Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes

Sarah R Martin; Theodore W Heyming; Michelle A Fortier; Zeev N Kain

doi:10.1136/emermed-2023-213858

Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes

Emerg Med J. 2024 May 8:emermed-2023-213858. doi: 10.1136/emermed-2023-213858. Online ahead of print.

Authors

Sarah R Martin^{1

2

3}, Theodore W Heyming^{3

4}, Michelle A Fortier^{2

5

6}, Zeev N Kain^{7

2

8

9}

Affiliations

¹ Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Irvine, California, USA sarahm7@hs.uci.edu.
² Center on Stress & Health, University of California, Irvine, Orange, CA, USA.
³ Emergency Medicine, Children's Hospital of Orange County, Orange, California, USA.
⁴ Department of Emergency Medicine, University of California Irvine, Irvine, California, USA.
⁵ Sue & Bill Gross School of Nursing, University of California Irvine, Irvine, California, USA.
⁶ Psychology, Children's Hospital of Orange County, Orange, California, USA.
⁷ Anesthesiology & Perioperative Care, University of California Irvine School of Medicine, Irvine, California, USA.
⁸ Children's Hospital of Orange County, Orange, California, USA.
⁹ Yale University Child Study Center, New Haven, CT, USA.

PMID: 38724104
DOI: 10.1136/emermed-2023-213858

Abstract

Background: Paediatric laceration repair procedures are common in the ED; however, post-discharge recovery remains understudied. Perioperative research demonstrates that children exhibit maladaptive behavioural changes following stressful and painful medical procedures. This study examined post-discharge recovery following paediatric laceration repair in the ED.

Methods: This prospective observational study included a convenience sample of 173 children 2-12 years old undergoing laceration repair in a paediatric ED in Orange, California, USA between April 2022 and August 2023. Demographics, laceration and treatment data (eg, anxiolytic medication), and caregiver-reported child pre-procedural and procedural pain (Numerical Rating Scale (NRS)) were collected. On days 1, 3, 7 and 14 post-discharge, caregivers reported children's pain and new-onset maladaptive behavioural changes (eg, separation anxiety) via the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery. Univariate and logistic regression analyses were conducted to identify variables associated with the incidence of post-discharge maladaptive behavioural change.

Results: Post-discharge maladaptive behavioural changes were reported in 43.9% (n=69) of children. At 1 week post-discharge, approximately 20% (n=27) of children exhibited maladaptive behavioural changes and 10% (n=13) displayed behavioural changes 2 weeks post-discharge. Mild levels of pain (NRS ≥2) were reported in 46.7% (n=70) of children on post-discharge day 1, 10.3% (n=14) on day 7 and 3.1% (n=4) on day 14. An extremity laceration (p=0.029), pre-procedural midazolam (p=0.020), longer length of stay (p=0.043) and post-discharge pain on day 1 (p<0.001) were associated with incidence of maladaptive behavioural changes. Higher pain on post-discharge day 1 was the only variable independently associated with an increased likelihood of maladaptive behavioural change (OR=1.32 (95% CI 1.08 to 1.61), p=0.001).

Conclusion: Over 40% of children exhibited maladaptive behavioural changes after ED discharge. Although the incidence declined over time, 10% of children continued to exhibit behavioural changes 2 weeks post-discharge. Pain on the day following discharge emerged as a key predictor, highlighting the potential critical role of proactive post-procedural pain management in mitigating adverse behavioural changes.

Keywords: pain management; pediatric emergency medicine; pediatric injury.