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Introduction: Many youth with pain lack access to pediatric pain expertise. There is a critical shortage of pediatric pain physicians, due partly to a paucity of training programs in Pediatric Pain Medicine. Pain fellowships are Anesthesiology-based and there is no pathway to fellowship training or Pain Medicine board certification for pediatricians. This workforce assessment sought to examine the current state of Pediatric Pain Medicine in the United States and future interest in pursuing Pain Medicine among pediatricians., Methods: A multidisciplinary working group of Pain Medicine clinicians designed three surveys to examine pediatric comprehensive pain programs in the US, practice patterns of pediatricians and their motivations and opinions regarding Pain Medicine board certification, and current residents' exposure to and interest in Pediatric Pain Medicine., Results: Wait times for initial evaluations are two months or longer for two-thirds of responding centers, and barriers to increase staff size and resources were reported, including an inadequate number of trained or available physicians. Pediatricians expressed interest in earning board certification in Pain Medicine, given the opportunity. Additionally, there is interest among pediatric residents in pursuing Pediatric Pain Medicine, and qualitative data highlight information residents perceived needing in order to pursue a career in the field., Discussion: Results demonstrate the need for increased training opportunities in pediatric pain medicine. A formal pathway to Pain Medicine for Pediatricians should be developed to increase the potential workforce and to address the lack of trained pediatric pain specialists, thereby improving access to care for youth with pain., Competing Interests: RBW is a consultant for Human, LLC, and the Autism Healthcare Collaborative. WTZ is a consultant for Lundbeck, Editas, and OmmioHealth. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest. The reviewer NS, declares that they are an emeritus faculty from the same affiliation as the author AK., (© 2024 Theriault, Burns, Goldschneider, Koka, Logan, Weisman, Wilder, Windsor and Zempsky.)

Background: Posterior spinal fusion is the most common surgical procedure performed for correction of adolescent idiopathic scoliosis in the United States. Intraoperative methadone has been shown to improve pain control in adult patients undergoing complex spine surgery, and current pediatric studies show encouraging results; however, prospective randomized-controlled trials are lacking in the pediatric literature., Aims: We conducted a single-center double-blind randomized-controlled trial to compare intraoperative use of methadone to morphine in pediatric patients undergoing posterior spinal fusion., Methods: A total of 47 adolescents undergoing posterior spinal fusion were randomized (stratified by sex) to either a methadone (n = 25) or morphine (n = 22) group. The primary outcome was postoperative opioid consumption. Secondary outcomes included postoperative pain severity, opioid-related side effects, and ratio of patient-controlled analgesia injections: attempts as a behavioral index of uncontrolled pain., Results: Patients in the methadone group consumed less total opioid postoperatively (median [interquartile range], 0.3 mg/kg [0.1, 0.5]) than patients in the morphine group (0.3 mg/kg [0.2, 0.6]), median difference [95% confidence interval] -0.07 [-0.2 to 0.02]; (p = .026). Despite the lower amount of opioid used postoperatively, pain scores for the methadone group (3.5 [3.0, 4.3]) were not significantly different from those in the morphine group (4.0 [3.2, 5.0]; p = .250). Groups did not differ on opioid-related side effects., Conclusions: A two-dose intraoperative methadone regimen resulted in decreased opioid consumption compared to morphine. Although the clinical significance of these results may be limited, the analgesic equipoise without increased opioid-related side effects and potential for a lower incidence of chronic pain may tip the balance in favor of routine methadone use for adolescents undergoing posterior spinal fusion., (© 2024 John Wiley & Sons Ltd.)

Physical activity is critical to functional rehabilitation for youth with chronic pain, which may be especially true for those with co-occurring obesity. To facilitate the development of physical activity interventions for youth with chronic pain, the newly developed "Rating of Perceived Exertion-Pediatric" scale was modeled after the widely used pain numeric rating scale-11. This study is an initial evaluation of the scale in a sample of adolescents ( n = 157, 13-17 years, 51% female) with four subgroups: (1) healthy controls (healthy weight/no pain); (2) chronic pain/healthy weight; (3) obese (no pain); (4) chronic pain/obese. Participants rated perceived exertion using the new scale and the Borg 6-20 Scale of Perceived Exertion while holding a three-minute yoga pose (Warrior II). In the whole sample, the Perceived Exertion-Pediatric scale showed good concurrent ( p < 0.001), convergent (all p s < 0.05), discriminant ( p = 0.431), and known-groups validity (all p s < 0.05). The chronic pain subgroup also showed good concurrent ( p < 0.001), mixed convergent ( p s < 0.001 to 0.315), and good discriminant validity ( p = 0.607). Limitations include the restricted age range, lack of diversity, and lack of test-retest reliability. The RPE-P shows promise as an assessment tool for perceived exertion in adolescents with and without chronic pain.

Stress is a commonly reported issue in pediatric populations of chronic and acute pain. Both outpatient and inpatient settings impose time constraints, which decreases opportunities to measure and address patient stress. The aim of these studies was to evaluate the validity of the Stress Numeric Rating Scale-11 (SNRS-11) in both inpatient and outpatient settings. The SNRS-11 is a single item stress measure ranging from 0 to 10 with endpoint anchors: 0 = "No stress" and 10 = "Highest stress possible". Results showed discriminative validity in the inpatient sample and convergent and discriminant validity in both outpatient and inpatient samples. Additionally, approximately 40% to 50% of the sample reported moderate-severe stress on all post-operative days. The SNRS-11 shows promise as a quick, easy, and free stress measure to be used in both inpatient and outpatient settings., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Introduction: After discharge from the emergency department (ED), pain management challenges parents, who have been shown to undertreat their children's pain. Our goal was to evaluate the effectiveness of a five-minute instructional video for parents on pain treatment in the home setting to address common misconceptions about home pediatric pain management., Methods: We conducted a randomized, single-blinded clinical trial of parents of children ages 1-18 years who presented with a painful condition, were evaluated, and were discharged home from a large, tertiary care pediatric ED. Parents were randomized to a pain management intervention video or an injury prevention control video. The primary outcome was the proportion of parents that gave their child pain medication at home after discharge. These data were recorded in a home pain diary and analyzed using the chi square test to determine significant difference. Parents' knowledge about components of at-home pain treatment were tested before, immediately following, and two days after intervention. We used McNemar's test statistic to compare incorrect pretest/correct post-test answers between intervention and control groups., Results: A total of 100 parents were enrolled: 59 parents watched the pain education video, and 41 the control video. Overall, 75% of parents completed follow-up, providing information about home medication use. Significantly more parents provided pain medication to their children after watching the educational video: 96% vs 80% (difference 16%; 95% CI 7.8-31.3%). Significantly more parents had correct pain treatment knowledge immediately following the educational video about pain scores (P = 0.04); the positive effects of analgesics (P <0.01); and pain medication misconceptions (P = 0.02). Most differences in knowledge remained two days after the video intervention., Conclusion: The five-minute educational video about home pain treatment viewed by parents in the ED prior to discharge significantly increased the proportion of children receiving pain medication at home as well as parents' knowledge about at-home pain management.

Background: Given that enforced quarantine is associated with psychological distress, our objective was to understand factors that either helped or harmed pediatric chronic pain patients during Wisconsin's 2020 safer-at-home quarantine., Methods: We reviewed the electronic medical records of 145 pediatric chronic pain patients seen at the Jane B. Pettit Pain and Headache Center, Children's Wisconsin, between April 1 and July 30, 2020., Results: Stress and poor/disturbed lifestyle factors were primary contributors to increased pain. Over half of the sample (58.7%) reported COVID-related stressors as contributing to increased stress levels. Coping, engagement, and socialization were primary contributors to patient functioning., Conclusions: Continued access to clinicians who can help with coping and stress management techniques is necessary for the well-being of pediatric chronic pain patients during a quarantine., (Copyright© Board of Regents of the University of Wisconsin System and The Medical College of Wisconsin, Inc.)

Objective: Pediatric obesity and chronic pain are each associated with an increased risk for numerous poor physical and mental health outcomes. Co-occurring chronic pain and obesity (CPO) result in greater functional disability compared with either condition alone. The aim of the present study was to use qualitative methods to better understand the challenges experienced by adolescents with CPO, with a specific focus on physical activity. Methods: Semistructured interviews were conducted with 13 youth with CPO. Participants were questioned about pain, physical activity, coping strategies, and the perceived relationship between weight and pain. Interviews were audiorecorded, transcribed, and analyzed according to Interpretative Phenomenological Analysis. Results: Superordinate themes expressed by youth included: Impact of Chronic Pain on Relationships, Impact of Pain on Self-Perception, Using Food to Cope with Pain, Perceived Relationship between Pain and Weight after Onset of Pain, Attitudes toward Physical Activity, Barriers to Physical Activity, and Supports to Physical Activity. Conclusions: Participants identified challenges associated with CPO. Notably, participants identified pain as a greater barrier to exercise than weight, implicating the salience of chronic pain in the lives of youth with CPO. Furthermore, participants identified a desire to be more physically active, yet discussed struggles and concerns about attempts to increase their physical activity and indicated a desire for guidance about being more active. This study highlights the complexities of the relationship between CPO and underscores the importance of providers collaboratively working with patients to develop a practical plan to resume movement and physical activity.

Adolescent obesity augments and impedes the treatment of chronic pain. This is associated with increased systemic inflammation and is more prominent in females. In addition, pain and obesity each independently affect the hypothalamic-pituitary-adrenal (HPA) axis. However, the interaction of pain and obesity on the HPA axis and the potential for sexual dimorphism in this phenomenon is not established. We hypothesized that dysregulation of the HPA axis occurs in female human adolescents with chronic pain, obesity, or the combination of the two and is associated with gonadal steroids. We measured serum cortisol, estradiol, and testosterone in 13-17-year-old adolescent females ( N  = 79) from venous blood drawn during the daytime (0830-1730 h) and analyzed the data in toto and partitioned by morning vs. afternoon sampling time. Subjects were categorized as healthy weight/no pain (controls; BMI = 56 th percentile [37-71]), healthy weight with chronic pain, obese without pain (BMI = 97 th percentile [95-99]), or the combination of obesity and chronic pain. Serum cortisol was lower with chronic pain and/or obesity compared to healthy controls and was lower with chronic pain and obesity compared to chronic pain alone (healthy weight). The lower serum cortisol in the pain alone group was more prominent in the morning compared to the afternoon. There was no relationship between serum estradiol and testosterone and study group. The decrease in the anti-inflammatory and other pain-ameliorating effects of cortisol may contribute to chronic pain and its resistance to treatment with concurrent obesity in female adolescents.

Introduction: The negative effects of chronic pain and obesity are compounded in those with both conditions. Despite this, little research has focused on the pathophysiology in pediatric samples., Objective: To examine the effects of comorbid chronic pain and obesity on the concentration of circulating inflammatory biomarkers., Methods: We used a multiple-cohort observational design, with 4 groups defined by the presence or absence of obesity and chronic pain: healthy controls, chronic pain alone, obesity alone, as well as chronic pain and obesity. Biomarkers measured were leptin, adiponectin, leptin/adiponectin ratio (primary outcome), tumor necrosis factor-alpha, interleukin 6, and C-reactive protein (CRP)., Results: Data on 125 adolescents (13-17 years) were analyzed. In females, there was an interaction between chronic pain and obesity such that leptin and CRP were higher in the chronic pain and obesity group than in chronic pain or obesity alone. Within the chronic pain and obesity group, biomarkers were correlated with worsened pain attributes, and females reported worse pain than males. The highest levels of interleukin 6 and CRP were found in youth with elevated weight and functional disability. We conclude that in adolescents, chronic pain and obesity interact to cause dysregulation of the inflammatory system, and this effect is more pronounced in females., Conclusion: The augmented levels of inflammatory biomarkers are associated with pain and functional disability, and may be an early marker of future pain and disability., Competing Interests: The authors have no conflicts of interest to declare.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.)

Objective: Acute neuropathic pain is a significant diagnostic challenge, and it is closely related to our understanding of both acute pain and neuropathic pain. Diagnostic criteria for acute neuropathic pain should reflect our mechanistic understanding and provide a framework for research on and treatment of these complex pain conditions., Methods: The Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) public-private partnership with the U.S. Food and Drug Administration (FDA), the American Pain Society (APS), and the American Academy of Pain Medicine (AAPM) collaborated to develop the ACTTION-APS-AAPM Pain Taxonomy (AAAPT) for acute pain. A working group of experts in research and clinical management of neuropathic pain was convened. Group members used literature review and expert opinion to develop diagnostic criteria for acute neuropathic pain, as well as three specific examples of acute neuropathic pain conditions, using the five dimensions of the AAAPT classification of acute pain., Results: AAAPT diagnostic criteria for acute neuropathic pain are presented. Application of these criteria to three specific conditions (pain related to herpes zoster, chemotherapy, and limb amputation) illustrates the spectrum of acute neuropathic pain and highlights unique features of each condition., Conclusions: The proposed AAAPT diagnostic criteria for acute neuropathic pain can be applied to various acute neuropathic pain conditions. Both the general and condition-specific criteria may guide future research, assessment, and management of acute neuropathic pain., (© The Author(s) 2021. Published by Oxford University Press on behalf of the American Academy of Pain Medicine. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objectives: The study of patient-controlled analgesia (PCA) behaviors has led to a greater understanding of factors that affect the pain experience. Although PCA behaviors can be influenced by cues to medication availability, no studies have examined the effects of such cues in pediatric populations., Materials and Methods: This randomized controlled trial examined patient satisfaction with pain management, PCA behaviors, opioid consumption, and state anxiety in a sample of 125 postsurgical children and adolescents (7 to 17 y). Patients were randomized to a "light" group (lockout period status cued by light on the PCA button) or control group (no cues to medication availability)., Results: Although cuing did not affect patient satisfaction with pain management (P=0.11), patients in the light group consumed significantly more opioid than those in the control group (adj. P=0.016). This effect was primarily because of children in the light group (median, 0.019; interquartile range, 0.012 to 0.036 mg/kg/h) consuming more opioid than children (12 y or younger) in control group (median, 0.015; interquartile range, 0.006 to 0.025 mg/kg/h) (P=0.007). In contrast to the control group, for patients in the light group, opioid consumption was unrelated to pain and the proportion of patients with a 1:1 injections:attempts ratio was higher (P<0.001) across the study period., Discussion: The overall pattern of results suggests that patients in the light group used their PCA in response to the light more than in response to their pain, which likely reflects operant influences on PCA behavior by pediatric patients.

Introduction: Obesity in adolescents is increasing in frequency and is associated with short-term and long-term negative consequences that include the exacerbation of co-occurring chronic pain., Objective: To determine whether the interaction between chronic pain and obesity would be reflected in changes in serum soluble urokinase plasminogen activator receptor (suPAR) concentrations, a novel marker of systemic inflammation associated with obesity, insulin resistance, and cardiovascular disease., Methods: We measured serum suPAR levels in 146 adolescent males and females with no pain or obesity (healthy controls; n = 40), chronic pain with healthy weight (n = 37), obesity alone (n = 41), and the combination of chronic pain and obesity (n = 28)., Results: Serum suPAR (median [interquartile range]) was not increased by chronic pain alone (2.2 [1.8-2.4] ng/mL) or obesity alone (2.2 [2.0-2.4] ng/mL) but was increased significantly with the combination of chronic pain and obesity (2.4 [2.1-2.7] ng/mL; P < 0.019). This finding confirms the proposition that pain and obesity are inflammatory states that display a classic augmenting interaction., Conclusion: We propose that measurement of serum suPAR can be added to the armamentarium of serum biomarkers useful in the evaluation of mechanisms of inflammation in adolescent obesity and chronic pain., Competing Interests: The authors have no conflicts of interest to declare.Sponsorships or competing interests that may be relevant to content are disclosed at the end of this article., (Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.)

Factors such as gender, ethnicity, and age affect pain processing in children and adolescents with chronic pain. Although obesity has been shown to affect pain processing in adults, almost nothing is known about pediatric populations. The aim of this pilot study was to explore whether obesity alters sensory processing in adolescents with chronic pain. Participants were recruited from a chronic pain clinic (Chronic Pain (CP), n = 12 normal weight; Chronic Pain + Obesity (CPO), n = 19 overweight/obesity) and from an obesity clinic (Obesity alone (O), n = 14). The quantitative sensory testing protocol included assessments of thermal and mechanical pain thresholds and perceptual sensitization at two sites with little adiposity. The heat pain threshold at the hand was significantly higher in the CPO group than in either the CP or O groups. Mechanical pain threshold (foot) was significantly higher in the CPO group than the CP group. No differences were found on tests of perceptual sensitization. Correlations between experimental pain and clinical pain parameters were found for the CPO group, but not for the CP group. This preliminary study provides important lessons learned for subsequent, larger-scale studies of sensory processing for youth with co-occurring chronic pain and obesity.

Purpose: Prospectively compare parent/nurse controlled analgesia (PNCA) to continuous opioid infusion (COI) in the post-operative neonatal intensive care unit (NICU) population., Design/methods: A randomized controlled trial compared neonates treated with morphine PNCA to those treated with morphine COI. The primary outcome was average opioid consumption up to 3 post-operative days. Secondary outcomes included 1) pain intensity, 2) adverse events that may be directly related to opioid consumption, and 3) parent and nurse satisfaction., Results: The sample consisted of 25 post-operative neonates and young infants randomized to either morphine PNCA (n = 16) or COI (n = 9). Groups differed significantly on daily opioid consumption, with the PNCA group receiving significantly less opioid (P = .02). Groups did not differ on average pain score or frequency of adverse events (P values > .05). Parents in both groups were satisfied with their infant's pain management and parents in the PNCA group were slightly more satisfied with their level of involvement (P = .03). Groups did not differ in nursing satisfaction., Conclusions: PNCA may be an effective alternative to COI for pain management in the NICU population. This method may also substantially reduce opioid consumption, provide more individualized care, and improve parent satisfaction with their level of participation., Clinical Implications: Patients in the NICU represent one of our most vulnerable patient populations. As nurses strive to provide safe and effective pain management, results of this study suggest PNCA may allow nurses to maintain their patients' comfort while providing less opioid and potentially improving parental perception of involvement., Study Type: Treatment study., Level of Evidence: I., (Copyright © 2020 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

We report the case of an 11-month-old boy with Wilm's tumor, who underwent nephrectomy. Postoperative pain was managed with a lumbar epidural for 3 days, with the formation of a persistent cerebral spinal fluid cutaneous fistula., (© 2019 John Wiley & Sons Ltd.)

Fewer randomized clinical trials (RCTs) are conducted for chronic or recurrent pain in pediatric populations compared with adult populations; thus, data to support treatment efficacy in children are limited. This article evaluates the design features and reporting practices of RCTs for chronic and recurrent pain that are likely unique to, or particularly important in, a pediatric population to promote improvements in the evidence base for pediatric pain treatments. Areas covered include outcome measure selection and reporting and reporting of adverse events and challenges to recruitment and retention. A search of PubMed and EMBASE identified primary publications describing RCTs of treatments for select chronic and recurrent pain conditions in children or adolescents published between 2000 and 2017. Only 49% of articles identified a primary outcome measure. The primary outcome measure assessed pain intensity in 38% of the trials, specifically measure by verbal rating scale (13%), faces pain scale (11%), visual analogue scale (9%), or numeric rating scale (5%). All of the CONSORT harms reporting recommendations were fulfilled by <50% of the articles. Discussions of recruitment challenges occurred in 64% of articles that enrolled <90% of their target sample. However, discussions regarding retention challenges only occurred in 14% of trials in which withdrawal rates were >10%. The goal of this article is to promote comprehensive reporting of pediatric pain RCTs to improve the design of future trials, facilitate conduction of systematic reviews and meta-analyses, and better inform clinical practice. PERSPECTIVE: This review of chronic and recurrent pediatric pain trials demonstrates inadequacies in the reporting quality of key features specifically important to pediatric populations. It provides recommendations that address these shortcomings to promote continued efforts toward improving the quality of the design and publication of future pediatric clinical pain trials., (Copyright © 2018. Published by Elsevier Inc.)

Obesity negatively impacts the kinematics and kinetics of the lower extremities in children and adolescents. Although yoga has the potential to provide several distinct benefits for children with obesity, this is the first study to examine the benefits of yoga for gait (primary outcome) in youths with obesity. Secondary outcomes included health-related quality of life (HRQoL), physical activity, and pain. Feasibility and acceptability were also assessed. Nine youths (11⁻17 years) participated in an eight-week Iyengar yoga intervention (bi-weekly 1-h classes). Gait, HRQOL (self and parent-proxy reports), and physical activity were assessed at baseline and post-yoga. Pain was self-reported at the beginning of each class. Significant improvements were found in multiple gait parameters, including hip, knee, and ankle motion and moments. Self-reported and parent-proxy reports of emotional functioning significantly improved. Time spent in physical activity and weight did not change. This study demonstrates that a relatively brief, non-invasive Iyengar yoga intervention can result in improved malalignment of the lower extremities during ambulation, as well as in clinically meaningful improvements in emotional functioning. This study extends current evidence that supports a role for yoga in pediatric obesity.

Objectives: The aim of this study was to conduct a randomized, controlled comparison of outcomes associated with parent/nurse-controlled analgesia (PNCA), with and without a basal (background) opioid infusion, with intravenous (IV) opioids intermittently administered by a nurse on an "as needed" basis (IV PRN) for postoperative pain management in children with developmental delay (DD)., Methods: Participants included children with DD expected to require IV opioids for at least 24 postoperative hours. Patients were randomized to one of three groups: PNCA with a basal infusion, PNCA without a basal infusion, or IV PRN opioids. Demographics, pain scores, opioid consumption, and frequency of side effects were collected beginning 12 hours after emerging from anesthesia to decrease the impact of anesthetic agents on outcomes., Results: The 81 participants (median = 12.0, 9.0-15.0 years) were primarily Caucasian (74%) males (58%), with severe DD (69%) having spinal surgery (41%). The proportion of patients in each group with pain scores ≤3 vs ≥ 4 revealed no between-group differences in any epoch (P = 0.09-0.27). Patients in the PNCA with a basal group consumed significantly more opioid (median = 0.03 mg/kg/h morphine equivalents, 0.02-0.03 mg/kg/h) than the PNCA without a basal infusion. No difference was found between the PNCA without a basal (median = 0.01 mg/kg/h morphine equivalents, 0.00-0.02 mg/kg/h) and the PRN groups (median = 0.01 mg/kg/h morphine equivalents, 0.01-0.02 mg/kg/h). There were no statistically significant differences in side effects, with the exception that more children in the PNCA group required supplemental oxygen (P = 0.05)., Conclusions: Results suggest there may be no advantage to PNCA over PRN opioids in this patient population after the first 12 postoperative hours with regard to pain scores, opioid consumption, or side effects.

Clinical trials to test the safety and efficacy of analgesics across all pediatric age cohorts are needed to avoid inappropriate extrapolation of adult data to children. However, the selection of acute pain models and trial design attributes to maximize assay sensitivity, by pediatric age cohort, remains problematic. Acute pain models used for drug treatment trials in adults are not directly applicable to the pediatric age cohorts-neonates, infants, toddlers, children, and adolescents. Developmental maturation of metabolic enzymes in infants and children must be taken into consideration when designing trials to test analgesic treatments for acute pain. Assessment tools based on the levels of cognitive maturation and behavioral repertoire must be selected as outcome measures. Models and designs of clinical trials of analgesic medications used in the treatment of acute pain in neonates, infants, toddlers, children, and adolescents were reviewed and discussed at an Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION) Pediatric Pain Research Consortium consensus meeting. Based on extensive reviews and continuing discussions, the authors recommend a number of acute pain clinical trial models and design attributes that have the potential to improve the study of analgesic medications in pediatric populations. Recommendations are also provided regarding additional research needed to support the use of other acute pain models across pediatric age cohorts.

This study aimed to describe utilization of opioid medications among infants, children, and adolescents on the inpatient setting. These data are needed to guide clinical trials and improve research methodologies, as well as to inform more about possible sources of opioid misuse in the United States. A retrospective chart review was conducted covering a span of 1 year, with a special focus on the prescription of opioids for long-term treatment of chronic pain. Opioid medications were prescribed for <5 days in most (75%) patients. Among those who were prescribed opioids for >14 days, the focus was often for reasons other than pain. These data indicate that models of chronic pain that may be utilized in clinical trials of longer-term opioid usage in pediatrics are exceedingly limited. In addition, the patterns of utilization indicate that opioid administration among pediatric inpatients is not a likely contributory factor to concerns about opioid misuse in the United States., Perspective: This article presents data on the administration of opioids in a major children's hospital, with a special eye toward usage beyond treatment for short-term acute pain. These data are important to better inform discussions of research strategies for chronic pain, as well as concerns for misuse in the pediatric population., (Copyright © 2017 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Objective: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (e.g., pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain., Setting: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM)., Methods: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions., Perspective: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms., Conclusions: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions., (© 2017 American Academy of Pain Medicine. This article has been co-published in Pain Medicine and The Journal of Pain. This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.org/licenses/by-nc-nd/4.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered or transformed in any way, and that the work is properly cited. For commercial re-use, please contact journals.permissions@oup.com.)

Objective: With the increasing societal awareness of the prevalence and impact of acute pain, there is a need to develop an acute pain classification system that both reflects contemporary mechanistic insights and helps guide future research and treatment. Existing classifications of acute pain conditions are limiting, with a predominant focus on the sensory experience (eg, pain intensity) and pharmacologic consumption. Consequently, there is a need to more broadly characterize and classify the multidimensional experience of acute pain., Setting: Consensus report following expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM)., Methods: As a complement to a taxonomy recently developed for chronic pain, the ACTTION public-private partnership with the US Food and Drug Administration, the APS, and the AAPM convened a consensus meeting of experts to develop an acute pain taxonomy using prevailing evidence. Key issues pertaining to the distinct nature of acute pain are presented followed by the agreed-upon taxonomy. The ACTTION-APS-AAPM Acute Pain Taxonomy will include the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms. Future efforts will consist of working groups utilizing this taxonomy to develop diagnostic criteria for a comprehensive set of acute pain conditions., Perspective: The ACTTION-APS-AAPM Acute Pain Taxonomy (AAAPT) is a multidimensional acute pain classification system designed to classify acute pain along the following dimensions: 1) core criteria, 2) common features, 3) modulating factors, 4) impact/functional consequences, and 5) putative pathophysiologic pain mechanisms., Conclusions: Significant numbers of patients still suffer from significant acute pain, despite the advent of modern multimodal analgesic strategies. Mismanaged acute pain has a broad societal impact as significant numbers of patients may progress to suffer from chronic pain. An acute pain taxonomy provides a much-needed standardization of clinical diagnostic criteria, which benefits clinical care, research, education, and public policy. For the purposes of the present taxonomy, acute pain is considered to last up to seven days, with prolongation to 30 days being common. The current understanding of acute pain mechanisms poorly differentiates between acute and chronic pain and is often insufficient to distinguish among many types of acute pain conditions. Given the usefulness of the AAPT multidimensional framework, the AAAPT undertook a similar approach to organizing various acute pain conditions., (Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.)

Tailored pain management strategies are urgently needed for youth with co-occurring chronic pain and obesity; however, prior to developing such strategies, we need to understand parent perspectives on weight in the context of pediatric chronic pain. Participants in this study included 233 parents of patients presenting to a multidisciplinary pediatric chronic pain clinic. Parents completed a brief survey prior to their child's initial appointment; questions addressed parents' perceptions of their child's weight, and their perceptions of multiple aspects of the relationship between their child's weight and chronic pain. The majority (64%) of parents of youth with obesity accurately rated their child's weight; this group of parents was also more concerned ( p < 0.05) about their child's weight than parents of youth with a healthy weight. However, the majority of parents of youth with obesity did not think their child's weight contributed to his/her pain, or that weight was relevant to their child's pain or pain treatment. Overall, only half of all parents saw discussions of weight, nutrition, and physical activity as important to treating their child's pain. Results support the need for addressing parents' perceptions of their child's weight status, and educating parents about the relationship between excessive weight and chronic pain., Competing Interests: The authors declare no conflict of interest.

Unlabelled: Most patients who undergo surgical procedures experience acute postoperative pain, but evidence suggests that less than half report adequate postoperative pain relief. Many preoperative, intraoperative, and postoperative interventions and management strategies are available for reducing and managing postoperative pain. The American Pain Society, with input from the American Society of Anesthesiologists, commissioned an interdisciplinary expert panel to develop a clinical practice guideline to promote evidence-based, effective, and safer postoperative pain management in children and adults. The guideline was subsequently approved by the American Society for Regional Anesthesia. As part of the guideline development process, a systematic review was commissioned on various aspects related to various interventions and management strategies for postoperative pain. After a review of the evidence, the expert panel formulated recommendations that addressed various aspects of postoperative pain management, including preoperative education, perioperative pain management planning, use of different pharmacological and nonpharmacological modalities, organizational policies, and transition to outpatient care. The recommendations are based on the underlying premise that optimal management begins in the preoperative period with an assessment of the patient and development of a plan of care tailored to the individual and the surgical procedure involved. The panel found that evidence supports the use of multimodal regimens in many situations, although the exact components of effective multimodal care will vary depending on the patient, setting, and surgical procedure. Although these guidelines are based on a systematic review of the evidence on management of postoperative pain, the panel identified numerous research gaps. Of 32 recommendations, 4 were assessed as being supported by high-quality evidence, and 11 (in the areas of patient education and perioperative planning, patient assessment, organizational structures and policies, and transitioning to outpatient care) were made on the basis of low-quality evidence., Perspective: This guideline, on the basis of a systematic review of the evidence on postoperative pain management, provides recommendations developed by a multidisciplinary expert panel. Safe and effective postoperative pain management should be on the basis of a plan of care tailored to the individual and the surgical procedure involved, and multimodal regimens are recommended in many situations., (Copyright © 2016 American Pain Society. Published by Elsevier Inc. All rights reserved.)

Study Objective: The J-Tip (National Medical Products Inc, Irvine, CA) uses air instead of a needle to push lidocaine into the skin. To our knowledge, no studies have investigated its use for venipuncture in young children. We determine whether the J-Tip decreased venipuncture pain in young children compared with vapocoolant spray., Methods: Children aged 1 to 6 years were randomized into 3 groups: intervention (J-Tip), control (vapocoolant spray), and sham (vapocoolant spray and pop of an empty J-Tip). The procedure was videotaped and scored with the Face, Legs, Activity, Cry and Consolability (FLACC) tool at 3 points; baseline, before approach; device, at J-Tip deployment; and at venipuncture. The FLACC tool was scored 0 (none) to 10 (severe). Comparisons of pain scores over time were made with the generalized estimating equation. Venipuncture success and adverse effects were assessed and compared with χ(2)., Results: Two hundred five children enrolled: intervention 96, control 53, and sham 56. There were no between-group differences in baseline characteristics. There was no mean change in pain scores from device to venipuncture in the intervention group (0.26; 95% confidence interval [CI] -0.31 to 0.82), but there was an increase in pain in the control (2.82; 95% CI 1.91 to 3.74) and sham (1.68; 95% CI 0.83 to 2.52) groups. This change was greater for the control and sham compared to the intervention group. There was no difference in venipuncture success between groups. No severe adverse events occurred. Minor adverse events were the same between groups., Conclusion: Use of the J-Tip for children aged 1 to 6 years reduced venipuncture pain compared with vapocoolant spray or sham treatment., (Copyright © 2015 American College of Emergency Physicians. Published by Elsevier Inc. All rights reserved.)

Objectives: Examine whether anxiety and pain catastrophizing are distinct constructs in relation to functional outcomes in pediatric chronic pain, and whether they differentially predict functional outcomes based on age., Methods: In all, 725 youth (191 children, 534 adolescents) with chronic pain completed measures of pain characteristics, anxiety, pain catastrophizing, functional disability, and health-related quality of life (HRQOL). Structural equation modeling was used to examine interrelationships., Results: Anxiety and pain catastrophizing were distinct. For both children and adolescents, pain catastrophizing predicted pain, functional disability, and HRQOL, and was a stronger predictor of pain intensity. For children, anxiety predicted HRQOL, and pain catastrophizing was a stronger predictor of functional disability. For adolescents, anxiety predicted functional disability and HRQOL, and anxiety was a stronger predictor of HRQOL., Conclusions: There were age-related differences regarding whether anxiety or pain catastrophizing more strongly predicted specific functional outcomes. Assessment and intervention efforts should emphasize both anxiety and pain catastrophizing., (Published by Oxford University Press on behalf of the Society of Pediatric Psychology 2015. This work is written by US Government employees and is in the public domain in the US.)

Unlabelled: There is increasing interest in the measurement of "readiness to change," or willingness to engage in a self-management approach to pain coping, as a predictor of treatment response in pediatric pain populations. The primary aim of the present study was to provide cross-validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions in a new, independent pediatric chronic pain sample by examining aspects of reliability, validity, and generalizability of the factor structures identified in the initial validation study. Secondary aims were to 1) expand upon previously identified differences between the Pain Stages of Change Questionnaire-Adolescent and -Parent versions and 2) examine previously unreported aspects of father data. Although slight differences emerged, the factor structures identified in the initial validation were largely replicated, suggesting that the psychometric properties of the measure are robust across pediatric outpatient chronic pain samples. Variability between parent and adolescent reports suggests that there may be meaningful differences in the interpretation of each measure and that factors other than readiness to change may influence response patterns. Findings highlight the need for more fine-tuned analyses of the way the construct operates in youth with pediatric pain and their parents., Perspective: Findings provide further validation of the Pain Stages of Change Questionnaire-Adolescent and -Parent versions measures in a new outpatient pediatric chronic pain sample. Previously uninvestigated father data showed good reliability and patterns of findings similar to validated mother reports. Moreover, the study suggests that the adolescent and parent versions may function in meaningfully different ways., (Copyright © 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.)

The purpose of this study is to examine prevalence rates of pain reports in youth with type 1 diabetes mellitus (T1DM) and potential predictors of pain. Pain is a common and debilitating symptom of diabetic polyneuropathies. There is currently little research regarding pain in youth with T1DM. It was predicted that self-care and general health factors would predict pain as suggested by the general pain literature. Participants (N = 269) ranged in age from 13 to 17 years; youth had a mean time since diagnosis of 5.8 years. Data collected included diabetes self-management variables, ratings of the patient's current functioning and pain intensity ('current'), and information collected about experiences that occurred in the time preceding each appointment ('interim'). About half of the youth (n = 121, 49.0%) reported any interim pain across both appointments. Female adolescents and those individuals who were physically active and/or utilized health-care system more acutely were more likely to report interim central nervous system pain. Improved diabetes self-management and increased level of physical activity may reduce experiences of pain and increase the quality of life of youth with T1DM. Regular monitoring of both current and interim pain experiences of youth with T1DM is recommended., (© The Author(s) 2013.)

The primary aim of the current study was to provide preliminary data on the feasibility, acceptability, and safety of alignment-based yoga for youths with chronic headaches. A secondary aim was to provide preliminary estimates of yoga's ability to improve headache pain, daily functioning, quality of life, and anxiety level in this population. The yoga intervention consisted of 8 weekly, 75-minute classes. Participant flow data revealed challenges to feasibility primarily due to recruitment and retention. Scores on most outcome measures changed in the predicted direction with medium effect sizes found for the functional outcomes. Pain measures did not change significantly. This pilot suggests that yoga for pediatric headaches may be acceptable, as indicated by positive parent and participant ratings of the yoga experience. These preliminary findings suggest that yoga trials for pediatric headaches include both challenges and promise. Recommendations for overcoming challenges include designs that optimize family convenience., (Copyright © 2014 American Society for Pain Management Nursing. Published by Elsevier Inc. All rights reserved.)

Background: Continuous opioid infusion (COI) remains the mainstay of analgesic therapy in the neonatal intensive care unit (NICU). Parent/nurse-controlled analgesia (PNCA) has been accepted as safe and effective for pediatric patients, but few reports include use in neonates. This study sought to compare outcomes of PNCA and COI in postsurgical neonates and young infants., Methods: Twenty infants treated with morphine PNCA were retrospectively compared with 13 infants treated with fentanyl COI in a Midwestern pediatric hospital in the United States. Outcome measures included opioid consumption, pain scores, frequency of adverse events, and subsequent methadone use., Results: The PNCA group (median 6.4 μg · kg(-1) · h(-1) morphine equivalents, range 0.0-31.4) received significantly less opioid (P < 0.001) than the COI group (median 40.0 μg · kg(-1) · h(-1) morphine equivalents; range 20.0-153.3), across postoperative days 0-3. Average daily pain scores (based on 0-10 scale) were low for both groups, but median scores differed nonetheless (0.8 PNCA vs 0.3 COI, P < 0.05). There was no significant difference in the frequency of adverse events or methadone use., Conclusion: Results suggest PNCA may be a feasible and effective alternative to COI for pain management in postsurgical infants in the NICU. Results also suggest PNCA may provide more individualized care for this vulnerable population and in doing so, may potentially reduce opioid consumption; however, more studies are needed., (© 2014 John Wiley & Sons Ltd.)

Typically, pain is measured by intensity and sensory characteristics. Although intensity is one of the most common dimensions of pain assessment, it has been suggested that measuring pain intensity in isolation is only capturing part of the pain experience and may not lead to an accurate measurement of how pain impacts a child's daily functioning. The current study aimed to develop a measure that would capture pain intensity along with frequency and duration in a clinical sample of youth diagnosed with chronic pain. The pain-frequency-severity-duration (PFSD) scale was developed and data were collected from a multidisciplinary pain clinic at a large, midwestern children's hospital. Validated measures of functional limitations and health related quality of life were also collected. Significant correlations were found between the PFSD composite score, functional limitations, and health related quality of life. Future research should continue to evaluate this questionnaire utilizing other validated pain measures and other areas potentially impacted by chronic pain and with more diverse samples. This initial finding suggests that the PFSD is a convenient self-reported measure and is strongly related to health related quality of life and functional disability.

Context: It is estimated that 1 in 5 children in the United States is affected by chronic pain. Increasing adaptive coping strategies and decreasing stress may be important in treatment. Research has suggested that mindfulness can help alleviate symptoms associated with medical illnesses and increase quality of life. Little is known about the effectiveness of mindfulness-based stress reduction (MBSR) in youth, partly due to insufficient methodological rigor in related studies., Objective: The primary purpose of the present study was to examine the feasibility, acceptability, and effectiveness of MBSR for a treatment-seeking sample of youth with chronic pain., Design: The current study was the first randomized, controlled pilot study of MBSR for pediatric chronic pain. The research team had intended to use block randomization involving a total of five recruitment waves, with each wave consisting of one MBSR group and one psychoeducation group. Due to difficulties with recruitment and attrition before the start of either group, however, only MBSR was conducted at each wave after the first wave., Setting: Participants were recruited from a multidisciplinary pain clinic in a large, Midwestern children's hospital., Participants: The final sample included six adolescents between the ages of 12 and 17 y, four in the MBSR group and two in the psychoeducation group., Intervention: Weekly sessions for the MBSR group were 90 min in length and followed a structured protocol. Sessions included a review of homework, an introduction to and practice of meditation, discussion of the session, and a review of the home practice assignment. The psychoeducation group participated in six group sessions, which were based on a cognitive-behavioral model of pain, and discussion topics included the nature of chronic pain and stress management., Primary Outcome Measures: Health-related quality of life, pain catastrophizing, anxiety, functional disability, mindfulness, and treatment acceptability were all assessed pre- and postintervention as well as at follow-up., Results: Recruitment and retention difficulties were experienced. Qualitative examination of participants' scores suggested increased mindfulness but inconsistent patterns on other outcome measures., Conclusions: The research team highlighted critical challenges faced by potential researchers aiming to investigate MBSR for pediatric chronic pain, and the study provides recommendations for research and implications for clinical practice.

Little is known about the broad application of acupuncture as adjuvant treatment for in-patient pediatric populations. We review a series of cases involving acupuncture for conditions ranging from insomnia to cyclic vomiting. The details of the protocol for each are included. This case series illustrates the benefits of an in-patient acupuncture treatment service, as well as the subtleties of an acupuncture protocol when treating children and adolescents.

Objectives: Outpatient pain management after acute injuries is an important part of emergency department (ED) care, but there is little evidence to support best practice. Satisfaction with care is one way to assess the effectiveness of current practice. This study describes the outpatient pain experience for children with an arm fracture and explores the variables associated with parents' dissatisfaction with pain treatment for 2 analgesics after ED care., Methods: As a part of a randomized clinical trial assessing pain treatment after an arm fracture, parents and their children completed daily diaries recording pain scores, function disruption (play, school, sleep, eating), and adverse effects for 3 days after discharge from the ED. Parents and children also completed the Total Quality Pain Management Instrument on the third day to assess pain experience. Parents' satisfaction was defined with an arm fracture lowest reported satisfaction during the study period., Results: A total of 244 children with complete diaries were analyzed. More than half of children reported pain at home that was present "all the time" or "quite a bit." Thirty-two percent of parents were not satisfied with home pain treatment for their child. Parents' dissatisfaction was strongly associated with inadequate pain relief. It was also independently associated with nausea, disruption in play and sleep, and increased doses of medication., Discussion: Children with arm fractures experience noteworthy pain in the outpatient setting. Parents' dissatisfaction with home pain management for children suggests that more research is needed to evaluate the factors that result in improvements in both parent and child satisfaction and the most effective way of producing those changes.

The focus of this brief review is to highlight to the reader some of the 'ripple effects' of broader systems-level healthcare issues and the implications they may have for effective treatment of pediatric chronic pain. Many healthcare providers focus almost exclusively on the patient, but lack the knowledge of how to intervene effectively at systems levels with families, schools and healthcare institutions surrounding the pediatric patient with pain. We provide a case example and consider this issue across three systems that are particularly relevant to pediatric pain management: the outpatient pain clinic, school and inpatient settings. The information presented will improve the healthcare provider's ability to effectively treat pediatric pain through an enhanced understanding of the multiple systems of care that surround children with pain.

Objective: Examine the psychometric properties of the SCARED in pediatric chronic pain., Methods: Participants were parents (n = 313 mothers, 163 fathers) and youth (n = 349) presenting for treatment of pediatric chronic pain. Participants completed the SCARED and measures of pain catastrophizing, internalizing problems, and health-related quality of life., Results: Internal consistency (Cronbach's α) of SCARED Total scores ranged from .92 to .93 across sources of report. All subscales except for School Phobia exhibited good internal consistency. SCARED scores were significantly positively related to internalizing symptoms and pain catastrophizing; and negatively related to health-related quality of life. Confirmatory factor analysis revealed acceptable fit of the SCARED measurement model., Conclusions: The SCARED shows promise as a measure of anxiety in pediatric pain. Important caveats for its usage and areas in need of additional research are discussed. Of importance in pediatric pain is improving current approaches for measuring school anxiety in this population.

The purpose of this study was to document the prevalence and characteristics of physical pain in a sample of severely obese children and adolescents. In this retrospective chart review, primary measures included current and past pain, pain intensity, and pain characteristics during a 5-minute walk test. Pain assessments for 74 patients (mean age 11.7 years; 53% female; 41% African American) were conducted by a physical therapist. Past pain was reported by 73% of the sample, with 47% reporting pain on the day of program enrollment. Although average pain intensity was moderate (M = 5.5/10), alarmingly, 42% of those with current pain reported severe pain (6/10 to 10/10). Overall, pain occurred primarily in the lower extremities and with physical activity. Patients reporting current pain had a significantly higher body mass index than those reporting no pain. These findings suggest that pain is common in severely obese youth, and furthermore, that pain should be recognized as a comorbidity of pediatric obesity. Routinely screening severely obese children and adolescents for pain presence and intensity is recommended.

Chronic and recurrent pain is experienced by many children and adolescents. Treatment of chronic pain using a multidisciplinary approach has been found to be effective for treatment of chronic pain. Parent satisfaction with treatment and treatment providers highly correlates to children's treatment adherence. Parents of children treated at a multidisciplinary chronic pain clinic were interviewed following their initial appointment. Parents reported high satisfaction with treatment team members and with the treatment plan. Parents also reported appreciation of multidisciplinary structure, the high level of expertise of the team members, and the team members' genuine interest in treating their children. This increase in satisfaction when compared to previous treatment is important since increases in satisfaction may correlate with a reduction in experiences of chronic pain. Parents reported high satisfaction with interactions with treatment team members and with the treatment plan provided for their children. Parents had appreciation of multidisciplinary team structure and the high level of expertise of the team members. This increase in satisfaction when compared to treatment from previous providers is important since increases in satisfaction may correlate with an increase in children's treatment adherence and a reduction in experiences of chronic pain.

Objective: To evaluate the feasibility, reliability, validity, and responsiveness of the Pediatric Quality of Life Inventory 4.0 Generic Core Scales (PedsQL) in the first 2 weeks after pediatric emergency department care of minor injury., Design: Prospective cohort study., Setting: Pediatric hospital emergency department., Participants: Children and adolescents with minor injury (n = 334)., Main Outcome Measures: Child- and parent-reported clinical outcomes and PedsQL scale scores., Results: The PedsQL had good to excellent internal consistency reliability (α range, 0.73-0.93). For each day that the clinical symptoms persisted, there were consistent decreases in mean health-related quality of life (HRQOL) scores (validity testing). There were significantly greater negative changes in mean HRQOL scores for fractures vs soft-tissue injuries and for lower vs upper extremity injuries. Clinical outcomes categorized as poor had large negative changes in HRQOL not seen in good outcome groups. Distribution-based indicators of change supported good responsiveness (effect sizes for the physical summary score, 0.01-2.44; group differences at follow-up exceeded estimates of the minimal importance difference)., Conclusions: The PedsQL is feasible, reliable, and demonstrates good construct and discriminant validity and responsiveness in measuring short-term outcome after minor injury care in the pediatric emergency department. Assessing short-term outcome from the patient perspective with HRQOL measures may greatly enhance our ability to evaluate the effectiveness of emergency department care.

Objective: School functioning is among the most important life domains impacted by chronic pain. This review provides a summary of the measures currently used by researchers to assess school functioning in children with chronic pain., Methods: We conducted a systematic review of the literature on school absenteeism and school functioning in children and adolescents with pain. Searches were restricted to a time frame including January 1985 to December 2010., Results: Fifty-three articles are reviewed: all include some form of assessment of school absenteeism or school functioning as part of the study outcome measures. Of the 53 articles, 26 assessed school absenteeism and 27 assessed an aspect of school functioning; 14 of these 27 articles assessed both., Conclusions: Understanding the comprehensive impact of pain on school functioning will require improvements in our current assessment methods.

Objective: To evaluate the psychometric properties of the Family Impact Module (FIM), a parent self-report measure of health-related quality of life (HRQOL) and family functioning, among parents of youth with chronic pain., Methods: Parents (N = 458) completed the FIM (Total Impact, HRQOL, and Family Functioning scales); parents and youth (N = 332) completed measures of pain catastrophizing, pediatric quality of life, and emotional/behavioral functioning., Results: The FIM demonstrated strong internal consistency and item-total correlations. All FIM scales were positively associated with pain catastrophizing, functional disability, and emotional/behavioral problems; and inversely related to pediatric quality of life. Mothers reported significantly worse HRQOL than fathers. Mothers and fathers did not differ on reports of Family Functioning. HRQOL and Family Functioning did not differ as a function of pain diagnosis., Conclusion: The FIM appears to be a suitable measure of parent self-reported HRQOL and family functioning in pediatric chronic pain.

Background: Sickle cell disease (SCD) pain is acute or chronic, leads to school absenteeism, impaired health-related quality of life and early mortality. Given that little is known about children with SCD and chronic pain, we (1) described characteristics of these children and (2) evaluated the impact of a multidisciplinary pain management model on health care utilization., Procedure: A retrospective cohort study of children with SCD evaluated and treated in our institution's multidisciplinary pain clinic between 1999 and 2008 was conducted. Referrals occur when children require chronic opioids and/or have frequent pain hospitalizations. Descriptive statistics evaluated patient characteristics and Wilcoxon-Signed Rank evaluated change in median number of pain hospitalizations 1 year before and after referral., Results: Median age of 19 children identified was 15 years (IQR 11-17); significantly more were female (78.9% vs. 21.1%; P = 0.012). At time of referral, all patients reported taking opioids, 68.4% were taking hydroxyurea, half of those not on hydroxyurea started it (n = 3), none were chronically transfused and one initiated transfusions upon referral. Majority (89.5%) learned non-pharmacologic pain management techniques. Median number of pain hospitalizations between the year before and after referral significantly decreased [5(IQR 3-6) to 1(IQR 0-4); P = 0.006]. To further delineate the pain clinic's effect, analysis was repeated after removing children initiating hydroxyurea/transfusions upon referral. The significant decrease in hospitalizations persisted [5(IQR 3-6) to 1(IQR 0-4; P = 0.022]., Conclusions: A multidisciplinary pain management model appears to have decreased SCD pain hospitalizations. Results of this retrospective study will need to be tested in a prospective randomized trial., (Copyright © 2010 Wiley-Liss, Inc.)

Background: infants and young children are often unable to verbalize pain or advocate for themselves which may increase their risk for poor pain assessment and management. Although patient-controlled analgesia (PCA) has been shown to be safe, effective, and superior to intermittent opioid dosing, infants and young children are not able to operate PCA independently. Allowing a parent or nurse to operate the PCA for the child [parent/nurse-controlled analgesia (PNCA)] may be an option for these children. However, the use of PNCA has been heavily scrutinized and more evidence of safety is needed to support this practice., Objectives: the primary purpose of this study was to evaluate safety outcomes associated with PNCA for infants and preschool aged children. Secondary outcomes regarding the frequency of untoward side effects and clinical effectiveness were also examined., Methods: a retrospective review of treatment with PNCA was conducted from a convenience sample of charts for 107 infants and preschoolers. Data were collected for 72 hours or until the PNCA was discontinued., Results: one hundred and seven infants and preschoolers with a mean age of 19.6 months (±12.12) were represented in this study. Mean pain scores were low, as was the number of PNCA injections and attempts and amount of opioid administered. Common opioid side effects were reported. Naloxone was administered to 1.9% of patients for respiratory depression, and potential contributing factors were identified., Discussion: diligent monitoring and education are crucial to ensure safety. Untoward side effects adverse events and pain scores suggest PNCA may be an effective method of pain control for this patient population.

Purpose: The purpose of this article was to report surgical and pain management outcomes of the initial Nuss procedure experience at the Children's Hospital of Wisconsin (Milwaukee) and to place this experience in the context of the published literature., Methods: The initial 118 consecutive Nuss procedures in 117 patients were retrospectively reviewed with approval of the Children's Hospital of Wisconsin human rights review board. Patient, surgical, complication, and pain descriptors were collected for each case. Statistical methods for comparison of pain strategies included the Kolmogorov-Smirnov test for normality, 1-way repeated measures analysis of variance, and paired t tests., Results: Patient, surgical, and complication descriptors were comparable to other large series. Complication rates were 7% early and 25% late. Epidural success rate was 96.4%. There was 1 episode of recurrence 2 years postbar removal (n = 114)., Conclusions: The institution of the Nuss procedure provides a highly desired result with significant complication rates. The ideal approach would deliver this result with lower risk. A pain service-driven epidural administration of morphine or hydromorphone with local anesthetic provides excellent analgesia for patients after Nuss procedure. The success of epidural analgesia is independent of catheter site and adjunctive medications. Ketorolac was an effective breakthrough medication., (Copyright © 2010 Elsevier Inc. All rights reserved.)