Preventive Nonopioid Analgesics Improve Children’s Postsurgical Pain Outcomes

pediatric pain management
The researchers’ goal was to identify variables linked to poor pediatric patient-reported postsurgical outcomes.

Administration of at least 2 classes of nonopioid analgesics before surgery can improve pain-related patient-reported outcomes in pediatric populations, according to research published in the British Journal of Anaesthesia.

Using data from the international PAIN OUT infant registry of children aged 4 years or older ( identifier NCT02083835), researchers sought to both identify the variables associated with patients’ desires for more pain treatment — measured on the day after surgery — and determine the efficacy of analgesic treatment and patient satisfaction.

Data were gathered roughly 24 hours after surgery from pediatric patients who had undergone either a tonsillectomy or an appendectomy. Questionnaires evaluated pain at rest, pain on movement, and worst pain since surgery as well as pain-related functional interference, side effects, and the desire for more pain treatment.

The study cohort included data from 932 patients from 12 hospitals in Germany, the Netherlands, Switzerland, and the United Kingdom. Studies with incomplete data were excluded, resulting in data from 898 patients that were available for analysis.

Just over 40% (n=42.2%) of patients filled out the questionnaire on their own (mean age, 12.6±2.5 years), 46.2% required assistance from a parent or caregiver (mean age, 8.0±2.9 years) to fill it out, and a parent or caregiver completed the questionnaire for 11.6% of participants, who were younger (5.5±2.2 years).

Pain composite scores were higher following appendectomy vs tonsillectomy (4.3 vs 3.7), but pain-related interference scores were comparable (2.3 vs 2.1). For appendectomy, the surgical technique — laparoscopic surgery, open surgery, or a combination — did not influence pain scores.

In total, 22.7% of children responded that they would have liked more pain treatment during the first 24 hours following surgery; no difference was noted with regard to the type of surgery. Pain and pain-related interference scores were both higher, and side-effects were more frequent, in patients who reported a desire for more treatment compared with those who did not.

Neither intraoperative opioid doses administered for anesthesia nor the proportion of patients receiving an opioid before emerging from anesthesia differed between groups. Following surgery, more children in the group desiring more pain treatment were given opioids.

Children who underwent tonsillectomy were more likely to receive a preventive nonopioid analgesic before the end of surgery compared with those who underwent appendectomy (92.0% vs 79.2%). Investigators noted an inverse association between the number of different classes of nonopioid analgesics and the desire for more analgesic treatment in both groups. Worst pain, movement-evoked pain, and pain composite score were lowest for patients who received 3 nonopioid analgesics.

Following surgery, between 2 and 3 doses on average of nonopioid analgesics were given in both the postanesthesia care unit and in the unit.

Among children who underwent tonsillectomy, the most high-impact variable was the administration of preventive nonopioid analgesics. For those undergoing appendectomy, this variable was not included because these children generally received fewer preventive nonopioid analgesics.

Study limitations include several possible confounders, including the children’s medical histories and psychological variables such as anxiety, pain coping efficacy, pain catastrophizing, and preoperative pain expectations as well as the assessment of patient-reported outcomes only once in the first day after surgery.

“Overall, pain management seems to be highly heterogenous, with large differences between hospitals, and obviously no standardized use of nonopioid analgesics,” the researchers concluded. “Pain management was insufficient in nearly one-quarter of the children who would have liked more treatment.”

“Opioid-related side-effects and pain-related interference might also be improved by preventive administration of at least two classes of nonopioid analgesics,” they added. “Further studies are needed to demonstrate the superiority of this regimen.”

Disclosure: Several study authors declared affiliations with the pharmaceutical industry. Please see the original reference for a full list of authors’ disclosures.


Stamer UM, Bernhart K, Lehmann T, et al. ‘Desire for more analgesic treatment’: pain and patient-reported outcome after paediatric tonsillectomy and appendectomy. Br J Anesth. Published online March 5, 2021. doi:10.1016/j.bja.2020.12.047