**4. Treatment of postoperative pain in pediatrics**

It is important to treat postoperative pain in pediatrics effectively to minimize discomfort and promote faster recovery, so some of the challenges associated with managing postoperative pain in children, including the lack of objective measures to assess pain, the variability in individual response to pain, and the need to balance the efficacy of treatment with potential side effects. It is important to explore various strategies to overcome these challenges such as the use of validated pain scales, personalization of treatment, and continuing education of healthcare personnel [2]. Treatment of postoperative pain in pediatrics may include a combination of pharmacological and non-pharmacological techniques. Some common treatment options include:


In addition to these treatment options, it is important that parents and medical staff work together to create a calm and comfortable environment for the patient.

Multimodal analgesia may include a combination of different drug classes such as nonsteroidal anti-inflammatory drugs (NSAIDs), opioids, local anesthetics, and gabapentinoids [3]. Drug selection and dosage must be individualized according to the needs of the patient. Furthermore, the choice of regional anesthesia technique may also influence the selection of multimodal analgesia. Regional anesthesia, such as epidural anesthesia or intravenous regional anesthesia, selectively blocks pain transmission from peripheral nerves to the spinal cord and brain, which may reduce the need for opioids and minimize opioid-associated side effects. In addition, regional anesthesia can reduce inflammation and the body's inflammatory response, which can help prevent chronic postoperative pain [4].

Some of the most commonly used NSAIDs in pediatrics include:


It is important to note that NSAIDs can have side effects such as gastric irritation, gastric ulcers, and kidney problems, so they should be used with caution and under the supervision of a physician. Also, each patient may react differently to medications, so it is important to adjust the dose and treatment regimen individually for each child [5].

The use of opioids in pediatrics is used to control moderate to severe pain in children and adolescents. However, their use must be carefully supervised by a doctor as they can have serious and potentially dangerous side effects. Opioids are used in situations where non-opioid pain relievers are not enough to control pain. They can be used for the management of postoperative pain, cancer pain, and pain associated with chronic diseases [6]. It is important to note that prolonged use of opioids in children and adolescents may increase the risk of developing dependence and addiction. Therefore, steps should be taken to reduce the amount of opioids used and their duration, in order to minimize the risk of long-term health problems.

There are different opioids that can be used in pediatrics, some of them are:

• Hydrocodone: It is recommended to start with the lowest possible dose and adjust the dose as necessary to achieve effective pain control without causing serious side effects. The recommended dose is 0.05–0.2 mg/kg every 4–6 hours as needed, with an upper limit of 5 mg per dose and 20 mg in 24 hours in children 6–12 years of age. In children over 12 years of age, the recommended dose is 2.5–10 mg every 4–6 hours as needed, with a maximum limit of 40 mg in 24 hours.


It is important to emphasize that the use of opioids in pediatrics must be carefully supervised by a physician since they can have serious and potentially dangerous side effects such as respiratory depression or excessive sedation. In addition, the dose and duration of treatment should be appropriate to the child's age and weight, and measures should be taken to reduce the amount of opioids used and their duration, in order to minimize the risk of dependence and long-term health problems.

Gabapentinoids, such as gabapentin and pregabalin, are also used in pediatrics for pain management. However, the evidence on its safety and efficacy in children is limited, and more studies are needed to determine its appropriate use in this population. Some studies have found that pregabalin may be effective for neuropathic pain in children and adolescents, but more research is needed in this field. Also, caution should be exercised when using gabapentinoids in children with kidney problems as these drugs are primarily eliminated by the kidneys [7].

The best option to decide pain management in pediatrics is the analgesic ladder. The pediatric analgesic ladder is based on the World Health Organization (WHO)

initiative for pain management in adult cancer patients. In 1986, the WHO proposed a guideline for pain management in adults with cancer, which became the WHO Analgesic Ladder in 1986. Later, in 1990, the WHO extended the analgesic ladder to include pain management in pediatric patients with cancer. Since then, the WHO analgesic ladder has become a standard guideline for pain management in pediatric and adult patients worldwide [8].

This staircase is divided into three levels:


The idea is to start at the bottom of the ladder and work your way up as necessary to control the patient's pain. It is important to note that analgesic selection should be based on the etiology of the pain and the age and weight of the patient, and that the dose and frequency should be individually adjusted [9].

Within the non-pharmacological alternatives for pain management, we can find psychological intervention. For this type of treatment, the importance of accurate assessment and diagnosis of the cause of the pain is paramount since there are different psychological approaches such as cognitive behavioral therapy, acceptance and commitment therapy, interpersonal therapy, and family therapy. There is evidence that suggests that these therapies can be effective in the management of chronic and recurrent pain in children and adolescents, improving the quality of life, functionality, and psychological well-being of patients. However, there are also limitations of psychological therapies such as:


However, more research is needed to determine the effectiveness of specific therapies for different types of pain: chronic and recurrent in specific populations of children and adolescents. To establish the best strategies for the implementation and integration of psychological treatments in pediatric medical care [10].
