Postoperative analgesia for cleft lip and palate repair in children

Abstract

Acute pain such as postoperative pain during infancy was ignored approximately three decades ago due to biases and misconceptions regarding the maturity of the infant's developing nervous system, their inability to verbally report pain, and their perceived inability to remember pain. More recently, these misconceptions are rarely acknowledged due to enhanced understanding of the developmental neurobiology of infant pain pathways and supraspinal processing. Cleft lip and palate is one of the most common congenital abnormalities requiring surgical treatment in children and is associated with intense postoperative pain. The pain management gets further complicated due to association with postsurgical difficult airway and other congenital anomalies. Orofacial blocks like infraorbital, external nasal, greater/lesser palatine, and nasopalatine nerve blocks have been successively used either alone or in combinations to reduce the postoperative pain. Since in pediatric population, regional anesthesia is essentially performed under general anesthesia, association of these two techniques has dramatically cut down the risks of both procedures particularly those associated with the use of opioids and nonsteroidal anti-inflammatory drugs. Definitive guidelines for postoperative pain management in these patients have not yet been developed. Incorporation of multimodal approach as an institutional protocol can help minimize the confusion around this topic.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

“…Orofacial clefts, such as cleft palate, are a common congenital abnormality associated with severe postoperative pain. 190 , 191 One study evaluated the efficacy of bilateral suprazygomatic maxillary nerve blocks on postoperative analgesia outcomes in pediatric patients undergoing cleft palate repair. 61 The authors reported that bilateral suprazygomatic maxillary nerve blocks with ropivacaine lowered the overall morphine consumption compared with placebo after 48 hours following surgery.…”

Dexmedetomidine during suprazygomatic maxillary nerve block for pediatric cleft palate repair, randomized double-blind controlled study

“…There is a growing awareness in recent years of the need for children's complete wellbeing in postoperative periods, and not only being pain free. Sedation and other adverse events related to opioids do not help in achieving this goal [19]. Postoperative pain may extend beyond the nerve block resolution duration.…”

A prospective randomized controlled double-blind trial to assess the effects of dexmedetomidine during cleft palate surgery

“…Surgical infiltration and various nerve blocks are used to repress the hemodynamic effects and to achieve adequate postoperative pain relief [ 5 6 16 ]. However, there is no single effective block for CP surgeries and a multimodal approach for to pain management has been recommended [ 17 ]. Despite the lack of FDA labeling for pediatric use, dexmedetomidine has been increasingly used in these patients over recent years [ 7 8 18 ].…”