Background: The management of acute and chronic pain for individuals living with sickle cell disease (SCD) is a clinical challenge. This reflects the paucity of clinical SCD pain research and limited understanding of the complex biological differences between acute and chronic pain. These issues collectively create barriers to effective, targeted interventions. Optimal pain management requires interdisciplinary care. Objective: These evidence-based guidelines developed by the American Society of Hematology (ASH) are intended to support patients, clinicians, and other health care professionals in pain management decisions for children and adults with SCD. Methods: ASH formed a multidisciplinary panel, including 2 patient representatives, that was thoroughly vetted to minimize bias from conflicts of interest. The Mayo Evidence-Based Practice Research Program supported the guideline development process, including updating or performing systematic reviews. Clinical questions and outcomes were prioritized according to importance for clinicians and patients. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach was used, including GRADE evidence-to-decision frameworks, to assess evidence and make recommendations, which were subject to public comment. Results: The panel reached consensus on 18 recommendations specific to acute and chronic pain. The recommendations reflect a broad pain management approach, encompassing pharmacological and nonpharmacological interventions and analgesic delivery. Conclusions: Because of low-certainty evidence and closely balanced benefits and harms, most recommendations are conditional. Patient preferences should drive clinical decisions. Policymaking, including that by payers, will require substantial debate and input from stakeholders. Randomized controlled trials and comparative-effectiveness studies are needed for chronic opioid therapy, nonopioid therapies, and nonpharmacological interventions.

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Increasing evidence has demonstrated that pain from venipuncture and intravenous cannulation is an important source of pediatric pain and has a lasting impact. Ascending sensory neural pain pathways are functioning in preterm and term infants, yet descending inhibitory pathways seem to mature postnatally. Consequently, infants may experience pain from the same stimulus more intensely than older children. In addition, painful perinatal procedures such as heel lancing or circumcision have been found to correlate with stronger negative responses to venipuncture and intramuscular vaccinations weeks to months later. Similarly, older children have reported greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures. Fortunately, both pharmacologic and nonpharmacologic techniques have been found to reduce children's acute pain and distress and subsequent negative behaviors during venipuncture and intravenous catheter insertion. This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain. Pediatrics 2008;122:S130-S133 E LIMINATION OR RELIEF of pain and suffering, whenever possible, is an important responsibility of physicians caring for children, 1 because unmanaged pain can result in a variety of negative long-term consequences. 2 This general precept encompasses the management of pain associated with venipuncture and intravenous (IV) cannulation, routine procedures that may be viewed by many health care professionals, erroneously, as having little significance and impact. Increasing evidence has demonstrated that venous access procedures are an important source of pediatric pain that should be managed proactively. The purpose of this review is to briefly summarize the data demonstrating the importance of managing pediatric procedural pain in general, and venous access pain in particular. GENERAL CONSIDERATIONSUnderstanding of the ontogeny of the pediatric pain experience has increased significantly over the past 2 decades. Accumulating evidence has indicated that pain is perceived earlier in life than had been previously believed. By the middle of the third trimester of human gestation, ascending pain fibers fully connect to the primary somatosensory cortex of the brain. 3,4 Anand's landmark article 5 demonstrated that preterm infants given fentanyl in addition to nitrous oxide had significantly lower hormonal responses to surgery for ligation of the patent ductus arteriosus than did infants who did not receive fentanyl. Neonates who received high-dose sufentanil compared with halothanemorphine had improved survival rates after cardiac surgery, 6 whereas infants in the NICU have been shown to be able to distinguish real from sham heel sticks. 7 These results are consistent with the existence of functioning neural pathways for pain sensation at early times. Descending inhibitory pain pathways, on the other hand, seem to r...

Control of pain and stress for children is a vital component of emergency medical care. Timely administration of analgesia affects the entire emergency medical experience and can have a lasting effect on a child' s and family' s reaction to current and future medical care. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can provide comfort to children in the emergency setting and improve staff and family satisfaction. Pediatrics 2012;130:e1391-e1405 BACKGROUND A systematic approach to pain management is required to ensure relief of pain and anxiety for children who enter into the emergency medical system, which includes all emergency medical services (EMS) agencies, interfacility critical care transport teams, and the emergency department (ED). 1 The administration of appropriate analgesia in children varies by age as well as by training of the ED team (which includes physicians, nurses, physician assistants, and nurse practitioners), however, and still lags behind analgesia provided for adults in similar situations. 2 Furthermore, neonates are at highest risk of receiving inadequate analgesia. 3,4 Encouragingly, improvements in the recognition and treatment of pain in children have led to changes in the approach to pain management for acutely ill and injured pediatric patients. 5 Studies have shown an increase in opiate use in children with fractures. [6][7][8] Recent advances in the approach and support for pediatric analgesia and sedation, as well as new products and devices, have improved the overall climate of the ED for patients and families in search of the "ouchless" ED. 5,9 Increased parental education regarding pain and sedation, physician comfort and desire to enhance patient satisfaction, and a quest to satisfy accreditation regulations have appropriately driven this effort. System-wide approaches for pain management awareness and strategies work best if they are woven into the fabric of the emergency medical system through education and protocol development. The purpose of this report was to provide information to optimize the comfort and minimize the distress of children and families as they are cared for in the emergency setting.

An evidence-based classification system for chronic SCD pain was constructed for the Analgesic, Anesthetic, and Addiction Clinical Trial Translations Innovations Opportunities and Networks-American Pain Society Pain Taxonomy initiative. Applying this taxonomy may improve assessment and management of SCD pain and accelerate research on epidemiology, mechanisms, and treatments for chronic SCD pain.

ImportanceSARS-CoV-2 infection is associated with persistent, relapsing, or new symptoms or other health effects occurring after acute infection, termed postacute sequelae of SARS-CoV-2 infection (PASC), also known as long COVID. Characterizing PASC requires analysis of prospectively and uniformly collected data from diverse uninfected and infected individuals.ObjectiveTo develop a definition of PASC using self-reported symptoms and describe PASC frequencies across cohorts, vaccination status, and number of infections.Design, Setting, and ParticipantsProspective observational cohort study of adults with and without SARS-CoV-2 infection at 85 enrolling sites (hospitals, health centers, community organizations) located in 33 states plus Washington, DC, and Puerto Rico. Participants who were enrolled in the RECOVER adult cohort before April 10, 2023, completed a symptom survey 6 months or more after acute symptom onset or test date. Selection included population-based, volunteer, and convenience sampling.ExposureSARS-CoV-2 infection.Main Outcomes and MeasuresPASC and 44 participant-reported symptoms (with severity thresholds).ResultsA total of 9764 participants (89% SARS-CoV-2 infected; 71% female; 16% Hispanic/Latino; 15% non-Hispanic Black; median age, 47 years [IQR, 35-60]) met selection criteria. Adjusted odds ratios were 1.5 or greater (infected vs uninfected participants) for 37 symptoms. Symptoms contributing to PASC score included postexertional malaise, fatigue, brain fog, dizziness, gastrointestinal symptoms, palpitations, changes in sexual desire or capacity, loss of or change in smell or taste, thirst, chronic cough, chest pain, and abnormal movements. Among 2231 participants first infected on or after December 1, 2021, and enrolled within 30 days of infection, 224 (10% [95% CI, 8.8%-11%]) were PASC positive at 6 months.Conclusions and RelevanceA definition of PASC was developed based on symptoms in a prospective cohort study. As a first step to providing a framework for other investigations, iterative refinement that further incorporates other clinical features is needed to support actionable definitions of PASC.

Analgesic trials pose unique scientific, ethical, and practical challenges in pediatrics. Participants in a scientific workshop sponsored by the US Food and Drug Administration developed consensus on aspects of pediatric analgesic clinical trial design. The standard parallel-placebo analgesic trial design commonly used for adults has ethical and practical difficulties in pediatrics, due to the likelihood of subjects experiencing pain for extended periods of time. Immediate-rescue designs using opioid-sparing, rather than pain scores, as a primary outcome measure have been successfully used in pediatric analgesic efficacy trials. These designs maintain some of the scientific benefits of blinding, with some ethical and practical advantages over traditional designs. Preferred outcome measures were recommended for each age group. Acute pain trials are feasible for children undergoing surgery. Pharmacodynamic responses to opioids, local anesthetics, acetaminophen, and nonsteroidal antiinflammatory drugs appear substantially mature by age 2 years. There is currently no clear evidence for analgesic efficacy of acetaminophen or nonsteroidal antiinflammatory drugs in neonates or infants younger than 3 months of age. Small sample designs, including cross-over trials and N of 1 trials, for particular pediatric chronic pain conditions and for studies of pain and irritability in pediatric palliative care should be considered. Pediatric analgesic trials can be improved by using innovative study designs and outcome measures specific for children. Multicenter consortia will help to facilitate adequately powered pediatric analgesic trials.

Whether a component of a disease process, the result of acute injury, or a product of a diagnostic or therapeutic procedure, pain should be relieved and stress should be decreased for pediatric patients. Control of pain and stress for children who enter into the emergency medical system, from the prehospital arena to the emergency department, is a vital component of emergency care. Any barriers that prevent appropriate and timely administration of analgesia to the child who requires emergency medical treatment should be eliminated. Although more research and innovation are needed, every opportunity should be taken to use available methods of pain control. A systematic approach to pain management and anxiolysis, including staff education and protocol development, can have a positive effect on providing comfort to children in the emergency setting.