Mother knows best…maybe

Myron Yaster

Alexandra S Kain, Michelle A Fortier, Candice D Donaldson, Daniel Tomaszewski, Michael Phan, Brooke N Jenkins. Parental Psychosocial Factors Moderate Opioid Administration Following Children's Surgery. Anesth Analg  2021 Jun 1;132(6):1710-1719 PMID: 33177324

there are known knowns; there are things we know we know. We also know there are known unknowns; that is to say, we know there are some things we do not know. But there are also unknown unknowns—the ones we don't know we don't know”. Donald Rumsfeld who died last week

First the known knowns: Each year, 5 million children undergo surgery in the United States, the majority of the procedures are done on an outpatient basis. It is a safe assumption (“a known known”), that many of these children will experience some degree of pain at home after surgery.  Most parents will receive instructions and prescriptions for analgesics such as acetaminophen, ibuprofen, and some opioid (in this study hydrocodone + acetaminophen or codeine). From many previous studies, we also know that parents will often not administer any of these drugs even if postoperative pain is obvious.

Next, the known unknowns: Does the appropriate use of opioids at a young age increase a person’s likelihood of later misuse? A very mixed bag of research results. This known unknown is a big driver of the opioid sparing/opioid omission cults.

Finally, unknown unknowns—the ones we don't know we don't know:  Do parental psychosocial variables have any impact on the administration of opioids to young children experiencing postoperative pain? Said differently, does parental anxiety, stress, and coping skills affect how they administer analgesics to their children?  The authors conclude “YES”!

When I practiced pediatric pain management a common aphorism I loved was “you can change many things in life, but you can never change your (or your patient’s) parents”.  So, the key finding of this study, that “parental stress and trait anxiety significantly moderate the relationship between child pain and opioid administration” is really not surprising.  The more stressed and anxious the parent, the more opioid and acetaminophen administered at home after surgery.  

In reality though, I’m not really sure how we can use this new “known known” knowledge in practice.  In the study, parents were given the state-trait anxiety inventory (STAI) preoperatively, a very well validated tool.  I just can’t imagine doing this in routine practice, so as practitioners we will be left with an unknown unknown.

A final thought: One issue I had with this paper was the use of hydrocodone as the therapeutic opioid for home.  Hydrocodone is only available as a combined product with acetaminophen.  Parents were given instructions to give both acetaminophen alone AND the hydrocodone (and its combined acetaminophen) as needed.  I think the potential for acetaminophen toxicity when doing this is too high for it to be accepted practice.  With all of its issues and problems, one of the reasons I always advocated for oxycodone was the ability to prescribe it as a single, non-acetaminophen combination product, so both it and acetaminophen could be used more safely.

Myron Yaster MD