Postoperative Pain Management in Children: Evidence on Efficacy

Acute postoperative pain has been reported by approximately 80% of those undergoing surgery, with 86% of cases characterized by moderate, severe, or extreme pain.¹ As research increasingly indicates that postoperative pain in children is treated inadequately — in part because of concerns regarding side effects of opioids and difficulty assessing pain in this population — the issue has become a significant concern in pediatric care.^2-4

Several studies conducted in adult patients have linked inadequate postoperative pain management with a greater risk for complications, longer recovery times, and increased mortality and morbidity. By contrast, adequate treatment has been found to contribute to increased patient satisfaction, shorter hospitalization times, and reduced hospital costs.^5-7 Although similar findings in the pediatric population are unavailable, evidence^8,9 suggests that “ineffective treatment of postoperative pain is in positive correlation with delayed wound healing, and the negative development of pain perception and chronic pain in the future,” wrote the authors of a systematic review recently published in Pediatric Anesthesia.¹⁰

Fewer randomized controlled trials (RCTs) include children vs adult cohorts, and the evidence pertaining to this population is further limited because pediatric trials are commonly discontinued because of issues such as insufficient patient recruitment, conduct problems, and funding shortages. A study published in 2016 showed that 19% of the 554 pediatric RCTs examined had been discontinued, and 30% of the 455 completed trials were not published.¹¹

In this context, the authors of the current review hypothesized that data regarding the safety and efficacy of postoperative pain interventions in children would be insufficient.⁸ They conducted an overview of systematic reviews, an approach they assert provides a “summary of evidence from more than one systematic review at a variety of different levels, including the combination of different interventions or the provision of a summary of evidence on the adverse effects of an intervention,” with the aim of summarizing results of RCTs on postoperative pain management in patients <18 years of age. This is the first review to focus on postoperative pain treatment in this patient population. “By analyzing available evidence from systematic reviews across various surgical conditions, we wanted to inspire clinical researchers to test successful approaches in other postoperative settings as well,” they stated.

Of the 45 reviews that met inclusion criteria — comprised of a total of 811 RCTs and a wide variety of surgery types — results were as follows:

• 19 systematic reviews presented conclusive evidence of efficacy: 18 supported the efficacy of diclofenac, ketamine (intravenously or added to caudal block), caudal analgesia, dexmedetomidine, music therapy, corticosteroids (after tonsillectomy), epidural analgesia, paracetamol and/or nonsteroidal anti-inflammatory drugs (rectal and intravenous), and transversus abdominis plane block; 1 systematic review showed evidence of equal efficacy for dexmedetomidine vs morphine and fentanyl.
• 14 systematic reviews reported conclusive evidence pertaining to safety, with positive evidence for dexmedetomidine, corticosteroids, epidural analgesia, transversus abdominis plane block, and clonidine.
• 7 systematic reviews reported conclusive evidence of equal safety for epidural infusion, intravenous diclofenac vs ketamine added to opioid analgesia, bupivacaine, ketamine, paracetamol, and dexmedetomidine vs intravenous opioids, diclofenac (oral or suppository), opioids only, midazolam, normal saline, no treatment, and placebo.
• 1 systematic review presented negative conclusive evidence supporting the safety of caudal analgesia vs noncaudal regional analgesia.
• Conclusive evidence of efficacy was lacking in more than half of systematic reviews, and only one-third of systematic reviews were conclusive regarding safety of the interventions examined. Methodologic quality was rated as medium for more than half of systematic reviews, and the 10 included Cochrane reviews demonstrated higher quality than the other reviews.

“Based on our findings, positive conclusive evidence of efficacy in postoperative pain is in line with current guidelines for the management of acute postoperative pain,” study co-author Borić Krste, MD, an orthopedic and trauma surgery resident at University Hospital Center Split in Croatia, told Clinical Pain Advisor. “Clinicians can use the findings of our paper to choose the optimal intervention for postoperative pain management in children, and to gain insight into the safety of these interventions,” he added.

However, because the reliability of these results depends on the methodologic quality of the research examined, future studies should ensure rigorous quality, he noted. “I think the next step is to investigate the range of efficacy and safety outcomes used in systematic reviews of interventions for postoperative pain in children, and compare them with outcome domains recommended in the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT).”¹²

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References

1. Apfelbaum JL, Chen C, Mehta SS, Gan TJ. Postoperative pain experience: results from a national survey suggest postoperative pain continues to be undermanaged. Anesth Analg. 2003;97(2):534-40, table of contents.
2. Segerdahl M, Warrén-Stomberg M, Rawal N, Brattwall M, Jakobsson J. Children in day surgery: clinical practice and routines. The results from a nation-wide survey. Acta Anaesthesiol Scand. 2008; 52(6):821-828.
3. Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manage. 2008;13:25-32.
4. Lee JY, Jo YY. Attention to postoperative pain control in children. Korean J Anesthesiol. 2014;66(3):183-188.
5. Sharrock NE, Cazan MG, Hargett MJ, Williams-Russo P, Wilson PD Jr. Changes in mortality after total hip and knee arthroplasty over a ten-year period. Anesth Analg. 1995;80(2):242-248.
6. Katz J, Jackson M, Kavanagh BP, Sandler AN. Acute pain after thoracic surgery predicts long-term post-thoracotomy pain. Clin J Pain. 1996;12:50-55.
7. Kehlet H, Holte K. Effect of postoperative analgesia on surgical outcome. Br J Anaesth. 2001;87(1):62-72.  
8. Boric K, Dosenovic S, Jelicic Kadic A, et al. Interventions for postoperative pain in children: an overview of systematic reviews. Paediatr Anaesth. 2017;27(9):893-904.
9. Anand KJS. Pain, plasticity, and premature birth: a prescription for permanent suffering? Nat Med. 2000;6(9):971-973.
10. Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med. 1998;152(2):147-149.
11. Pica N, Bourgeois F. Discontinuation and nonpublication of randomized clinical trials conducted in children. Pediatrics. 2016;138(3):e20160223.
12. McGrath PJ, Walco GA, Turk DC, et al. Core outcome domains and measures for pediatric acute and chronic/recurrent pain clinical trials: PedIMMPACT recommendations. J Pain. 2008;9(9):771-783.