Journal Logo

Pediatric

Inpatient postoperative undesirable side effects of analgesics management: a pediatric patients and parental perspective

Chabot, Biancaa; Ferland, Catherine E.a,b,c,*, on behalf of the Quebec Consortium on Adverse Effects of Pain Medications

Author Information
doi: 10.1097/PR9.0000000000000845
  • Open

1. Introduction

Postoperative pain in pediatric patients has been associated with limitations in daily living such as reduced school attendance, extracurricular activities, social activities, household tasks, and sleep quality.8 Not only can these consequences have a severe impact on the patient, but they also place a burden on their families, their social environment and the healthcare system at large.7 It is, therefore, critical to manage and treat postoperative pain as well as possible. However, even if the best pain management is provided and pain is well controlled, recovery may be prolonged due to the side effects of pain medication.13 The use of analgesics such as opioids, acetaminophen, and nonsteroidal anti-inflammatory drugs for the treatment of postoperative pain is common in both adult1,2,16,29 and pediatric patients.2 However, such medications are known in both populations for common potential side effects such as sedation, nausea, vomiting, constipation, itching, dizziness, headache, respiratory depression, and digestive organ irritability.2,23,29 A better understanding of the challenges confronted by pediatric patients in the acute postoperative period in terms of analgesic-caused side effects may present valuable details to improve care provided.

A review of the scientific literature on the postoperative challenges confronted by pediatric inpatients was completed to identify the needs of patients and their parents after surgery and after hospital discharge. This brief report aims to answer specific questions relevant to 4 distinct themes: (1) Analgesic use and side effects: What are the common side effects of postoperative analgesics reported by patients? How do these side effects disrupt patients' quality of life? (2) Self-management strategies: What are the common self-care strategies that patients use to attenuate side effects of analgesics? (3) Education provided by healthcare providers: What education is provided by healthcare providers on analgesics and their side effects? What is the perception of patients and/or their parents on the education provided on analgesics and their side effects? (4) Patients' and parents' concerns: What are the concerns of patients and/or their parents in terms of medication use?

2. Methods

A literature search was conducted using the online databases of PubMed, Medline, and Scopus as well as using the snowballing method of reference tracking using combinations of the following terms: pediatric, analgesic, pain medication, side effects, adverse effects, nausea and vomiting, postoperative, postdischarge, self-care, self-management, management, self-care strategies, patient expectations, patient concerns, and education. Articles published between 1990 and 2019 were searched for. The year 1990 was chosen because this is when opioids were increasingly used and studied, and became the first line of treatment for pain.12,20

Studies included had to relate to postoperative analgesic use by pediatric patients. The literature search included peer-reviewed articles published in English and studies using pediatric patients or their parents as participants. The term parent refers to any adult responsible for the child's care and supervision. The search was also limited to studies investigating patients scheduled to undergo or who have undergone a surgery that required incision, anesthesia, and a postoperative hospital stay. Only studies investigating common medications used in North America were included. Articles that were excluded were those that investigated the postoperative period after 6 months, patients undergoing outpatient surgery, adult patients (mean age >18 years), and patients with cancer. These exclusions had the purpose of homogenizing the populations and narrowing the research being discussed.

Articles were screened and excluded based on the relevance of their abstracts and on whether they fulfilled the criteria by 2 independent reviewers. The full texts of the remaining articles were selected, read, and summarized by one reviewer.

3. Results

Ten studies met the criteria. A summary of the characteristics and results of the studies included are presented in Table 1.

Table 1 - Study characteristics.
Article # of participants Patient age range (y) Surgery type Methodology Results—side effects Results—self-care strategies Results—concerns Results—interventions and education
Tesler et al.25 131 patients 8–17 Orthopedic, thoracic, abdominal, urologic, neurologic, other Review of medical records
Interviews on postoperative days 1–5
Patients prescribed, on average, 3.1 analgesics per child during 5 postoperative days
Analgesics prescribed: acetaminophen with codeine, acetaminophen, meperidine, codeine, hydromorphone, hydrocodone with acetaminophen, aspirin
Analgesics administered: morphine, meperidine, hydromorphone, codeine, acetaminophen with codeine, hydrocodone with acetaminophen, acetaminophen with aspirin
Iodice et al.11 54 patients 0–18 Cardiac Retrospective review of patient records Analgesics received: morphine, acetaminophen with NSAIDs (diclofenac or ibuprofen), acetaminophen alone
Reported side effects: nausea, vomiting, itching
Howard et al.9 10, 079 patients 0–20 Head and neck, neurologic, plastic, cardiothoracic, urologic, orthopedic, general Prospective data collection Reported side effects: oversedation, respiratory depression, nausea or vomiting, itching
Swanson et al. (2012) 217 patients 0–12 Orthopedic Retrospective review of patient charts Most patients treated with nonopioids
Medications: acetaminophen, morphine, codeine and Percocet
Severe nausea and vomiting and sedation not observed
Chen et al.3 60 patients 7–14 ENT, orthopedic RCT (hydromorphone vs morphine) Analgesics: hydromorphone, morphine
Reported side effects: nausea, vomiting, urinary retention
No difference in side effects between both groups
Czarnecki et al.5 62 patients 10–19 Orthopedic Retrospective review of charts including records of follow-up telephone interviews Less side effects with oxycodone-CR than morphine
Reported side effects: sedation, dizziness, constipation, pruritus, nausea, vomiting, respiratory depression
PCA: sedation and pruritus
Oxycodone-CR: constipation, nausea, dizziness
Lim et al.14 14 parents of patients 6–12 Not mentioned Semistructured interviews Parents' need to be involved in the child's postoperative care
Parents' need for information and support from nurses
Sama et al.17 106 patients 0–15 Abdominal, orthopedic, urogenital, plastic, thoracic, neurologic, other Prospective descriptive survey Analgesics: acetaminophen, ketoprofen, tramadol, morphine
Reported side effects: nausea, vomiting, urinary retention, respiratory depression
Simons and Roberson18 20 nurses and 20 parents of patients Not mentioned Moderate to major surgery Matched interviews Concerns about child's side effects and overconsumption of medication Parents' need for more information on pain management
Hesitancy approaching busy nurses
Education approach not standardized
Lack of communication between parents and nurses
Vincent et al.27 108 parents and their children 7–17 ENT, thoracic, orthopedic Prospective, two-group, pretest-posttest, quasiexperimental study
Educational intervention group vs standard education group
Analgesics: mostly acetaminophen Concerns about efficacy of analgesics, the change in medication intake schedule after transition from hospital to home, side effects No significant difference in parental satisfaction between both groups
ENT, ear, nose, throat; NSAIDs, nonsteroidal anti-inflammatory drugs; Oxycodone-CR, oxycodone—controlled release; RCT, randomized control trial.

3.1. Analgesic use and reported side effects

The time window observed in the included studies ranged from the day after surgery to a few days after discharge. Analgesics that were administered or prescribed to patients after surgery were acetaminophen,11,17,24,25,27 morphine,3,5,11,17,24 codeine,24,25 meperidine,25 hydromorphone,3,25 hydrocodone,25 oxycodone,5 tramadol,17 aspirin,25 diclofenac,11 ibuprofen,11 and ketoprofen.17 Tesler et al.25 found that the patients in their sample were prescribed 3.1 analgesics in the 5 days after surgery. Side effects reported by patients were respiratory depression,5,9,17 sedation,5,9 nausea,3,5,9,11,17 vomiting,3,5,9,11,17 pruritus,5,9,11 dizziness,5 constipation,5 and urinary retention.3,17 No literature was found on how these side effects may affect patients' quality of life.

3.2. Self-management strategies

Patients may engage in self-care activities to attenuate the severity and frequency of their side effects. However, no studies were found in which this was investigated in pediatric patients.

3.3. Education provided by healthcare providers

It was common for parents of patients to feel as though they are not adequately knowledgeable about pain management and potential side effects.14,18 Simons and Roberson18 found that, in the days after surgery, about half of the parents they interviewed reported the need for more information on pain management. Many parents reported feeling overwhelmed with the amount of information they had to take in about pain management and felt hesitant to approach busy nurses for more support.14,18 Parents identified the need for more involvement in the patient's recovery and the need for more support and education from nurses concerning analgesic use and side effects.14,18

3.4. Patients' and parents' concerns

Parents also have concerns about their child's analgesic use.27 Parents have expressed worries about the efficacy of analgesics, the change in medication intake schedule after transitioning from hospital to home, the overconsumption of medication, and the side effects of postoperative analgesics.18,27

4. Discussion

The results found made it difficult to address the specific queries of this review due to limited published research in the field. A major issue that came out of the review is that parents commonly report lacking knowledge about analgesic use and side effects. Pain management education should aim to provide parents and patients with adequate and consistent age-specific information about the possible side effects of postoperative drugs and their duration, and advise them on how to manage them.6,15,28 Although discussing pain management and side effects one-on-one with a healthcare provider is important, written information should be provided in addition to this.10 This combination would allow the patient and parents to not only discuss concerns with a healthcare provider but also look back at written information if forgotten. A mobile application containing information about the postoperative period may be useful for patients and allow for access at any time.19 The implementation of knowledge translation intervention programs such as Evidence-based Practice for Improving Quality, in which contextual program tailoring, leadership support, staff engagement, and time and resource allocation are important factors,22 has also been shown to improve patient pain outcomes in a hospital setting.21,22

This review highlighted that parents have many concerns about their child's medication use and side effects such as the efficacy of analgesics, the change in medication use after transitioning from hospital to home, the overconsumption of medication, and the side effects of analgesics.18,27 Patients and parents should be knowledgeable about analgesic use and the risk for side effects in the weeks before surgery and their concerns should continuously be addressed thereafter by the same team to avoid them forgetting information and to ensure correct and consistent education.26 Prescribing antiemetics based on the reason for symptoms and administering prophylactic treatment to patients is frequent.4,28 However, parents and patients may not be comfortable with the consumption of additional medications; therefore, clinicians should also educate patients on nonpharmacological strategies for pain management and side effects.

Furthermore, the fact that information given to patients and parents is being perceived as being inadequate may be due to a lack of research conducted on pediatric inpatients' perspectives on the challenges they experience postoperatively. Most studies investigating this topic have used pediatric patients who have undergone day-surgery. Although outpatients may be more at risk of feeling unknowledgeable after discharge, the invasiveness of inpatient surgery usually requires the consumption of more analgesics; therefore, they may differ in terms of postoperative experience. A systematic review including both populations should be conducted. Also, only 4 of the 10 studies reviewed used a qualitative approach for data collection.5,14,18,25 Additional studies using qualitative methods can allow us to gain a deeper understanding of the patients' perspective on which side effects they find most disruptive and how they manage them. Moreover, how daily living is affected and which self-care strategies are used are important to study because they may have a significant impact on recovery. Knowing which self-care activities patients engage in and whether they are effective is important so that they can potentially be recommended as alternative side effect management strategies.

Disclosures

The authors have no conflicts of interest to declare.

Acknowledgements

This study was supported by the Quebec Consortium on Adverse effects of pain medications, an initiative funded by the Quebec Pain Research Network (QPRN) of the Fonds de recherche du Québec-Santé.

Quebec Consortium on Adverse effects of pain medications are (in alphabetical order): Aline Boulanger, Anaïs Lacasse, Catherine E. Ferland, Céline Gélinas, David Lussier, Émilie Paul-Savoie, Éric Troncy, Gérard Huni, Gilles Lavigne, Graciela Pineyro, Hélène Beaudry, Jennifer Cogan, Kadija Perreault, Laurent Dupuis, Line Guénette, Lise Dassieu, Louis Gendron, M. Gabrielle Pagé, Manon Choinière, Mélanie Bérubé, Nabiha Benyamina Douma, Nancy Julien, Philippe Sarret, Pierre Rainville, Sylvie Lafrenaye, Sylvie Lemay, and Yoram Shir.

References

[1]. Austrup ML, Korean G. Analgesic agents for the postoperative period: Opioids. Surg Clin North Am 1999;79:253–73.
[2]. Carter GT, Duong V, Ho S, Ngo KC, Greer CL, Weeks DL. Side effects of commonly prescribed analgesic medications. Phys Med Rehabil Clin 2014;25:457–70.
[3]. Chen F, Liu H, Zhang G, Huang Z, Zhang X, Lu Y, Li J, Lian Q, Shangguan W. The effect of hydromorphone for postoperative analgesia in children. Int J Clin Exp Med 2016;9:18579–82.
[4]. Cruthirds D, Sims PJ, Louis PJ. Review and recommendations for the prevention, management, and treatment of postoperative and postdischarge nausea and vomiting. Oral Surg Oral Med Oral Pathol Oral Radiol 2013;115:601–11.
[5]. Czarnecki ML, Jandrisevits MD, Theiler SC, Huth MM, Weisman SJ. Controlled-release oxycodone for the management of pediatric postoperative pain. J Pain Symptom Manage 2004;27:379–86.
[6]. Devine EC. Effects of psychoeducational care for adult surgical patients: a meta-analysis of 191 studies. Patient Edu Couns 1992;19:129–42.
[7]. Dueñas M, Ojeda B, Salazar A, Mico JA, Failde I. A review of chronic pain impact on patients, their social environment and the health care system. J Pain Res 2016;9:457–67.
[8]. Fortier MA, Chou J, Maurer EL, Kain ZN. Acute to chronic postoperative pain in children: preliminary findings. J Pediatr Surg 2011;46:1700–5.
[9]. Howard RF, Lloyd-Thomas A, Thomas M, Williams DG, Saul R, Bruce E, Peters J. Nurse-controlled analgesia (NCA) following major surgery in 10,000 patients in a children's hospital. Paediatr Anaesth 2010;20:126–34.
[10]. Huth MM, Broome ME, Mussatto KA, Morgan SW. A study of the effectiveness of a pain management education booklet for parents of children having cardiac surgery. Pain Manag Nurs 2003;4:31–9.
[11]. Iodice FG, Thomas M, Walker I, Garside V, Elliott MJ. Analgesia in fast-track paediatric cardiac patients. Eur J Cardiothorac Surg 2011;40:610–13.
[12]. Jones MR, Viswanath O, Peck J, Kaye AD, Gill JS, Simopoulos TT. A brief history of the opioid epidemic and strategies for pain medicine. Pain Ther 2018;7:13–21.
[13]. Lerman J. Surgical and patient factors involved in postoperative nausea and vomiting. Br J Anaesth 1992;69:24S–32S.
[14]. Lim SH, Mackey S, Liam JL, He HG. An exploration of Singaporean parental experiences in managing school-aged children's postoperative pain: a descriptive qualitative approach. J Clin Nurs 2012;21:860–9.
[15]. Messerer B, Gutmann A, Weinberg A, Sandner-Kiesling A. Implementation of a standardized pain management in a pediatric surgery unit. Pediatr Surg Int 2010;26:879–89.
[16]. Power I, Barratt S. Analgesic agents for the postoperative period: Nonopioids. Surg Clin North Am 1999;79:275–95.
[17]. Sama HD, Bang'na Maman AF, Djibril M, Assenouwe M, Belo M, Tomta K, Chobli M. Post-operative pain management in paediatric surgery at Sylvanus Olympio University Teaching Hospital, Togo. Afr J Paediatr Surg 2014;11:162–5.
[18]. Simons J, Roberson E. Poor communication and knowledge deficits: obstacles to effective management of children's postoperative pain. J Adv Nurs 2002;40:78–86.
[19]. Specht K, Agerskov H, Kjaersgaard-Andersen P, Jester R, Pedersen BD. Patients' experiences during the first 12 weeks after discharge in fast-track hip and knee arthroplasty: a qualitative study. Int J Orthop Trauma Nurs 2018;31:13–19.
[20]. Stein C. Opioid treatment of chronic nonmalignant Pain1. Anesth Analg 1997;84:912–14.
[21]. Stevens BJ, Yamada J, Estabrooks CA, Stinson J, Campbell F, Scott SD, Cummings G. Pain in hospitalized children: effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes. PAIN 2014;155:60–8.
[22]. Stevens BJ, Yamada J, Promislow S, Stinson J, Harrison D, Victor JC. Implementation of multidimensional knowledge translation strategies to improve procedural pain in hospitalized children. Implement Sci 2014;9:120.
[23]. Strassels SA, McNicol E, Suleman R. Postoperative pain management: a practical review, part 2. Am J Health Syst Pharm 2005;62:2019–25.
[24]. Swanson CE, Chang K, Schleyer E, Pizzutillo PD, Herman MJ. Postoperative pain control after supracondylar humerus fracture fixation. J Pediatr Orthop 2012;32:452–5.
[25]. Tesler MD, Wilkie DJ, Holzemer WL, Savedra MC. Postoperative analgesics for children and adolescents: prescription and administration. J Pain Symptom Manage 1994;9:85–95.
[26]. Veal FC, Thompson AJ, Perry LJ, Bereznicki LR, Peterson GM. Pain intensity and pain self-management strategies following discharge after surgery: an Australian prospective observational study. J Clin Pharm Ther 2018;43:8–14.
[27]. Vincent C, Chiappetta M, Beach A, Kiolbasa C, Latta K, Maloney R, Van Roeyen LS. Parents' management of children's pain at home after surgery. J Spec Pediatr Nurs 2012;17:108–20.
[28]. Waterman H, Leatherbarrow B, Slater R, Waterman C. Post‐operative pain, nausea and vomiting: qualitative perspectives from telephone interviews. J Adv Nurs 1999;29:690–6.
[29]. Wu CL, Raja SN. Treatment of acute postoperative pain. Lancet 2011;377:2215–25.
Keywords:

Pediatrics; Pain; Medication; Undesirable side effects; Perioperative pain

Copyright © 2020 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.