In the pediatric population, pain is frequently under-recognized and inadequately treated. Improved education and training of health care providers can positively impact the management of pain in children. The purpose of this review is to provide a practical clinical approach to the management of acute pain in the pediatric inpatient population. This will include an overview of commonly used pain management modalities and their potential pitfalls. For institutions that have a pediatric acute pain service or are considering initiating one, it is our hope to provide a useful tool to aid clinicians in the safe and effective treatment of pain in children. Keywords Pediatric acute pain • Pain assessment • Acute pain service • Opioid • Multimodal management Approach to pain Effective pain management is ideally practiced in a multidisciplinary model focusing on patient-centered care. The World Health Organization (WHO) [1] analgesic ladder provides a strong foundation for the treatment of pain that can be built upon to reflect more modern thinking and techniques around pain management (Fig. 1). Some of these modifications are presented in an updated WHO ladder with guiding principles on post-operative management of acute pain [2], which advocates 5 recommendations for the correct use of analgesics: (1) use the oral form of medication whenever possible, (2) analgesics should be given at regular intervals, (3) analgesics should be administered based on the severity of pain assessed using a pain intensity scale, (4) medication dosing should be tailored to the individual patient, and (5) attention to detail should be maintained throughout the prescription of pain medications. The acute pain service The acute pain service (APS) is a specialized, multidisciplinary inpatient team consulted to assist with management of severe pain. Within our institution, this team consists of a pediatric anesthesiologist, pediatric anesthesia fellow, clinical nurse specialist, and pediatric psychiatrist. The APS works in collaboration with the patient's primary care team, bedside nurse, family, and pharmacists to provide a patient-centered multi-modal pain plan. Generally, the APS is consulted to assist in pain management when either a patient's analgesic needs have grown beyond standard opioid dosing (Table 1) that their primary service is comfortable prescribing, or there is anticipated need for APS involvement for postoperative patients. Postoperative patients who automatically require APS management in our institution include those with an indwelling regional or neuraxial block catheter, patients who have received a single-shot peripheral nerve block, patients with a patient-controlled analgesia (PCA) technique, or patients receiving a Ketamine infusion.

Despite trial registration being an accepted best practice, RCTs published in anesthesiology journals have a high rate of inadequate registration. While mandating trial registration has increased the proportion of adequately registered trials over time, there is still an unacceptably high proportion of inadequately registered RCTs. Among adequately registered trials, there are high rates of discrepancies between registered and reported outcomes, suggesting a need to compare a published RCT with its trial registry entry to be able to fully assess the quality of the study. If clinicians base their decisions on evidence distorted by primary outcome switching, patient care could be negatively affected.

Coronavirus disease 2019 (COVID-19) has affected anesthetic care worldwide, including the provision of anesthesia for pediatric patients. Hospitals have balanced the risks associated with the potential surges of resource-intensive COVID-19 patients against the probable morbidity of delaying elective surgical procedures. These decisions are complicated by the unclear influence that COVID-19 has on the perioperative risk for disease-positive pediatric patients. We conducted a comprehensive literature search on MEDLINE for publications involving pediatric patients with COVID-19 who underwent general anesthesia. A total of eight publications met inclusion criteria, and together described 20 patients. Nine patients had documented preoperative COVID-19 symptoms and one perioperative death was reported. Overall, further studies are needed to increase patient numbers and properly assess the perioperative risk. As we continue to provide care without clear guiding data, we present a discussion of modified anesthetic techniques for pediatric patients with suspected or confirmed COVID-19.

This cross-sectional study evaluates changes in reporting practices for race, sex, and socioeconomic status in randomized clinical trials in 2015 vs 2019.

ClinicalTrials.gov (NCT02400892). Registered 27 March 2015.