Pediatric Postoperative Pain Management at Home Barriers in Assessment and Treatment

Marcia L. Buck, PharmD, FCCP, FPPAG, BCPPS


Pediatr Pharm. 2016;22(8) 

In This Article

Pain Assessment and Management

A 2012 study by Stewart and colleagues at the Royal Children's Hospital in Melbourne evaluated the severity and duration of pain and analgesia requirements after common pediatric surgeries.[1] One hundred and five children undergoing tonsillectomy, orchidopexy, or inguinal hernia repair were enrolled. After discharge, parents were asked to document their child's pain using the Parents' Postoperative Pain Measure (PPPM), a validated 15-item observational checklist with a score of 6 or greater representing significant pain. A daily Functional Activity Score (FAS) was also recorded, as well as the amount of analgesics administered.

The tonsillectomy group had the highest PPPM scores, with over half of the children having a score greater than 6 throughout the first week after surgery. Day 12 was the first day that the median PPPM score was zero. The median PPPM scores after orchidopexy or inguinal hernia returned to zero by days 6 and 4, respectively. Patients in the orchidopexy group had the lowest scores overall, with a median score greater than 6 only on the first day after surgery. Functional limitations were most evident on the first 2 days after surgery in all three groups. Time to a full return to normal activities also varied among the groups, with the majority of tonsillectomy patients not considered to be back to their baseline until 12 days. In contrast, most patients undergoing inguinal hernia repair had returned to normal activities within 7 days and most orchidopexy patients within 5 days after surgery.

Children who had undergone tonsillectomy typically received acetaminophen with codeine or acetaminophen alone. Most of these patients were no longer receiving analgesics after day 9. Over half of the tonsillectomy patients were taken to their pediatrician during their recovery. Additional prescription analgesics were prescribed in 17% of those visits. Acetaminophen was the most common agent after inguinal hernia repair, followed by ibuprofen alone. The majority of children in this group were no longer being given analgesia after day 3. The recommendation given to the families of the orchidopexy patients was a regimen using both ibuprofen and acetaminophen. Most patients in this group were no longer receiving analgesia by postoperative day 4.

This study was one of the first to follow patients from surgery to full recovery, with assessment of both pain and functional limitations. It serves as useful tool for establishing the anticipated recovery time for three common pediatric surgeries and guidance for estimating the number of analgesic doses needed. The authors suggest that acetaminophen alone may be adequate for patients undergoing inguinal hernia repair, with most requiring treatment for only 1–2 days. They found a multimodal regimen of acetaminophen and ibuprofen to be effective in the orchidopexy patients, with patients needing treatment for 4–5 days. Children undergoing tonsillectomy, however, tended to have more significant pain for a longer period of time and may require an opioid in combination with OTC analgesics. They noted the frequent use of codeine in this study, particularly in the tonsillectomy patients, which is no longer recommended due to the potential for toxicity in patients with CYP2D6 polymorphisms. The authors acknowledge that this was the result of its availability as an OTC medication in Australia and a lack of dissemination of warnings against use in younger children at that time.

In 2014, Vons and colleagues at the University Medical Center, Utrecht evaluated pain assessments in an observational cohort study of 167 children less than 13 years of age undergoing adenoidectomy (AD) or adenotonsillectomy (ATE).[2] The AD patients received acetaminophen before and after surgery, while the ATE patients received both acetaminophen and diclofenac suppositories. The AD patients were treated on an as needed basis. The parents of the ATE patients received recommendations to administer acetaminophen three times daily with diclofenac twice daily for the first 5 postoperative days. Parents assessed their child's pain with the PPPM tool and a visual analogue scale (VAS).

Children in the ATE group had a higher mean pain score than that in the AD group, beginning at arrival in the recovery area and continuing for the duration of the study. The first scores evaluated by the parents upon arrival at home were the highest, with a mean PPPM of 1.5 and VAS of 2 for the AD patients and a PPPM of 9 and VAS of 4.5 for the ATE patients. By day 2, the median AD patients PPPM and VAS scores were zero while the ATE patients had median PPPM score of 6 and a VAS score of 3. Daytime activities normalized by day 2 in the AD group and day 7 in the ATE group. Twenty-five percent of the patients in the AT group received acetaminophen on postoperative day 1, but only 7% were still receiving analgesics on postoperative day 7. On day 1, 95% of the ATE group received acetaminophen and 97% were given diclofenac. This had decreased to 44% and 9%, respectively, by day 7. The average length of therapy was 4.5 days for acetaminophen and 3.8 days for diclofenac. The authors noted that their study was limited by the lack of a validated objective pain scale and the tendency of parents to stop documenting pain scores once their child began to improve. In spite of these limitations, the study remains a useful addition to the literature for its detailed assessment of pain in children undergoing these two procedures.

Similar findings were reported in a study from the Children's Hospital of Orange County (CHOC) published in the February 2016 issue of Anesthesia and Analgesia.[3] Brown and colleagues studied pain scores and analgesic use in 105 Hispanic children after ATE.[3] Families were asked to assess their child's pain each day using the Faces Pain Scale-Revised (FPS-R) and instructed to give acetaminophen on a scheduled based and codeine or hydrocodone every 3 to 4 hours as needed. Seventy percent of children were reported by the families to have scores indicating significant pain on the first day at home; however, 32% received fewer than two doses of an analgesic. Nearly a quarter of the children (21%) received fewer than five doses over the first week after treatment.