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

Improving Postoperative Analgesic Use

These studies suggest that children are frequently assessed by their parents to be in significant pain after outpatient or short-stay surgery, yet they receive relatively little analgesia. Two recent papers have described structured programs to improve access to analgesics and ensure appropriate administration instructions as a means of removing barriers to effective care. In 2013, Hegarty and colleagues evaluated the benefit of providing analgesics at discharge for pediatric outpatient surgeries.[7] The authors randomized 200 children into two groups: one group received both written and verbal instructions on medication instructions and a packet of medications (ibuprofen every 8 hours for 48 hours and acetaminophen/codeine as needed) at discharge. The other group received the medication instructions alone. Pain ratings were similar between groups; 59% of the children in the group given the medication packet were rated as having no or mild pain, compared to 62% in the group given instructions alone. Rates for moderate to severe pain were also similar (41% versus 38%, respectively). Postoperative medication instructions were followed by 89% of families who received instructions and medications and in 86% of families given instructions alone (p = 0.68), suggesting that providing analgesics at discharge may not be the key to improving analgesic use. Although medication instructions appeared to have been useful, only 48% of parents could recall the information they were given at discharge on the following day, indicating a need for more effective educational tools and better training for those giving the instructions.

A similar program was implemented by Walther-Larsen and coworkers at Copenhagen University Hospital.[8] Their structured intervention consisted of a multimodal analgesia plan using weight-based doses of ibuprofen and acetaminophen. The same acetaminophen dose was used around the clock for 24 hours, but the ibuprofen dose and frequency (around the clock versus as needed) varied by the type of surgery. Medication information was provided to the parents, as well as a supply of the drugs in a formulation chosen by the parent and child. All parents were instructed to give the medication on a fixed schedule for the first 24 hours. In a prospective observational cohort study, the authors assessed the effect of their intervention on pain scores in 149 children following outpatient surgery. Parental assessment of pain was performed with the PPPM short form and a numeric rating scale (NRS). The median PPPM score on postoperative day 0 was 4, with a median score of 1 on day 1. Median NRS scores were 2 on day 0 and 1 on day 1. The authors found a significant correlation between the two assessment tools (p < 0.0001). A total of 97% of the children received acetaminophen as recommended. Seventy-two percent of patents received ibuprofen around-the-clock on the first postoperative day and 19% were given ibuprofen as needed. The authors concluded that their structured discharge plan resulted in pain that was well managed at home.