We are delighted to present the Emerging Trends in Pediatric Pain 2022 article collection. This collection showcases the high-quality work of internationally recognized researchers in the early to mid stages of their research careers. These rising star researchers have been recognized by the Frontiers in Pain Research Editors for their potential to influence the future directions in their respective fields. The work presented here highlights the diversity of research performed across the entire breadth of pediatric pain and presents advances in theory, experimental techniques, and methodology along with their application. New articles will be added to this collection as they are published.

University of Rovira i Virgili

University of British Columbia

The prevention of chronic pain in pediatric patients is a pressing issue, and this research topic explores the various interventions and strategies that can be used to improve the quality of life of these patients. <ul> <li>The pTPS was established to address four main areas of need related to the prevention of chronic pain in pediatric patients, and works with healthcare providers, patients, and their families to improve quality of life.</li> <li>MyoActivation needling therapy was found to improve pain, flexibility, and range of motion, suggesting that a larger, prospective clinical trial is warranted to further explore its impact.</li> <li>Gender-specific peer support can help disrupt the trajectory to adverse outcomes for adolescent girls living with scoliosis.</li> <li>Regional pain control interventions can be effective and safe for relieving pain and suffering in pediatric cancer patients at the end of life.</li> <li>The use of 24% sucrose prior to skin-breaking procedures in preterm infants was effective in reducing pain over the course of their NICU hospitalization.</li> </ul>

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Frontiers in Pain Research

Pediatric Pain

Emerging Trends in Pediatric Pain

Editorial on the Research Topic <a href="https://www.frontiersin.org/research-topics/45201/emerging-trends-in-pediatric-pain">Emerging trends in pediatric pain</a>Only recently have clinicians, investigators, and the public come to recognize unique requirements for assessment and treatment of pain in infants, young children, and adolescents as well as related longstanding inadequacies in clinical practice. Transformations in the experience, expression, and response to care through progression from infancy to adolescence (and continuing stages of life) require attention when providing treatment. One cannot talk to infants to either discover the nature of their painful distress or to provide solace, necessitating attention to nonverbal expression, and, while verbal capacities in older children and adolescents permit at least limited access to experience, careful attention to nonverbal expression in these populations allows a broader understanding of sensations, feelings, and thoughts. This series of six papers illustrates the necessity of incorporating consideration of the developmental stage of the person in an effort to understand and ameliorate painful distress. <a href="https://doi.org/10.3389/fpain.2023.1127800">Cuviello et al.</a>, in their paper, Regional blocks for pain control at the end of life in pediatric oncology demonstrate the importance of attending to personal distress at the end of life at all stages of childhood. The paper by <a href="https://doi.org/10.3389/fpain.2023.1110502">Bueno et al.</a>, The effectiveness of repeated sucrose for procedural pain in neonates in a longitudinal observational study demonstrates that standardized detailed behavioural observation reveals the benefits of sucrose administration in newborns during skin-breaking procedures. Similarly, but in older children, <a href="https://doi.org/10.3389/fpain.2023.1225088">Bhatnagar et al.</a>, show the value of behavioural observation in their paper, Assessing changes in range of motion in adolescent patients undergoing myoActivation® for chronic pain related to myofascial dysfunction. <a href="https://doi.org/10.3389/fpain.2023.1125963">Vigouroux et al.</a>, demonstrate the potential adverse effects of preconceptions concerning the pain of others in “He told me my pain was in my head”: Mitigating testimonial injustice through peer support. The risks that injustice appraisals will exacerbate emotional upheaval are evident in the paper by <a href="https://doi.org/10.3389/fpain.2023.1080461">Daenen et al.</a>, Youth baseline and state pain-related injustice appraisals are associated with emotional responses of anger and sadness: An experimental study. The paper, Development and expansion of a pediatric transitional pain service to prevent complex chronic pain, by <a href="https://doi.org/10.3389/fpain.2023.1173675">Isaac et al.</a>, demonstrates the benefits of systematically structuring services to ensure acute pain does not transition into a prolonged problem.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

Editorial: Emerging trends in pediatric pain

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child&apos;s pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for &gt;3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain

IntroductionmyoActivation® assessment utilizes systemized movement tests to assess for pain and limitations in motion secondary to myofascial dysfunction. myoActivation needling therapy resolves the myofascial components of pain and is associated with immediately observed changes in pain, flexibility, and range of motion. The principal aim of this feasibility study was to objectively characterize the kinematic metrics of upper and lower body motion before and after myoActivation movement tests and therapy.</sec>MethodsFive consecutive eligible adolescent participants considered appropriate for myoActivation were consented to receive their myoActivation intervention in a motion laboratory. Clinical motion analysis was used to measure the changes in maximum range of motion (maxROM) and maximum angular speed to maximum ROM (speedROM) of movement tests predicted to change. Metrics were analyzed to assess changes over specified time intervals - i) baseline to after initial myoActivation session, and ii) baseline to after complete myoActivation course. Each participant served as their own control.</sec>ResultsWe demonstrated objective evidence of improved maxROM and/or speedROM in 63% of the movement tests predicted to change after just one session of myoActivation and in 77% of movement tests predicted to change over the complete course of treatment. The myoActivation clinician observed positive change in 11/19 of movement tests across all patients, that were predicted to change after the initial myoActivation session; 81% of these positive changes were confirmed by the kinematic data.</sec>DiscussionClinical motion analysis provides objective support to clinicians evaluating, treating, and teaching myofascial release. A larger, prospective clinical trial is warranted to explore the impact of myoActivation on movement. Refinement of observation techniques and outcome measures established in this feasibility study will strengthen future clinical motion analysis of the myoActivation process.</sec>

Introduction: myoActivation® assessment utilizes systemized movement tests to assess for pain and limitations in motion secondary to myofascial dysfunction. myoActivation needling therapy resolves the myofascial components of pain and is associated with immediately observed changes in pain, flexibility, and range of motion. The principal aim of this feasibility study was to objectively characterize the kinematic metrics of upper and lower body motion before and after myoActivation movement tests and therapy.Methods: Five consecutive eligible adolescent participants considered appropriate for myoActivation were consented to receive their myoActivation intervention in a motion laboratory. Clinical motion analysis was used to measure the changes in maximum range of motion (maxROM) and maximum angular speed to maximum ROM (speedROM) of movement tests predicted to change. Metrics were analyzed to assess changes over specified time intervals - i) baseline to after initial myoActivation session, and ii) baseline to after complete myoActivation course. Each participant served as their own control.Results: We demonstrated objective evidence of improved maxROM and/or speedROM in 63% of the movement tests predicted to change after just one session of myoActivation and in 77% of movement tests predicted to change over the complete course of treatment. The myoActivation clinician observed positive change in 11/19 of movement tests across all patients, that were predicted to change after the initial myoActivation session; 81% of these positive changes were confirmed by the kinematic data.Discussion: Clinical motion analysis provides objective support to clinicians evaluating, treating, and teaching myofascial release. A larger, prospective clinical trial is warranted to explore the impact of myoActivation on movement. Refinement of observation techniques and outcome measures established in this feasibility study will strengthen future clinical motion analysis of the myoActivation process.

Assessing changes in range of motion in adolescent patients undergoing myoActivation® for chronic pain related to myofascial dysfunction: a feasibility study

IntroductionWomen with disabilities are exposed to sexism and ableism, earn less income, and work in exceptionally challenging conditions compared to women without disabilities and men with or without disabilities. Adolescent girls living with scoliosis may begin experiencing this compounding bias during their encounters with healthcare from the moment they start noticing differences in their bodies. Being significantly more likely than boys to progress to a curve angle where painful treatment such as bracing or spinal fusion surgery is required, adolescent girls living with scoliosis are therefore more likely to experience chronic pain. The long-term impact of pain and pain-related stigma includes lower educational attainments, decreased vocational functionality, and social impairments in adults after having experienced chronic pain in adolescence.</sec>ApproachIn this article, the authors will explore the effects and mechanisms of gender-specific peer support in disrupting this trajectory to adverse outcomes. Through individual interviews consisting of open-ended questions, the researchers gathered narrative data from Curvy Girls members, a community-based peer support group for girls and young women living with scoliosis. The data was analyzed using an applied philosophical hermeneutics approach, with intersectionality and testimonial injustice as their framework.</sec>FindingsThey found that the study participants had their pain narratives reinterpreted by the adults in their lives, including their parents and healthcare practitioners, leading them to question and doubt their own experiences.</sec>DiscussionThese negative outcomes were mitigated through the peer support they received and offered from Curvy Girls. Participants reported having gained confidence and a sense of belonging after they joined this group, allowing them to better cope with their condition more effectively in different facets of their lives.</sec>

Introduction: Women with disabilities are exposed to sexism and ableism, earn less income, and work in exceptionally challenging conditions compared to women without disabilities and men with or without disabilities. Adolescent girls living with scoliosis may begin experiencing this compounding bias during their encounters with healthcare from the moment they start noticing differences in their bodies. Being significantly more likely than boys to progress to a curve angle where painful treatment such as bracing or spinal fusion surgery is required, adolescent girls living with scoliosis are therefore more likely to experience chronic pain. The long-term impact of pain and pain-related stigma includes lower educational attainments, decreased vocational functionality, and social impairments in adults after having experienced chronic pain in adolescence.Approach: In this article, the authors will explore the effects and mechanisms of gender-specific peer support in disrupting this trajectory to adverse outcomes. Through individual interviews consisting of open-ended questions, the researchers gathered narrative data from Curvy Girls members, a community-based peer support group for girls and young women living with scoliosis. The data was analyzed using an applied philosophical hermeneutics approach, with intersectionality and testimonial injustice as their framework.Findings: They found that the study participants had their pain narratives reinterpreted by the adults in their lives, including their parents and healthcare practitioners, leading them to question and doubt their own experiences.Discussion: These negative outcomes were mitigated through the peer support they received and offered from Curvy Girls. Participants reported having gained confidence and a sense of belonging after they joined this group, allowing them to better cope with their condition more effectively in different facets of their lives.

“He told me my pain was in my head”: mitigating testimonial injustice through peer support

BackgroundYouth pain-related injustice appraisals are associated with adverse functioning; however, mechanisms by which injustice appraisals exert their impact have yet to be elucidated. Adult injustice literature suggests anger, sadness, and attention bias to anger (AB) as potential mechanisms. This study examined the effects of injustice appraisals in a healthy youth sample by applying a justice violation manipulation. We hypothesized the justice violation condition to lead to worse pain outcomes with effects mediated by anger, sadness, and AB as compared to the control condition. We further explored associations between both baseline and state injustice appraisals and anger, sadness, and AB across conditions.</sec>MethodsA 2 × 2 time by condition design was used to test hypotheses. 133 healthy youth aged 9–16 years old completed two cold pressor tasks (CPTs). In the experimental (i.e., justice violation) group, participants were initially told to complete one CPT, but were told afterwards to perform it again due to experimenter negligence. In the control group, no justice violation occurred. Baseline injustice appraisals and pain catastrophizing were assessed with the Injustice Experience Questionnaire and Pain Catastrophizing Scale for Children; state outcomes (i.e., injustice, catastrophizing, anger, sadness) were assessed after CPTs. AB was indexed using a dot-probe task.</sec>ResultsFindings indicated no effects of the justice violation on pain outcomes or associated mechanisms, nor on injustice appraisals, suggesting manipulation failure. However, across conditions, baseline and state injustice appraisals were positively associated with anger and sadness, but not with AB.</sec>ConclusionsDespite the experimental justice violation failing to elicit differential injustice appraisals across conditions, the current study supports both anger and sadness as key emotional responses associated with pain-related injustice appraisals in a healthy youth sample.</sec>

Background: Youth pain-related injustice appraisals are associated with adverse functioning; however, mechanisms by which injustice appraisals exert their impact have yet to be elucidated. Adult injustice literature suggests anger, sadness, and attention bias to anger (AB) as potential mechanisms. This study examined the effects of injustice appraisals in a healthy youth sample by applying a justice violation manipulation. We hypothesized the justice violation condition to lead to worse pain outcomes with effects mediated by anger, sadness, and AB as compared to the control condition. We further explored associations between both baseline and state injustice appraisals and anger, sadness, and AB across conditions.Methods: A 2 × 2 time by condition design was used to test hypotheses. 133 healthy youth aged 9–16 years old completed two cold pressor tasks (CPTs). In the experimental (i.e., justice violation) group, participants were initially told to complete one CPT, but were told afterwards to perform it again due to experimenter negligence. In the control group, no justice violation occurred. Baseline injustice appraisals and pain catastrophizing were assessed with the Injustice Experience Questionnaire and Pain Catastrophizing Scale for Children; state outcomes (i.e., injustice, catastrophizing, anger, sadness) were assessed after CPTs. AB was indexed using a dot-probe task.Results: Findings indicated no effects of the justice violation on pain outcomes or associated mechanisms, nor on injustice appraisals, suggesting manipulation failure. However, across conditions, baseline and state injustice appraisals were positively associated with anger and sadness, but not with AB.Conclusions: Despite the experimental justice violation failing to elicit differential injustice appraisals across conditions, the current study supports both anger and sadness as key emotional responses associated with pain-related injustice appraisals in a healthy youth sample.

Youth baseline and state pain-related injustice appraisals are associated with emotional responses of anger and sadness: An experimental study

BackgroundPain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients.</sec>ObjectiveTo describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology.</sec>MethodsA retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated.</sec>ResultsTwenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were −2.5 and −2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists (96% and 93%, respectively). Twenty-three (85%) had physician orders for scope of treatment orders completed before death.</sec>ConclusionRegional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life.</sec>

Background: Pain management at the end of life is a fundamental aspect of care and can improve patients' quality of life. Interventional approaches may be underutilized for pediatric cancer patients.Objective: To describe a single institution's 10 years of experience with regional pain management at the end of life in pediatric oncology.Methods: A retrospective cohort study of 27 patients with pediatric cancer who died between April 2011 and December 2021 and received continuous nerve block (CNB) catheters or single-shot nerve blocks (SSBs) during their last three months of life. The type of blocks, analgesic efficacy, and palliative care involvement were evaluated.Results: Twenty-two patients (81.5%) had solid tumor diagnoses, including carcinomas, sarcomas, and neuroblastoma. Most (59%) patients received CNB catheters, and 12 patients (44%) received SSBs for pain control. The mean pain score decreases for CNB catheters and SSBs after interventions were −2.5 and −2.8, respectively, on an 11-point scale. Decreases in opioid patient-controlled analgesia dosing requirements were noted in 56% of patients with CNB catheters; likewise, in 25% of patients with SSBs at 24 h and in 8% at 5 days after interventions. Nearly all patients had PC involvement and received care from pain specialists (96% and 93%, respectively). Twenty-three (85%) had physician orders for scope of treatment orders completed before death.Conclusion: Regional pain control interventions can be effective and safe for relieving regional pain and suffering in dying children and young adults. The collaboration between palliative care and pain management specialists at the end of life can help alleviate suffering and improve quality of life.

Regional blocks for pain control at the end of life in pediatric oncology

GoalTo determine the analgesic effectiveness of repeated sucrose administration for skin-breaking (SB) procedures over the Neonatal Intensive Care Unit (NICU) hospitalization of preterm infants.</sec>MethodsLongitudinal observational study, conducted in four level III Canadian NICUs. Eligible infants were <32 weeks gestational age at birth, and <10 days of life at enrollment. Infants received 24% sucrose (0.12 ml) prior to all painful procedures. The Premature Infant Pain Profile – Revised (PIPP-R) was used at 30 and 60 seconds after a medically-required SB procedure as soon as possible after enrollment and weekly up to three additional times for scheduled procedures.</sec>Results172 infants (57.3% male, gestational age 28.35 (±2.31) weeks) were included. The mean 30 s PIPP-R scores were 6.11 (±3.68), 5.76 (±3.41), 6.48 (±3.67), and 6.81 (±3.69) respectively; there were no statistically significant interactions of study site by time (p = 0.31) or over time (p = 0.15). At 60 s, mean PIPP-R scores were 6.05 (±4.09), 5.74 (±3.67), 6.19 (±3.7), and 5.99 (±3.76) respectively; there were no study site by time interactions (p = 0.14) or differences over time (p = 0.52). There was a statistically significant site difference in the effectiveness of sucrose at 30 and 60 seconds (p < 0.01).</sec>ConclusionsConsistently low PIPP-R scores following a skin-breaking procedure indicated that the analgesic effectiveness of the minimal dose of sucrose was sustained over time in the NICU. Further research is required to determine the optimal combination of sucrose and other pain management strategies to improve clinical practice and the impact of consistent use of repeated use of sucrose on neurodevelopment.</sec>

Goal: To determine the analgesic effectiveness of repeated sucrose administration for skin-breaking (SB) procedures over the Neonatal Intensive Care Unit (NICU) hospitalization of preterm infants.Methods: Longitudinal observational study, conducted in four level III Canadian NICUs. Eligible infants were &lt;32 weeks gestational age at birth, and &lt;10 days of life at enrollment. Infants received 24% sucrose (0.12 ml) prior to all painful procedures. The Premature Infant Pain Profile – Revised (PIPP-R) was used at 30 and 60 seconds after a medically-required SB procedure as soon as possible after enrollment and weekly up to three additional times for scheduled procedures.Results: 172 infants (57.3% male, gestational age 28.35 (±2.31) weeks) were included. The mean 30 s PIPP-R scores were 6.11 (±3.68), 5.76 (±3.41), 6.48 (±3.67), and 6.81 (±3.69) respectively; there were no statistically significant interactions of study site by time (p = 0.31) or over time (p = 0.15). At 60 s, mean PIPP-R scores were 6.05 (±4.09), 5.74 (±3.67), 6.19 (±3.7), and 5.99 (±3.76) respectively; there were no study site by time interactions (p = 0.14) or differences over time (p = 0.52). There was a statistically significant site difference in the effectiveness of sucrose at 30 and 60 seconds (p &lt; 0.01).Conclusions: Consistently low PIPP-R scores following a skin-breaking procedure indicated that the analgesic effectiveness of the minimal dose of sucrose was sustained over time in the NICU. Further research is required to determine the optimal combination of sucrose and other pain management strategies to improve clinical practice and the impact of consistent use of repeated use of sucrose on neurodevelopment.