Paediatric pain: Journals & articles

Abstract
The prevalence of pain in children and adolescents with psychiatric conditions is rarely investigated. The aims of the current study were to (a) describe the prevalence of headaches and abdominal pain in children and adolescents with psychiatric conditions, (b) compare the prevalence of pain in children and adolescents with psychiatric conditions with that in the general population, and (c) investigate the associations between pain experience and different types of psychiatric diagnoses. Families with a child aged 6-15 years who had been referred to a child and adolescent psychiatry (CAP) clinic completed the Chronic Pain in Psychiatric Conditions questionnaire. Information about the child/adolescent's psychiatric diagnosis(es) was extracted from the CAP clinic's medical records. The children and adolescents included in the study were divided into diagnostic groups and compared. Their data were also compared with data of control subjects collected during a previous study of the general population. Abdominal pain was more common among girls with a psychiatric diagnosis (85%) than in the matched control population (62%, p = 0.031). Children and adolescents with neurodevelopmental diagnoses had a higher prevalence of abdominal pain than children and adolescents with other psychiatric diagnoses. Pain conditions in children and adolescents with a psychiatric diagnosis are common and must be addressed.

Abstract
Objectives: Pediatric chronic pain is common and can be detrimental to children's social, emotional, and school functioning. Nonpharmacological approaches to chronic pain, like cognitive- behavioral therapy (CBT), can be effective. Schools could provide children with chronic pain access to these interventions. However, school professionals (ie, nurses and mental health providers) are seldom trained in CBT, creating a barrier to accessing such help. A seminar was created to introduce CBT strategies for chronic pediatric pain to school professionals. Feasibility, acceptability, and self-reported knowledge gained from the seminar were examined.

Materials and methods: Two introductory seminars (~2.5 h each) were held separately for the Michigan Association of School Nurses and the health department of Northwest Michigan (n = 71 total). The seminar provided an understanding of pain and pain-focused CBT strategies (eg, activity pacing, positive self-statements, and psychoeducation). Fifty-two school nurses, 16 mental health professionals, and 3 participants (unidentified title) rated program acceptability and self-reported knowledge of CBT before and after training (1 = strongly disagree, 5 = strongly agree).

Results: Of the respondents, 89.6% agreed the training was helpful, and 87.5% were interested in additional training. For all questions relating to knowledge of CBT, a mixed-model interaction showed a meaningful, increase of at least 1 point (on a 5-point Likert Scale), F(2, 69.83) = 3.93, P = 0.024.

Conclusion: This study underscores the feasibility and acceptability of training school health providers in CBT for pediatric chronic pain. This project also established key partnerships in Michigan to expand future work in this realm with more comprehensive training and assessment of outcomes.

Abstract
Objective: Brain areas activated during pain can contribute to enhancing or reducing the pain experience, showing a potential connection between chronic pain and the neural response to pain in adolescents and youth.

Methods: This study examined changes in brain activation associated with experiencing physical pain and observing physical and emotional pain in others by using functional magnetic resonance imaging (fMRI) before and after intensive interdisciplinary pain treatment (IIPT). Eighteen youths (age 14 to 18) with widespread chronic pain completed fMRI testing before and after IIPT to assess changes in brain activation in response to physical and emotional pain.

Results: Broadly, brain activation changes were observed in frontal, somatosensory, and limbic regions. These changes may suggest improvements in descending pain modulation via thalamus and caudate, and the different pattern of brain activation after treatment suggests potentially better discrimination between physical and emotional pain. Brain activation changes were also correlated with improvements in clinical outcomes of catastrophizing (reduced activation in right caudate, right mid-cingulate, and postcentral gyrus) and pain-related disability (increased activation in precentral gyrus, left hippocampus, right middle occipital cortex, and left superior frontal gyrus).

Discussion: These changes could indicate that reduced brain protective responses to pain were associated with treatment-related improvements. This pilot study highlights the need for larger trials designed to better understand the brain mechanisms involved in pediatric widespread pain treatment.

Abstract
Background: Paracetamol and ibuprofen are the most commonly used drugs for pain treatment in children and their combination has shown improved analgesic effect compared to treatment with either drug alone. Current literature lacks specific guidelines regarding the settings in which this combination should be adopted.

Methods: The survey, conducted with Delphi methodology, involved 75 hospital and outpatient pediatricians with clinical experience in the management of pain in children. Pediatricians involved were asked to validate or not the results of the previous NominalGroup Tecnique (NGT) consensus and thus specify the optimal clinical settings in which the paracetamol/ibuprofen fixed-dose combination could be adopted.

Results: The results confirm the importance of the fixed-dose paracetamol and ibuprofen combination for the control of mild-to-moderate acute pain in children. Particularly, this association seems to be appropriate in case of headache, earache, odontalgia and musculoskeletal pain, and in specific settings such as post-operative and post-procedural pain. The broadening of the panel brought to slight variations in clinical management practices between hospital and outpatient specialists. Nonetheless, overall consensus supports the notion that the fixed dose combination is more efficacious than monotherapies and it is well tolerated. Moreover, experts unanimously agree on the usefulness of the combination for caregivers, leading to improved adherence and effectiveness.

Conclusions: Both the NGT consensus and the broader Delphi consensus confirm the usefulness of the paracetamol-ibuprofen fixed-dose combination in pediatric pain. This is attributed to its superior effectiveness compared to monotherapies, a good tolerability profile, and improved compliance and ease of use. Some pain settings related to chronic, inflammatory and rheumatological pathologies remain to be investigated to evaluate the use of this combination.

Keywords: Delphi consensus; Pain management; Paracetamol/ibuprofen fixed-dose combination; Pediatrics.

Abstract
Objective: Enhanced recovery after surgery (ERAS) guidelines have been successfully applied to children and neonates. There is a need to provide evidence-based consensus recommendations to manage neonatal pain perioperatively to ensure adequate analgesia while minimising harmful side effects.

Methods: Following a stakeholder needs assessment, an international guideline development committee (GDC) was established. A modified Delphi consensus iteratively defined the scope of patient and procedure inclusion, topic selection and recommendation content regarding the pharmacologic management of neonatal pain. Critical appraisal tools assessed the relevance and quality of full-text studies. Each recommendation underwent a formal Grades of Recommendation, Assessment, Development and Evaluation (GRADE) assessment of the quality of evidence and expert consensus was used to determine the strength of recommendations.

Results: The GDC included paediatric anaesthesiologists, surgeons, and ERAS methodology experts. The population was defined as neonates at >32 weeks gestational age within 30 days of life undergoing surgery or painful procedures associated with surgery. Topic selection targeted pharmacologic opioid-minimising strategies. A total of 4249 abstracts were screened for non-opioid analgesia and 738 abstracts for the use of locoregional analgesia. Full-text review of 18 and 9 articles, respectively, resulted in two final recommendations with a moderate quality of evidence to use regular acetaminophen and to consider the use of locoregional analgesia. There was inadequate evidence to guide the use of other non-opioid adjuncts in this population.

Conclusions: Evidence-based, ERAS-driven consensus recommendations were developed to minimise opioid usage in neonates. Further research is required in this population to optimize multimodal strategies for pain control.

Abstract
Introduction: Congenital heart disease is a common birth defect, but advancements in diagnosis and treatment have improved survival rates. Enhanced recovery after surgery (ERAS) programmes have emerged in paediatric cardiac surgery. Multimodal pain management, as a vital part of ERAS programmes, has been found to be effective in reducing pain and improving outcomes in cardiac surgery patients. Traditional methods of pain control using high-dose opioids can lead to complications, so nonopioid analgesics and regional anaesthesia techniques are being used to reduce the consumption. However, there is a significant variability in pain management practices in paediatric cardiac surgery. A network meta-analysis (NMA) is needed to comprehensively compare the effects of different analgesic interventions in this population.

Methods and analysis: A comprehensive electronic literature database search will be performed using electronic databases, mainly including PubMed, EMBASE, Web of Science and Cochrane Central Register of Controlled Trials. All randomised controlled trials associated with perioperative pain management for paediatric cardiac surgery will be included. The primary outcome will be visual analogue score or numeric rating scale of pain and total opioid consumption (or equivalent) 24 hours after postoperative tracheal extubation. The Revised Cochrane Risk of Bias Tool will be employed to assess the quality of included articles. A random-effects pairwise meta-analysis will be performed to report the head-to-head comparison. Following the assessment of individual articles, an NMA will be conducted using a Bayesian framework with random-effects' models.

Ethics and dissemination: Ethics approval is not necessary because this study will be based on publications. The results of this study will be published in a peer-reviewed journal.

Abstract
Objective: To evaluate studies related to pain management associated with arteriovenous fistula cannulation among children.

Methods: The systematic review comprised literature search on Embase, ProQuest, Science Direct, Scopus, SpringerLink and Wiley Online databases for studies published in English between 1998 and 2021. The search used key words, including pain management OR analgesia AND child OR paediatric AND haemodialysis OR dialysis AND arteriovenous fistula OR arteriovenous fistula cannulation OR fistula needle OR arteriovenous fistula insertion OR needle insertion. The quality of the studies was evaluated using the Joana Briggs Institute checklist. General characteristics of the and pain outcomes were noted.

Results: Of the 2,877 studies initially identified, 8(0.27%) were analysed; 7(87.5%) quasi-experimental and 1(12.5%) randomised controlled trial. Overall, there were 283 participants aged 6-18 years. The strategies used for reducing arteriovenous fistula puncture-related pain among children undergoing haemodialysis included cryotherapy, lidocaine agents, virtual reality (VR), guided visualisation, balloon inflation, aromatherapy, and other programmed distractions. The strategies had a positive effect on reducing arteriovenous fistula cannulation-related pain among children.

Conclusion: Non-pharmacological pain management is an easier, simpler, inexpensive and more effective method of atraumatic care among children undergoing haemodialysis.

Abstract in English, French
Objective: To evaluate the effectiveness of art therapy in reducing pain and anxiety in adolescents with painful conditions treated in the ED.

Methods: We conducted a prospective pilot study of patients 12-18 years old presenting with a painful condition to a tertiary-care children's hospital ED. Primary outcome was pain intensity measured using the Verbal Numerical Rating Scale (scored 0-10); a decrease of ≥ 20% was clinically significant. Anxiety was measured using the short-form six-item State-Trait Anxiety Inventory (scored 20-80: 20-40 = zero-low anxiety; 41-60 = moderate anxiety; 61-80 = high anxiety); a change from higher to lower category was clinically significant. Outcomes were measured at baseline, immediately after, and 1 h after art therapy completion. A standardized interview was conducted immediately after art therapy completion.

Results: We enrolled a convenience sample of 50 patients. Mean duration of art therapy was 34.7 min. Mean baseline pain was 6.2 and decreased by 23.2% (95% CI 14.9-31.5) and 28.6% (95% CI 9.2-48), immediately after and 1 h after art therapy completion, respectively. Mean baseline anxiety was 48 (moderate) and decreased to 38 (low) and 43 (moderate) at the same time points, respectively. Forty-eight patients (96%) reported feelings of relaxation, decreased pain intensity, and/or empowerment (e.g., "Very relaxing"; "I didn't feel as much pain"; "Really showed my emotions"; "A way to explain to doctors what I'm feeling and what parts hurt").

Conclusion: Art therapy may be associated with clinically significant decreases and qualitative improvements in pain and anxiety in adolescents with painful conditions being treated in the ED. This novel treatment may improve the holistic care of adolescents with painful conditions in the ED.

Abstract
Purpose: Pain and anxiety-inducing interventions have a major impact on pediatric patients. Pain reduction by virtual reality (VR) during port and vein punctures is well studied. This study investigates peri-interventional reduction of pain, anxiety and distress using VR compared to the standard of care (SOC) in a pediatric oncology outpatient clinic.

Methods: In a randomized, controlled cross-over design, patients aged 6-18 years experience potentially painful interventions accompanied by VR. Observational instruments include NRS, FPS-r, BAADS, mYPAS-SF, PedsQL and SSKJ3-8R. All patients undergo two observations: SOC (A) and VR (B) in a randomized order. In addition, parents and staff are interviewed. Specific conditions for VR in an outpatient clinic setting derived from interprofessional focus group discussion are being explored.

Results: Between July 2021 and December 2022 57 eligible patients were included and randomized to the orders A/B (n = 28) and B/A (n = 29). Thirty-eight patients completed both observations. Characteristics in both groups did not differ significantly. More than half of the patients had no previous experience with VR, 5% decided to discontinue VR prematurely. Peri-interventional pain, anxiety and distress were significantly reduced by VR compared with SOC. 71% of patients and 76% of parents perceived punctures with VR to be more relaxed than previous ones. 95% of patients perceived fun with VR goggles. Detailed questionnaires on individual stress and anxiety were returned from 26 of 38 patients. Focus group discussion with staff yielded evidence for successful implementation of VR in an outpatient clinic.

Conclusions: The present study shows that VR can be used for peri-interventional reduction of pain, anxiety, and distress in the special environment of a pediatric outpatient clinic. Specific conditions must be met for successful implementation. Further studies are needed to identify particularly susceptible patients and to illuminate alternatives for distraction that are feasible to implement with limited resources.

Abstract
Background: There is little experience on the use of the WHO Standards for improving the quality of care (QOC) for children. We describe the use of four prioritised WHO Standard-based Quality Measures to assess the provision of care for children with pain in emergency departments (EDs).

Methods: In a multicentre observational study in 10 EDs with different characteristics in Italy, we collected data on 3355 children accessing the EDs between January 2019 and December 2020. The association between children and facility characteristics and quality measures was analysed through multivariate analyses.

Results: The proportion of children whose pain was measured was 68.7% (n=2305), with extreme variations across different centres (from 0.0% to 99.8%, p<0.001). The proportion of children treated for pain was 28.9% (n=970) again with a wide range (5.3%-56.3%, p<0.001). The difference between the frequency of children with pain measured and pain treated varied widely between the facilities (ranging from -24.3 to 82). Children with moderate and severe pain were more frequently treated (48.9% and 62.9% of cases, respectively), although with large variations across centres (ranges: 0%-74.8% and 0%-100% respectively, p<0.001). After correction for children's characteristics, the variable more strongly associated with analysed outcomes was the facility which the child accessed for care. Being a facility in Northern Italy was associated with a higher rate of pain measurement (67.3%-95% CI: 39.9% to 94.6%, p<0.001) compared with facilities in South Italy (-22.1% lower (95% CI: -41.7% to -2.50%, p=0.03).

Conclusions: The use of few WHO Standard-based measures related to pain can help identifying priority gaps in QOC for children and in monitoring it over time. There is a need for more implementation research to establish which are the most sustainable and effective interventions to improve the QOC for acute pain in children.

Abstract
Opioid therapy is the mainstay for managing pain in pediatric oncology. This narrative review describes the current literature regarding opioids for pediatric cancer pain. The review explores the multifaceted landscape of opioid utilization in this population, including the role of opioids in certain clinical circumstances, modalities of opioid delivery, unique opioids, outpatient and at-home pain management strategies, and other key concepts such as breakthrough pain. This review highlights the importance of individualized dosing and multimodal approaches to enhance efficacy and minimize adverse effects. Drawing from a wide range of evidence, this review offers insights to optimize pediatric oncology pain management.

Abstract
Pediatric regional anesthesia has been in existence for over 125 years, but significant progress and widespread use has occurred in the last few decades, with the increasing availability of ultrasound guidance. Evidence supporting the safety of regional anesthesia when performed under general anesthesia has also allowed the field to flourish. Newer techniques allow for more precise nerve blockade and in general this has resulted in more peripheral blocks replacing central blocks, such as caudal epidurals and spinal anesthesia. Current controversial topics in the field include the method of obtaining loss of resistance when placing epidural catheters, the role of regional anesthesia in compartment syndrome and post-hypospadias repair complications, and utility of test doses.

Abstract
Chronic pain is common among children and adolescents; however, the diagnoses in the newly developed 11th revision of the International Classification of Diseases (ICD-11) chronic pain chapter are based on adult criteria, overlooking pediatric neurodevelopmental differences. The chronic pain diagnoses have demonstrated good clinical applicability in adults, but to date, no field study has examined these diagnoses to the most specific diagnostic level in a pediatric sample. The current study aimed to explore pediatric representation within the ICD-11, with focus on chronic primary pain. Healthcare professionals (HCPs) at a specialized pediatric pain center documented the symptoms of and assigned both ICD-10 and ICD-11 diagnoses to N = 402 patients. Using criteria-based computer algorithms, specific ICD-11 pain diagnoses were allocated for each documented pain location, with residual diagnoses (ie, "unspecified") assigned if criteria were not (fully) met. Within the ICD-11, the algorithms assigned specific pain diagnoses to most patients (73.6%). In ICD-10, HCPs could not specify a diagnosis for 5.2% of patients; the ICD-11 algorithm allocated a residual chronic primary pain diagnosis in 51.2%. Residual categories were especially prevalent among younger children, boys, patients with headaches, and those with lower pain severity. Overall, clinical utility of the ICD-11 was high, although less effective for chronic back pain and headache diagnoses. The latter also exhibited the lowest agreement between HCPs and algorithm. The current study underscores the need for evidence-based improvements to the ICD-11 diagnostic criteria in pediatrics. Developing pediatric coding notes could improve the visibility of patients internationally and improve the likelihood of receiving reimbursement for necessary treatments through accurate coding.

Abstract in English, French
Purpose: Tonsillectomy is one of the most common ambulatory procedures performed in children worldwide, with around 40,000 procedures performed in Canada every year. Although a prior systematic review indicated a clear role for dexamethasone as an analgesic adjunct, the quantity effect on opioid consumption is unknown. In the current systematic review with meta-analysis, we hypothesized that the use of dexamethasone reduces perioperative opioid consumption in pediatric tonsillectomy but does not increase rates of postoperative hemorrhage.

Source: We systemically searched MEDLINE, Embase, Cochrane Databases, and Web of Science from inception to 23 April 2024. Randomized controlled trials that compared intravenous dexamethasone to placebo in pediatric tonsillectomy were included in the study. The primary outcome was perioperative opioid consumption, and the secondary outcomes included the incidence of postoperative hemorrhage. We used a random effects meta-analysis to compute the mean difference (MD) or risk ratio (RR) with 95% confidence interval (CI) for each outcome.

Principal findings: Of the 1,329 studies identified in the search, we included 16 in the final analysis. Intravenous dexamethasone administration significantly reduced opioid consumption (MD, -0.11 mg·kg-1 oral morphine equivalent; 95% CI, -0.22 to -0.01) without increasing the incidence of readmission (RR, 0.69; 95% CI, 0.28 to 1.67) or reoperation due to postoperative hemorrhage (RR, 3.67; 95% CI, 0.79 to 17.1).

Conclusions: Intravenous dexamethasone reduced perioperative opioid consumption in pediatric tonsillectomy without increasing the incidence of postoperative hemorrhage.

Abstract
Purpose: Acetaminophen is the most common drug used to treat acute pain in the pediatric population, given its wide safety margin, low cost, and multiple routes for administration. We sought to determine the most efficacious route of acetaminophen administration for postoperative acute pain relief in the pediatric surgical population.

Methods: We conducted a systematic review of randomized controlled trials (RCTs) that included children aged between 30 days and 17 yr who underwent any type of surgical procedure and that evaluated the analgesic efficacy of different routes of administration of acetaminophen for the treatment of postoperative pain. We searched MEDLINE, CENTRAL, Embase, CINAHL, LILACs, and Google Scholar databases for trials published from inception to 16 April 2023. We assessed the risk of bias in the included studies using the Cochrane Risk of Bias 1.0 tool. We performed a frequentist network meta-analysis using a random-effects model. Our primary outcome was postoperative pain using validated pain scales.

Results: We screened 2,344 studies and included 14 trials with 829 participants in the analysis. We conducted a network meta-analysis for the period from zero to two hours, including six trials with 496 participants. There was no evidence of differences between intravenous vs rectal routes of administration of acetaminophen (difference in means, -0.28; 95% confidence interval [CI], -0.62 to 0.06; very low certainty of the evidence) and intravenous vs oral acetaminophen (difference in means, -0.60; 95% CI, -1.20 to 0.01; low certainty of the evidence). For the comparison of oral vs rectal routes, we found evidence favouring the oral route (difference in means, -0.88; 95% CI, -1.44 to -0.31; low certainty of the evidence). Few trials reported secondary outcomes of interest; when comparing the oral and rectal routes in the incidence of nausea and vomiting, there was no evidence of differences (relative risk, 1.20; 95% CI, 0.81 to 1.78).

Conclusion: The available evidence on the effect of the administration route of acetaminophen on postoperative pain in children is very uncertain. The outcomes of postoperative pain control and postoperative vomiting may differ very little between the oral and rectal route. Better designed and executed RCTs are required to address this important clinical question.

Abstract
In this study, we describe the development and validation of a revised Pediatric Chronic Pain Grading (P-CPG) for children aged 8 to 17 years that adds emotional impairment to previously used measures of pain intensity and functional impairment. Such a measure enables the assessment of chronic pain severity in different epidemiological and clinical populations, the stratification of treatment according to pain severity, and the monitoring of treatment outcome. The P-CPG was developed using a representative sample of school children with chronic pain (n = 454; Mage = 12.95, SD = 2.22). Construct validity and sensitivity to change were examined within a sample of N = 2448 children and adolescents (Mage = 12.71, SD = 2.47) comprising 3 subsamples (school n = 1562, primary care n = 129, and tertiary care n = 757) affected by chronic pain to varying extents. Results showed that P-CPG grades differed significantly among the 3 subsamples, with school children being least affected by chronic pain and tertiary care patients being most affected. As P-CPG grade increased, so did pain intensity, functional impairment, pain-related school absence, and emotional impairment. Convergent validity was demonstrated by significant positive correlations between the P-CPG and global ratings of pain severity as well as objective claims data; the latter reflects greater health care costs with increasing P-CPG scores. Sensitivity to change was supported by a significant reduction in baseline P-CPG grades 3 and 6 months after intensive interdisciplinary pain treatment in tertiary care sample. In conclusion, the P-CPG is an appropriate measure of pain severity in children and adolescents with chronic pain in clinical as well as epidemiological settings.

Abstract
Background: The use of acetaminophen in the perioperative period has emerged as an attractive option for providing safer and cost-effective analgesia in children.

Aims: The primary aim of our project was to increase the use of acetaminophen (both oral and intravenous) in the perioperative period from a baseline of 39.5% to 50% for all surgical patients within 24 months. The secondary aim was to increase the use of enteral acetaminophen from 10% to 52.5% during the same period.

Methods: A multidisciplinary team was formed, and model for improvement was chosen as the QI methodology. The primary measure was the total percentage of surgical patients receiving any form of perioperative acetaminophen, while our secondary measure was the percentage use of oral acetaminophen administration. We also tracked the average maximum PACU (Post Anesthesia Care Unit) pain scores and the percentage of patients receiving IV opioids. Multiple interventions were conducted, including education, increasing the availability of acetaminophen, and optimizing the electronic medical record (EMR). Monthly data was collected using an automated report in the EMR.

Results: We successfully achieved our goal, increasing the use of acetaminophen from 39.5% to 70% within four months. Despite some fluctuations, by the end of 24 months, we not only met but surpassed our goal, with 63% of patients receiving perioperative acetaminophen. Similarly, the usage of oral acetaminophen increased from a baseline of 10% to 78%. Our average maximum PACU pain scores improved from 5.4 to 5.2, and the percentage of patients receiving rescue opioids decreased from 15.4 to 13.1.

Conclusion: We successfully achieved and sustained our goals of improving acetaminophen use for our surgical patients without worsening pain scores or worsening use of intravenous opioids. Future directions include further refining our strategies and exploring additional opportunities to optimize pain management in pediatric perioperative settings.

Abstract
The landscape of ambulatory surgery is changing, and tonsillectomy with or without adenoidectomy is one of the most common pediatric surgical procedures performed nationally. The number of children undergoing tonsillectomy on an ambulatory basis continues to increase. The 2 most common indications for tonsillectomy are recurrent throat infections and obstructive sleep-disordered breathing. The most frequent early complications after tonsillectomy are hemorrhage and ventilatory compromise. In areas lacking a dedicated children's hospital, these cases are managed by a nonpediatric specialized anesthesiologist and general otolaryngology surgeon. In response to requests from our members without pediatric fellowship training and/or who care for pediatric patients infrequently, the Pediatric Committee of the Society for Ambulatory Anesthesia (SAMBA) developed a position statement with recommendations for the safe perioperative care of pediatric patients undergoing tonsillectomy with and without adenoidectomy in freestanding ambulatory surgical facilities. This statement identifies children that are more likely to experience complications and to require additional dedicated provider time that is not conducive to the rapid pace and staffing ratios of many freestanding ambulatory centers with mixed adult and pediatric practices. The aim is to provide health care professionals with practical criteria and suggestions based on the best available evidence. When high-quality evidence is unavailable, we relied on group consensus from pediatric ambulatory specialists in the SAMBA Pediatric Committee. Consensus recommendations were presented to the Pediatric Committee of SAMBA.

Abstract
Objectives: This retrospective, cross-sectional study investigated the nature and extent of burden experienced by caregivers of adolescents and children with chronic pain, and factors associated with increased caregiver burden.

Methods: The Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC) database provided prospectively collected data from 1,929 families attending 9 pediatric chronic pain services across Australia and New Zealand. Data included demographic information, responses to child pain and functioning measures, caregiver work impairment and psychosocial functioning.

Results: Caregivers of pediatric chronic pain patients reported work impairment associated with their child's pain (mean 15%±SD 25 absenteeism; 38%±SD 29 productivity lost), significantly worse than published international population norms (large-scale community survey data), most other caregiver samples of adults and children with other chronic conditions, and adult samples with various pain conditions. Caregivers reported considerable burden in multiple psychosocial functioning domains, particularly leisure functioning, pain-related catastrophizing, and adverse parenting behaviors (with greater pain-related avoidance). Caregiver psychosocial burden was significantly associated with child psychosocial functioning (β=-0.308, P<0.01), school absenteeism (β=0.161, P<0.01), physical disability (β=0.096, P<0.05) and pain duration (β=0.084, P<0.05), but not pain intensity. Caregiver work productivity lost was significantly associated with school absenteeism (β=0.290, P<0.01), child physical disability (β=0.148, P<0.01), child healthcare utilization (β=0.118, P<0.05) and worst pain intensity (β=0.101, P<0.05).

Discussion: These results highlight the significant and varied impacts experienced by caregivers of children with chronic pain. This work is novel in reporting significant work impairment and confirms psychosocial burden in a larger sample than previous studies.

Abstract in English, French
Purpose: In children, the relationship between the dose of intraoperative opioid and postoperative outcomes is unclear. We examined the relationship between intraoperative opioid dose and postanesthesia care unit (PACU) pain scores and opioid and antiemetic administrations.

Methods: We performed a single-institution retrospective cohort study. Patients who were aged < 19 yr, had an American Society of Anesthesiologists Physical Status of I-III, were undergoing one of 11 procedures under general anesthesia and without regional anesthesia, and who were admitted to the PACU were included. Patients were analyzed by quartiles of total intraoperative opioid dose using multivariable regression, adjusting for confounders including procedure. An exploratory analysis of opioid-free anesthetics was also performed.

Results: Three thousand, seven hundred and thirty-three cases were included, and the mean age of included patients was 8.3 yr. After adjustment, there were no significant differences between the lowest and higher quartiles for first conscious pain score, mean pain score, PACU opioid dose, or PACU length of stay; in addition, estimated differences were small. Patients in higher quartiles were estimated to be more likely to receive antiemetics, significantly so for those in the second quartile. Patients in the lowest quartile received significantly more intraoperative nonopioid analgesics. In the exploratory analysis, no significant difference in PACU pain scores was found in cases without intraoperative opioids.

Conclusions: Children who received lower doses of intraoperative opioids did not have worse PACU pain outcomes but required fewer antiemetics and received greater numbers of nonopioid analgesics intraoperatively. These findings suggest that lower doses of intraoperative opioids may be administered to children as long as other analgesics are used.

Abstract
Objectives: This study tested performance measures of physical functioning and pain-related psychosocial measures as potential mechanisms of improvements in outcomes following intensive outpatient interdisciplinary pain rehabilitation for adolescents. We hypothesized that improvements in performance measures of physical functioning, fear of pain, pain catastrophizing, and self-efficacy during treatment would be related to improvements in pain, functional disability, and depressive symptoms.

Methods: Seventy-seven adolescents, 10-18 years old, completed self-report measures prior to treatment, after the first week, at discharge, and at 3-months follow-up. Participants completed physical performance measures of physical and exercise capacity and core strength on day one, after the first week, and at discharge. Linear mixed models were used to examine the association between changes in potential mechanisms and changes in outcomes, adjusting for age, sex, pain duration and baseline functional disability.

Results: Statistically significant improvement in functional disability, pain, and depressive symptoms was demonstrated across the four time points. Improvements were also demonstrated in physical performance measures, fear of pain, pain catastrophizing and self-efficacy. Improvements in pain catastrophizing predicted improvements in functional disability, pain and depressive symptoms. Improvements in self-efficacy predicted improvements in all outcome variables except depression. Improvements in physical performance measures predicted improvements in some aspects of functional disability and pain, but not depressive symptoms.

Discussion: This study contributes to the growing literature on the effectiveness of pediatric intensive interdisciplinary pain rehabilitation programs and mechanisms that influence improvements in outcomes, an area that is currently underexplored. Results are important to guide future research and inform clinical practice.

Abstract
Objectives: to evaluate the effect of music applied within ten and 15 minutes, combined with swaddling, on behavioral (facial action) and physiological (heart rate) responses to pain in full-term newborns, before and during venipuncture for blood sampling.

Methods: a randomized, triple-blind, clinical trial with 52 rooming in infants randomly assigned to four groups of 13: Experimental 1 (music [ten minutes] plus swaddling), Experimental 2 (music [15 minutes] plus swaddling), Control 1 (no music [ten minutes] plus swaddling), and Control 2 (no music [15 minutes] plus swaddling). Pain was measured using the Neonatal Facial Coding System in the basal and procedural moments.

Results: experimental 2 group showed high pain absence (p < 0.05); low heart rate mean (p < 0.0001) in the basal and procedural (antisepsis, puncture, blood squeezing/aspiration, compression) moments.

Conclusions: neonates who listened to 15 minutes of music plus swaddling showed a greater absence of facial pain actions.

Abstract
Medication error has emerged as a significant problem in healthcare, especially in the past 2 decades. In anaesthesia, the paediatric age group is particularly at risk of such events because of complex age- and weight-based drug calculation, drug formulations, serial dilutions, and often limited staff experience in handling such patients. We searched PubMed, Cochrane, and Google Scholar for literature on medication errors in paediatric anaesthesia in children (< 18 years of age). Two authors searched for the articles independently, and a third author sorted any consensus differences. A total of 2979 articles were retrieved. We studied primary outcomes, the results, and conclusions of the various studies. A total of 21 relevant articles were selected finally. Following preventive strategies like colour coding, accurate dose calculations, verification by a second individual, and checking and encouraging self-reporting can improve perioperative safety in the paediatric population to a significant extent.

Abstract
Introduction: A major challenge in conducting clinical trials is recruitment. Trial under-enrollment leads to underpowered studies. Behavioral economics offers strategies that may enhance trial recruitment. This study assessed the impact of behavioral economic strategies versus a standard biological approach to recruit children into a randomized clinical trial assessing a biofeedback-based virtual reality intervention for postoperative pain management. We hypothesized the behavioral economics-informed approach would increase enrollment into the future trial, intention to adhere to therapy, acceptability of the intervention, and perceived efficacy while decreasing perception of treatment burden and risk.

Methods: This single-center, prospective, randomized trial recruited patients 12-18 years old undergoing surgery requiring postoperative admission and narcotic administration. Patient-parent dyads were randomized to watch a behavioral economics-informed (n = 64) or standard biological (n = 66) recruitment video about a study designed to assess impact of a virtual reality pain management intervention.

Results: There was no difference in rates of intention to enroll in the study between groups (behavioral economics: 75%, control: 79%, p = 0.744) or in median response scores to questions regarding intention to adhere to therapy (4.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p=0.084), acceptability of therapy (4.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p = 0.376), perceptions of treatment burden (3.0 [3.0, 4.0] vs. 4.0 [3.0, 4.0], p=0.251), and efficacy (3.0 [3.0, 4.0] vs. 3.0 [3.0, 4.0], p = 0.914). Patients in the behavioral economics group were less likely to perceive risk associated with virtual reality versus the control group (behavioral economics: 2.0 [1.0, 2.0], control: 2.0 [2.0, 3.0], p = 0.023).

Discussion: A behavioral economics-informed video did not increase patients' intentions to enroll into a clinical trial assessing the impact of virtual reality intervention for postoperative pain management.

Conclusion: Either approach would be sufficient for patient recruitment for this type of clinical trial since the overall intention to enroll rate was 77%.

Abstract
Pain is a common consequence of childhood cancer. While most research has examined biomedical predictors of post-cancer pain, biopsychosocial conceptualisations such as the Cancer Threat Interpretation (CTI) model hold promise for guiding comprehensive pain management strategies. Guided by the CTI model, this cross-sectional study evaluated correlates of post-cancer pain in childhood cancer survivors including threat-related risk factors (bodily threat monitoring, fear of cancer recurrence, help-seeking) and mindsets about the body. In the preceding three months, 21.8% of survivors reported chronic pain (>3 months) and 14.3% experienced pain most days. Greater bodily threat monitoring, more fear of cancer recurrence, and more help-seeking was associated with more pain. There was heterogeneity in the mindsets that survivors of childhood cancer hold about their bodies. Holding the mindset that the 'body is an adversary' was associated with more pain, greater bodily threat monitoring and more fear of cancer recurrence. Holding the mindset that the 'body is responsive' was associated with less bodily threat monitoring, while the mindset that the 'body is capable' was associated with greater help-seeking. A path model demonstrated a significant combined indirect effect of the 'body is an adversary' mindset on pain through bodily threat monitoring and fear of cancer recurrence. Overall, this study supported that a sub-group of childhood cancer survivors experience persistent and interfering pain and provided cross-sectional support for threat-related correlates for pain aligning with the CTI model. Body mindsets were associated with pain and threat-related correlates and may represent a novel target to support survivors with pain.

Abstract
Introduction: Tonsillectomy is associated with significant pain and post-operative pain control is often unsatisfactory. This study sought to evaluate the effect of peritonsillar infiltration of tramadol-ketamine combination, tramadol alone and ketamine alone on post-tonsillectomy pain in children.

Patients and methods: A randomized double-blinded interventional study involving 90 patients aged 3-15 years of American society of anesthesiologists I or II physical status scheduled for elective adenoidectomy, tonsillectomy or adenotonsillectomy at JUTH was conducted. Patients were randomized into one of three groups: group I received tramadol 2mg/kg, group II received ketamine 1mg/kg plus tramadol 2mg/kg and group III received ketamine 1mg/kg only all made up to 2mls with normal saline and 1ml given per tonsillar bed. All patients had standard general anaesthesia with endotracheal intubation and monitoring. Data was analyzed using Epi-info version 7.1.5 with p £ 0.05.

Result: The analysis of data showed that the mean ages of the participants in group I, II and III were 5.70±2.00, 5.69±3.22 and 4.47±2.01 years respectively (p-value=0.091). Group II had significantly lower pain scores, longer time to first request of analgesia, earlier oral intake and discharge from the hospital compared to the group that received either tramadol or ketamine alone. Minimal side effects were noted across all the groups in the study.

Conclusion: Peri-tonsillar infiltration of tramadol-ketamine combination immediately after tonsillectomy (but before extubation of patients) significantly decreased post-tonsillectomy pain without increasing the incidence of side effects compared to tramadol or ketamine alone in children undergoing adenotonsillectomy.

Abstract
Differently from the adult patients, in paediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, a selection of appropriate pain assessment tools should consider the age, the cognitive level, the presence of eventual disability, the type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drug pharmacokinetics should facilitate a better management of childhood pain. The objective of this update is to discuss the current practice and the recent advances in pediatric pain management. Using PubMed and the Cochrane Library we conducted an extensive literature analysis on pediatric pain assessment and commonly used analgesic agents in this kind of patients. According to our results, a multimodal analgesic regimen provides a better pain control and a functional outcome in children. Cooperation and communication among the anaesthesiologist, the surgeon and the paediatrician remains essential for successful anaesthesia and pain management in childhood.

This open access journal is the official Journal of the Iranian Society of Regional Anesthesia and Pain Medicine (ISRAPM), covering clinical and basic research, education, patient care, health economics, and policy to inform all practitioners in pain management, such as anesthesiologists, interventional pain physicians, neurosurgeons, neurologists, and any specialists who are interested in pain medicine.

British Journal of Pain is a peer-reviewed quarterly British journal with an international multidisciplinary Editorial Board. The journal publishes Original Papers and Reviews on all major aspects of pain and pain management reflecting the body of evidence of the topic and suitable for a multidisciplinary readership. Where empirical evidence is lacking, the reviews reflect the generally held opinions of experts in the field.

The Clinical Journal of Pain explores all aspects of pain and its effective treatment, bringing you the insights of leading anesthesiologists, surgeons, internists, neurologists, orthopedists, psychiatrists and psychologists, clinical pharmacologists, and physical and rehabilitation therapists.

A multi-disciplinary, international journal that aims to be a global forum on all aspects of pain research and pain management. The journal publishes clinical and basic science research papers relevant to all aspects of pain and its management.

The Journal of Headache and Pain is a peer-reviewed open access journal specifically dedicated to researchers involved in all aspects of headache and related pain syndromes, including epidemiology, public health, basic science, translational medicine, clinical trials and real-world data.

This journal aims to improve the care of patients in pain by providing a forum for clinical researchers, basic scientists, clinicians, and other health professionals to publish original research. Other content includes invited critical reviews, invited commentaries on reviews, and exceptional case studies.

This journal provides a forum for the publication of the latest clinical research and best practices related to the relief of illness burden among patients afflicted with serious or life-threatening illness.

PAIN® is the official publication of the International Association for the Study of Pain® (IASP®). PAIN® publishes original research on the nature, mechanisms, and treatment of pain and provides a multidisciplinary forum for the dissemination of research in the basic and clinical sciences.

Pain Medicine is dedicated to pain clinicians, educators, and researchers with an interest in pain from various medical specialties and related health disciplines. The journal reflects the rapid growth in pain science and practice, as well as the field's need for policy, ethical, and forensic commentary on pain and its management. It promotes the visibility and development of pain medicine as a worldwide interdisciplinary medical specialty within a collaborative, multidisciplinary pain field.

A peer-reviewed, multi-disciplinary journal written by and directed to an audience of interventional pain physicians, clinicians and basic scientists with an interest in interventional pain management and pain medicine.

Pain Practice, the official journal of the World Institute of Pain, publishes international multidisciplinary articles on pain and analgesia that provide its readership with up-to-date research, evaluation methods, and techniques for pain management.

Pain Research and Management is a peer-reviewed, open access journal which publishes original research articles and review articles involving laboratory, including neuroimaging and neurophysiology, and clinical findings in the field of pain research. The journal also looks into the prevention, treatment and management of pain. The journal aims to increase the current knowledge about the pain mechanisms and encouraging the development of effective and safety treatments for pain.

Pediatric Critical Care Medicine is the official journal of the Society of Critical Care Medicine​ and the World Federation of Pediatric Intensive and Critical Care Societies, and it is devoted to research and clinical care of critically ill or injured infants, children, and adolescents.

Regional Anesthesia & Pain Medicine, the official publication of the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine), is a monthly journal that publishes peer-reviewed scientific and clinical studies to advance the understanding and clinical application of regional techniques for surgical anesthesia and postoperative analgesia. Coverage includes intraoperative regional techniques, perioperative pain, chronic pain, obstetric anesthesia, paediatric anesthesia, outcome studies, and complications.

The Scandinavian Journal of Pain (SJPAIN) publishes internationally relevant articles on all aspects of pain. The journal is the official quarterly publication of the Scandinavian Association for the Study of Pain and serves as a forum for original research on the nature of pain, pain mechanisms, and pain management.