Accepted: 27 August 2017

DOI: 10.1111/pan.13256

RESEARCH REPORT

A prospective audit of pain profiles following general and

urological surgery in children

Caroline A. Wilson1 | David Sommerfield2 | Thomas F. E. Drake-Brockman2,3 |

2 4 2,3
Claudia Lagrange | Anoop Ramgolam | Britta S. von Ungern-Sternberg

1
Department of Paediatric Anaesthesia,
Bristol Royal Hospital for Children, Bristol, Summary
UK Background: Postoperative pain is frequently undertreated in children both in hospital
2
Department of Anaesthesia and Pain
and at home following discharge. Pain has both short- and long-term consequences for
Management, Princess Margaret Hospital
for Children, Perth, WA, Australia children, their families, and the healthcare system. A greater understanding of proce-
3
School of Medicine and Pharmacology, dure-specific postoperative pain trajectories is required to improve pain management.
The University of Western Australia, Perth,
WA, Australia Aim: To determine the duration and severity of acute postoperative pain experi-
4
Telethon Kids Institute, Perth, WA, enced by children undergoing 8 different general and urological procedures (primary
Australia
outcomes). Behavioral disturbance rates, nausea and vomiting scores, and parental
Correspondence satisfaction were also examined during the follow-up period (secondary outcomes).
Britta S. von Ungern-Sternberg, Department
Method: Families of children (0-18 years) undergoing common general and urologi-
of Anaesthesia and Pain Management,
Princess Margaret Hospital for Children, cal procedures were invited to enroll in the study. Children’s pain scores, measured
Subiaco, WA, Australia.
using a parental proxy 0-10 numerical rating scale, were collected by telephone
Email: [email protected]
interview until pain was resolved. Analgesia prescribed and given, behavioral distur-
Funding Information
bance, nausea and vomiting scores, the method of medication education communi-
Britta S von Ungern-Sternberg holds the
Callahan Chair in Paediatric Anaesthesia and cation, and parental satisfaction were also measured.
is partly funded by the Late Frank Callahan,
Results: Of 360 patients recruited, 326 complete datasets were available. Patients
the Princess Margaret Hospital Foundation
and the Stan Perron Charitable Trust. underwent laparoscopic appendicectomy (57), open appendicectomy (19), circumci-
sion (50), cystoscopy (52), hypospadias repair (22), inguinal hernia repair (51), orchi-
Section Editor: Jerrold Lerman
dopexy (51), or umbilical hernia repair (24). Postoperative pain peaked on the day of
or the day after surgery in all groups, and decreased over time. Pain lasted a median
duration of 5 postoperative days following open appendicectomy, and 0-2 postoper-
ative days for other procedures. Behavioral disturbance rates closely followed pain
scores. Analgesia administration at home varied widely between and within groups.
Conclusion: Pain management was inadequate in most of the groups studied, partic-
ularly after appendicectomy or umbilical hernia repair, with most children experienc-
ing at least moderate pain on the day of and day after surgery. There was a need for
a standardized management, with increased dual analgesia prescribing, to ensure that
children receive adequate postoperative analgesia in hospital and at home.

KEYWORDS
acute pain, ambulatory care, analgesia, children, day surgery, outpatient, pediatric anesthesia,
pediatrics

Pediatric Anesthesia. 2017;27:1155–1164. wileyonlinelibrary.com/journal/pan © 2017 John Wiley & Sons Ltd | 1155
1156 | WILSON ET AL.

1 | INTRODUCTION
What is already known
Pain is common following surgery in children.1 It is frequently under-
treated both in hospital2-4 and at home following discharge.2,5 Imme-
• Pain following surgery is a significant burden to children,
their families, and the healthcare system. Inadequately
diately, postoperative pain causes behavioral disturbance,6
treated pain in children results in both short- and long-
disordered sleep,6,7 parental dissatisfaction,8,9 and disrupts family
term consequences.
life. Inadequate management burdens the healthcare system, and
may result in unplanned presentation to a general practitioner or
What this article adds
hospital.10
Inadequate postoperative pain management following major sur- • Pain profiles are reported following a range of general
gery is associated with chronic postsurgical pain in children.11 Fol- and urological procedures, including procedures not pre-
lowing inguinal hernia repair in children chronic pain occurs in 5% of viously described. For groups previously studied, more
12
children and in 13.3% following other general, orthopedic, and extensive datasets with extended follow-up are provided.
urological procedures.13
Improved understanding of postoperative pain and the factors
affecting pain management in children will improve individual care the difficulties of speaking to children over the telephone, child
and reduce burden on the healthcare system. Existing studies are assent was not obtained. Telephone surveys were performed by
limited in terms of the range of procedures included,5,14,15 sample trained members of the anesthesia research group. Families were
size, and length of follow-up period. We aimed to determine the contacted on the first postoperative day and then every second
duration and severity of postoperative pain experienced by children day, until each child was no longer reported as being in pain. Dur-
after 8 different general and urological procedures (primary out- ing each follow-up, data for that day and the previous day were
comes). Behavioral disturbance rates, nausea and vomiting scores, recorded. Patients were considered “lost to follow-up” if the study
and parental satisfaction were also measured until pain had resolved team could not contact them within 3 days of patient discharge or
(secondary outcomes). last contact. Families were free to withdraw at any point.

2 | MATERIALS AND METHODS 2.3 | Anesthesia and analgesia

Anesthetic and analgesic management in hospital were at the discre-
2.1 | Study design and setting
tion of the patient’s anesthetist and acute pain team and indepen-
Children at Princess Margaret Hospital (PMH) undergoing appen- dent of the study. Intra-operative analgesia and antiemetics varied
dicectomy (laparoscopic or open), circumcision, cystoscopy, hypospa- between procedures. It is standard practice in our institution for
dias repair, inguinal hernia repair, orchidopexy, and umbilical hernia appendicectomy patients to receive dual intra-operative antiemetics
repair were prospectively studied. We opportunistically recruited up (ondansetron and dexamethasone) and for patients over 2 years of
to 57 patients per group as the availability of research staff allowed. age in other surgical groups to receive ondansetron only. Hypospa-
Patients having appendicectomies were inpatients, while patients in dias repair and circumcision patients routinely receive either a caudal
other groups were day of surgery admissions. or penile block for postoperative pain relief. Inguinal hernia repair
This study was approved as a quality of care audit with the and orchidopexy patients receive a caudal anesthetic or local infiltra-
requirement for written informed consent waived by the PMH Ethics tion. Umbilical hernia repair patients receive local anesthetic infiltra-
Committee (2015103QP) and registered with the University of tion. Cystoscopy patients receive lidocaine gel (xylocaineâ, 2%
Western Australia (RA/4/1/5964). lidocaine hydrochloride jelly, AstraZenaca Pty Ltd, Macquarie Park,
Australia).
Postoperative medications for use in the postanesthesia care unit
2.2 | Participants
(PACU) and on the ward were prescribed by the anesthetist. Chil-
Children (0-18 years of age) who had one of the specified proce- dren undergoing open appendicectomy and those undergoing laparo-
dures were identified from the Theatre Management System. scopic appendicectomy with a ruptured or perforated appendix may
Patients of all ASA grades (American Society of Anesthesiologists have received a fentanyl or morphine patient-controlled analgesia
physical status classification system) were included. Children were (PCA) infusion. In children not deemed competent to manage PCA, a
excluded if they underwent multiple procedures at the same time, continuous infusion would be used. If not prescribed parenteral opi-
were a ward of the state, or if a translator was required. oids, then oral oxycodone (0.1 mg/kg up to 4 times daily) would
Recruitment occurred postoperatively by telephone call with generally be prescribed.
the patient’s parent or guardian or in person on the ward. Verbal Discharge medications were prescribed by the surgical teams.
consent for participation was obtained from the patient’s parent or Standard doses, in line with our hospital prescribing policy, for dis-
guardian during initial contact and subsequently if relevant. Due to charge were paracetamol 15 mg/kg 4 times daily, and ibuprofen
WILSON ET AL. | 1157

either 5 mg/kg 4 times daily or 10 mg/kg 3 times daily. Opioids was that 95% of parents would be satisfied with both their child’s
were infrequently prescribed for discharge, most often oxycodone treatment overall and their child’s pain management.
0.1 mg/kg up to 4 times daily as required. Codeine phosphate
1 mg/kg up to 4 times daily as required was used rarely and was
2.5 | Data analysis
removed from the hospital formulary from April 2015. Parents not
receiving a prescription for opioids were frequently instructed to Data were collated in Microsoft Excel 2003 (Microsoft Corporation,
use Painstop (Painstopâ Daytime, oral syrup containing paracetamol Redmond, WA, USA). Data processing, descriptive statistics, and plot
24 mg/mL and codeine 1 mg/mL, Care Pharmaceuticals Pty Ltd, generation were performed with the R statistical environment (R
Bondi Junction, Australia) if simple analgesics did not provide suffi- Foundation for Statistical Computing, Vienna, Austria).
cient pain relief. Painstop is available over the counter (OTC) with-
out prescription from pharmacies in Australia. If used as directed,
the child receives approximately 12 mg/kg of paracetamol and 3 | RESULTS
0.5 mg/kg of codeine phosphate in a dose.
Of 368 patients invited to participate, 8 parents declined and 34
patients were subsequently withdrawn (23 lost to follow-up, 2 com-
2.4 | Variables and data measurement
munication difficulty, and 9 with missing data). Complete datasets
Data were collected using a standardized form. Data were collected for 326 patients (aged 0-18 years) were analyzed (Table 1). Seventy-
for each postoperative day for each patient until their pain score three non-appendicectomy patients spent more than 24 hours in
reached 0 or returned to presurgical baseline and they no longer hospital which were planned overnight stays due to other preexist-
required pain medication. Parental proxy 0-10 numerical rating scale ing conditions.
(0 = “no pain”, 10 = “worst pain possible”) was used to assess pain
levels, which parents were accustomed to using while in hospital.
3.1 | Pain severity and duration
Further instruction on pain scoring was provided if required. We
classified pain scores of 1-3 as mild, 4-6 as moderate, and 7-10 as After laparoscopic appendicectomy, 70% (40; 95% CI: 58%-82%) of
severe. Vomiting scores were collected in line with routine clinical parents reported that their child experienced moderate or severe
measurement in our institution (1 = once, 2 = twice, and 3 = three pain on the day of surgery (Figure 1A). The proportion of patients in
or more times). Nausea was recorded as either present or absent as pain decreased over time, lasting for a median (range) of 2 (0-10)
young children have difficulty describing this symptom in detail.16 A days. After open appendicectomy, 53% (10; 95% CI: 30%-75%) of
subset of Parent’s Postoperative Pain Measure (PPPM) items was patients experienced moderate or severe pain on the day of surgery
collected: trouble sleeping, behavioral issues, ease of upset, interest (Figure 1B), increasing to 68% (13; 95% CI: 48%-89%) on the first
in normal activities, and normal eating patterns.17 Trouble sleeping postoperative day. Pain resolved over a median (range) of 5 (0-10)
and behavioral issues were scored using numerical values (as per days.
Appendix S1) and other items were assessed as either present or Following circumcision, 54% (27; 95% CI: 40%-68%) of boys had
absent. The method by which pain management education was com- moderate or severe pain on the day of surgery (Figure 1C) which
municated at discharge and parent’s preferred method were also lasted for a median (range) of 1 (0-7) day. Of cystoscopy patients,
recorded. Parents were asked to rate their satisfaction with their 25% (13; 95% CI: 13%-37%) of parents reported that their child was
child’s pain management, postoperative nausea and vomiting man- in moderate or severe pain on the day of surgery (Figure 1D) with
agement, and overall treatment on a 5-point Likert scale. Our target pain usually resolving on the same day but lasting up to 9 days at

T A B L E 1 Demographics for each procedure group studied

Admission length (h)

Procedure Recruited Age (y) ≤24 24-48 >48

Appendicectomy, laparoscopic 57 11.4 (2.5-15.8) 2 (4%) 16 (28%) 39 (68%)
Appendicectomy, open 19 10.2 (0.5-14.5) 0 3 (16%) 16 (84%)
Circumcision 50 5.3 (0.01-17.8) 37 (74%) 9 (18%) 4 (8%)
Cystoscopy 52 5.5 (0.13-16.3) 41 (79%) 4 (8%) 7 (13%)
Hypospadias repair 22 1.4 (0.6-9.3) 10 (45%) 12 (55%) 0
Inguinal hernia repair 51 1.8 (0.08-15.5) 30 (59%) 19 (37%) 2 (4%)
Orchidopexy 51 5.4 (0.2-17.2) 38 (74%) 12 (24%) 1 (2%)
Umbilical hernia repair 24 3.9 (0.43-9.9) 21 (88%) 3 (12%) 0

Data are presented as median (range) or number (proportion).

1158 | WILSON ET AL.

100 (A) Laparoscopic appendicectomy 100 (B) Open appendicectomy

80 80

60 60

40 40

20 20

0 0
DOS 1 2 3 4 5 6 7 8 9 10 DOS 1 2 3 4 5 6 7 8 9 10

100 (C) Circumcision 100 (D) Cystoscopy

80 80

60 60

40 40

20 20
Proportion

0 0
DOS 1 2 3 4 5 6 7 8 9 10 DOS 1 2 3 4 5 6 7 8 9 10

100 (E) Hypospadias repair 100 (F) Inguinal hernia repair

80 80

60 60

40 40

20 20

0 0
DOS 1 2 3 4 5 6 7 8 9 10 DOS 1 2 3 4 5 6 7 8 9 10

100 (G) Orchidopexy 100 (H) Umbilical hernia repair

80 80

60 60

40 40

20 20

0 0
DOS 1 2 3 4 5 6 7 8 9 10 DOS 1 2 3 4 5 6 7 8 9 10
Day

Mild Moderate Severe

F I G U R E 1 Pain scores by day for children who underwent general and urological surgery. Bars represent proportion of children experiencing
mild (1-3), moderate (4-6), and severe pain (7-10). Those children with no pain were excluded from the figure DOS, Day of Surgery

worst. After hypospadias repair, 63% (14; 95% CI: 44%-84%) of This decreased over time, lasting a median (range) of 1 (0-7) day.
patients had moderate or severe pain on the day of surgery (Fig- Following orchidopexy, 45% (23; 95% CI: 31%-59%) of patients had
ure 1E) and resolved after a median (range) of 2 (0-8) days. moderate or severe pain on the day of surgery (Figure 1G) with pain
For inguinal hernia repair patients (Figure 1F), 47% (24; 95% CI: lasting a median (range) of 1 (0-7) day. On the day of surgery, 67%
33%-61%) were in moderate or severe pain on the day of surgery. (16; 95% CI: 48%-86%) of umbilical hernia repair patients had
WILSON ET AL. | 1159

moderate or severe pain (Figure 1H). The total number in pain on receive a text message. No parents preferred communication via
the first postoperative day increased; however, the severity telephone or email.
decreased with 54% (13) experiencing moderate or severe pain. Pain
lasted a median (range) of 2 (0-5) days.
3.6 | Parental satisfaction
Overall 97% (316) of parents were satisfied or highly satisfied with
3.2 | Analgesia
their child’s treatment, which met our target of 95%. Regarding pain
In hospital following laparoscopic appendicectomy, children received management, 95% (311) of parents were also satisfied or highly sat-
paracetamol (84%), ibuprofen (57%), oxycodone (38%), and/or fen- isfied (Table 2).
tanyl or morphine PCA or infusion (23%). Median (range) length of
stay was 2 (0-20) days. Following open appendicectomy, patients
received paracetamol (100%), ibuprofen (89%), as required oxy- 4 | DISCUSSION
codone (68%), and/or opioid PCA or infusion (47%). Median (range)
length of stay was 4 (1-36) days. The results of this study demonstrate patterns of pain and behav-
Various analgesia was given at home by parents (Figure 2A-H) ioral disturbance over time following common general and urological
including simple analgesics (paracetamol and ibuprofen) as well as procedures. Pain and behavioral disturbance lasted longest in chil-
opioids (codeine, oxycodone, and Painstop). The majority of children dren following open appendicectomy as expected. Following other
received only simple analgesics at home (Figure 2A-C, E-H). Cys- procedures, median pain duration was 0-2 days. Moderate or severe
toscopy patients frequently received no analgesia following dis- pain on the day of surgery occurred in up to 67%-70% of cases for
charge (19, 37%) (Figure 2D). children undergoing laparoscopic appendicectomy and umbilical her-
nia repair, and as few as 25% of cases for children undergoing cys-
toscopy. Behavioral disturbance generally followed pain incidence.
3.3 | Behavioral disturbances
At home, patients usually received simple analgesia following dis-
Overall rates of behavioral disturbance tracked pain profiles in each charge, although prescribing was not standardized with various anal-
group (Figure 3). After open appendicectomy, 95% (18) of patients gesics prescribed and administered. Most parents received pain
had difficulty eating and were disinterested in their normal activities. management instructions on discharge and stated that their pre-
Return to normal eating and activities took a median (range) of 4 (0- ferred communication method was the same method by which dis-
9) and 4 (0-11) days, respectively (Figure 3A). Of laparoscopic charge instructions were given to them. Almost all parents reported
appendicectomy patients, 54% (31) had difficulty eating on the day being satisfied or highly satisfied with their child’s pain management.
of surgery and returned to eating normally after a median (range) of Pain after appendicectomy was more severe than has been previ-
2 (0-9) days and returned to normal activities after a median (range) ously reported with 68% and 70% of children experiencing moderate
of 1 (0-10) day. or severe pain after open and laparoscopic procedures, respec-
tively.18-20 Tomecka et al. found 33% of children on the day of sur-
gery had pain scores of >4 for more than 60% of the time following
3.4 | Nausea and vomiting
laparoscopic appendicectomy,18 with most patients (80%) prescribed
On the day of surgery, 44% (25) and 42% (8) of children undergoing an as required simple analgesic and opioid, and only 11% prescribed
laparoscopic and open appendicectomy, respectively, were reported a PCA. Liu et al. reported an improved substantial pain incidence
to have nausea. Vomiting was reported in 26% (5) of children after (pain score >4 for >60% of the time) of 12% in patients following
open, and 19% (11) of children following laparoscopic surgery, laparoscopic appendicectomy where a multimodal analgesia protocol
resolving over a median of 3 and 2 days for open and laparoscopic was implemented, incorporating a PCA.19 Morton et al. found that
procedures, respectively (Figure 4A-B). Rates of nausea and vomiting open appendicectomy patients had significantly less pain on move-
following other procedures were below 10% from the first postoper- ment when diclofenac was used with a morphine PCA, compared to
ative day onwards (Figure C-H). using a morphine PCA alone.20 Although simple analgesics were pre-
scribed for most of our patients (paracetamol 84%-100%, ibuprofen
57%-89%), fewer than half of the open appendicectomy patients
3.5 | Discharge information
(47%) and only 23% of laparoscopic patients received an opioid PCA
The families of 98% (319) of children reported receiving pain man- or infusion. Clinicians caring for children may underestimate surgical
agement education at discharge. Instructions were conveyed verbally pain after appendicectomy. Standardized protocols are required, and
with written material to 57% (185) of families, verbally only in 31% should include opioid analgesics, using PCA for open appendicec-
(101) of cases, and with 10% (33) of families receiving written mate- tomy,21 and regional techniques.22,23
rial only. Parents preferred receiving both verbal and written instruc- Significant postoperative pain was reported by parents after cir-
tions in 63% (205) of cases, 23% (75) preferred verbal only, 11% cumcision, especially on the day of surgery (54% with moderate or
(36) preferred written only, and 3% (10) would have preferred to severe pain), which agrees with previous findings (on the day of
1160 | WILSON ET AL.

35 (A) Laparoscopic appendicectomy 35 (B) Open appendicectomy

30 30

20.0 %
25 25
27.3 %

20 20

15 15
41.7 %
22.2 %
10 10
28.6 %

5 5
0.0 %
0 0
0 1 2 0 1 2

35 (C) Circumcision 35 (D) Cystoscopy

30 30

29.2 %
25 25
38.1 % 9.5 %
10.0 %
20 20

15 15

30.0 %
10 10
Numbers of patients

5 0.0 % 5
)

0 0
0 1 2 0 1 2

35 (E) Hypospadias repair 35 (F) Inguinal hernia repair

10.3 %
30 30

25 25

20 20
23.5 %

15 15
9.1 %
10 25.0 % 10

0.0 %
5 0.0 % 5

0 0
0 1 2 0 1 2

35 (G) Orchidopexy 35 (H) Umbilical hernia repair

30 30

20.0 %
25 25

5.0 %
20 20

15 15 7.7 %
10.0 %
10 10

0.0 %
5 5
0.0 %
0 0
0 1 2 0 1 2
Number of simple analgesics and overall opioid administered

With opioids Without opioids

F I G U R E 2 Frequency of parental administered analgesic types following discharge for children who underwent general and urological
surgery. Bars represent the number of children per surgery type receiving 0-2 simple analgesics, with or without opioids (dark and light
shading, respectively). The percentage of children receiving opioids is also expressed numerically at the top of each bar

surgery, 77% experienced pain in one study24 and the mean pain study, however, less children overall experienced pain on the day of
7
score recorded by parents was 4.3 in another). A previous study of surgery (68% vs 86% in this study) or on the first postoperative day
pain following inguinal hernia repair found similar results to our (43% vs 65% in our study).24 In patients undergoing orchidopexy,
study with pain usually lasting for 2 days postoperatively. In that other studies either reported similar pain scores on the day of
WILSON ET AL. | 1161

100
(A) Laparoscopic appendicectomy 100
(B) Open appendicectomy

80 80

Trouble sleeping
Difficult behaviour
60 60
Easily upset
Uninterested in activities
Difficult eating
40 40

20 20

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

100 (C) Circumcision 100 (D) Cystoscopy

80 80

60 60

40 40

20 20
Frequency (%)

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

100 (E) Hypospadias repair 100 (F) Inguinal hernia repair

80 80

60 60

40 40

20 20

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

100 (G) Orchidopexy 100 (H) Umbilical hernia repair

80 80

60 60

40 40

20 20

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11
Day

FIGURE 3 Frequency of behavioral disturbances by day in children following general and urological surgery DOS, Day of surgery

surgery and first postoperative day (72% in pain on day of surgery poorly studied, with only 3 patients with 48-hour follow-up previ-
and 74% on the first postoperative day, compared with 72% and ously described, and reported together with other surgical conditions
62%, respectively, in our study),25 and higher pain scores on the sec- limiting interpretation.7 Pain severity and prevalence was high for
ond postoperative day (70% in pain on the second postoperative this procedure (67% had moderate or severe pain on the day of sur-
day vs 47% in our study).26 Pain after umbilical hernia repair is gery), and requires improved management. We are unaware of
1162 | WILSON ET AL.

(A) Laparoscopic appendicectomy (B) Open appendicectomy

50 50

40 40

30 30 Nausea
Vomitting

20 20

10 10

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

50 (C) Circumcision 50 (D) Cystoscopy

40 40

30 30

20 20

10 10
Frequency (%)

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

50 (E) Hypospadias repair 50 (F) Inguinal hernia repair

40 40

30 30

20 20

10 10

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11

50 (G) Orchidopexy 50 (H) Umbilical hernia repair

40 40

30 30

20 20

10 10

0 0

DOS 1 2 3 4 5 6 7 8 9 10 11 DOS 1 2 3 4 5 6 7 8 9 10 11
Day

FIGURE 4 Frequency of nausea or vomiting symptoms by day in children following general and urological surgery

existing reports of postoperative pain over time in children undergo- superior pain management following ambulatory surgery.27 Most cir-
ing hypospadias repair or cystoscopy. cumcision and hypospadias patients received a penile block or caudal
At home, pain management was poor for all groups, except for for postoperative analgesia; however, parents frequently reported
cystoscopy patients. Patients most often received 1 simple analgesic moderate pain on the day of surgery. This likely occurs as blocks
alone rather than dual, even though dual simple analgesia offers subside. Education on block duration and the need to commence
WILSON ET AL. | 1163

T A B L E 2 Parental satisfaction rates Target recruitment was 50 patients per procedure. We only
Procedure Overall treatment Pain management recruited 19 open appendicectomy patients, 22 hypospadius repair
patients, and 24 umbilical hernia repair patients—procedures which
Appendicectomy, laparoscopic 52 (91%) 51 (89%)
are performed infrequently in our institution.
Appendicectomy, open 19 (100%) 19 (100%)
Intra- and postoperative analgesia was not standardized during
Circumcision 50 (100%) 50 (100%)
the conduct of this observational audit. Surgical staff and surgical
Cystoscopy 49 (94%) 49 (94%)
technique was not controlled and variation may have affected post-
Hypospadius repair 21 (95%) 21 (95%)
operative outcomes.
Inguinal hernia repair 51 (100%) 48 (94%)
All patients in this study eventually reached a pain score of 0 or
Orchidopexy 51 (100%) 50 (98%) returned to baseline. We expect that 5%-13%12,13 of patients
Umbilical hernia repair 23 (96%) 23 (96%) should have residual or chronic pain—which is ether not the case in
Data are presented as number (percentage) of parents who reported our population, or not accurately captured by our methodology.
being satisfied or highly satisfied. Patients were not contacted after pain scores reached 0 and we
assumed that pain scores remained at 0 for the subsequent days
oral analgesics prior to the block wearing off is now emphasized analyzed.
at discharge. We recommend standardized discharge analgesia The gold standard for pain measurement, self-reported pain
regimes for circumcision and hypospadias repair, along with umbili- scoring, was considered impractical in this study as children were
cal hernia and orchidopexy patients, with scheduled dual simple often either unavailable or unable to self-report and due to diffi-
analgesia for 2 postoperative days and an oral opioid for break- culties associated with interviewing children via telephone.
through pain on the day of surgery. We need to improve analgesia Parental proxy reporting is a practical alternative17,31 with parental
further in umbilical hernia repair in view of the high pain scores 0-10 numerical rating scale being a validated method.32 Parental
28,29
found, which may be aided by a rectus sheath block. Follow- proxy reporting has, however, been associated with underreport-
ing inguinal hernia repair, we recommend scheduled dual simple ing.33
analgesics alone.10,25 We selected a subset of behavioral items from the PPPM ques-
The highest rates of nausea (29%) and vomiting (22%) on the tionnaire,17 due to time constraints. The PPPM is only validated in
day of surgery were in children having inguinal hernia repair, which children between 2 and 12 years of age,17 and was not validated for
is similar to rates previous studies have found (28% with nausea or the use of individual items. Factors such as anxiety likely impact on
vomiting) in this group.25 We recommend dual, rather than single, behavior and pain,34 and are not accounted for in our PPPM subset.
antiemetic therapy to children over 2 years of age undergoing ingu-
inal hernia repair.
Behavioral measures, being surrogate markers of pain and dis- 5 | CONCLUSIONS
tress, were expected to trend with pain scores as was found in this
and existing studies.6,30 Most children experienced pain on the day of and day after surgery.
Despite suboptimal analgesia for most procedures, almost all par- The worst pain scores were in patients following appendicectomy
ents were satisfied or very satisfied with pain management. It is pos- and umbilical hernia repair. Pain is being underappreciated and
sible that repeated contact involved in the study falsely elevated undertreated by both medical staff and by families at home. A tai-
satisfaction. lored approach is required to ensure that children receive adequate
The data presented in this paper add significantly to the sparse postoperative analgesia, including dual simple analgesics, both in
literature concerning postoperative follow-up of patients after cys- hospital and at home. Our findings provide clinicians with detailed
toscopy and repair of hypospadias and umbilical hernia. We report a information about the severity and duration of pain for these com-
greater follow-up duration for the other procedures compared to mon pediatric surgical procedures.
available literature.

ETHICAL APPROVAL
4.1 | Study limitations
This study met the criteria for a quality of care audit and the Prin-
Parental recall bias, particularly in-hospital analgesia, is a significant cess Margaret Hospital Ethics Committee determined that formal
limitation of this study. Inpatient data review was performed to miti- ethics approval was not required (2015103QP). The study was regis-
gate this source of error in both appendicectomy groups, given that tered with the University of Western Australia (RA/4/1/5964).
many children had a significant postoperative hospital stay. Pain
scores were also subject to recall bias, collected up to 2 days retro-
DISCLOSURES
spectively, with lost to follow up declared when contact was lost for
3 days. We recruited children 0-18 years of age, which may increase Britta S. von Ungern-Sternberg is a Section Editor of Pediatric Anes-
the variability of pain scores within each group. thesia.
1164 | WILSON ET AL.

ORCID 20. Morton NS, O’Brien K. Analgesic efficacy of paracetamol and

diclofenac in children receiving PCA morphine. Br J Anaesth.
Thomas F. E. Drake-Brockman http://orcid.org/0000-0002-7649- 1999;82:715-717.
3951 21. Howard R, Carter R, Curry J, et al. Good practice in postoperative
and procedural pain management. Pediatr Anesth. 2012;22:1-79.
Britta S. von Ungern-Sternberg http://orcid.org/0000-0002-8043-
22. Splinter WM, Thomson ME. Somatic paravertebral block decreases
8541 opioid requirements in children undergoing appendectomy. Can J
Anesth. 2010;57:206-210.
23. Carney J, Finnerty O, Rauf J, Curley G, McDonnell JG, Laffey JG.
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