Paediatric pain: Journals & articles

Abstract
Objectives: The current study investigated the concurrent impact of anxiety and pain catastrophizing on both pain-related impairment (i.e., functional disability, pain-intensity) and on pain-related psychological treatment outcomes in youth with FAPD.

Method: This is a secondary analysis of data from a psychological treatment study (Aim to Decrease Anxiety and Pain Treatment; ADAPT) for youth with FAPD. Participants completed six weeks of ADAPT (psychological intervention) and treatment as usual or treatment as usual alone. Regressions and analysis of covariance models examined the relationship between baseline pain catastrophizing and anxiety on baseline functional disability and pain intensity, while analysis of covariance models assessed the effect of these baseline psychological factors on pain-related outcomes at post-assessment (8 weeks later) while accounting for group assignment. The effects of ADAPT on post-assessment pain catastrophizing and anxiety, as well as their moderating effects on pain-related outcomes were also explored.

Results: Results indicated that baseline pain catastrophizing, but not anxiety, predicted baseline functional disability and pain intensity, as well as post-assessment functional disability. Participants in the ADAPT group also demonstrated significantly lower pain catastrophizing at post-assessment. However, there were no moderating effects of post-assessment pain catastrophizing or anxiety on pain-related outcomes.

Discussion: Findings suggest that assessment of pain catastrophizing is important to better understand pain-related impairment in FAPD.

Abstract
Objective: Pain acceptance predicts better quality of life, physical functioning, and treatment outcomes in youth with chronic pain. However, we know little about the factors that promote pain acceptance in youth. This study investigated body mindsets and their associations with facets of pain acceptance, specifically pain willingness and activity engagement, in adolescents with chronic pain.

Methods: The sample comprised 102 adolescents with chronic musculoskeletal pain (aged 8-17; 72.3% female, 49.5% Caucasian/White) attending a tertiary pain clinic. Hierarchical linear regression analyses examined associations of body mindsets with pain acceptance controlling for demographic factors, pain and mental health symptoms, and basic functioning.

Results: There was significant variation in the mindsets that adolescents with chronic pain held about their bodies - some endorsed the mindset that their Body is an Adversary, others endorsed the mindsets that their Body is Responsive or Body is Capable. Hierarchical linear regression analyses indicated that endorsing the mindset that their Body is an Adversary was associated with lower willingness to experience pain, while endorsing the mindset that their Body is Capable was associated with greater engagement in valued activities despite pain, even after accounting for demographic factors, pain characteristics, and basic functioning. Together, all three mindsets explained 6.6-26.8% unique variance in pain acceptance.

Discussion: Body mindsets are significantly associated with pain acceptance in youth with chronic pain even after controlling for pain characteristics and basic functioning. Experimental research should investigate whether body mindsets are modifiable in this population and whether they could represent interventional targets fostering pain acceptance.

Abstract
Objectives: Attrition from pediatric chronic pain clinics limits patients from receiving maximum benefit from evidence-based interventions, with likely persistence of chronic pain, functional and psychosocial impairments. We aimed to determine attrition prevalence from interdisciplinary pediatric outpatient chronic pain clinics and identify any associated patient and caregiver factors.

Methods: A retrospective analysis was performed of longitudinal data from patients and caregivers attending 10 interdisciplinary pediatric outpatient chronic pain clinics in Australia or New Zealand contributing to the Paediatric electronic Persistent Pain Outcomes Collaboration (PaedePPOC) database. Data was retrieved for patient attrition, patient and caregiver factors at treatment commencement and subsequent documentation of the episode end for treatment completers and non-completers. Statistical associations with patient attrition were assessed using logistic regression analyses.

Results: The prevalence of patient attrition was 19.3% in the PaedePPOC cohort (N=1051), occurring steadily over 11 months. Patients ending their treatment prematurely presented with longer pain duration (>12 mos) (χ2(1, n=879)=8.23, P=0.004) than treatment completers. In the regression model, only older patient age (P=0.010) and higher caregiver psychosocial burden (P=0.025) at treatment commencement were associated with attrition. While pain intensity, patient physical and psychosocial functioning scores and caregiver partner status were not.

Discussion: One in five patients commencing an interdisciplinary pediatric outpatient chronic pain clinic intervention did not complete it. Identifying patients at pre-intervention screening with longer pain duration, older in age and from families with greater reported caregiver burden and providing tailored supports may minimize attrition, therefore optimizing efficiency of service provision.

Abstract
Pain and mental health symptoms frequently co-occur in adolescents, often posing physical, social, and emotional challenges. While previous research has focused on clinician perspectives on chronic pain in isolation, limited knowledge exists on the potential unique challenges these co-occurring symptoms' present to clinicians in providing appropriate support to adolescents. This study examined clinician perspectives on the challenges and barriers to treating adolescents who experience co-occurring pain and mental health symptoms. Using a cross-sectional qualitative online vignette survey, responses were collected from 40 clinicians, including psychologists, physiotherapists, and doctors involved in treating adolescents (11-19 years) who experience co-occurring chronic pain and mental health symptoms. Participants, recruited from several countries, were asked about their perceived challenges to treating adolescents with co-occurring chronic pain and mental health symptoms. Vignettes were analyzed using reflexive thematic analysis. The analysis generated two themes. The first, 'tangled threads', describes how clinicians perceive mistrust from the adolescents based on previous negative clinician encounters and a perceived need to 'undo' this anticipated harm. The second theme 'the difficult-to-pursue integrated approach' depicts how fragmentation and siloed services for pain and mental health hinder effective treatment for adolescents who experience both symptoms. Co-occurring pain and mental health symptoms in adolescents are often initially mismanaged because they do not fit the mould of the services available to treat them, resulting in a more complex presentation to clinicians. The development of a more integrated clinical approach to treating adolescents with co-occurring pain and mental health symptoms is needed. PERSPECTIVE: This study identifies that clinicians perceive they face challenges treating adolescents with co-occurring pain and mental health symptoms, often due to the adolescent's prior clinical experiences and the limited comprehensive treatment options available to them. An integrated approach is urgently needed to tailor care and reduce harm.

Abstract
The aim of this systematic review was to identify and critically analyse the tools available for categorising pain as nociceptive, neuropathic and nociplastic pain in children and adolescents. Studies were included if they (i) included children and adolescents with a mean age of 0-24 years old, (ii) examined assessment tools that categorise pain as nociceptive, neuropathic or nociplastic, and (iii) examined the psychometric properties of the tools. Sensitive searches were conducted in five online databases in March 2024. Eligible studies were assessed for risk of bias and quality by two authors using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) criteria. The search yielded 26 studies for 11 tools. No assessment tool had evidence for all nine recommended psychometric properties. Quantitative Sensory Testing, a tool used to identify signs and symptoms of nociplastic and neuropathic pain, was the most studied tool and had moderate evidence for construct validity, criterion validity and reliability. Three self-reported questionnaires, the Self-reported Leeds Assessment of Neuropathic Symptoms and Signs (S-LANSS), Central Sensitisation Inventory (CSI) and PainDETECT, had moderate evidence for construct validity and show promise as preliminary tools to identify possible neuropathic or nociplastic pain. However, they had low specificity when used in isolation. All assessment methods would benefit from further psychometric evaluation and validation in children and adolescents. PERSPECTIVE: This systematic review highlights the limited validation of pain assessment tools for children and adolescents. While Quantitative Sensory Testing and self-reported questionnaires show promise in identifying pain mechanisms, their applicability remains uncertain. Further psychometric validation is crucial to improve pain assessment and guide personalized treatment in young populations.

Abstract
Background and aims: Percutaneous electrical nerve field stimulation (PENFS) is a minimally invasive, nonpharmacologic approach to treat children with functional abdominal pain disorders (FAPD). Allodynia refers to pain from a stimulus that does not usually provoke pain. We aimed to characterize auricular allodynia during PENFS and associate it with outcomes.

Materials and methods: We conducted a retrospective cohort study reviewing charts of patients who underwent PENFS for an FAPD. We included demographic data, medical history, and validated questionnaire responses. Allodynia was noted through physician notes of localized ear pain, soreness, or tenderness. Baseline clinical scores and PENFS outcomes were compared in patients with and without allodynia.

Results: Of 219 patients with FAPD (mean age 16.2 ± 2.7 years), 79% were female, and 87% were Caucasian; 28% of patients experienced allodynia with no significant demographic differences. The most common gastrointestinal symptoms were abdominal pain (100%) and nausea (70%), and the most common FAPD diagnoses included irritable bowel syndrome (58%) and functional dyspepsia (54%). Of the 93 total visits with allodynia, 44% of the visits had patients report allodynia once and 34% twice. Common interventions included placing
Conclusion: Allodynia in patients with FAPD who underwent PENFS had worse clinical outcomes. Excitation thresholds of rapidly conducting Aβ fibers in the ear are lower than those of nociceptive slowly conducting Aδ and C fibers. Patients with allodynia may require adjustment of nerve fiber stimulation to improve outcomes.

Abstract
Objectives: To identify health professional's perception of barriers, facilitators and training needs when working with children experiencing chronic pain.

Methods: Cross-sectional online survey of health professionals working with children experiencing chronic pain. Survey questions were a range of exploratory open and closed-ended questions, which included yes/no responses, choosing from a list, ranking options and open responses. Quantitative data were analysed using descriptive statistics and percentages; qualitative data were analysed using content analysis.

Results: 180 health professionals took part, of which 44% were physiotherapists. Tertiary hospitals and private practices were most common workplaces. The most frequently reported categories of both barriers and facilitators were workforce and system factors, child factors and parent factors. The most frequently reported confidence areas and development areas were health professional factors, approaches to care and team structure. 75% of participants reported they were moderately to extremely interested in further training in paediatric chronic pain management and indicated a preference for interactive training rather than "passive" learning formats.

Discussion: Health professionals report a diverse range of perspectives when working with children experiencing chronic pain, including perceived barriers and facilitators to care. Most health professionals were interested in future training in paediatric chronic pain management. Future research exploring the parent and child perspective and how these factors present clinically is needed to inform future training opportunities for health professionals working with children experiencing chronic pain.

Abstract
Objectives: This study aimed to characterize pain intensity (average, worst) and disease severity in youth with inflammatory bowel disease in the 12-months post-diagnosis, and to examine the relation between pain and risk (disease severity) and resilience (optimism, pain self-efficacy) factors over time.

Methods: Data collection ran from February 2019 to March 2022. Newly diagnosed youth aged 8-17 with IBD completed numerical rating scales for average and worst pain intensity, Youth Life Orientation Test for optimism, and Pain Self-Efficacy Scale for pain self-efficacy via REDCap; weighted Pediatric Crohn's Disease Activity Index and the Pediatric Ulcerative Colitis Activity Index were used as indicators of disease severity. Descriptive statistics characterized pain and disease severity. Multilevel modeling explored relations between variables over time, including moderation effects of optimism and pain self-efficacy.

Results: At baseline, 83 youth (Mage=13.9, SD=2.6; 60.2% Crohn's disease; 39.8% female) were included. Attrition rates at 4 and 12 months were 6.0% and 9.6%, respectively. Across time, at least 52% of participants reported pain. Participants in disease remission increased from 4% to 70% over 12-months. Higher disease severity predicted higher worst pain, regardless of time since diagnosis. Higher pain self-efficacy: (a) predicted lower average and worst pain, especially at later time points; and (b) attenuated the association between disease severity and worst pain when included as a moderator. Higher optimism predicted lower worst pain.

Discussion: Pain is prevalent in pediatric inflammatory bowel disease and impacted by disease severity, pain self-efficacy, and optimism. Findings highlight modifiable intervention targets.

Abstract
Background: Access to adequate pain treatment is a fundamental right, yet international data suggest that a considerable number of children experience acute and persistent pain. Little is known about the occurrence of both acute and persistent pain in children. The incidence of persistent postoperative pain in children is an unexplored area but international studies suggest that many children experience long-term pain after surgery, with a major impact on daily life. In 4P, Persistent Postoperative Pediatric Pain, we want to estimate the incidence of acute and persistent postoperative pediatric pain. The European Society for Paediatric Anaesthesiology has developed guidelines for perioperative pain management. We aim to examine how well these guidelines are followed and whether adherence to guidelines influences the pain experienced after surgery.

Method: 4P is a prospective observational study of children aged 1-17, planned for surgery in southern Sweden 2023-2024. After agreement from all caregivers, data concerning preoperative pain, pre-emptive analgesia, perioperative management and postoperative pain will be collected. Via an electronic management software, pain will be evaluated at home (or in hospital) at 24h, 3, 6 and 12 months after surgery. We will include 1000 patients.

Discussion: 4P will prospectively follow a large number of children after general pediatric surgeries and evaluate the occurrence of postoperative pain, both acute (APOP) and persistent (PPOP). The study will assess pain treatment regimens and identify risk factors associated with the development of acute and persistent pediatric postoperative pain.

Abstract
Autistic adolescents are at greater risk of chronic pain, but it is unclear how autistic features may relate to individual aspects of chronic pain. As autism traits exist in the general population as well, it is important to know if autistic traits could impact how effective chronic pain management is for adolescents. Here we examined autistic traits in 112 patients (12-18yrs) recruited from a UK national specialist adolescent pain rehabilitation programme. Participants completed screening questionnaires for autistic traits upon entry to the programme, as well as clinically recognised pain measures before and after the 3-week treatment program. Autistic traits predicted greater psychological challenges at treatment onset. Critically, autistic traits were not related to the magnitude of improvement in pain measures during the pain management program. Our study suggests that adolescents with greater autistic traits may benefit from existing pain rehabilitation programs at similar rates to their peers. Additionally, these data suggest no reason for therapeutic pessimism for autistic pain patients. We do however acknowledge that these data may differ in populations with an autistic diagnosis, and that barriers may still exist for autistic people in treatment for pain. PERSPECTIVE: Autistic traits were explored in patients undergoing an Intensive Interdisciplinary Pain Treatment (IIPT). Higher autistic traits correlated with more pain related psychological difficulties at intake. Autistic traits were not related to the magnitude of improvement following IIPT. Our data therefore suggests that autism should not be a barrier to IIPT. DATA AVAILABILITY: Data is held in the PAIRED Pain Rehabilitation Database: Bath and Bristol, individual data used in the current analyses are therefore not available.

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.

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