Anxiety and adverse childhood events are associated with increased perioperative pain in children

Background:
Anxiety has been noted to influence pain perception, but limited research exists demonstrating the impact of anxiety on children undergoing low-risk surgery. We hypothesized that higher pediatric anxiety would predict elevated perioperative pain perception.

Methods:
We recruited 53 patients aged 7-18 years undergoing elective operations in 2018-2019. Patients reported their personal anxiety and pain levels, and parents reported their own anxiety as well as the amount of pain they believed their child was experiencing. Participants completed an age-appropriate version of the State-Trait Anxiety Inventory (STAI), as well as a visual analog pain scale at a pre-surgical visit (V1), day of surgery (V2), and 2-week post-operative follow-up (V3). Demographic data and peri-operative conditions were recorded. Analysis was completed with multivariate regression using stepwise selection and student’s t-test.

Results:
Children with high pre-operative anxiety reported higher pain at all timepoints, including pre-op (p<0.001, R2=0.44), day of surgery (p=0.046, R2=0.41), and post-op (p=0.03, R2=0.15). A history of adverse childhood events was associated with higher pain at V1 (p=0.04) and V2 (p=0.01).
Parents reported their children experienced more pain at V1 for children with higher anxiety and a history of adverse childhood events (p=0.0001, R2=0.47); at V2 for female children and older children (p=0.009, R2=0.17); and at V3 for children with higher pre-op anxiety and higher post-op adult anxiety (p=0.02, R2=0.32).

Conclusions:
Children with high pre-operative anxiety as well as a history of adverse childhood events are significantly more likely to report higher pain throughout the perioperative period. These results suggest that adverse childhood experiences (ACEs) may play an early role in the pediatric general surgical setting. Our data provide the base from which future interventions may be established to reduce anxiety and improve perioperative pain in children.