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COMMENTARY |
Department of Pediatrics,
University of Miami Miller School of Medicine,
Miami, FL 33101
Concerns about inadequate treatment of pain in children have prompted policy statements and clinical reports by the American Academy of Pediatrics.1,2 It has also been suggested that failure to treat children's pain constitutes substandard practice and is unethical.3 The pediatric community is aware now that pain is an important symptom that deserves aggressive treatment for the purpose of relieving suffering. This awareness has led to steady advances and improvements in pediatric pain management.2 However, acute abdominal pain has remained largely off limits to analgesic treatment, primarily because of concerns of pediatric surgeons that pain is a crucial symptom of appendicitis and other acute abdominal injuries, as noted by Vane4 in his commentary. Surgeons have been concerned that the use of analgesics may mask the underlying condition, leading to delays in diagnosis and appropriate surgical intervention.
Green and colleagues5 examined whether early treatment with analgesia would result in missed symptoms, delayed treatment, or increased adverse outcomes in children presenting to emergency departments with acute abdominal pain. They also examined whether treatment with narcotic analgesia would affect the pain perception of the children. There was no evidence that early treatment with narcotics resulted in any differences in detection of acute appendicitis when compared with placebo, nor did children treated with narcotic analgesia differ in their outcomes after surgery. A statistically and clinically significant difference in pain perception was detected for children receiving early narcotic analgesia.
These results are encouraging. They challenge long-held assumptions of pediatric surgeons that analgesia will significantly mask crucial symptoms associated with acute abdominal pain, a practice that has often resulted in children experiencing substantial pain for a prolonged period while awaiting surgical intervention. Providing early treatment with analgesic narcotics in this sample did not affect the ability of the surgeons, at both the attending and senior-resident levels, to make accurate diagnoses and offer appropriate surgical intervention. In addition, the use of early analgesia did not increase the occurrence of surgical intervention for nonpathologic conditions.
Pain perception was statistically and clinically lower with early narcotic analgesia than placebo. However, it was not eliminated completely; the 2.2-cm change in the self-report pain measure for the early-analgesia group was just beyond the threshold established for clinical significance. This change did not represent absence of pain, only that the pain was reduced. This may be an important factor in the outcomes of this study. Reducing but not fully eliminating pain through the use of early analgesia may provide a dual benefit by lessening the level of suffering without sacrificing diagnostic accuracy.
The results of this study suggest that changes in use of analgesics for acute abdominal pain should be considered, particularly in a school-aged population, with narcotic dosing strategies similar to those reported by Green and colleagues. However, there are several issues that will need to be addressed before this becomes a standard of care.
In this study, a convenience sample was used, because 1 of the institutional surgeons refused to participate. It is likely that many pediatric surgeons may find this approach to be unacceptable without additional support from larger, multicenter studies.
Additional research is needed to determine if the type of analgesic and dosing strategy proposed by Green and colleagues is the optimal management strategy. It is possible that narcotics are not the best pain medication to use or that increased doses of narcotics or use of other nonnarcotic pain medications may provide the same or a better level of relief without compromising diagnostic accuracy.
Finally, this study included only otherwise healthy, school-aged children. It does not help with decisions about infants and toddlers presenting with acute abdominal pain, nor are the results generalizable to children with developmental disabilities, special health care needs, or other high-risk conditions. Future research on this topic needs to systematically address whether early analgesia is safe and effective with these special populations and whether modifications in the approach may be necessary.6
Since the 1980s the pediatric community has been working to improve treatment of pain in children. This has required accumulating evidence to support changes in practice that were based on years of training and experience. Green and colleagues have offered new, preliminary evidence that challenges some long-held beliefs about analgesia and acute abdominal pain. Additional research is needed before this evidence will change practice, but the work of Green and colleagues is a welcome and needed contribution to the desired goal of offering optimal care with minimal suffering.
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FOOTNOTES |
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Address correspondence to F. Daniel Armstrong, PhD, Department of Pediatrics, University of Miami Miller School of Medicine, PO Box 016820 (D-820), Miami, FL 33101. E-mail: darmstrong{at}miami.edu
No conflict of interest declared.
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REFERENCES |
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 TOP REFERENCES |
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This article has been cited by other articles:
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  H A Amoli, A Golozar, S Keshavarzi, H Tavakoli, and A Yaghoobi Morphine analgesia in patients with acute appendicitis: a randomised double-blind clinical trial Emerg. Med. J., September 1, 2008; 25(9): 586 - 589. [Abstract] [Full Text] [PDF]
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 S. R. Ranji, L. E. Goldman, D. L. Simel, and K. G. Shojania Do opiates affect the clinical evaluation of patients with acute abdominal pain? JAMA, October 11, 2006; 296(14): 1764 - 1774. [Abstract] [Full Text] [PDF]
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 Journal Watch Arch. Dis. Child., March 1, 2006; 91(3): 274 - 275. [Full Text] [PDF]
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 Analgesia for Children with Acute Abdominal Pain Journal Watch (General), October 18, 2005; 2005(1018): 5 - 5. [Full Text]
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 F. D. Armstrong Analgesia for Children With Acute Abdominal Pain: A Cautious Move to Improved Pain Management Pediatrics, October 1, 2005; 116(4): 1018 - 1019. [Full Text] [PDF]
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