Among health professionals, it is common knowledge that children are “not just little adults.”1 Children have anxieties,2 anatomies3 and pathologies4 that are unique from those found in adults. Children’s different perspectives and reactions are particularly important to surgery, which can be induce trauma for young people.5 Behavioral preparation programs that focus on skills acquisition and modeling are sometimes offered to pediatric patients and their families to prepare everyone for surgery.5 Because untreated anxiety and pain have implications for children’s short- and long-term recovery, future interactions with the medical system and mental health, it is crucial that clinicians take special precautions for children undergoing procedures.5 Given their role in pain management, anesthesia providers are essential to making the child’s experience as pleasant as possible.6 Anesthesiology practitioners have opportunities before, during and after a child’s procedure to ensure satisfactory pain management and anxiety reduction.7
The anesthesia provider should begin by providing the patient and family with preoperative education and preparation.7 A review by Fortier and Kain recommends individualized web-based behavioral preparation programs, as they are convenient and can provide unique care to patients and families based on at-home dynamics.5 The pediatric anesthesiologist, perhaps along with a Child Life Specialist,8 should provide parents and children with information about anesthesia induction and equipment in order to reduce anxiety.9 A study by Bogusaite et al. on pediatric preoperative information needs found that parents and children most often requested information about duration of anesthesia, recovery from anesthesia, the postoperative regimen and postoperative pain management.10 The families also preferred information provided in written form on the day before the procedure.10 In addition to speaking with families, the anesthesia provider is also responsible for picking appropriate anesthetic drugs and preparing the surgical space. The American Academy of Pediatrics (AAP) has developed guidelines for preparing the pediatric anesthesia environment, including tailoring pain management to the procedure, the patient’s pain perception and the options available for analgesia.9 The anesthesia provider should collaborate with other health professionals to prepare the operating room with appropriate-sized equipment.9
After patient education and preparation are complete, the anesthesia provider should remain vigilant throughout the procedure. Different medications may be useful depending on the child’s condition or procedure type. Topical anesthetics may be useful for outpatient pediatric procedures, but may be ineffective for more invasive surgeries.11 In their study of pain management for pediatric urology procedures, Morrison et al. found that nerve blocks were the most commonly used intraoperative anesthetics, followed by epidural or caudal.12 Some discrepancies existed with regards to opioid use and age limits.12 While recent researchers aim use local anesthetics and reduce opioid use,13 there is a lack of consensus in pain management for many types of procedures.12,14 This may be due to the individualized nature of pediatric anesthesia.14 For example, Nowicki et al. found that a variety of medications could be used in pediatric orthopedic surgery depending on the patient’s perception of pain, including nonopioid and opioid analgesia; local anesthetic injection; and regional analgesia such as intrathecal morphine, epidural therapy and peripheral nerve blocks.14 Another study found that intraoperative use of methadone for children undergoing the Nuss procedure was effective in reducing postoperative pain.15 Thus, intraoperative medication administration depends on the patient’s age and condition, the type of procedure and the family’s choices.
The anesthesia provider should base postoperative pain management on the pediatric patient’s own perception of pain, using a pain management “ladder.”16 The type of drug used can range from a nonsteroidal anti-inflammatory (NSAID) to intravenous opioids, depending on the type of procedure and pain level.16 Corticosteroids may also be useful in reducing postoperative nausea and vomiting (PONV) and pain.16 In addition to providing pain relief, the anesthesiology practitioner should monitor the patient’s status to prevent complications. Vital signs monitoring standards differ by age, co‐morbidities, extent and complexity of the surgery and use of sedative medications, with particular attention given to infants less than one year of age.16 Before the patient is discharged, the anesthesia providers should give the family detailed instructions for pain management, perhaps with a highly structured format.17
Pain management for pediatric patients is dissimilar from pain management for adults. The anesthesia provider is responsible for preparing the child and family for the procedure, for providing accurate dosing of appropriate anesthetic medications and for closely monitoring the patient after surgery.7 Pain management may depend on the child’s perception of pain, age, stage of development, condition and type of procedure. Future research should aim to standardize pediatric pain management and provide education to pediatric health professionals.18
1. Arbuckle R, Abetz-Webb L. “Not Just Little Adults”: Qualitative Methods to Support the Development of Pediatric Patient-Reported Outcomes. The Patient: Patient-Centered Outcomes Research. 2013;6(3):143–159.
2. Kingery JN, Roblek TL, Suveg C, Grover RL, Sherrill JT, Bergman RL. They’re not just “little adults”: Developmental considerations for implementing cognitive-behavioral therapy with anxious youth. Journal of Cognitive Psychotherapy. 2006;20(3):263.
3. Thomas NJ, Jouvet P, Willson D. Acute Lung Injury in Children—Kids Really Aren’t Just “Little Adults”. Pediatric Critical Care Medicine. 2013;14(4):429–432.
4. Schroeder KM, Hoeman CM, Becher OJ. Children are not just little adults: Recent advances in understanding of diffuse intrinsic pontine glioma biology. Pediatric Research. 2014;75(1):205–209.
5. Fortier MA, Kain ZN. Treating perioperative anxiety and pain in children: A tailored and innovative approach. Pediatric Anesthesia. 2015;25(1):27–35.
6. Blount RL, Zempsky WT, Jaaniste T, et al. Management of pediatric pain and distress due to medical procedures. Handbook of Pediatric Psychology, 4th Ed. New York, NY, US: The Guilford Press; 2009:171–188.
7. Howard D, Davis KF, Phillips E, et al. Pain management for pediatric tonsillectomy: An integrative review through the perioperative and home experience. Journal for Specialists in Pediatric Nursing. 2014;19(1):5–16.
8. What Is a Certified Child Life Specialist? The Child Life Profession 2018.
9. Section on Anesthesiology. Guidelines for the Pediatric Perioperative Anesthesia Environment. Pediatrics. 1999;103(2):512–515.
10. Bogusaite L, Razlevice I, Lukosiene L, Macas A. Evaluation of Preoperative Information Needs in Pediatric Anesthesiology. Medical Science Monitor. 2018;24:8773–8780.
11. Maclaren JE, Cohen LL. Interventions for paediatric procedure-related pain in primary care. Paediatrics & Child Health. 2007;12(2):111–116.
12. Morrison K, Herbst K, Corbett S, Herndon CDA. Pain Management Practice Patterns for Common Pediatric Urology Procedures. Urology. 2014;83(1):206–210.
13. Frizzell KH, Cavanaugh PK, Herman MJ. Pediatric Perioperative Pain Management. The Orthopedic Clinics of North America. 2017;48(4):467–480.
14. Nowicki PD, Vanderhave KL, Gibbons K, et al. Perioperative pain control in pediatric patients undergoing orthopaedic surgery. The Journal of the American Academy of Orthopaedic Surgeons. 2012;20(12):755–765.
15. Singhal NR, Jones J, Semenova J, et al. Multimodal anesthesia with the addition of methadone is superior to epidural analgesia: A retrospective comparison of intraoperative anesthetic techniques and pain management for 124 pediatric patients undergoing the Nuss procedure. Journal of Pediatric Surgery. 2016;51(4):612–616.
16. Vittinghoff M, Lönnqvist P-A, Mossetti V, et al. Postoperative pain management in children: Guidance from the pain committee of the European Society for Paediatric Anaesthesiology (ESPA Pain Management Ladder Initiative). Pediatric Anesthesia. 2018;28(6):493–506.
17. Walther-Larsen S, Aagaard GB, Friis SM, Petersen T, Møller-Sonnergaard J, Rømsing J. Structured intervention for management of pain following day surgery in children. Pediatric Anesthesia. 2016;26(2):151–157.
18. Lundeberg S. Pain in children—are we accomplishing the optimal pain treatment? Pediatric Anesthesia. 2015;25(1):83–92.