Peri - Operative Pain

Last modified by Lisa Stromquist on 2018/02/08 18:07

Welcome to the toolbox about how acute post-operative pain and distress can be minimized for children. Current best evidence supports the use of suggested medications in children >6 months of age, however we suggest you consult your local formulary for more specific guidance. Physical and psychological interventions can be used in all ages.


“More than 80% of patients who undergo surgical procedures experience acute postoperative pain and approximately 75% of those with post-operative pain report the severity as moderate, severe, or extreme. Evidence suggests that less than half of patients who undergo surgery report adequate postoperative pain relief. Inadequately controlled pain negatively affects quality of life, function, and functional recovery, the risk of post-surgical complications, and the risk of persistent postsurgical pain.” {American Pain Society, The Journal of Pain, 2016}

Inadequately treated pain following surgery in infants and children delays healing and increases morbidity. Short-term consequences include pain and distress for the child, parents and healthcare providers, inadequate patient assessment, and slower healing. Long-term consequences include increased sensitivity to pain, healthcare avoidance, social hyper-vigilance and higher levels of anxiety before a medical visit. Expeditious and effective pain care improves patient and caregiver satisfaction, decreases the ‘wind-up’ phenomenon of untreated pain, and optimizes discharge times. 

The purpose of this toolbox is to make the treatment of children’s pain and distress easier in your clinical practice. We have seen these interventions suggested used for the pain and distress associated with appendectomy, fracture management surgery, tonsillectomy, spinal surgery, and other pediatric operative conditions. We strongly urge you to consider utilizing more than one complementary intervention, along with the medications, for children who have acute post-operative pain. The contents, which have been provided by your clinical colleagues around the country, can help you move these pharmacologic, physical, and psychological interventions into your regular practice, help create a policy for use their use in your organization, support clinical education in pain treatment efforts, and provide clinical resources to make these interventions easier to use. Use as many of the resources as you need and modify them to fit your organizational context. 

Physical and psychological interventions can also be used in conjunction with pharmacological (ie ibuprofen or opioids) pain management. Links to recommendations and resources for these techniques can be found through the main webpage for the CAPHC acute procedural pain toolboxes.


In this box you’ll find:

  • Family resources, including a brochure of comfort strategies, and a list of useful handheld device applications to help with distress & distraction.
  • Clinician Resources including dosing summary sheets, analgesia dosing handbooks, and pain management algorithms.
  • An example of hospital policy for the assessment and step-wise treatment of acute pain. This exemplar can be used to create your own organizational policy based on your needs and context.
  • Educational PowerPoint presentations developed by your clinical colleagues to support education about measuring and treating acutely painful conditions with physical and psychological interventions. These slides can be modified and delivered for your needs and context but please acknowledge the original authors and the CAPHC Pain CoP for their contributions.
  • Videos  from the UK about pain management in general aimed at parents
  • Background articles outlining the current best research evidence to support the assessment and treatment of peri-operative pain. These include general articles, as well as condition-specific articles.

Please note, examples of policies are provided for reference purposes, only. We encourage all users of the toolkit who wish to adopt a similar policy at their institution to review, adapt, and modify the examples, as needed. The providers of these examples do not endorse their use outside of the institution for which it was originally created

If you have any comments, questions or additions for the box, please contact CAPHC at
Thank you for supporting the CAPHC Pain Community of Practice’s mission to to improve health outcomes for infants and children by reducing pain experienced during medical procedures, healthcare interventions and chronic conditions, disease or disability. 

Family Resources

Podcasts and Apps for Pain Coping

Phone Applications for Mindfulness/Meditation:

  1. Smiling Mind (Free): Guided meditation for ages 7 to adult
  2. Headspace (Free): Guided meditation with animation
  3. Healing Buddies Comfort Kit (Free): Guided practice of skills for pain and nausea

Phone Applications for Anxiety:

  1. Mindshift (Free): Anxiety tracking app that helps people track anxiety triggers and situations

Biofeedback Tools:

  1. Heartmath software:
  2. Inner Balance for iPhoneStress Cards on Amazon

Kaiser Guided Imagery Podcasts

  1. Enter the link below in your browser

Other Websites / Tools:

  1. Pain Management Network – Relaxation Techniques and Mindfulness:
 Brochures and Handouts

Pain management after surgery - Holland Bloorview Kids Rehabilitation Hospital
Acute Pain Postcard - Holland Bloorview Kids Rehabilitation Hospital
Pain, Pain, Go Away: Helping children With Pain (Booklet) -  Patrick J. McGrath, G. Allen Finley, Judith Ritchie, and Stephanie J. Dowden  *Please note that, as of 2013, Health Canada does NOT support the use of codeine in children <12 years of age
Comfort Tips - Child Life Council
Comfort Holds - Stollery Children's Hospital 
Clinical Resources
  1. Assessment and Management of Pain Third Edition (RNAO 2013) *This is a comprehensive guide to pain assessment in nursing. Please see Appendices E,I, and J for pediatric-specific pain measurement tools, Appendix F for an algorithm-based approach to assessing pain in children, and Appendix N for an excellent summary of strategies for acute pain management in children
  2. Developmental Impacts of Hospitalization (Angela Mark BA CCLS)
  3. Mindful Distraction - Dr Bernie Whitaker RN BAppSci(Adv Nur) MNSt. Ph.D
  4. Non-pharmacological Interventions for Pain Management
  5. Pain After Surgery in Children and Infants - Fact Sheet (© Copyright 2017 International Association for the Study of Pain.)
  6. Rx Files  Cheat Sheet (L Regier BSP BA, B Jensen BSP, B Kessler BSP © Mar 2017)  *Please note that Health Canada does NOT support the use of codeine in children <12 years of age. Further, all health care professionals performing procedural sedation should have pediatric advanced life support training, and adhere to local patient monitoring guidelines when performing sedation.
  7. Stollery Pain Handbook - Alberta Health Services (2014)
  8. Stollery Pain Management Algorithm - Alberta Health Services (Reid, Lukenchuk, 2012)
  9. Practice Points: Acute Pain Management National Association of Orthopaedic Nurses

Hospital Policy
Educational PowerPoint
  1. Assessing Pediatric Pain in the Hospital and at Home - Vikram Sabhaney, MD, FRCPC
  2. Play Away the Pain - Bernadette Sanchez, CCLS
 VideosParent videos from the UK about pain management in general.   (Please note that there is some variation as they talk about “paracetamol”, etc)  
Title and video link: My Child is in Pain
Background ArticlesBackground Article list PDF

Agency Medical Directors Group (AMDG), Interagency Guideline on Prescribing Opioids for Pain Third Edition 2015 (See Part III, pages 26-31 for general opioid use recommendations for acute pain. Not specific to children)

American Pain Society, Management of Postoperative Pain: A Clinical Practice Guideline From the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists’ Committee on Regional Anesthesia, Executive Committee, and Administrative Council, The Journal of Pain, Vol 17, No 2 (February), 2016: pp 131-157

American Society of Anesthesiologists, Practice Guidelines for Postanesthetic Care An Updated Report by the American Society of Anesthesiologists Task Force on Postanesthetic Care, 2013  Anesthesiology, V 118  No 2 (This American Society of Anesthesiologists Guideline is for peri-operative pain, and while it includes evidence for pediatric patients, it is not a pediatric-specific resource.)

Drendel AL, Kelly BT, Ali S, Pain Assessment for Children Overcoming Challenges and Optimizing Care, Pediatric Emergency Care & Volume 27, Number 8, August 2011 (Please note that the Wong-Baker Faces Pain Scale is no longer considered a recommended tool for pain measurement in children, due to its highly subjective and culturally variable interpretation of the faces.)

Good Practice in Postoperative and Procedural Pain Management 2nd Edition, 2012 A Guideline from the Association of Paediatric Anaesthetists of Great Britain and Ireland, doi: 10.1111/j.1460-9592.2012.3838.x

Greco C, Berde C, Pain Management for the Hospitalized Pediatric Patient, Pediatr Clin N Am 52 (2005) 995– 1027 doi:10.1016/j.pcl.2005.04.005

Rusy L, Weisman S, Acute Postoperative Pediatric Pain Management: Pearls from a Busy Children’s Hospital, Techniques in Regional Anesthesia and Pain Management, Vol 6, No 2 (April), 2002: pp 66-69 doi:10.1053/trap.2002.122931Practice Guidelines for Acute Pain Management in the Perioperative Setting An Updated Report by the American Society of Anesthesiologists Task Force on Acute Pain Management, Anesthesiology, (2012) V 116  No 2

WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses (2012) (See Section 3, pages 36-53 for specific guidance regarding pharmacologic management of children’s pain)
Created by Lisa Stromquist on 2017/07/19 22:42