Guideline Development

The American Pediatric Surgical Association Outcomes and Evidence-based Practice committee identified 3 primary questions for review:

What are the risks of opioid misuse, diversion, heroin use, and conversion to long-term use in the pediatric population?

What nonopioid regimens are effective to manage postoperative pain in children (oral, intravenous and regional) (2a)? Relatedly, what procedures do not require opioids for postoperative recovery (2b), and what are the FDA black box warnings for tramadol and codeine (2c)?

What teaching or preparation regarding opioid use and perioperative pain management after surgery should be provided to patients and families?

For each question, controlled vocabulary and associated keywords and synonyms were used to search PubMed (MEDLINE) (eMethods1 in the Supplement), then adapted to search the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase, and Cochrane databases. Opioid misuse was defined according to the National Survey on Drug Use and Health (NSDUH) (eMethods2 in the Supplement).¹⁶ The pediatric population was defined as those younger than 18 years. Retrospective reports from adults of adolescent opioid use were included. Studies limited to the neonatal intensive care setting, animal and experimental studies, case reports, non–English language articles, reviews, editorials, studies of natural orifice endoscopy (upper or lower endoscopy, cystoscopy, and bronchoscopy), emergency department procedures, venipuncture, and dressing changes were excluded.

For question 1, searches were limited to January 1988 to February 2019. Estimates of adolescent opioid misuse and diversion were obtained from the 2017 NSDUH data files (eMethods 3 in the Supplement). For question 2, searches were limited to January 1997 through February 2019. For question 2b, searches of the FDA website and associated gray literature were performed.^17,18 Of note, in 1992, the US Agency for Health Care Policy and Research published recommendations for health care professionals on postoperative pain management in children.^19,20 Key recommendations included around-the-clock opioid administration. For this reason, the review for question 3 was limited to January 2003 through February 2019.

Articles selected for inclusion underwent abstract review by each working group: opioid misuse (L.I.K.-Q., M.G.K., C.M.H., and J.E.S.), nonopioid alternatives (E.K., R.L.R., K.A.D., R.B., and J.A.),and perioperative education (H.W., C.M.H., A.B., P.G., and M.C.W.H.). Abstract review and article inclusion was determined by working group consensus, and grading of evidence was performed using the Oxford Centre for Evidence-Based Medicine 2011 levels of evidence (eTables 1 and 2 in the Supplement).²¹ Disagreement on article inclusion was determined by working group leaders(L.I.K.-Q.,R.L.R., and C.M.H.). Risk of bias was assessed using Cochrane Handbook for Systematic Reviews of Interventions.²² The Preferred Reporting Items for Systematic Reviews and Meta-Analyses(PRISMA)guidelines were followed.²³ Overall quality of available evidence for each guideline was graded according to GRADE levels of quality (eTable 3 in the Supplement).²⁴ After conclusion of review, A Measurement Tool to Assess Systematic Reviews–2(AMSTAR-2) was used to grade the overall rigor of the review (eTable 4 in the Supplement),²⁵ and the protocol was registered on Open Science Framework. Outcomes measured to address literature review questions are outlined in eTable 5 in the Supplement.

A 2-day in-person meeting was held, including an experience guideline facilitator (R.B.) and a nonvoting record keeper (E.M.M.). Working groups presented literature reviews, discussed quality of data reviewed, risk of bias, and preliminary guideline statements. Anonymous, real-time electronic voting (https://www.polleverywhere.com/) was performed. Consensus was determined using a modified Delphi technique, requiring 80% consensus.