Treating children's post-operative pain is a science and an art. It requires managing expectations of the child and the parents, understanding a child's mindset, administering the right medications at the right time and teaching parents how to continue treating pain at home. If you're planning to increase your pediatric caseload, here's some advice for ensuring a smooth recovery for your youngest patients.

Treat pain preemptively
Adequate preemptive amnesia and analgesia are key to easing the separation from parents and stopping pain before it starts, says Andy Herlich, MD, DMD, an anesthesiologist at Temple University School of Medicine in Philadelphia and the Shriner's Hospital of Philadelphia. He adds that in general, it's not appropriate for babies between 9 months and 1 year old to receive pre-operative sedation, as they're not old enough to experience seperation anxiety. For common pediatric outpatient procedures such as ear tube surgery, Dr. Herlich suggests administering midazolam syrup in the waiting room while the child is still with the parents. Give the medication enough time to take effect - after about 15 minutes to 20 minutes, the child should be relaxed enough to be brought to the pre-op area without the parents. There is no data to suggest that a child does any better during induction if the parent is present and prior sedation has been given.

Once patients enter the OR, the anesthesiologist can maintain analgesia based on the type of surgery and the provider's preference, says Dr. Herlich. Intramuscular morphine, nasal fentanyl (which may have a calming effect), ketamine and ketorolac are all potential choices (although proper dosing for ketorolac can be tricky in children younger than 2 years old). For ENT cases, intraoperative dexamethasone may reduce post-op pain and PONV. Dr. Herlich also uses acetaminophen suppositories and IM morphine for infants undergoing surgery. For all patients, injecting local anesthesia (lidocaine or bupivacaine) at the surgical site is also critical.

Dr. Herlich says preemptive pain management minimizes the risk of emergence delirium, in which children become extremely agitated and distressed after awakening from some types of short-acting anesthetics (most notably, sevoflurane). In the past, when faced with a delirious patient, anesthesiologists simply put the patient under anesthesia again and hoped they woke up calmer the second time, says Dr. Herlich. Providers eventually realized that preemptive analgesia as well as increased use of benzodiazepines (midazolam, for example) helped avoid this complication altogether.

Preemptive analgesia starts at home if the child requires IV anesthesia induction. A 1999 study of children undergoing outpatient gastrointestinal endoscopies with IV sedation showed that letting parents apply EMLA cream to the insertion site of the IV was just as effective as having clinicians apply it at the surgical facility. Also, children didn't need to arrive early and wait for the cream to take effect.

Assess pain accurately
Fear and anxiety exacerbate physical pain in children. Kids may fear being separated from their parents, getting injections and even dying or being mutilated during surgery, says Myra Huth, PhD, RN, an assistant vice president at the Center for Professional Excellence of the Cincinnati Children's Hospital Medical Center in Cincinnati.

Because pain, fear and anxiety are so intertwined in pediatric patients, assessing pain can be extremely challenging, even if the child is able to use numeric or pictorial pain scales. Compounding this problem is the fact that many clinicians fear giving a child too much pain medication, and consequently, children's pain is underdosed, says Dr. Huth.

Reduce psychological stressors to assess physical pain accurately, recommends Dr. Herlich. Once the child awakens and is physically stable, bring the parents back to the recovery area. This will reduce a lot of anxiety and you can then assess pain using a numeric scale, the Wong-Baker FACES scale or whatever is most appropriate, and get a better idea of how much pain medication is needed.

Realize that children may underreport pain because they are afraid of shots, says Dr. Huth. She recommends reassuring a child first that he won't get a shot (provided one isn't needed) before asking about pain levels.

Educate parents
Dr. Huth and Dr. Herlich both emphasize educating parents about their children's pain.

"Many facilities don't provide parents with the guidance and specific strategies that they need to manage their children's pain," says Dr. Huth.

Here are some tips:

• Manage parents' expectations. "Tell parents pre-operatively that their child will probably have some post-pain," says Dr. Huth. Parents who expect pain will be able to treat it more effectively.
• Encourage parents to bring favorite toys and books to the surgery facility to help comfort their child in the recovery area.
• Emphasize the importance of constantly assessing pain once the child returns home and administering pain medications on a regular schedule. "Parents need to know that just because a child is sleeping doesn't mean that he isn't in pain," says Dr. Huth. "Too often, parents don't awaken the child to take pain medication or they wait too long between doses."
• Give parents clear instructions on whom to call if their child's pain doesn't abate.
• Tell parents about simple, non-pharmacologic pain relief methods, such as using bags of frozen peas as ice packs.

Prepare your staff
Having surgeons, anesthesiologists and nurses who are experienced in pediatrics is a great benefit, but not every facility is so lucky. If you need ideas on how to design pediatric protocols and make your facility child-friendly, check out the American Society of Anesthesiology (www.asahq.org) and the Society of Pediatric Anesthesia (www.pedsanesthesia.org).

Facilities that host a large volume of pediatric cases often have child life specialists on staff, according to Dr. Herlich. These professionals meet with patients and their parents, give tours of the facility and serve as substitute parents during the surgical stay. If you don't need a full-time child life specialist, consider contracting with someone from a nearby hospital or training a nurse to handle special pediatric needs.

Create child-friendly areas
Even if you don't host pediatric cases often, create at least one pre-op and post-op recovery area for your occasional pediatric patient. This involves child-friendly wallpaper in one of your recovery areas and keeping toys, videos and books on hand.

Meeting the challenge
It's estimated that 60 percent of all pediatric surgical procedures are performed outpatient. These cases can be challenging, but by preparing your facility, your patients and your patients' parents, you can help make pediatric cases among the most rewarding in your surgical schedule.