Journal of Clinical Anesthesia 39 (2017) 100–104

Contents lists available at ScienceDirect

Journal of Clinical Anesthesia

Original Contribution

Factors influencing postoperative pain following discharge in pediatric

ambulatory surgery patients
Yi Cai, BA a, Lindsay Lopata, MD a, Arthur Roh, BA a, Mary Huang, DNP a, Matthew A. Monteleone, MD a,
Shuang Wang, PhD c, Lena S. Sun, MD a,b,⁎
a
Department of Anesthesiology, Columbia University, 622 West 168th Street, New York, NY 10032, United States
b
Department of Pediatrics, Columbia University Medical Center, 3959 Broadway, New York, NY 10032, United States
c
Department of Biostatistics, Columbia University, 722 West 168th St., New York, NY 10032, United States

a r t i c l e i n f o a b s t r a c t

Article history: Study objective: To identify demographic, intraoperative, and parental factors that influence the postoperative
Received 24 February 2017 pain experience in ambulatory surgery pediatric patients. We also monitored postoperative maladaptive behav-
Received in revised form 14 March 2017 ior changes (PMBCs) to investigate the relationship between pain and PMBCs.
Accepted 19 March 2017 Design: Prospective cohort study.
Available online xxxx
Setting: Discharge period after ambulatory surgery.
Patients: 204 patients ages 1–6 years undergoing ambulatory orthopedic, urology, general surgery, and otolaryn-
Keywords:
Pediatric postoperative pain
gology surgical procedures who were American Society of Anesthesiologists (ASA) physical status I or II.
Postoperative maladaptive behavior Interventions: None.
Pediatric ambulatory surgery Measurements: We administered telephone questionnaires to parents of ambulatory surgery patients 1–6 years
Pain medications old exploring pain ratings, behavior change ratings, and medication compliance at 2–3 days and 1–2 weeks
after surgery. Pain and behavioral change scores were obtained using the Parents Postoperative Pain Measure
(PPPM) and Post-Hospital Behavior Questionnaire (PHBQ). Parental medication compliance was defined as par-
ents who followed the discharge instructions for pain medication administration.
Main results: For our cohort, 69% of patients experienced pain after 2–3 days and 17% after 1–2 weeks post-dis-
charge. PMBCs were reported in 55% after 2–3 days, and in 15% after 1–2 weeks. In addition, PMBCs occurred in
the absence of pain (PPPM = 0) at rates of 20% and 5% at 2–3 days and 1–2 weeks after surgery, respectively. Fe-
male sex, anesthesia duration, and otolaryngology procedures correlated with higher postoperative pain (PPPM)
scores in univariate and multivariate analysis. Intraoperative medications did not correlate with PPPM or PHBQ
scores. Higher pain scores were associated with parents who were compliant with discharge instructions for pain
medications.
Conclusions: Many pediatric patients experienced short-term pain and PMBCs after ambulatory surgery, but these
largely resolved by 1–2 weeks following discharge. Patient sex, anesthesia duration, and surgical procedure influ-
enced postoperative pain and/or PMBCs. Furthermore, PMBCs were associated with, but not solely a manifesta-
tion of, postoperative pain.
© 2017 Published by Elsevier Inc.

1. Introduction
Children may experience pain and maladaptive behavioral changes
in the days and weeks after surgery, which importantly contribute to
the overall postoperative experience [1–3]. After surgery, 44–93% of pe-
diatric patients have been reported to experience postoperative pain [1,
3,4]. In addition, over half may exhibit new maladaptive behaviors two
⁎ Corresponding author at: E.M. Papper Professor of Pediatric Anesthesiology, Professor
of Anesthesiology and Pediatrics, Columbia University Medical Center, 622 W 168th St, CH
4-440 N, New York, NY 10032, United States.
E-mail address: lss4@columbia.edu (L.S. Sun).
weeks following discharge, and in 20% of children, these can persist for
up to six months [5]. Poor control of postoperative pain may contribute
to maladaptive behavioral changes and is associated with patient or
family dissatisfaction, perioperative morbidity and potentially have
long term effects on the child's emotional and cognitive well-being [2,
6–9].
Management of postoperative pain may be particularly challenging
in ambulatory surgery patients, as parents and caretakers must oversee
the majority of the recovery period. In younger children who may not be
able to adequately express their pain, this may be even more challeng-
ing. Several factors are known to influence the postoperative pain expe-
rience, including patient age, sex, and presence of pre-operative anxiety

http://dx.doi.org/10.1016/j.jclinane.2017.03.033
0952-8180/© 2017 Published by Elsevier Inc.
 Y. Cai et al. / Journal of Clinical Anesthesia 39 (2017) 100–104
[10,11]. Specific surgical subspecialty and type of operative procedure
within each subspecialty could also play important roles in influencing
postoperative pain in pediatric patients. For example, in pediatric pa-
tients, myringotomy with tube placement led to much less postopera-
tive pain than tonsillectomy (another otolaryngology procedure), as
well as less pain when compared to circumcision and inguinal hernia re-
pair [12]. The duration of postoperative pain also varied among proce-
dures, with tonsillectomy causing a longer duration of pain than
orchiopexy or inguinal hernia repair [13].
In addition to differences attributable to procedure-specific varia-
tions, the choice of anesthetic agents or adjunct medications and paren-
tal factors can also affect the postoperative pain experience. In pediatric
patients undergoing inguinal hernia repair, use of intravenous ketorolac
and supplemental local anesthesia more effectively reduced the severity
of post-discharge pain, compared to caudal anesthesia alone [14]. In
tonsillectomy patients, paracetamol in combination with codeine was
significantly more effective than the combination of paracetamol and
ibuprofen in reducing postoperative pain [15]. However, a comprehen-
sive analysis of the effects of intraoperative anesthetic and analgesic
agents on post-discharge pain has not been performed in pediatric pa-
tients. Specific parental factors that have been identified to affect post-
operative pain control include ability of parents to accurately evaluate
pain and compliance with discharge instructions related to pain medi-
cation use [16,17].
Maladaptive behavioral changes – such as in eating, sleeping and
separation anxiety – can also occur during the postoperative period
[18]. Postoperative maladaptive behavior changes (PMBCs) have many
different contributing factors, of which postoperative pain has been sug-
gested as an important contributor, and possibly a causal factor [19,20].
Other important factors include age, child temperament, ethnicity,
emotional disturbances and anxiety, which have also been shown to in-
crease the incidence of postoperative maladaptive behavior changes
[19–21].
The purpose of this study was to characterize factors that influence
postoperative pain in healthy pre-school age children during the two
weeks following ambulatory surgery, and to examine the relationship
between PMBCs and pain in this patient cohort. We hypothesized that
intraoperative factors including type of surgical procedure and anes-
thetic management are important factors influencing postoperative
pain and PMBCs in pediatric ambulatory patients.
2. Methods
This study was approved by the Columbia University Medical Center
Institutional Review Board, and informed written consent was obtained
from parents of all participants.
2.1. Patient criteria
This study examined postoperative pain management in female and
male patients ages 1–6 years undergoing ambulatory surgery in ortho-
pedic, urology, general surgery, and otolaryngology (OTO) procedures.
All American Society of Anesthesiologists (ASA) physical status I or II pa-
tients who stayed ≤23 h in the Post-anesthesia Care Unit (PACU) were
included in the study. Exclusion criteria included patients with ASA
physical status III or above, patients who were admitted as inpatients
for recovery, patients transferred to the Pediatric Intensive Care Unit,
or any patients with conditions that would affect pain expression or
sensation. We approached all eligible patients for participation in the
study and obtained consent from parents.
2.2. Data collection
Perioperatively, patient demographics, premedication received, and
intraoperative data were collected on the day of surgery and confirmed
by review of the anesthesia records. After discharge, parents/caregivers
101
were interviewed by telephone using the PPPM, PHBQ, and a question-
naire focused on pain medication management to understand post-dis-
charge pain management. The pain medication management telephone
questionnaire specifically queried adherence to pain medication regi-
men. These interviews were conducted at both 2–3 days and 8–
12 days, as per parent availability, after discharge from the PACU. Re-
sponses recorded at 2–3 days were considered short-term follow-up
and responses at 8–12 days (denoted 1–2 weeks) were considered
late follow-up.
2.3. Pain and behavior measure tools
The PPPM is a 15-item questionnaire, each item corresponding to a
score of 1 if positive. Thus, total scores range from 0 to 15. This tool
has been shown to be reliable between raters and is well-validated
[21,22]. It was originally validated for children age 7–12 years who
had undergone surgery based on examining relationships between par-
ent-report and child-rated pain, but has also been validated for children
aged 1–6 years with good internal consistency [21,23]. In our study, a
PPPM score of 0 was interpreted as no pain. Scores of 1–4, 5–9, and
≥ 10 were defined as mild, moderate, and severe pain, respectively.
The PHBQ, originally developed and validated in 1966, is a widely
used questionnaire to score behavioral changes in children after hospi-
talization. The 27-item questionnaire has questions in six subcategories:
apathy and withdrawal, aggression toward authority, general anxiety,
separation anxiety, eating disturbance, and sleep anxiety [24]. The
PHBQ items were scored on a 5-point Likert scale grading how much
the child exhibits a behavior postoperatively compared to a baseline
(1 = much less than before, 3 = same as before, 5 = much more
than before). Each item rated by parents as a 4 or 5 contributed one
point to the overall PHBQ score, ranging from 0 to 27. A score above 0
signifies the presence of maladaptive behavioral changes.
2.4. Pain medication
All medications were expressed as milligrams per kilogram, and opi-
oid medications (fentanyl, hydromorphone, remifentanil, and mor-
phine) were converted to total morphine equivalents in dose per
kilogram using the following conversion factors: 0.1 for fentanyl, 5 for
hydromorphone, 0.05 for remifentanil, and 1 for morphine.
2.5. Statistical analysis
Patient demographics that were examined as potential factors af-
fecting PPPM and PHBQ scores included age, sex, and insurance status.
Intraoperative variables that were examined included total dose of in-
traoperative drugs, duration of anesthesia, and type of surgery. Lastly,
pain medication compliance was defined as adherence to discharge in-
structions regarding use of pain medications at home in a subset of pa-
tients (n = 119) who had received medication prescription of pain
medications and discharge instructions for pain medications. Patients
who were not prescribed pain medications (n = 82) were grouped in
a separate category.
Patients undergoing otolaryngology, plastics, orthopedic, urology
and general surgery procedures were recruited. Due to the relatively
small sample sizes for many of the surgical subgroups, a total of three
groups of surgical procedures were included in the analysis, denoted
“OTO,” “Gen/Uro,” and “Others.” OTO procedures consisted of all tonsil-
lectomy and adenoidectomy/tonsillectomy procedures. The second
group consisted of general surgical and urological procedures as a single
group (Gen/Uro), given overlapping procedures such as inguinal hernia
repair. Plastic surgeries, orthopedic surgeries, and myringotomies
(when performed alone) were grouped into a single category as
“Others.”
In univariate analyses, we used two-sample t-tests or ANOVA to
compare PPPM and PHBQ scores between different groups and used
102 Y. Cai et al. / Journal of Clinical Anesthesia 39 (2017) 100–104

Table 1
Patient and intraoperative characteristics for pediatric ambulatory surgeries (n = 204).
Patients undergoing procedures in the following subspecialties were recruited: otolaryn-
gology (e.g. tonsillectomy and/or adenoidectomy, myringotomy); urology (e.g. circumci-
sion, inguinal hernia repair, hypospadias repair); general surgery (e.g. umbilical or
inguinal hernia repair); plastic surgery (e.g. local lesion excision); and orthopedic surgery
(e.g. finger release, forearm fracture reduction and internal fixation).

Age, mean ± standard deviation 4.1 ± 1.6 years

(SD)
Anesthesia duration, mean ± SD 78 ± 35 min
Morphine equivalents, mean ± SD 0.23 ± 0.59
mg/kg

Patient sex, n (%)

Male 141 (69)
Female 63 (31)

Insurance status, n (%)

n = 175 Private/self-pay 136 (78)
Medicaid 39 (22)

Surgery type, n (%)

Otolaryngologya 96 (47)
General 88 (43)
surgery/Urology
Others 20 (10)

Prescribed pain medication

Fig. 2. PHBQ score distribution in pediatric ambulatory surgery patients at 2–3 days and 1–
Yes, n (%) 2 weeks post-discharge, n = 204.
n = 119 Compliant 104 (87)
Not compliant 15 (13) of the study population. Statistical analysis was performed using Statis-
No, n tical Analysis System 9.2 and significance was defined as p b 0.05.
n = 82 82
a
This does not include myringotomies, which have been grouped in the “Others” category. 3. Results

We enrolled 214 patients, but 10 were lost to follow-up (i.e. were

Pearson correlation to correlate PPPM and PHBQ scores with continuous
predictors. In multivariate analyses, Poisson regressions were used to
examine the associations between surgery type and PPPM and PHBQ
scores, adjusting for other variables. Medication compliance was not ad-
justed when examining the effect of surgery type, as the effect of med-
ication compliance on PPPM and PHBQ scores was only meaningful
among those who had pain medication prescriptions, a smaller subset
unable to be reached by telephone). The demographic and periopera-
tive characteristics for the remaining 204 patients are shown in Table 1.
The PPPM and PHBQ score distributions for our cohort at 2–3 days
and 1–2 weeks post-discharge are shown in Figs. 1 and 2. The majority
of patients experienced some degree of postoperative pain and/or
PMBCs in the short term. At 2–3 days after discharge, 44% of patients ex-
perienced mild pain, while 18% and 6% experienced moderate or severe
pain, respectively. However, 31% of patients experienced no pain and
45% had no behavioral changes at 2–3 day follow-up. At 1–2 weeks
after discharge, 83% of patients had no pain and 85% had no PMBCs.
Though PPPM and PHBQ scores correlated with each other at both
time points (r = 0.73 and p b 0.0001 at 2–3 days; r = 0.67, p b 0.0001
at 1–2 weeks), PMBCs also occurred in the absence of postoperative
pain. In the 64 patients with a PPPM score of 0 at 2–3 day follow-up,
13 (20%) patients had at least one maladaptive behavioral change. At
1–2 week follow-up, 166 patients had a PPPM score of 0 and nine of
these patients (5%) had at least one maladaptive behavioral change.
In univariate analysis, age and insurance status had no statistically
significant effect on PPPM or PHBQ scores. Girls had statistically signifi-
cantly higher 2–3 day PHBQ scores than did boys (girls = 2.52 ± 2.97

Table 2
p-Values from univariate analyses between PPPM and PHBQ scores and predictors in pe-
diatric ambulatory surgery patients.

PPPM score PHBQ score

2–3 1–2 2–3 1–2

days weeks days weeks

Age 0.335 0.052 0.720 0.739

Anesthesia duration 0.001 0.010 0.002 0.016
Morphine equivalents 0.875 0.990 0.986 0.889
Patient sex (n = 204) 0.289 0.791 0.040 0.383
Surgery type (n = 204) 0.040 0.679 0.418 0.679
Insurance status (n = 175) 0.152 0.233 0.713 0.967
Medication compliance among those with 0.52 0.70 0.36 0.43
Fig. 1. PPPM score distribution in pediatric ambulatory surgery patients at 2–3 days and 1–
prescribed pain medication (n = 119)
2 weeks post-discharge, n = 204.
 Y. Cai et al. / Journal of Clinical Anesthesia 39 (2017) 100–104 103

Table 3
Patient PPPM and PHBQ scores by surgery typesa.

PPPM score PHBQ score

All surgeries (n = 204) OTOb (n = 96) Gen/Uroc (n = 88) Others (n = 20) All surgeries (n = 204) OTO (n = 96) Gen/Uro (n = 88) Others (n = 20)

2–3 days 2.89 ± 3.39 2.77 ± 3.13 3.39 ± 3.76 1.30 ± 2.34 1.95 ± 2.67 2.15 ± 2.76 1.89 ± 2.65 1.30 ± 2.23
1–2 weeksd 0.52 ± 1.70 0.54 ± 1.69 0.56 ± 1.84 0.20 ± 0.89 0.50 ± 1.67 0.56 ± 1.83 0.49 ± 1.63 0.20 ± 0.89
a
Presented are mean ± SD.
b
Otolaryngology.
c
General surgery/Urology.
d
PPPM at 1–2 weeks has n = 200.

versus boys = 1.70 ± 2.49), but the difference could not be considered
clinically significant. Among intraoperative variables, only anesthesia
duration was associated with PPPM and PHBQ scores (Table 2). Use of
pre-medication midazolam, intraoperative midazolam, acetaminophen,
and dexamethasone were not associated with PPPM and PHBQ scores.
Opioid medications, expressed as morphine equivalents were not asso-
ciated with PPPM and PHBQ scores. Ketorolac and dexmedetomidine
were used in only 5% and 7% of patients, respectively. Thus, due to the
small number of patients, no further analysis was performed. Type of
surgery was associated with PPPM score at 2–3 days (Table 2). The
mean PPPM and PHBQ scores by surgery type are shown in Table 3.
In multivariate analysis, the type of surgery and sex affected PPPM
and PHBQ scores on follow-up at 2–3 days, but not at 1–2 weeks
(Table 4). In particular, otolaryngology procedures and female sex
were associated with higher PPPM and PHBQ scores. Anesthesia dura-
tion was associated with PPPM and PHBQ scores at all time points
after adjusting for other covariates (Table 4). Anesthesia duration signif-
icantly differed across the three surgery groups (p = 0.02) with mean
durations of 71.9 ± 17.6, 85.3 ± 43.3, and 70.9 ± 49.3 min for the
OTO, Gen/Uro, and Others groups. Among those who had pain prescrip-
tions, parent compliance with pain medication instructions did not af-
fect PPPM and PHBQ scores during the follow up period (Table 2).
Compared to parents who reported compliance with prescribed pain
medications, those who were not prescribed any medications at dis-
charge had lower short-term PPPM, late PPPM, short-term PHBQ, and
late PHBQ scores (two-sample t-test with p b 0.05, data not shown).
4. Discussion
Our results indicate that many ambulatory pediatric surgical pa-
tients experience pain at early follow up after discharge, but postopera-
tive pain was mostly resolved by 1–2 weeks following discharge.
Though similar patterns have been reported in previous studies, the
rates of postoperative pain in our study were much lower [5,17]. In pa-
tients post-tonsillectomy and adenoidectomy, 7.2% continued to experi-
ence significant pain 2 weeks after discharge in a study reported in
2009, compared to 1.5% in our cohort [17]. The pattern was similar for
behavioral changes. At 2-week follow-up, PMBCs occurred in 15% of
our patients, compared to 54% in a study by Kain et al. in 1996 [5].
With regards to the decreased pain rates in tonsillectomy patients,
part of the decrease may be due to the adoption of less painful surgical
techniques, such as partial tonsillectomy in recent years [25].
However, the lower rates of pain and behavioral changes from our
study may suggest improved understanding and management of pain
during the postoperative, post-discharge period. This is supported by
our data on pain medication use and PPPM scores. In the post-discharge
period, postoperative pain is largely managed by parents, but must be
guided by clinicians via discharge instructions on the use of pain medi-
cations. In our study, higher PPPM scores were found in children whose
parents were compliant with discharge instructions for pain medica-
tions than when compared to those for children who were not pre-
scribed any pain medications. These findings suggest that children
who were more likely to experience postoperative pain were being
identified and prescribed medications; furthermore, their parents were
compliant with pain medication prescriptions. Our results thus suggest
an improvement in both clinician and parental management of the post-
operative experience. Nonetheless, our results still found that many pedi-
atric ambulatory surgery patients continued to have pain and
maladaptive behavioral changes after surgery. Therefore, there should
be continued efforts to further improve postoperative management in
the ambulatory pediatric surgical patient population [2].
Several limitations of our study must be addressed. Parental re-
ports of pain and behavioral change are subjective and thus may
not be comprehensive with regard to what was experienced by
their child. However, the instruments we utilized in this study are
validated pain and behavior scales that have been widely used and
provide standardization to the responses. We further acknowledge
that our study may well be affected by the Hawthorne effect due to
the observational nature of the study. Finally, we recognize that sev-
eral variables (i.e. parent education level, attitudes toward pain
medication, prior history of surgery) could affect the pediatric post-
operative pain experience and were not specifically examined in the
present study. These are areas that would be of interest for future
studies.

Table 4
p-Values from multivariate analyses between PPPM and PHBQ scores and predictors in pediatric ambulatory surgery patients (n = 175 complete responses).

2–3 day PPPM score 1–2 week PPPM score 2–3 day PHBQ score 1–2 week PHBQ score

Estimate 95% confidence p-Value Estimate 95% confidence p-Value Estimate 95% confidence p-Value Estimate 95% confidence p-Value
interval interval interval interval

Anesthesia duration 0.006 0.004 to 0.008 b0.0001 0.013 0.008 to 0.017 b0.0001 0.010 0.006 to 0.011 b0.0001 0.014 0.009 to 0.019 b0.0001
Morphine −0.008 −0.157 to 0.914 −0.116 −0.580 to 0.665 −0.113 −0.367 to 0.387 −0.102 −0.563 to 0.665
equivalents 0.140 0.347 0.142 0.359
Patient sex 0.292 0.101 to 0.483 0.003 0.008 −0.453 to 0.288 0.405 0.179 to 0.632 0.001 0.249 −0.210 to 0.288
0.470 0.709
Surgery type: OTO vs 1.040 0.579 to 1.501 b0.0001 0.983 −0.062 to 0.065 0.747 0.296 to 1.198 0.001 1.073 0.029 to 2.118 0.044
Others 2.027
Surgery type: 1.164 0.692 to 1.637 b0.0001 1.066 0.001 to 2.131 0.050 0.539 0.064 to 1.014 0.026 0.830 −0.247 to 0.131
Gen/Uro vs Others 1.906
Insurance status −0.180 −0.386 to 0.087 0.832 0.184 to 1.480 0.985 −0.132 −0.396 to 0.325 0.005 −0.523 to 0.985
0.026 0.131 0.533
104 Y. Cai et al. / Journal of Clinical Anesthesia 39 (2017) 100–104
No previous study has evaluated the potential effect of intraopera-
tive medications on postoperative pain. We found that PPPM scores
were not affected by any specific intraoperative medications or the
amount of opioids administered. However, our data showed that
PPPM scores were related to surgery type, anesthesia duration, and pa-
tient sex. Our data agree with prior studies indicating surgery type influ-
ences postoperative pain [12,13]. To our knowledge, anesthesia
duration has not been specifically studied in conjunction with PPPM
and PHBQ scores. Anesthesia duration may be a function of extensive-
ness of surgery, but surgery types were not shown to have any con-
founding effect per our multivariate analysis. Thus, future studies are
needed to examine the relationship between anesthesia duration and
postoperative pain.
Postoperative maladaptive behavior changes have been conjectured
to be related to or serve as an expression of postoperative pain in young
children. Although our data found a correlation between postoperative
pain and behavioral change scores, these results cannot be used to sug-
gest a causal relationship between postoperative pain and maladaptive
behavioral changes. Furthermore, we determined that 20% of patients
with no pain 2–3 days after surgery experienced PMBCs. Our results
thus indicate that maladaptive behavioral changes were likely more
than just a manifestation of postoperative pain.
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