Young children undergoing ambulatory orthopedic, urology, general surgery, and otolaryngology surgical procedures frequently experience post-surgical pain and exhibit maladaptive behaviors, such as increased crying, difficulty with sleep, and acting out.1

Researchers wanted to know whether the maladaptive behavior accompanying post-op pain was a phenomenon in the pediatric population of children 1-6 years of age, says Lena Sun, MD, Emanuel M. Papper professor of pediatric anesthesiology at Columbia University Medical Center in New York.

Investigators found that 69% of 204 patients in the study had experienced pain after two to three days, and 17% still experienced pain after one or two weeks post-discharge. The maladaptive behaviors were reported in 55% of children after two or three days and 15% after one or two weeks post-surgery. Investigators used a questionnaire survey to determine the pediatric patients’ pain levels and whether children exhibited maladaptive behaviors. They used the Parents’ Postoperative Pain Measure (PPPM) and Post-Hospital Behavior Questionnaire (PHBQ).1

“We wanted to know in an ambulatory population whether or not this was a prevalent issue,” Sun says. “We found it does occur for the first couple of days, but is relatively rare after a week.”

Previous research literature reported that children experienced pain for longer periods. But ASCs today are better at taking care of pediatric patients and preventing longer-term discomfort, she notes.

“Our data suggest that the providers are giving children and parents directions to prescriptions to pain medications, and they’re very compliant with taking those medications,” Sun says. “With this group we’ve studied, this has contributed to the findings that we’re doing a much better job than we used to do.”

Communication is key. “Postoperative pain is something that always should be discussed with patients,” Sun says.

“It’s very challenging to take care of young children,” Sun adds. “Especially with surgery and anesthesia, we don’t want them to get upset about every potential issue that occurs, so we want to give them the resources they need.”

Plus, physicians are better about identifying patients who need pain medication, and they’re communicating the importance of treating the children’s pain. The surgery team’s experience helps identify patients who might experience more pain. They can judge how well pediatric patients might do based on what they observe about patients in the recovery room, she adds.

“Surgeons know which type of surgical procedures are most likely to be painful, and they need to make sure parents are instructed that this procedure will be painful and which medications, including Tylenol and ibuprofen, they might want to think about,” Sun says.

If the procedure is not expected to be very painful, then that expectation can be conveyed, too. The point is that ASCs and physicians have gotten better at relaying these expectations along with post-surgery pain instructions.

“In the past, parents either didn’t fill the prescription or didn’t follow instructions well, so there was a barrier,” Sun says. “In our study cohort, the compliance rate appears to be quite good.”

The maladaptive behaviors identified in the children was associated with pain, but the other factors that affect such behavior are unknown, Sun says.

“It’s not due entirely to pain,” Sun says. “There are patients with zero pain who still have maladaptive behavior changes, so it’s not 100% related to pain.”

This is an area that should be studied further, she adds. It also helps families cope with their children’s pain and maladaptive behaviors if they can call someone to whom they can express concerns or ask questions.

“It’s important to make sure you have clear instructions and manage expectations and have communication open,” Sun says. “Parents should be able to call us from time to time, and I think that needs to be emphasized.”


  1. Cai Y, Lopata L, Roh A, et al. Factors influencing postoperative pain following discharge in pediatric ambulatory surgery patients. J Clin Anesth 2017;39:100-104.