Additional Material

Definition of Pain

“Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”

-IASP, 1979

Postoperative Pain in Pediatrics

• Pediatric patients often receive inadequate pain management.
• Unrelieved pain has potentially dire consequences for our patients.
• Fear of pain is a source for great distress in children and adolescents e.g. what will happen next? What is going on? Why do I feel this way?
• Increased attention to pain relief improves satisfaction with medical treatment.
• There are many effective treatments for pediatric pain. Using non pharmacological treatments along with medications substantially improve patients outcomes.
• Organizational culture and pain team approaches are important to improving pain management and updating believes and attitudes of healthcare providers.

Common Causes of Pain in Pediatrics

All Children

• Headache
• Oral/dental pain
• Abdominal pain
• Musculoskeletal pain
  • Limb pain
  • Back pain

Hospitalized Children

• Cancer pain
• Abdominal pain
• Back pain
• Postoperative pain

Prevalence of Moderate-Severe Pain after Surgical Procedures in Hospitalized Children

Types of Pain

Nociceptive Pain

Caused by activity in neural pathways in response to potentially tissue-damaging stimuli.

• Postoperative pain
• Arthritis
• Mechanical low back pain
• Pain from injuries
• Sickle cell crisis
• Pancreatitis

Mixed Type

Caused by a combination of both primary injury and secondary effects.

Neuropathic Pain

Initiated or caused by primary lesion or dysfunction in the nervous system.

• Postherpetic neuralgia
• Neuropathic low back pain
• Distal polyneuropathy (e.g., diabetic, HIV)
• CRPS
• Trigeminal neuralgia
• Central post-stroke pain

Learn About Scoliosis

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• Most common spinal deformity worldwide
• Causes curvature of the spine 
• Spine sometimes looks more like the letter “S” or “C” than the letter “I” 
• Spine can be rotated or twisted 
• Pulls ribs to form multidimensional curve
• Peak prevalence: adolescents 10-18 years of age 
• Can occur in younger children
• More likely to progress in girls

Etiology

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• Affects as many as 3 in 100 Americans 
• Origin of idiopathic scoliosis remain unknown 
• Research has shown it has a genetic component 
  • Continued research needed to determine specific genes and genetic markers 
• Frequently detected in school screening

Signs and Symptoms

Signs and Symptoms of Idiopathic Scoliosis

• Difference in shoulder height
• Head is not centered with the rest of the body
• Difference in hip height or position
• Difference in shoulder blade height or position
• Tilted pelvis
• A difference in the way the arms hang beside body – when standing straight
• The sides of the back differ in height – when bending forward
• Clothing does not hang straight
• Mild or moderate scoliosis is not painful 
• Mild idiopathic scoliosis does not cause any symptoms 
  • Parents/children may be concerned about cosmetic appearance of back 
• 39% of patients with scoliosis severe enough to require surgery have mod-severe pain preoperatively but are not usually taking analgesics (Sieberg CB et al)

Adams Forward Bend Test

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Courtney's Xray

• Thoracic curve 21
• Risser 2 (skeletal growth not complete)

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Non Surgical Treatment: Back Brace

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Courtney's Back Brace

Courtney talks about her treatment with her back brace.

Surgical Intervention: Spinal Fusion

Another treatment option is surgical intervention to fuse the spine.

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Spinal Fusion Pain

• One of the most invasive surgeries  in adolescents 
• Extensive tissue and bone trauma 
• Involves severe post operative pain
•  >7 on a scale of 0-10  
• About half of all patients suffer from prolonged postoperative pain at the surgical site

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Bowel Medications While on Opioids

• Stool softener – Miralax, dulcolax
• Motility agent – Senna, bisacodyl (also available as suppository)
• Stomach protection
  • H2 blocker (e.g cimetidine or ranitidine)
  • Proton pump inhibitor (e.g. esomeprazole)

Instructions for Parents and Children

• Target 1-2 soft stool per day
• If stool is hard, increase stool softeners
• If frequency is less than 1 per day, increase motility agent