Managing Children’s Pain After Surgery

I want to say THANK YOU to Dr. Klass for this article and to all of the commenters here for sharing their agonizing experiences. Reading all this has given me the inspiration to write to the University hospital near us who, when my daughter broke both wrists 13 years ago, gave my 6-year-old girl no pain medication before manipulating her wrists in all directions for the xrays, then (long story short) gave her an IV in her ankle, again withouth any sedative. Not having any experience with this kind of trauma, and being rather traumatized myself, I thought all this was necessary for her before surgery to repair the fractures. I asked the ER resident later whether she could've received pain medication; she replied yes, but that the triage nurse had bypassed the ER doc and sent my daughter straight to the XRay department. To make things even worse, when I spoke to the Charge Nurse to let her know what had happened, she said that it was my fault: "The parents are the first line of defense," she proclaimed. I didn't know, up intil that point, that family was required to "defend" their loved ones from those who are supposed to deliver care. Now I do... And I hope everyone reading this will know the same. Thank you again, and Peace to us all!

When my son was small, he broke his arm and was in a lot of pain. He coped pretty well with the pain. However, to him, a kid who took shots well, a needle meant more pain and he felt like he couldn't cope with any more pain, so the sight of a needle (or something vaguely like a needle, such as a pen in a nurse's hand) had him shrieking like a banshee. Efforts to convince him that the shot would kill his pain were a waste of time. His only experience of shots was vaccines, some of which left him with a mildly sore arm for a day. Add to that, the medical personnel had been saying his arm would be as good as new in a few weeks. So, he didn't trust the notion that a shot could provide real and swift pain relief, as opposed to more pain now and less pain at some unknown point in the future. He'd have gritted his teeth and passed out from pain before he requested a needle.

When I was growing up both dentists and doctors thought pain would make boys into better men. That is very recent history. As Americans we have to face the fact that we have the very worst and the most expensive least effective health care in the world and we are number one on pain patient abuse, ignorance and incompetence. Nothing will change as long as our health care is bound to Homeland Security (why is that anyway?) and serves as a pipeline to our jails. Law enforcement has NO place in a hospital or a doctor's office.

I have advocated (loudly) on my own behalf and that of family members, for numbing agents during painful medical procedures. If you are obnoxious enough, for long enough, doctors will often give in and order something. Nurses usually can't do this on their own, the doctor has to order it. But many doctors don't like to be bothered with numbing agents, and some are nasty about it. I have had many experiences with this; it is not a fluke.

When I was a child, I had awareness during surgery for a double hernia, meaning I felt every slice of the knife. As a younger teenager, I had major abdominal surgery, followed by 24 hours of almost no pain medication. The nurse took it upon herself to refuse to administer the morphine, on the grounds that it was addictive. She also refused to answer my calls. Best she could manage was to offer a Darvon every four hours, which took half an hour to act, and then lasted for only another half an hour of close to the same level of pain. By the time the doctor assessed me the next day, it did not matter that he chewed out the nurse. I had already been tortured for far too long. Nervous systems subjected to this level of agony never really recover. Something changes permanently. It's not just a life-long hypersensitivity to pain, but an overall edginess in living. So, yes; the topic of pain management in children matters.

My son has had three surgeries since birth in 2010, he has never been offered pain medication afterward. One inguinal hernia surgery, and two eye muscle surgeries (both eyes each time).

Another open heart surgery baby here, and the pain was immobilizing...

Think what happens to children in impoverished or war-torn countries. When the Russians bomb Serbian children with American weapons, you can bet the pediatric victims are lucky to get any pain relief at all.

My almost 2 year old son was intubated but conscious and began to pull at his breathing tube. As a solution, the resident ordered a paralytic - not an atavan or versed or anything to calm him - just a drug to stop him from moving. After the drug, Tears were streaming down his paralyzed face. I flew into a rage, telling the doctors they must do better. This is unacceptable. The resident told me it was fine “because he won’t remember this.” I stared at her in disbelief. I went to the attending doctor and explain. He’s in pain. You can fix this, and you will. We got opioids and atavan with no side effects.

Having worked in pediatrics for 15 years, if you can’t tell the difference in a 4 year old’s crying in pain, from wanting their parents or being scared, you need to be in a different field.

I had open heart surgery as a 9 month old baby in the early ‘70s. My parents were told I didn’t need pain medication, so I didn’t get it after the surgery. As a kid and now as an adult, I have a ridiculously and dangerously high pain tolerance - walking around for weeks on a broken foot (I didn’t think it hurt *that* bad), multiple shoulder separations, and subsequent surgeries where I didn’t feel like I needed pain meds after a day. I’m convinced that my childhood experience of not having pain relief caused my brain/body to be permanently recalibrated out of whack.

My daughter had shunt surgery 4 months ago when she was 3 months old. When my husband inquired about what they were doing to manage her pain somehow pain medication had not been ordered for her. He threw a fit. Sadly through experience you need to watch this stuff like a hawk. The communication with teams is poor. They ask you the same questions 10 times and they still somehow get it wrong and will use scare tactics if you request something not on their one size fits all chart. Even the opposite can be true. My oldest is paralyzed from the waist down and does not handle anesthesia well. When her leg broke we told them that localized is fine and she wouldn’t be in too much discomfort because she wasn’t. We only knew her leg was broken by the feel of her leg being really loose and she was fine and cheerful and had no idea. They had such a hard time of switching their focus of general broken leg management for all kids to one that can’t feel the pain due to her condition so you don’t need to over medicate. As predicted she did much better then when she was put under. You can’t trust hospitals to do it right. You need to advocate in person if a loved one is having surgery. They are going through too much to properly advocate for themselves.

When I was just short of five I broke my elbow and arm. After the surgery I woke up in the dark of the night in a hospital room with probably six other children. I started crying, in part for being in a strange place, in part for missing my parents, but mostly because I was in a lot of pain after the surgery. A nurse came and told me to stop crying because I was waking up the other kids. She did not ask me about my pain or try to comfort me.

My 13 year old son had neurosurgery and helping him come out of anesthesia while the NICU team got his pain under control was one of the most stressful parenting experiences I’ve had, and he remembers it. As much as we discussed and felt prepared for his surgery, his pain management just following surgery was something we did not discuss. We had excellent care, it just wasn’t on my mind until the heat of the moment. I wish I had been more prepared, for example if and to what extent they need the patient lucid to assess neurological function. This article highlights the importance of practitioners and families giving pain management careful thought and discussion in advance of surgery so that parents are prepared for different scenarios specific to the surgery, the child’s age and condition.

I had open heart surgery at eight in 1969, when the only imaging was from x-rays. Though I have only vague memories of pain and misery, what bothered me even more - and re-emerged after a medical crisis in my 50s - was being left alone in the ICU for all but 5 minutes of the hour. Psychological pain like that hurts as much, or more, than physical pain on a long-term basis. I'm just as glad that those policies have changed as well.

In 1952, i was severely burned as a child — age 2 1/2 — I remember the sheer terror I felt awaiting each burn treatment — I trembled and screamed and finally disassociated into the lights above the treatment table. To this day I have a terror of being powerless and helpless — I was forcibly held down as they treated my burns. Grown men scream under similar treatments. For the child’s sake PLEASE give them good pain management— don’t torture a child!

Thank you for writing this article. I had my first open heart surgery in 1980 at age 2. I don't have conscious memories of it, but when I was frequently sick as an older child, I was absolutely terrified of anything that might be even a tiny bit painful -- they would have to hold me down just to give me a shot. Today, it seems like every time I have a procedure all the past experiences come back and it becomes very re-traumatizing. I'm just not a trooper anymore. I have also had repeated experiences with doctors who don't take my pain and personal knowledge of what works for me seriously, so I really appreciate that this writer acknowledges that we all respond differently to medication. Two weeks ago I had my pacemaker replaced ( I am only 40 ) and it was an awful experience. I ended up in the ER a few days later (on Christmas) because the pain was so unbearable and the cardiologists on call treated me like a drug seeking crazy person (thanks, opioid crisis). (Unlike most people, my pacemaker is in my abdomen, so it wasn't such a straightforward surgery.) Anyway, I sometimes wonder about that very first surgery and how it shaped me, and how it might have been different--better. I'm so glad there has been some progress in this area.

Anthem is moving to stop reimbursement for pain management any time within 10 days of surgery. The rationale is that the surgeons should be able to do it. Once they establish this new policy other will undoubtedly follow suit. ...and the progress that has been made will be shoved backwards in the name of corporate profits. - The only way to stop Anthem and other insurance companies from returning pediatric (and adult) pain management to the dark days is to know about it, and to put pressure on them. Now you know about it - please apply appropriate pressure.

I was in the hospital many times as a child. I am now in my 60's. I was severely traumatized by my experiences in the hospital. To this day I dread any encounter with MDs and have a real phobia about being hospitalized. I was too young to remember some of my experiences but the ones I do recall are absolutely horrifying, especially when I was alone overnight and in pain and miserable with one arm forced to be held straight out with an IV in it and the other arm in a sling when I had osteomyelitis of the collar bone which caused severe pain down my arm so they wanted it immobile. I remember wetting the bed and having to wait for a nurse and pushing the call button and feeling humiliated and alone and wanting to die. My parents seemed incapable of understanding how badly I felt. When they did visit, they just kept saying "You'll be fine" but it certainly didn't feel that way. I wish someone in the hospital had been able to recognize that I was way too isolated and in pain and had at least sent someone who could have talked to me and read me a story or something. No, I was just left alone for hours and hours and I thought I was going insane.

As a 3month old infant in 1952, I had major abdominal surgery. I can only imagine how dismal the post pain management was then given how poorly we do this in 2019! As a retired nurse, I advocated for adequate post-op pain management for all my patients. With compassionate pain management, systemic stress in the body is lowered and people tend to recover more quickly. They move sooner. They can eat nourishing meals sooner. The psychological impact of untreated post-op pain is horrible and serves zero purpose in any patient. Without question we have an opioid crisis everywhere, but the knee jerk reaction to refuse post-op patients necessary and adequate pain control is cruel, especially for children. We can and must do better.

During the late 70's and early 80's I worked in the Operating Rooms of a major Pediatric teaching Hospital in the Midwest. One of the General Surgeons would often bring young children to the OR for placement of Broviac/Hickman catheter (for long term fluid administration). She insisted no sedation was necessary. She would wrap them in a very tight swaddle, then tape (using 2" wide tape) their little bodies to our smallest OR Table (the Swenson table), taping their heads too, to the side to position them for the procedure. She administered a small amount of local anesthesia but never waited for it to work. Many of these children were about 18-36 months old. As the RN Circulator it was my role to keep the child still and (attempt) to comfort them while they cried and screamed in pain. She insisted they would never remember this. I will never be convinced that these children were not traumatized by this experience. I know that I certainly was. A small amount of sedation would have made a world of difference- but she didn't want to slow down and take the time for that. I am certain that their parents had no idea of the trauma inflicted upon their child. So happy to know that their is advocacy for Pediatric patients today. I was a young nurse then and would not have questioned the authority of a Surgeon. Older and wiser now.

Remarkable how willing we humans have been to dismiss the pain of others who are not like us--in this case our own children! I see the same lack of empathy in our treatment of other races, minorities, and animals. The presumption should be, should always have been, that of course others experience pain. Do unto others...

As retired RN of over 30 years and as a mom, I recall clearly when kids, even after quite serious surgery, would be given only Tylenol (when Tylenol with Codeine was very available). Also, I disagree with Dr . Borde about using non opioid methods of pain relief rather than opioids. Opioids work by far the best for pain. I feel the doctor's opinion is based on the effects of the current "opioid epidemic" hysteria. These other methods should be adjuncts, not primary.

How sad to read this while seeing the impact of the CDCs new guidelines that have effectively prohibited treatment of post-surgical pain in adults. If you do not have the median response to surgery and pain medication, just suffer. "I'm not going to risk losing my license because you're in pain."

Such a great article!!

As a child I did not experience the same pain as I do now, even though I had several fractures and surgeries. I’m sure this has to do with brain and nervous system development as discussed in this article. Also I healed much faster as a child, which meant pain would only last for a week or two. But I remember usually receiving strong narcotic pain relievers after surgery for extreme pain, even at 4 or 5 years of age. Any doctor who does not approve appropriate pain medication is just ignorant and cruel. And I have never had a problem with addiction, now 52 years old with over 50 broken bones.

The people who soothe and care for these children are truly providing important, merciful care. Can children with severe chronic pain also be taught biofeedback or self hypnosis for some relief? Fortunately , modern disposable needles are not as large as the needles in the 1950s, etc.

A child of mine needed open-heart surgery as an infant and the doctors wanted me to stop using the opioid pain medication within a week of surgery. I just couldn't stop giving it to her when her hiccups (she had them a lot) clearly hurt her so badly. I think I made the right call. Due to the surgery, she also had RSV antibodies given to her regularly that winter, where they have a huge injection with a large needle. She's very frightened of needles still; she needed several nurses to hold her down for vaccinations until she was ten. I think such painful procedures are remembered at a very deep level. I would still have chosen the RSV vaccination, of course, because if she had gotten the virus it would have been very bad for her weakened body, far worse than the needle phobia. Neither I, nor my other kids has such a phobia.

“Too undeveloped to feel pain” is, not surprisingly, the same defense used by animal cruelty apologists.

In 1996, my son had emergency surgery for liver fracture at a major children's hospital (major abdominal surgery). He was 6 years old, and the "pain management team" wanted to have him manage his own pain by him pushing the button for IV. There was no way that he was in any condition for him to have made that kind of judgment on his own. Fortunately, one of his nurses had made it her personal crusade to make sure her patients had adequate pain management. She asked us what kind of child he normally was. He was a very well behaved 6 year old. In the hospital, he was clenching his muscles in pain. The nurse gave us a sigh and sad smile as she remarked "Well behaved children will suffer more because they don't want to make trouble". When she gave him the pain test with the faces, he pointed to the face with the tears, the highest level of pain. She immediately changed the order for pain meds to regular doses on a regular schedule. He made a full recovery.

When I was having my first permanent tooth drilled for a cavity as a youngster, the dentist offered me (actually offered my mother who authorized it) nitrous oxide or "Sweet-Air" as he called it, instead of lidocaine. I took the gas which did not eliminate the pain from drilling but it allowed me to detach myself from the pain. It was like I was in the dentist's chair and the pain was on the ceiling. It was an experience that decades later I applied to mindfulness practice. That is, you can experience pain (to a point) and see it as "not self." I wouldn't have believed this was possible were it not for the experience of using nitrous oxide at the dentist.

This is required reading for parents, and for anyone responsible for children. Some past experiences with children make me wonder if some of them, who had had painful ( and repeated) medical procedures, might have reactions not unlike torture victims which interfere with their development, and present lifelong challenges. As for outpatient surgery, where it's possible, I think it is desirable for a child to recuperate at home as long as parents are completely prepared - and not overwhelmed. But Dr or medical team should not assume that they can handle this, and there should be discretion.

My 12 year old daughter had ACL and meniscus surgery last year and was prescribed opioids; she also came home with a nerve block pump inserted in her leg. Managing the pain was of utmost importance and we did it very carefully, but she had significant and miserable opioid withdrawl for 2 days after only a week of opioid painkillers. There has to be a better way to provide children with pain relief without exposing their still-maturing bodies to the danger of opioids and more research done to better understand how children react to opioids. It was a terrifying experience for all of us.

I was born with a condition that led to multiple surgeries in my childhood and teen years. I think it's disgusting that opioid hysteria has trickled down to limiting children's pain relief even more than it already was. When I was little no one besides my parents cared if I was in pain. I remember being in so much pain from a surgery once that my only thought as I lay on the bed crying was wanting to die. I was 9. I was one of the lucky ones. My mom stayed with me 24/7 in the hospital and did her best to get me what pain relief they would offer. I certainly was not ready to be off heavy duty pain meds within a week of most of my surgeries. After one major back surgery the pharmacist refused to fill my pain medication prescription because he didn't believe a young teen needed opioid pain meds. Never mind that I had just had metal rods implanted and ribs removed. Pain control was better for my last and most minor related surgery. I had a nerve block which allowed me to use moderate amounts of a mild opioid instead of stronger medications and the nurses were very on top of the pain. It's well know that you can use less pain medication if you use it early instead of waiting to see if the pain continues to worsen (after surgery it does!). Yet I know talk to many parents whose children are having serious suegeries and are being given only tylenol and advil as they lay there screaming. A new generation of people like me, who have PTSD from poor medical care, is being created.

I remember as a young child being encouraged by my dentist to not use Novocain while drilling and his accolades of what a brave little boy I was. How I did that I will never know.