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

Prevalence of Moderate-Severe Pain after Surgical Procedures in Hospitalized Children
Surgical Specialty Prevalence Mod-Severe Pain (%)
General surgery 65
Plastic surgery 47
Neurosurgery 42
ENT 38
Urology 36
Orthopedics 35

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

Illustration of scoliosis in a female child from either side and the back
Scoliosis in a child
  • 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


Illustration of a spine
  • 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

Illustration of a normal spine next to a spine deformed from scoliosis
Normal spine compared to a spine deformed by scoliosis

Courtney's Xray

  • Thoracic curve 21
  • Risser 2 (skeletal growth not complete)
Courtney's xray of the spine
Photo courtesy of Children’s Hospital of Philadelphia

Non Surgical Treatment: Back Brace

Illustration showing adolescent female wearing a back brace
Back brace

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.

Illustration shows fused spine
Spinal fusion

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
Xray shows spine with scoliosis on the left and the same spine corrected with spinal fusion on the right
Spinal fusion

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
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