Pain Management in Pediatric Surgery: New Horizons

Claudia Filisetti; Manuela De Gregori; Massimo Allegri; Dario Bugada; Lorenzo Cobianchi; Giovanna Riccipetitoni

doi:10.4172/2167-0846.1000240

ISSN: 2167-0846

Journal of Pain & Relief

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Pain Management in Pediatric Surgery: New Horizons

*Claudia Filisetti^1,2,Manuela De Gregori^3,4,5,Massimo Allegri^4,6,7,Dario Bugada^4,7,Lorenzo Cobianchi^8andGiovanna Riccipetitoni¹**
¹“V. Buzzi” Children Hospital, Division of Pediatric Surgery, Milan, Italy
²University of Pavia, Lombardy, Italy
³Pain Therapy Service, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
⁴SIMPAR (Study in Multidisciplinary Pain Research) group, Rome, Italy
⁵YAP (Young against Pain) group, Rome, Italy
⁶Departments of Anesthesia, ICU and Pain Therapy, University Hospital of Parma, Parma, Italy
⁷Departments of Surgical Sciences, University of Parma, Parma, Italy
⁸Departments of Clinical, Surgical, Diagnostic and Pediatric Sciences, University of Pavia. General Surgery Department, IRCCS Foundation Policlinico San Matteo, Pavia, Italy
Corresponding Author :	Lorenzo Cobianchi Department of Clinical, Surgical, Diagnostic and Pediatric Sciences University of Pavia. General Surgery Department IRCCS Foundation Policlinico San Matteo, Pavia, Italy Tel: 339-4421128 E-mail: l.cobianchi@smatteo.pv.it
Received March 01, 2016; Accepted March 17, 2016; Published March 21, 2016
Citation: Filisetti C, Gregori MD, Allegri M, Bugada D, Cobianchi L, et al. (2016) Pain Management in Pediatric Surgery: New Horizons. J Pain Relief 5:240. doi:10.4172/2167-0846.1000240
Copyright: © 2016 Filisetti C, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

The pain management in pediatric surgery is a very complex and relevant problem with many clinical implications. Pain in children requires special considerations due to physical and psychological immaturity. The enhancement in pain management results in a reduction of recovery time and complications. Few studies are available in the literature focused on postoperative pain and analgesia requirements in children following surgical procedures. In the present brief review we summarize the current strategies of pain management in pediatric surgery and we envision the new hypothetical horizons in this field.

Introduction

Pain control after surgery is a popular matter when children are involved. Since the mid-1980s, the need to improve postoperative pain control started to be a cherished problem. In the last 20 years, pediatric hospitals have implemented pain management protocols improving postoperative pain relief of patients and families’ satisfaction, although pain management continued to be a problem after pediatric surgery [1- 3]. Today, the importance of postoperative pain control is well recognized; pain is considered as the fifth vital sign, and needs clinical innovations in improving its care. Indeed, the enhancement in pain management results in a reduction of recovery time and complications. Pain is a complex and unsolved phenomenon, characterized by different pathophysiological changes potentially leading to relevant postoperative morbidity and can strongly affect the clinical outcome [4].

General features of pain in children

Pain in children requires special consideration due to physical and psychological immaturity. We have few data regarding clinical features and the pathophysiology of postsurgical pain in children. In particular, few studies have focused on postoperative pain and analgesia requirements in children following surgical procedures [1-11]. For the review we used the following search criteria using PRISMA flow chart considering the last 5 years: “pediatric pain management”; “pediatric pain management guidelines”; “pediatric pain management review”; “post operative pain management in children; “pain management in pediatric surgery”. We summarized in the (Table 1) the most relevant papers published in the last 5 years (source PubMed/MedLine). None of these studies directly assessed functional limitation or provided detailed information about the type and duration of analgesia use. We were unable to identify any studies that systematically followed patients after specific surgical procedures through to full recovery. Stewart and coworkers described the clinical features (duration and severity) of postoperative pain and analgesia requirements in children after tonsillectomy, orchidopexy, or inguinal hernia repair [12]. The investigation on the different clinical and pathophisiolological features of the pain related to different surgical procedure is crucial to develop new strategies in the management of pain in children. From the data available the incidence of perioperative pain in children is high [13].

Current strategies for pain management in children

Until now, we cannot predict which patients will develop severe postoperative acute and/or persistent pain, and the standard analgesia is chosen by considering patient personal data (weight and age) and clinical conditions. We have to consider that little data are available about how painful the pediatric surgery is, due to the difficulty of pain assessment [13]. Nevertheless, in order to stem the problem of pain evaluation in neonates, infants, and children under 4 years, physiological parameters such as increases in heart rate, respiratory rate and blood pressure with the presence of sweating, high cortisol and cortisone levels, and endorphin concentrations are measured, together with the evaluation of the facial expressions.

Considering that different receptors and neurochemicals are involved in postoperative pain pathways, pain management should be multimodal [14]. By using minor, moderately active or major analgesics, it is possible to act on the transduction of the stimulus into the electrical signal, on the transmission of the signal along the pain pathways, and on its modulation and perception, which is also modulated by cognitive, emotional and cultural factors.

Currently, the systemic multimodal approach includes different drugs, ranging from paracetamol (acetaminophen), to nonsteoroidal anti-inflammatory drugs (NSAIDs), opioids, adjuvants as ketamine and clonidine and regional anesthetics [15]. Another analgesic technique involves the On-Q pain 0pump, which allows a continuous infusion of continuous local analgesia by a catheter placed deeply in the fascial planes, without the risks associated to the epidural catheterization but with the advantage to provide similar analgesia [16].

Great advantages are associated with regional anesthesia, too. A substantial body of literature supports the safety and efficacy of performing regional anesthetic techniques in children; evidence-based literature shows that combined regional and general anesthesia in paediatric patients can decrease hospital stay and improve outcomes [17]. Advances in ultrasonography and precise dosing regimens have facilitated widespread applications of regional anaesthetic techniques in infants, children, and adolescents. Prospective studies indicate that these techniques can be safely performed and positively impact on the outcomes of paediatric patients undergoing painful procedures and those who suffer from chronic pain [17]. In order to obtain maximum pain relief reducing the side effects as much as possible, new strategies are needed. New research about the inter individual variability of pediatric patients in terms of genetics and epigenetics and new tools (based on nanotechnology), would permit a major use of local drugs and the personalized dosage of systemic drugs. We are confident that in near future molecular analysis and nanotechnology will help the traditional medicine, towards the personalization of postoperative pain treatment and an improvement of patient’s quality of life.

Future Perspectives: From Nanotechnology to Molecular Features

One of the most important current objectives of the research in pain therapy consists in personalizing the treatments, by a multidisciplinary approach including new analgesic deliveries (based on nanotechnology) and a deeper knowledge about pharmacogenetics and epigenetics (in terms of histone changes, mRNA expression, and DNA methylation). Sprints and collaborators, already in 2012, discussed the key role of Nano medicine in the development of innovative pain management [18]. The importance of developing implantable devices for tailored local drug release, as nano-structured devices, are due to the drug release only into the targeted tissue affected by the surgery, dissolving any side effect related to the systemic release of the traditional treatments.

Several literature data demonstrated the importance of the genetic background in determining the inter-individual variability of pain sensitivity (such as COMT), drug pharmacodynamics (such as OPRM1) and pharmacokinetics (such as CYP2D6) in the postoperative setting [19-22]. Recent data show that modification of epigenetic processes are involved in the development of chronic pain [23,24]. Orlova and coworkers showed the modulation of microRNA in complex regional pain syndrome, and recent data demonstrated the dynamicity of microRNA due to opioids and opioid tolerance [25]. On the other hand, Dohering and coworkers observed an increase of DNA methylation in patients under chronic opioid use [26]. The same effect of opioids has been also described in the postoperative period, while a demethylating effect has been shown for the local anesthetics [27].

Shaw and Martin determined the potential of epigenetics on modulating surgery wound healing in a murin model (Shaw and Martin). Their discovery also demonstrates, once again, the importance of animal studies in pain therapy, as recent discussed by Gigliuto and coworkers for big animal models [28]. We are confident that new tools and multidisciplinary approaches, in postoperative medicine, might improve pediatric patient outcome (Figure 1).

Acknowledgements

Young Researcher Project: New nanotechnology and biomedical approaches to improve postoperative pain treatment reducing risks related to opioids Project Code: GR-2010-2318370.