Korean J Pain.  2015 Oct;28(4):244-253. 10.3344/kjp.2015.28.4.244.

Predictive Factors of Postoperative Pain and Postoperative Anxiety in Children Undergoing Elective Circumcision: A Prospective Cohort Study

• Zavras N
• Tsamoudaki S
• Ntomi V
• Yiannopoulos I
• Christianakis E
• Pikoulis E

• KMID: 2151667
• DOI: http://doi.org/10.3344/kjp.2015.28.4.244

Abstract

BACKGROUND
Although circumcision for phimosis in children is a minor surgical procedure, it is followed by pain and carries the risk of increased postoperative anxiety. This study examined predictive factors of postoperative pain and anxiety in children undergoing circumcision.
METHODS
We conducted a prospective cohort study of children scheduled for elective circumcision. Circumcision was performed applying one of the following surgical techniques: sutureless prepuceplasty (SP), preputial plasty technique (PP), and conventional circumcision (CC). Demographics and base-line clinical characteristics were collected, and assessment of the level of preoperative anxiety was performed. Subsequently, a statistical model was designed in order to examine predictive factors of postoperative pain and postoperative anxiety. Assessment of postoperative pain was performed using the Faces Pain Scale (FPS). The Post Hospitalization Behavior Questionnaire study was used to assess negative behavioral manifestations.
RESULTS
A total of 301 children with a mean age of 7.56 +/- 2.61 years were included in the study. Predictive factors of postoperative pain measured with the FPS included a) the type of surgical technique, b) the absence of siblings, and c) the presence of postoperative complications. Predictive factors of postoperative anxiety included a) the type of surgical technique, b) the level of education of mothers, c) the presence of preoperative anxiety, and d) a history of previous surgery.
CONCLUSIONS
Although our study was not without its limitations, it expands current knowledge by adding new predictive factors of postoperative pain and postoperative anxiety. Clearly, further randomized controlled studies are needed to confirm its results.

Keyword

Anxiety, Child; Circumcision; Pain measurement; Phimosis; Postoperative pain; Predictive value of tests; Questionnaires

MeSH Terms

Anxiety*
Child*
Circumcision, Male*
Cohort Studies*
Demography
Education
Female
Hospitalization
Humans
Male
Models, Statistical
Mothers
Pain Measurement
Pain, Postoperative*
Phimosis
Postoperative Complications
Predictive Value of Tests
Prospective Studies*
Siblings
Surgical Procedures, Minor

Reference

1. Beyaz SG. Comparison of postoperative analgesic efficacy of caudal block versus dorsal penile nerve block with levobupivacaine for circumcision in children. Korean J Pain. 2011; 24:31–35. PMID: 21390176.

2. Tree-Trakarn T, Pirayavaraporn S. Postoperative pain relief for circumcision in children: comparison among morphine, nerve block, and topical analgesia. Anesthesiology. 1985; 62:519–522. PMID: 3885795.

3. Wollin SR, Plummer JL, Owen H, Hawkins RM, Materazzo F, Morrison V. Anxiety in children having elective surgery. J Pediatr Nurs. 2004; 19:128–132. PMID: 15077211.

4. Ader R, Cohen N, Felten D. Psychoneuroimmunology: interactions between the nervous system and the immune system. Lancet. 1995; 345:99–103. PMID: 7815892.

5. Caumo W, Broenstrub JC, Fialho L, Petry SM, Brathwait O, Bandeira D, et al. Risk factors for postoperative anxiety in children. Acta Anaesthesiol Scand. 2000; 44:782–789. PMID: 10939690.

6. Bonica JJ. The need of a taxonomy. Pain. 1979; 6:247–248. PMID: 460931.

7. Beesdo K, Knappe S, Pine DS. Anxiety and anxiety disorders in children and adolescents: developmental issues and implications for DSM-V. Psychiatr Clin North Am. 2009; 32:483–524. PMID: 19716988.

8. Kain ZN, Mayes LC, Cicchetti DV, Bagnall AL, Finley JD, Hofstadter MB. The Yale Preoperative Anxiety Scale: how does it compare with a "gold standard"? Anesth Analg. 1997; 85:783–788. PMID: 9322455.

9. Cumino Dde O, Cagno G, Gonçalves VF, Wajman DS, Mathias LA. Impact of preanesthetic information on anxiety of parents and children. Braz J Anesthesiol. 2013; 63:473–482. PMID: 24565345.

10. Christianakis E. Sutureless prepuceplasty with wound healing by second intention: an alternative surgical approach in children's phimosis treatment. BMC Urol. 2008; 8:6. PMID: 18318903.

11. Cuckow PM, Rix G, Mouriquand PD. Preputial plasty: a good alternative to circumcision. J Pediatr Surg. 1994; 29:561–563. PMID: 8014816.

12. Bieri D, Reeve RA, Champion GD, Addicoat L, Ziegler JB. The Faces Pain Scale for the self-assessment of the severity of pain experienced by children: development, initial validation, and preliminary investigation for ratio scale properties. Pain. 1990; 41:139–150. PMID: 2367140.

13. Gedaly-Duff V, Ziebarth D. Mothers' management of adenoid-tonsillectomy pain in 4- to 8-year-olds: a preliminary study. Pain. 1994; 57:293–299. PMID: 7524009.

14. Vernon DT, Schulman JL, Foley JM. Changes in children's behavior after hospitalization. Some dimensions of response and their correlates. Am J Dis Child. 1966; 111:581–593. PMID: 5939538.

15. Vernon DT, Thompson RH. Research on the effect of experimental interventions on children's behavior after hospitalization: a review and synthesis. J Dev Behav Pediatr. 1993; 14:36–44. PMID: 8432877.

16. Karling M, Stenlund H, Hägglöf B. Child behaviour after anaesthesia: associated risk factors. Acta Paediatr. 2007; 96:740–747. PMID: 17462064.

17. Kain ZN, Wang SM, Mayes LC, Caramico LA, Hofstadter MB. Distress during the induction of anesthesia and postoperative behavioral outcomes. Anesth Analg. 1999; 88:1042–1047. PMID: 10320165.

18. Stargatt R, Davidson AJ, Huang GH, Czarnecki C, Gibson MA, Stewart SA, et al. A cohort study of the incidence and risk factors for negative behavior changes in children after general anesthesia. Paediatr Anaesth. 2006; 16:846–859. PMID: 16884468.

19. Yuki K, Daaboul DG. Postoperative maladaptive behavioral changes in children. Middle East J Anaesthesiol. 2011; 21:183–189. PMID: 22435270.

20. Kain ZN, Mayes LC, Caldwell-Andrews AA, Karas DE, McClain BC. Preoperative anxiety, postoperative pain, and behavioral recovery in young children undergoing surgery. Pediatrics. 2006; 118:651–658. PMID: 16882820.

21. Kain ZN, Mayes LC, Wang SM, Hofstadter MB. Postoperative behavioral outcomes in children: effects of sedative premedication. Anesthesiology. 1999; 90:758–765. PMID: 10078677.

22. Watson AT, Visram A. Children's preoperative anxiety and postoperative behaviour. Paediatr Anaesth. 2003; 13:188–204. PMID: 12641680.

23. Lardner DR, Dick BD, Crawford S. The effects of parental presence in the postanesthetic care unit on children's postoperative behavior: a prospective, randomized, controlled study. Anesth Analg. 2010; 110:1102–1108. PMID: 20103538.

24. Aguilera IM, Patel D, Meakin GH, Masterson J. Perioperative anxiety and postoperative behavioural disturbances in children undergoing intravenous or inhalation induction of anaesthesia. Paediatr Anaesth. 2003; 13:501–507. PMID: 12846706.

25. Liu X, Guo C, Okawa M, Zhai J, Li Y, Uchiyama M, et al. Behavioral and emotional problems in Chinese children of divorced parents. J Am Acad Child Adolesc Psychiatry. 2000; 39:896–903. PMID: 10892232.

26. Weaver JM, Schofield TJ. Mediation and moderation of divorce effects on children's behavior problems. J Fam Psychol. 2015; 29:39–48. PMID: 25419913.

27. Duru E, Poyrazli S. Personality dimensions, psychosocial demographic variables, and English language competency in predicting level of acculturative stress among Turkish international students. Int J Stress Manag. 2007; 14:99–110.

28. Suarez-Morales L, Lopez B. The impact of acculturative stress and daily hassles on pre-adolescent psychological adjustment: examining anxiety symptoms. J Prim Prev. 2009; 30:335–349. PMID: 19408124.

29. Behnke AO, MacDermid SM, Coltrane SL, Parke RD, Duffy S, Widaman KF. Family cohesion in the lives of Mexican American and European American parents. J Marriage Fam. 2008; 70:1045–1059.

30. Sam DL, Berry JW. Acculturation: when individuals and groups of different cultural backgrounds meet. Perspect Psychol Sci. 2010; 5:472–481. PMID: 26162193.

31. Leidy MS, Parke RD, Cladis M, Coltrane S, Duffy S. Positive marital quality, acculturative stress, and child outcomes among Mexican Americans. J Marriage Fam. 2009; 71:833–847.

32. Karling M, Hägglöf B. Child behaviour after anaesthesia: association of socioeconomic factors and child behaviour checklist to the Post-Hospital Behaviour Questionnaire. Acta Paediatr. 2007; 96:418–423. PMID: 17407469.

33. Kain ZN, Mayes LC, O'Connor TZ, Cicchetti DV. Preoperative anxiety in children. Predictors and outcomes. Arch Pediatr Adolesc Med. 1996; 150:1238–1234. PMID: 8953995.

34. Kotiniemi LH, Ryhänen PT, Moilanen IK. Behavioural changes in children following day-case surgery: a 4-week follow-up of 551 children. Anaesthesia. 1997; 52:970–976. PMID: 9370839.

35. Eckenhoff JE. Relationship of anesthesia to postoperative personality changes in children. AMA Am J Dis Child. 1953; 86:587–591. PMID: 13103772.

36. Thompson RH, Vernon DT. Research on children's behavior after hospitalization: a review and synthesis. J Dev Behav Pediatr. 1993; 14:28–35. PMID: 8432876.

37. Fortier MA, Del-Rosario AM, Martin SR, Kain ZN. Perioperative anxiety in children. Paediatr Anaesth. 2010; 20:318–322. PMID: 20199609.

38. Kain ZN, Caldwell-Andrews AA, Maranets I, McClain B, Gaal D, Mayes LC, et al. Preoperative anxiety and emergence delirium and postoperative maladaptive behaviors. Anesth Analg. 2004; 99:1648–1654. PMID: 15562048.

39. Kain ZN, Caramico LA, Mayes LC, Genevro JL, Bornstein MH, Hofstadter MB. Preoperative preparation programs in children: a comparative examination. Anesth Analg. 1998; 87:1249–1255. PMID: 9842807.

40. Margolis JO, Ginsberg B, Dear GL, Ross AK, Goral JE, Bailey AG. Paediatric preoperative teaching: effects at induction and postoperatively. Paediatr Anaesth. 1998; 8:17–23. PMID: 9483593.

41. Pederson C. Effect of imagery on children's pain and anxiety during cardiac catheterization. J Pediatr Nurs. 1995; 10:365–374. PMID: 8544113.

42. Bringuier S, Dadure C, Raux O, Dubois A, Picot MC, Capdevila X. The perioperative validity of the visual analog anxiety scale in children: a discriminant and useful instrument in routine clinical practice to optimize postoperative pain management. Anesth Analg. 2009; 109:737–744. PMID: 19690240.

43. Ericsson E, Wadsby M, Hultcrantz E. Pre-surgical child behavior ratings and pain management after two different techniques of tonsil surgery. Int J Pediatr Otorhinolaryngol. 2006; 70:1749–1758. PMID: 16814402.

44. Palermo TM, Drotar D. Prediction of children's postoperative pain: the role of presurgical expectations and anticipatory emotions. J Pediatr Psychol. 1996; 21:683–698. PMID: 8936897.

45. Logan DE, Rose JB. Is postoperative pain a self-fulfilling prophecy? Expectancy effects on postoperative pain and patient-controlled analgesia use among adolescent surgical patients. J Pediatr Psychol. 2005; 30:187–196. PMID: 15681313.

46. Crandall M, Lammers C, Senders C, Braun JV. Children's tonsillectomy experiences: influencing factors. J Child Health Care. 2009; 13:308–321. PMID: 19833669.

47. Elemen L, Seyidov TH, Tugay M. The advantages of cyanoacrylate wound closure in circumcision. Pediatr Surg Int. 2011; 27:879–883. PMID: 20941598.