undergoing basic and invasive care procedures

Pain experience, physical function, pain coping, and catastrophizing in children with sickle cell disease who had normal and abnormal sensory patterns
Hyacinth O, Machado Silva-Rodrigues F, Darezzo Rodrigues Nunes M, et al.  J Pain Symptom Manage 2020;60(6):1079-1091  doi: 10.1016/j.jpainsymman.2020.07.006
Comparative design study of children with SCD, with and without abnormal sensory patterns, part of a larger study examining pain and symptom management in children with SCD.

Pain in children and adolescents with sickle cell disease: multidimensional assessment
Abadesso C, Pacheco S, Machado MC, et al.  J Pediatr Hematol Oncol 2020;42(8):455-462  doi: 10.1097/MPH.0000000000001941
Study assessing pain in Portuguese children and adolescents with SCD

Development and psychometric evaluation of PROMIS pediatric pain intensity measure in children and adolescents with chronic pain
Mara CA, Kashikar-Zuck S, Cunningham N, et al. J Pain 2021;22(1):48-56  doi: 10.1016/j.jpain.2020.04.001
Study presenting the development and testing of a self-report measure

Pain catastrophizing in children with chronic pain and their parents: proposed clinical reference points and reexamination of the Pain Catastrophizing Scale measure
Pielech M, Ryan M, Logan D, et al. Pain 2020;155(11):2360-2367 doi: 10.1016/j.pain.2014.08.035
Evaluation of the psychometric properties of the English version of the PCS-C and PCS-P with a sample of 679 pediatric chronic pain patients and their parents

Initiating palliative care referrals in pediatric oncology
Cuviello A, Raisanen JC, Donohue PK, et al. J Pain Symptom Manage 2021;61(1):81-89  doi: 10.1016/j.jpainsymman.2020.07.008
Mixed-methods study using semi-structured interviews of 77 pediatric oncology providers from two academic institutions.

Stress and perception of procedural pain management in Chinese parents of children with cancer
Yan C, Cheung RS, Wong CL, et al. J Pain Symptom Manage 2021;61(1):90-102  doi: 10.1016/j.jpainsymman.2020.06.028
Prospective study using structured questionnaire assessing parental stress and parental attitude towards analgesics involving 265 parents of children with cancer in Guangzhou and Hong Kong.

“I could never prepare for something like the death of my own child”: parental perspectives on preparedness at end of life for children with complex chronic conditions.
Bogetz JF, Revette A, Rosenberg AR, et al. J Pain Symptom Manage 2020;60(6):1154-1162  doi: 10.1016/j.jpainsymman.2020.06.035
Cross-sectional study including 110 parents at US academic pediatric medical center.

Human touch via touchscreen: rural nurses’ experiential perspectives on telehealth use in pediatric hospice care.
Weaver MS, Neumann ML, Navaneethan H, et al. J pain Symptom manage 2020;60(5):1027-1033  doi: 10.1016/j.jpainsymman.2020.06.003
Qualitative study including voice-recorded interviews with rural hospice nurse telehealth users

Journals were reviewed for three months (11/2020 to 1/2021) and included:

• Anesthesiology
• Anesthesia & Analgesia
• British Journal of Anaesthesia
• Pediatric Anesthesia
• Regional Anesthesia and Pain Medicine
• Pediatrics
• The Journal of Pediatrics
• Pediatric Critical Care Medicine
• Journal of Pediatric Intensive Care
• Journal of Pediatric Hematology/Oncology
• Journal of Pediatric Orthopedics
• Journal of Pediatric Surgery
• JAMA Pediatrics/Surgery
• The Lancet Child & Adolescent Health
• Pain, The Journal of Pain
• Journal of Pain and Symptom Management
• The Journal of Palliative Care, Journal of Palliative Medicine