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

Factors Affecting Analgesic use

In 2009, Fortier and colleagues at CHOC evaluated pain scores and their relation to analgesic administration in 261 children 2 to 12 years of age following ATE.[4] All patients were hospitalized for 24 hours after surgery, and families were sent home with instructions to give 10 mg/kg acetaminophen with 1 mg/kg codeine every 4 to 6 hours for scores ≥ 3 on the Bieri Faces pain scale. The median PPPM score peaked on day 2 after surgery. Although 86% of parents rated their children's pain as significant, only 76% of children received more than one dose of an analgesic. The median number of total analgesic doses administered over the 2-week observation period was 6 (range 0–14). The majority (71%) received fewer than half of the available analgesic doses prescribed. No correlation was found between PPPM scores and the number of doses given. Bieri scores and their correlation to medication administration were not reported. The authors also reported no associations between the frequency of analgesic administration and demographic variables, preoperative patient distress, parent education, anxiety about the surgery, parent coping skills, or the child's temperament.

In a subsequent study of 132 children undergoing outpatient surgery, several of these investigators assessed parental attitudes about pain assessment and analgesic use prior to surgery and then compared those results with the child's postoperative pain management.[5] In addition to PPPM scores, knowledge and attitudes about pain management in children were scored with the Parental Pain Expression Perceptions (PPEP) tool and the Medication Attitude Questionnaire (MAQ). Higher PPEP scores represent misinformation or attitudinal barriers to treatment. A pain scoring tool (faces or numeric scales) was also provided by the hospital for parents to use in evaluating their child.

The median number of analgesic doses given at home per patient on postoperative day 1 was one (range 0–3), with 26% of patients not receiving analgesia. Thirty percent of parents reported their child asked for pain medicine; however, only 7% of parents used the pain scoring tool provided by the hospital to evaluate their child's pain. Ninety-five percent of the parents reported receiving specific instructions regarding analgesic use at home and 69% used the prescribed analgesic. Fifty-five percent administered the prescribed dose, but only 35% followed the prescribed instructions for how frequently to administer it. The most frequently cited reasons for variance were the use of over the counter (OTC) analgesics instead of the acetaminophen/codeine preparation (20%) and the use of smaller than prescribed doses (12%). Nearly half of parents (44%) stated that the child refused doses because of the bad taste. There was no correlation between PPEP and PPPM scores, suggesting that attitudinal and knowledge barriers were not a significant predictor of parents' report of their child's pain. However, decreased PPPM scores and higher MAQ scores predicted the administration of fewer analgesic doses (p < 0.01), suggesting that parents' uncertainties and misconceptions about analgesics are likely to affect their willingness to give their children medication after surgery.

The authors found a similar relationship between medication beliefs and analgesic use in the postoperative management of 161 Hispanic children undergoing outpatient surgery.[6] A majority of parents expressed misunderstanding and misconceptions about both assessing pain in children and the use of analgesics. Following surgery, 61% of families rated their child's pain with the PPPM tool as severe, but only 57% of those children received the recommended number of analgesic doses. As in their previous paper, PPEP and MAQ scores suggested that expression of concerns related to analgesic use predicted the use of fewer doses of analgesics on the first postoperative day (p = 0.028).