Jennifer Rabbitts, MD is Professor and Chief of Pediatric Pain Management at Stanford University School of Medicine. Dr. Rabbitts directs an NIH-funded research laboratory focused on improving long-term pain and health outcomes in children and adolescents undergoing surgery. Her research is devoted to understanding and preventing chronic postsurgical pain, a disabling condition affecting 20% youth undergoing major surgery. Her current research studies investigate the role of biopsychosocial mechanisms including child psychosocial factors, parental/family factors, and psychophysical processes underlying acute to chronic pain transition. Current clinical trials focus on testing feasibility and efficacy of psychosocial and complementary and integrative interventions to improve acute postsurgical pain and prevent transition to chronic pain.

Dr Rabbitts is passionate about mentoring, serving as mentor for the Women's Empowerment and Leadership Initiative and for the Mission Driven Mentoring Program for Diversity, Equity, and Inclusion, of the Society for Pediatric Anesthesia. She serves as section editor for Psychology, Psychiatry and Brain Neuroscience Section for Pain Medicine, on the editorial boards for Pediatric Anesthesia and Journal of Pain, and actively serves on committees in the United States Association for the Study of Pain.

Clinical Focus

  • Pain Medicine

Academic Appointments

Administrative Appointments

  • Chief of Pediatric Pain Management, Stanford University (2023 - Present)
  • Governance Committee, Department of Anesthesiology, Perioperative, and Pain Medicine, Stanford University (2023 - Present)
  • Council on University Relations, University of Washington (2022 - 2023)
  • Executive Steering Committee, Center for Clinical and Translational Sciences, Seattle Children’s Research Institute (2022 - 2023)
  • Faculty Senate, University of Washington (2022 - 2023)
  • Program Chair, Research Platform Award, Center for Clinical and Translational Sciences, Seattle Children's Research Institute (2022 - 2023)

Honors & Awards

  • NIH HEAL Director’s Trailblazer Honorable Mention and Travel Award, NIH HEAL Initiative (2023)
  • NIH HEAL Spotlight, NIH HEAL Initiative, NIH HEAL (2023)
  • Future Leaders in Pain Research Award, American Pain Society (2015)
  • Judy Y.L. Su. Ph.D. Endowed Research Training Award, University of Washington (2015)
  • Junior Investigator Award for Pain in Infants, Children, and Adolescents, Shared Interest Group for Pain in Infants, Children, and Adolescents, American Pain Society (2015)
  • Science Advance in Pain Research, the Interagency Pain Research Coordinating Committee, NIH IPRCC (2015)
  • Duane K. Rorie Award in Laboratory Research, Mayo Clinic College of Medicine, Rochester (2010)
  • Richard A. Theye Award in Clinical Research, Mayo Clinic College of Medicine, Rochester, MN (2009)

Boards, Advisory Committees, Professional Organizations

  • Opioid Stewardship Committee, Stanford Children's Health (2023 - Present)
  • Scientific Program Chair for the 14th International Symposium on Pediatric Pain, IASP (2023 - 2023)
  • Section Editor, Psychology, Psychiatry and Brain Neuroscience Section, Pain Medicine (2021 - Present)
  • Mentor, Mission Driven Mentoring Program for Diversity, Equity, and Inclusion, Society for Pediatric Anesthesia (2022 - Present)
  • Member, Society for Pediatric Anesthesia Young Investigator Grant Review Committee, Society for Pediatric Anesthesia (2021 - Present)
  • Mentor, Women’s Enrichment and Leadership Initiative, Society for Pediatric Anesthesia (2018 - Present)
  • Editorial Board Member, Journal of Pain (2016 - Present)
  • Member, Biomarkers and Study Design Working Group, Early Phase Pain Investigation Clinical Network, Help End Addiction Longterm (HEAL) Initiative, NIH (2021 - 2023)
  • Member, Coalition Building Committee, United States Association for the Study of Pain, USASP (2021 - 2023)
  • ChildKind International Resource Committee Chair, ChildKind International (2019 - 2023)
  • Director-at-Large (elected), Board of Directors, American Pain Society (2019 - 2019)
  • Chair elect, Shared Interest Group on Pain in Infants, Children, and Adolescents, American Pain Society, American Pain Society (2018 - 2019)
  • Chair, Early Career Advisory Group, American Pain Society, American Pain Society (2015 - 2017)

Professional Education

  • Board Certification: American Board of Anesthesiology, Pediatric Anesthesia (2015)
  • Board Certification: American Board of Anesthesiology, Anesthesia (2010)
  • Fellowship: Mayo Clinic Training Programs GME Verification (2010) MN
  • Residency: Mayo Clinic Training Programs GME Verification (2009) MN
  • Internship: Mayo Clinic Internal Medicine Residency (2006) MN
  • Medical Education: University of Stellenbosch (2002) South Africa
  • Research Fellowship, Mayo Clinic Rochester MN (2011)
  • Fellowship, Mayo Clinic Rochester MN (2010)
  • Residency, Mayo Clinic Rochester MN (2009)
  • Medical Education, Faculty of Medicine and Health Sciences, University of Stellenbosch (2002)

Clinical Trials

  • Digital Health Psychosocial Intervention for Adolescent Spine Surgery Preparation and Recovery Recruiting

    This is a randomized controlled trial to test effectiveness of the SurgeryPal intervention vs. education control to improve acute and chronic pain and health outcomes in youth undergoing major musculoskeletal surgery. Youth will be randomized on an individual level using a factorial design to SurgeryPal or Education during 2 phases of intervention: 1) pre-operative phase (4 week duration delivered over the 4 weeks leading up to surgery), and 2) post-operative phase (4 week duration following surgery). Thus there will be 4 treatment arms. Participants will undergo 4 assessments, independent of their treatment assignment: T1: Baseline (pre-randomization); T2: acute post-surgery outcomes (daily assessment of acute outcomes beginning day 1 through day 14 after hospital discharge from surgery); T3: Post-surgery follow-up (assessment of outcomes at 3-months post-surgery); T4: Final post-surgery follow-up (assessment of outcomes at 6-months post-surgery).

    View full details

  • Studying Melatonin and Recovery in Teens Not Recruiting

    The goal of this feasibility clinical trial is to learn if melatonin can help teens having spinal fusion surgery by promoting healthy sleep. Melatonin is available as a dietary supplement that may be effective in promoting longer, higher quality sleep. This study will assess the feasibility and acceptability of melatonin for teens undergoing spinal fusion surgery, as well as determine optimal measured outcomes (sleep, pain, health-related quality of life) at short- and long-term follow-up.

    Stanford is currently not accepting patients for this trial. For more information, please contact Jennifer A Rabbitts, M.D., 650-725-0540.

    View full details


  • Mechanisms of transition from acute to chronic pain in youth undergoing musculoskeletal surgery (R01AR073780), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS, NIH) (2018 - 2024)

    Background: Chronic postsurgical pain (CPSP) has been recognized as a major health concern across the lifespan. Adolescents undergoing invasive musculoskeletal surgeries, such as spinal fusion, are particularly at risk for developing CPSP. At present, little is known about the critical recovery period during the initial weeks after spinal fusion surgery when acute postsurgical pain begins to transition to CPSP, or the mechanisms contributing to this transition.

    Aims: 1) Identify acute recovery patterns that predict CPSP, using short-term trajectories of pain, sleep quality, mood, and physical function over the first 30 days following spinal fusion surgery. 2) Determine the psychosocial and psychophysical mechanisms of the relationship between acute recovery and the development of chronic postsurgical pain.

    Study Design: Participants will be 160 youth, ages 10-18, and scheduled for spinal fusion surgery at Seattle Children's Hospital and CHOC, along with one of their parents/caregivers. Participants will complete 5 timepoints over 1 year. Assessments include 4 online questionnaire measures for parents and youth, 30 days of brief online check-ins post-surgery, and 3 lab-based evaluations of pain thresholds for youth.


    Seattle, WA

  • Effectiveness of an mHealth psychosocial intervention to prevent transition from acute to chronic postsurgical pain in adolescents (UG3/UH3HD102038), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD, NIH) (2019 - 2024)

    Background: Acute and chronic postsurgical pain (CPSP) are a major health concern across the lifespan. Adolescents undergoing invasive musculoskeletal surgeries are particularly at risk, with 20% developing CPSP and associated deterioration in health-related quality of life (HRQL). Despite research demonstrating the importance of psychological factors in the persistence of pain and opioid use following surgery, standard perioperative care in youth relies on opioids to treat pain. Non-pharmacological interventions are not accessible or widely used in this population.

    Aims: 1) Determine the effectiveness of a pre-operative mHealth psychosocial intervention to improve acute pain outcomes in adolescents undergoing major musculoskeletal surgery, 2) Determine the effectiveness of a post-operative mHealth psychosocial intervention to improve chronic pain outcomes at 3 months in adolescents undergoing major musculoskeletal surgery, 3) Determine the combined effects of pre-and post-operative CBT on chronic pain outcomes, and 4) Explore mechanisms of a mHealth psychosocial intervention to prevent CPSP.

    Study Design: The study design is a randomized controlled trial in 500 youth, ages 12-18 years, undergoing spinal fusion surgery and their parents. In addition to standard perioperative care, participants will be randomized using a factorial design to receive psychosocial intervention (SurgeryPal) or education (attention control condition) at two treatment phases, each of 4-weeks duration (pre-operative and post-operative) to test the timing of intervention delivery. Primary study outcomes are acute pain severity and opioid use assessed over the first 2 weeks after surgery, and chronic pain and HRQL at 3- and 6-month follow-ups. Secondary outcomes include psychosocial distress, sleep disturbance, and opioid misuse.


    Seattle, WA

  • Preventing the Transition from Acute to Chronic Musculoskeletal Pain in Adolescents after Surgery: The Role of Sleep (K24AR080786), National Institute of Arthritis and Musculoskeletal and Skin Diseases (NIAMS, NIH) (2023 - 2028)


    Stanford, CA

  • Prevalence and predictors of opioid misuse after adolescent spinal fusion surgery (UH3HD102038-02S1), Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD, NIH) (2020 - 2024)


    Seattle, WA

All Publications

  • Prescription Opioid Decision-Making and Use Behaviors in Adolescents with Acute Pain: A Qualitative Study. The Clinical journal of pain Kapos, F. P., Gordon, G. O., Groenewald, C. B., Slack, K., Wang, V., Palermo, T. M., Wilson, A. C., Rabbitts, J. A. 2024


    Understanding adolescent perspectives on prescribed opioids in the context of medical care for acute pain is needed to prevent opioid-related adverse outcomes. We explored factors that may influence opioid decision-making and use behaviors among adolescents prescribed opioids for acute pain.We conducted semi-structured interviews with nineteen adolescents (63% females, ages 12-17) prescribed opioids upon discharge from surgery or intensive care unit admission. Interview transcripts were coded using inductive thematic analysis.Five themes were identified: "Opioid use to reduce extreme pain and facilitate acute recovery"; "Familiarity with risks and negative effects of opioids"; "Assessment of opioid risk based on individual characteristics and use behaviors"; "Careful balance of risks, benefits, and symptoms when taking opioids"; "Importance of trusted adults for adolescent opioid management". Adolescents commonly believed opioids are only appropriate for severe pain that cannot be managed with other strategies. Most (but not all) adolescents were aware of addiction and other potential opioid harms, and generally disapproved of misuse. However, a few adolescents would consider taking unprescribed opioids for severe pain. Adolescents wanted to be well informed for opioid decision-making, considering guidance from trusted adults.Adolescents often demonstrated active and sound participation in shared opioid decision-making, influenced by complex integration of inputs and self-reflection. Conversely, potential factors that could contribute to risky behaviors included low personal risk perceptions, uncertainty about what constitutes opioid misuse, and avoidance of prescribed opioids despite extreme pain. Future studies may explore associations of adolescents' opioid decision-making with longer-term pain and opioid-related outcomes.

    View details for DOI 10.1097/AJP.0000000000001205

    View details for PubMedID 38347761

  • Feasibility and reliability of a quantitative sensory testing protocol in youth with acute musculoskeletal pain postsurgery or postinjury PAIN Li, R., Holley, A. L., Palermo, T. M., Ohls, O., Edwards, R. R., Rabbitts, J. A. 2023; 164 (7): 1627-1638


    Quantitative sensory testing (QST) is increasingly used in pediatric chronic pain; however, assessment in youth with acute musculoskeletal (MSK) pain is limited. This study evaluated the feasibility, reliability, and sources of variability of a brief QST protocol in 2 clinical samples of youth with acute MSK pain. Participants were 277 youth (M age = 14.5 years, SD = 2.0, range = 11-18 years, 59% female, 81% non-Hispanic) across 3 geographic study sites who completed a QST protocol assessing pressure and thermal pain sensitivity, temporal summation of pain, and conditioned pain modulation 8 weeks after MSK surgery (n = 100) or within 4 weeks after an acute MSK injury (n = 177). High feasibility was demonstrated by protocol completion rates ranging from 97.5% to 100% for each task, with 95.3% of youth completing all tasks. Reliability was high, with reliability coefficients of >0.97 for 7 out of 8 QST parameters and minimal influence of examiner or participating site effects. Younger youth had lower pressure and heat pain thresholds (11-12 vs 13-18 years, d = -0.80 to -0.56) and cold pain tolerance (d = -0.33). Hispanic youth had higher pressure and heat pain thresholds (d = 0.37-0.45) and pain ratings for cold pain tolerance (d = 0.54) compared with non-Hispanic youth. No significant differences were observed in QST values by sex or personal contextual factors at the time of assessment (momentary pain, menstrual period, use of pain medications). Overall findings demonstrate feasibility of a brief QST protocol with youth with diverse acute MSK pain and data provide initial support for the reliability of this QST protocol for multisite research studies.

    View details for DOI 10.1097/j.pain.0000000000002865

    View details for Web of Science ID 001011949500021

    View details for PubMedID 36727891

    View details for PubMedCentralID PMC10277219

  • A pilot feasibility and acceptability study of an Internet-delivered psychosocial intervention to reduce postoperative pain in adolescents undergoing spinal fusion CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR Murray, C. B., Bartlett, A., Meyyappan, A., Palermo, T. M., Aaron, R., Rabbitts, J. 2022; 6 (1): 12-23


    Spinal fusion surgery is a common and painful musculoskeletal surgery performed in the adolescent population. Despite the known risk for developing chronic postsurgical pain, few perioperative psychosocial interventions have been evaluated in this population, and none have been delivered remotely (via the Internet) to improve accessibility.The aim of this single-arm pilot study was to evaluate the feasibility and acceptability of the first Internet-based psychological intervention delivered during the perioperative period to adolescents undergoing major spinal fusion surgery and their parents.Thirteen adolescents (M age = 14.3; 69.2% female) scheduled for spine fusion surgery and their parents were provided access to the online psychosocial intervention program. The program included six lessons delivering cognitive-behavioral therapy skills targeting anxiety, sleep, and acute pain management during the month prior to and the month following surgery. Feasibility indicators included recruitment rate, intervention engagement, and measure completion. Acceptability was assessed via quantitative ratings and qualitative interviews.Our recruitment rate was 81.2% of families approached for screening. Among participating adolescent-parent dyads, high levels of engagement were demonstrated (100% completed all six lessons). All participants completed outcome measures. High treatment acceptability was demonstrated via survey ratings and qualitative feedback, with families highlighting numerous strengths of the program as well as areas for improvement.These findings suggest that this online psychosocial intervention delivered during the perioperative period is feasible and acceptable to adolescents and their parents. Given favorable feasibility outcomes, an important next step is to evaluate the intervention in a full-scale randomized controlled trial.

    View details for DOI 10.1080/24740527.2021.2009334

    View details for Web of Science ID 000782271800001

    View details for PubMedID 35434455

    View details for PubMedCentralID PMC9009921

  • Trajectories, Risk Factors, and Impact of Persistent Pain After Major Musculoskeletal Surgery in Adolescents: A Replication Study JOURNAL OF PAIN Ellyson, A. M., Gordon, G., Zhou, C., Rabbitts, J. A. 2022; 23 (6): 995-1005


    Studies have identified high rates of chronic postsurgical pain in adolescents. Characterizing patterns of pain in the transition from acute to chronic following major surgery may pinpoint critical periods of recovery. This observational study modelled pain trajectories over 1-year following surgery to attempt replication of prior work and evaluate baseline psychosocial factors and 12-month health outcomes. Adolescents 10 to 18 years completed electronic daily pain reporting for 7 days and self-reported health outcomes, at 5 assessment timepoints. Group-based trajectory modelling identified two trajectories with similar starting points in-hospital but distinct recovery courses at home. Pain declined steadily in one group across the study period ("Declining Pain"; estimated probability,18.9%), but pain increased after hospital discharge and remained high through 12-months in the other group ("High and Persistent Pain"; estimated probability,81.1%). Pre-surgery pain (Aor = 1.86, P = .001) and sleep quality (Aor = 0.49, P = .029) were associated with the High and Persistent pain trajectory in multivariate regressions. This trajectory was associated with lower total quality of life (B=-9.79, P = .002), physical health (B = -15.93, P < .001), psychosocial health (B = -6.73, P = .06), and greater fatigue (B = -13.61, P = .001). This study replicated prior findings identifying two post-surgical pain trajectories with diverging pain in the first two weeks. Clinical detection of those with increasing pain and early intervention may interrupt persistence of pain. PERSPECTIVE: This article replicates a prior study identifying distinct post-surgical pain trajectories, Declining Pain and High and Persistent Pain. The High and Persistent pain trajectory is associated with pre-surgery pain, pre-surgery sleep quality, and lower quality of life (total, physical, and psychosocial health as well as fatigue) at 12-month follow-up.

    View details for DOI 10.1016/j.jpain.2021.12.009

    View details for Web of Science ID 000817997000008

    View details for PubMedID 34974171

    View details for PubMedCentralID PMC9232895

  • A digital health peri-operative cognitive-behavioral intervention to prevent transition from acute to chronic postsurgical pain in adolescents undergoing spinal fusion (SurgeryPal<SUP>TM</SUP>): study protocol for a multisite randomized controlled trial TRIALS Rabbitts, J. A., Zhou, C., de la Vega, R., Aalfs, H., Murray, C. B., Palermo, T. M. 2021; 22 (1): 506


    Spinal fusion surgery is associated with severe acute postsurgical pain and high rates of chronic postsurgical pain in adolescents. Psychological distress, sleep disturbance, and low pain self-efficacy predict higher acute pain and likelihood of developing chronic postsurgical pain. Interventions targeting baseline psychosocial risk factors have potential to interrupt a negative trajectory of continued pain and poor health-related quality of life (HRQL) over time but have not yet been developed and evaluated. This randomized controlled trial will test effectiveness of a digital peri-operative cognitive-behavioral intervention (SurgeryPalTM) vs. education-control delivered to adolescents and their parents to improve acute and chronic pain and health outcomes in adolescents undergoing spine surgery.Adolescents 12-18 years of age undergoing spinal fusion for idiopathic conditions, and their parent, will be recruited from pediatric centers across the USA, for a target complete sample of 400 dyads. Adolescents will be randomized into 4 study arms using a factorial design to SurgeryPalTM or education control during 2 phases of treatment: (1) pre-operative phase (one-month before surgery) and (2) post-operative phase (1 month after surgery). Acute pain severity and interference (primary acute outcomes) and opioid use will be assessed daily for 14 days following hospital discharge. Chronic pain severity and interference (primary acute outcomes), as well as HRQL, parent and adolescent distress, sleep quality, and opioid use/misuse (secondary outcomes), will be assessed at 3 months and 6 months post-surgery.Demonstration of effectiveness and understanding optimal timing of perioperative intervention will enable implementation of this scalable psychosocial intervention into perioperative care. Ultimately, the goal is to improve pain outcomes and reduce reliance on opioids in adolescents after spine surgery.NCT04637802 Registered on November 20, 2020.

    View details for DOI 10.1186/s13063-021-05421-3

    View details for Web of Science ID 000679722200001

    View details for PubMedID 34330321

    View details for PubMedCentralID PMC8325315

  • AAAPT: Assessment of the Acute Pain Trajectory PAIN MEDICINE Bayman, E. O., Oleson, J. J., Rabbitts, J. A. 2021; 22 (3): 533-547


    Define and contrast acute pain trajectories vs. the aggregate pain measurements, summarize appropriate linear and nonlinear statistical analyses for pain trajectories at the patient level, and present methods to classify individual pain trajectories. Clinical applications of acute pain trajectories are also discussed.In 2016, an expert panel involving the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks (ACTTION), American Pain Society (APS), and American Academy of Pain Medicine (AAPM) established an initiative to create a pain taxonomy, named the ACTTION-APS-AAPM Pain Taxonomy (AAAPT), for the multidimensional classification of acute pain. The AAAPT panel commissioned the present report to provide further details on analysis of the individual acute pain trajectory as an important component of comprehensive pain assessment.Linear mixed models and nonlinear models (e.g., regression splines and polynomial models) can be applied to analyze the acute pain trajectory. Alternatively, methods for classifying individual pain trajectories (e.g., using the 50% confidence interval of the random slope approach or using latent class analyses) can be applied in the clinical context to identify different trajectories of resolving pain (e.g., rapid reduction or slow reduction) or persisting pain. Each approach has advantages and disadvantages that may guide selection. Assessment of the acute pain trajectory may guide treatment and tailoring to anticipated symptom recovery. The acute pain trajectory can also serve as a treatment outcome measure, informing further management.Application of trajectory approaches to acute pain assessments enables more comprehensive measurement of acute pain, which forms the cornerstone of accurate classification and treatment of pain.

    View details for DOI 10.1093/pm/pnaa440

    View details for Web of Science ID 000637323000002

    View details for PubMedID 33735384

    View details for PubMedCentralID PMC7971475

  • Subacute pain trajectories following major musculoskeletal surgery in adolescents: A pilot study CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR Rabbitts, J. A., Groenewald, C. B., Zhou, C. 2020; 4 (4): 3-12


    Adolescents who undergo major surgery experience high rates of disabling acute and chronic postsurgical pain (CPSP). However, little is known about the subacute period when acute to chronic pain transition occurs.Examine feasibility of electronic daily monitoring of pain and opioid use in adolescents during the first 30-days at home following major surgery, and identify target features of subacute pain curves associated with CPSP at 4 months.25 youth (10-18 years) undergoing major musculoskeletal surgery reported daily pain severity, interference, and opioid use on the Brief Pain Inventory, each evening for 30 days after hospital discharge, to form short time series trajectories. At 4 months, youth reported on pain intensity and health-related quality of life. Characteristics of subacute pain severity and interference curves were compared by 4-month CPSP status.At 4 months, 20.8% of youth met criteria for CPSP. During the 30-day monitoring period, youth who went on to develop CPSP reported high pain severity on 45.9% of days as compared to 2.9% of days in youth who recovered (P=0.005), and high pain interference on 49.4% of days vs. 9.7% in youth who recovered (P=0.01). Pain variability and rate of change were not significantly associated with CPSP in our pilot sample.We found it feasible to collect daily pain data in youth recovering at home after major surgery. Pilot findings suggest that daily electronic monitoring may identify early recovery problems at home after surgery. Larger studies are needed to validate subacute pain trajectory features to identify risk for CPSP.

    View details for DOI 10.1080/24740527.2020.1765692

    View details for Web of Science ID 000605584200002

    View details for PubMedID 33415314

    View details for PubMedCentralID PMC7787390

  • A Conceptual Model of Biopsychosocial Mechanisms of Transition from Acute to Chronic Postsurgical Pain in Children and Adolescents JOURNAL OF PAIN RESEARCH Rabbitts, J. A., Palermo, T. M., Lang, E. A. 2020; 13: 3071-3080


    Acute and chronic pain are highly prevalent and impactful consequences of surgery across the lifespan, yet a comprehensive conceptual model encompassing biopsychosocial factors underlying acute to chronic pain transition is lacking, particularly in youth. Building on prior chronic postsurgical pain models, we propose a new conceptual model of biopsychosocial mechanisms of transition from acute to chronic postsurgical pain. This review aims to summarize existing research examining key factors underlying acute to chronic postsurgical pain transition in order to guide prevention and intervention efforts aimed at addressing this health issue in children. As pain transitions from acute nociceptive pain to chronic pain, changes in the peripheral and central nervous system contribute to the chronification of pain after surgery. These changes include alterations in sensory pain processing and psychosocial processes (psychological, behavioral, and social components), which promote the development of chronic pain. Patient-related premorbid factors (eg, demographic factors, genetic profile, and medical factors such as premorbid pain) may further modulate these changes. Factors related to acute injury and recovery (eg, surgical and treatment factors), as well as biological response to surgery (eg, epigenetic, inflammatory, and endocrine factors), may also influence this process. Overall, longitudinal studies examining temporal pathways of biopsychosocial processes including both risk and resiliency factors will be essential to identify the mechanisms involved in the transition from acute to chronic pain. Research is also needed to unravel connections between the acute pain experience, opioid exposure, and sensory pain processing during acute to chronic pain transition. Furthermore, future studies should include larger and more diverse samples to more fully explore risk factors in a broader range of pediatric surgeries. The use of conceptual models to guide intervention approaches targeting mechanisms of transition from acute to chronic pain will significantly advance this field and improve outcomes for children and adolescents undergoing surgery.

    View details for DOI 10.2147/JPR.S239320

    View details for Web of Science ID 000600929100001

    View details for PubMedID 33262642

    View details for PubMedCentralID PMC7699440

  • Long-Term Pain and Recovery After Major Pediatric Surgery: A Qualitative Study With Teens, Parents, and Perioperative Care Providers JOURNAL OF PAIN Rabbitts, J. A., Aaron, R. V., Fisher, E., Lang, E. A., Bridgwater, C., Tai, G., Palermo, T. M. 2017; 18 (7): 778-786


    Research developing targeted treatment focused on coping with children's long-term pain after surgery is needed because of the high prevalence of chronic pain after surgery. This qualitative study aimed to: 1) understand the child's and family's experiences of pain over the course of their surgical experience, and 2) gather stakeholder input regarding potential barriers and facilitators of perioperative intervention delivery. Fifteen children ages 10 to 18 years who underwent recent major surgery, their primary caregivers, and 17 perioperative health care providers were interviewed. Interviews were coded using semantic thematic analysis. The perioperative period presented emotional challenges for families. Families felt unprepared for surgery and pain. Recovery and regaining physical functioning at home was challenging. Families struggled to return to valued activities. Families reported interest in a perioperative psychosocial intervention. Providers endorsed that families would benefit from enhanced coping skills. They emphasized that families would benefit from more detailed preparatory information. Providers suggested that flexible intervention delivery at home would be ideal. Research developing interventions addressing pain and anxiety in children undergoing major surgery is critically needed. The findings of the present study can inform intervention development with the aim of improving short- as well as long-term recovery in children undergoing major surgery.This qualitative study examined children and their parents' experience of long-term pain and recovery after major surgery, identifying barriers and facilitators of perioperative intervention delivery. Families experienced surgery as stressful, and felt underprepared for pain and recovery. Families and health care providers expressed interest in a preoperative intervention teaching coping skills.

    View details for DOI 10.1016/j.jpain.2017.02.423

    View details for Web of Science ID 000404946200003

    View details for PubMedID 28232147

    View details for PubMedCentralID PMC5484738

  • Prevalence and Predictors of Chronic Postsurgical Pain in Children: A Systematic Review and Meta-Analysis JOURNAL OF PAIN Rabbitts, J. A., Fisher, E., Rosenbloom, B. N., Palermo, T. M. 2017; 18 (6): 605-614


    Emerging research suggests that pain may persist longer-term for many children after major surgery, with significant effects on their health outcomes. This systematic review identified the prevalence of chronic postsurgical pain (CPSP) in children after surgery, and determined presurgical biomedical and psychosocial risk factors associated with CPSP prevalence or severity. Prospective studies assessing CPSP 3 to 12 months after surgery in children 6 to 18 years of age published in English in MedLine, EMBASE, PsycINFO, and Cochrane Database of Systematic Reviews since 1996 were eligible for inclusion. Of 16,084 abstracts yielded by the search, 123 full articles were assessed for eligibility, and 12 studies were included in the review. Overall quality of included studies assessed using the Quality in Prognostic Studies tool was low. On the basis of 4 studies with a total of 628 participants across all surgery types, median prevalence of CPSP across studies was 20% (25th percentile = 14.5%, 75th percentile = 38%) at 12 months after surgery. Presurgical pain intensity, child anxiety, child pain coping efficacy, and parental pain catastrophizing were the only presurgical factors identified as predictive of CPSP. Biological and medical factors assessed were not associated with CPSP in any study. Well designed studies examining prevalence and predictors of CPSP are critically needed in children.In this systematic review, the median prevalence of CPSP in children was 20% across studies. Presurgical pain intensity, and child and parent psychosocial factors predicted CPSP. Additional resources and interventions are needed for youth who report persistent pain after surgery.

    View details for DOI 10.1016/j.jpain.2017.03.007

    View details for Web of Science ID 000403129400001

    View details for PubMedID 28363861

    View details for PubMedCentralID PMC5457338

  • Longitudinal and Temporal Associations Between Daily Pain and Sleep Patterns After Major Pediatric Surgery JOURNAL OF PAIN Rabbitts, J. A., Zhou, C., Narayanan, A., Palermo, T. M. 2017; 18 (6): 656-663


    Approximately 20% of children develop persistent pain after major surgery. Sleep disruption has been implicated as a predictor of children's acute postsurgical pain. However, perioperative sleep patterns have not been longitudinally assessed, and the role of sleep in persistence of postsurgical pain has not been explored. We aimed to examine sleep patterns over 4 months in children having major surgery, and temporal relationships between daily sleep and pain. Sixty children age 10 to 18 (mean = 14.7) years having major surgery completed 7 days of actigraphy sleep monitoring (sleep duration, efficiency), twice daily electronic diaries (sleep quality, pain intensity, medication use), and validated questionnaires at presurgery, 2 weeks, and 4 months postsurgery. Generalized linear models, controlling for age, sex, naps, and medication, showed sleep quality (β [B] = -.88, P < .001) and efficiency (B = -1.50, P = .036) were significantly reduced at 2 weeks compared with presurgery, and returned to baseline by 4 months. Poorer night-time sleep quality was significantly associated with greater next day pain intensity (B = -.15, P = .005). Sleep duration and efficiency were not associated with subsequent pain; daytime pain was not associated with subsequent sleep. Findings suggest sleep quality may be an important target for intervention after surgery in children; research is needed to understand how other sleep parameters may relate to recovery.This study assessed longitudinal sleep patterns over 4 months after major pediatric surgery using actigraphy, diaries, and validated measures. Sleep quality and efficiency were significantly reduced at 2 weeks. Poorer sleep quality was associated with greater next day pain intensity suggesting that sleep quality may be an important target for intervention.

    View details for DOI 10.1016/j.jpain.2017.01.004

    View details for Web of Science ID 000403129400006

    View details for PubMedID 28131699

    View details for PubMedCentralID PMC5457334

  • Trajectories of postsurgical pain in children: risk factors and impact of late recovery on long-term health outcomes after major surgery PAIN Rabbitts, J. A., Zhou, C., Groenewald, C. B., Durkin, L., Palermo, T. M. 2015; 156 (11): 2383-2389


    Over 1 million children undergo inpatient surgery annually in the United States. Emerging research indicates that many children have longer-term problems with pain. However, limited data exist on the course of pain over time and the impact of pain recovery on long-term health outcomes. We sought to prospectively characterize children's postsurgical pain trajectories using repeated assessments over 12 months. In addition, we identified presurgical child and parent psychological risk factors associated with persistent pain and examined relationships between pain trajectories and long-term health outcomes. Sixty children aged 10 to 18 years undergoing major surgery and their parent/guardian were enrolled. Participants completed assessments at 5 time points: presurgery, inhospital, 2 weeks, 4 months, and 1 year postsurgery. Child and parent pain catastrophizing was assessed during the week before surgery. Children completed daily monitoring with an electronic pain diary and reported on pain characteristics, health-related quality of life, and activity limitations. Group-based longitudinal modeling revealed 2 distinct trajectories of postsurgical pain: early recovery (n = 49, 82%) and late recovery (n = 11, 18%). In a logistic regression model controlling for age and sex, parental pain catastrophizing before surgery significantly predicted membership in the late recovery group (odds ratio = 1.11, P = 0.03), whereas child catastrophizing and baseline pain did not (Ps < 0.05). In a multivariate regression controlling for age and sex, late pain recovery was significantly associated with poorer health-related quality of life (β = -10.7, P = 0.02) and greater activity limitations (β = 3.6, P = 0.04) at 1 year. Our findings suggest that preoperative interventions that modify parent behaviors and cognitions might be beneficial in this population.

    View details for DOI 10.1097/j.pain.0000000000000281

    View details for Web of Science ID 000364110700031

    View details for PubMedID 26381701

    View details for PubMedCentralID PMC4607609

  • Longitudinal Resilience and Risk Factors in Pediatric Postoperative Pain (LORRIS): Protocol for a Prospective Longitudinal Swiss University Children's Hospitals-Based Study. BMJ open Hochreuter, J., Dreher, T., Hasler, C. C., Canonica, S., Locher, C., Held, U., Rabbitts, J., Koechlin, H. 2024; 14 (3): e080174


    Chronic postsurgical pain (CPSP) is defined as pain that persists after a surgical procedure and has a significant impact on quality of life. Previous studies show the importance of psychological factors in CPSP, yet the majority of studies focused solely on negative emotions. This longitudinal observational study aims to broaden this knowledge base by examining the role of emotional state, emotion variability, emotion regulation and emotion differentiation on the child and the parent level for the development CPSP, and to describe pain and emotion-related trajectories following surgery.We intend to include 280 children and adolescents aged 8-18 years with a planned orthopaedic surgery and their parents. A total of five assessment time points is planned: 3 weeks before surgery (baseline), 2 weeks after surgery (post) and 3 months (follow-up (FU) 1), 6 months and 12 months after surgery. At baseline and post only, children and parents are asked to complete a daily diary thrice a day for a week where they rate their current emotional state and their pain severity (children only). Emotional state ratings will be used to calculate indices of emotion variability, emotion regulation and emotion differentiation. Children and parents will complete questionnaires at each time point, including measures on quality of life, social support, sleep, and symptoms of anxiety and depression.To predict development of CPSP, generalised linear regression models will be used, resulting in ORs and 95% CIs. Pearson product-moment correlations between predictors and outcomes will be evaluated at each time point. The primary outcome of the prediction model is CPSP at FU1. For the trajectory analysis, the classification method K-means for longitudinal data will be used to determine clusters in the data.The Ethics Committee of the Canton of Zurich, Switzerland, has approved the study (ID: 2023-01475). Participants will be compensated, and a dissemination workshop will be held.NCT05816174.

    View details for DOI 10.1136/bmjopen-2023-080174

    View details for PubMedID 38548365

  • Opioid prescription rates associated with surgery among adolescents in the United States from 2015 to 2020. Paediatric anaesthesia Sofia, J. T., Kim, A., Jones, I., Rabbitts, J. A., Groenewald, C. B. 2023


    The United States currently faces an epidemic of opioid misuse which extends to adolescent surgical populations. Opioid prescriptions after surgery are associated with persistent opioid use and serve as a reservoir for diversion. However, it is unclear what proportion of opioid prescriptions are surgical, and little is known about trends in opioid prescription rates associated with surgery in adolescents in the United States. This study aims to describe national trends in postsurgical opioid prescription rates over time among adolescents in the United States.We conducted a population-based cross-sectional analysis of data captured in the Medical Expenditure Panel Survey (MEPS) from 2015 to 2020. MEPS classified adolescents 10-19 years of age (n = 26 909) as having a surgical procedure if they had any inpatient, outpatient, or emergency department visit during which a surgical procedure was performed.Mean age (SD) of the sample was 14.4 (0.01) years. Sociodemographic characteristics were representative of the USA adolescent population. In total, 4.7% of adolescents underwent a surgical procedure. The surgery rate remained stable between 2015 (4.3%): and 2020 (4.4%) and was lower among minority populations. The combined rate of opioid prescribing for surgical and nonsurgical indications significantly decreased from 4.1% in 2015 to 1.4% in 2020 among all adolescents, an estimated difference of 2.7% (95% confidence interval (CI): 1.7%-3.7%, p < .0001). However, opioid prescribing for surgery remained relatively stable (1% in 2015 vs. 0.8% in 2020).Opioid prescription rates associated with surgery remained stable between 2015 and 2020 in the United States, despite significant decreases in prescribing among nonsurgical populations. Surgery is now a leading source of medical prescribed opioids among adolescents. Secondary findings included a stable trend in surgery utilization between 2015 and 2020, as well as continued racial disparities, both in terms of surgery utilization and opioid prescribing.The large number of adolescents being prescribed opioids for surgery in the USA each year, suggests there is a need for national guidelines aimed at adolescent opioid use, similar to the recent CDC guidelines aimed at adult opioid use.

    View details for DOI 10.1111/pan.14753

    View details for PubMedID 37789737

  • Clinical Trials in Pancreatitis: Opportunities and Challenges in the Design and Conduct of Patient-Focused Clinical Trials in Recurrent Acute and Chronic Pancreatitis Summary of a National Institute of Diabetes and Digestive and Kidney Diseases Workshop PANCREAS Hart, P. A., Andersen, D. K., Lyons, E., Cote, G. A., Cruz-Monserrate, Z., Dworkin, R. H., Elmunzer, B., Fogel, E. L., Forsmark, C. E., Gilron, I., Golden, M., Gozu, A., McNair, L., Pandol, S. J., Perito, E. R., Phillips, A., Rabbitts, J. A., Whitcomb, D. C., Windsor, J. A., Yadav, D., Palermo, T. M. 2022; 51 (7): 715-722


    Recurrent acute pancreatitis and chronic pancreatitis represent high morbidity diseases, which are frequently associated with chronic abdominal pain, pancreatic insufficiencies, and reduced quality of life. Currently, there are no therapies to reverse or delay disease progression, and clinical trials are needed to investigate potential interventions that would address this important gap. This conference report provides details regarding information shared during a National Institute of Diabetes and Digestive and Kidney Diseases-sponsored workshop on Clinical Trials in Pancreatitis that sought to clearly delineate the current gaps and opportunities related to the design and conduct of patient-focused trials in recurrent acute pancreatitis and chronic pancreatitis. Key stakeholders including representatives from patient advocacy organizations, physician investigators (including clinical trialists), the US Food and Drug Administration, and the National Institutes of Health convened to discuss challenges and opportunities with particular emphasis on lessons learned from trials in participants with other painful conditions, as well as the value of incorporating the patient perspective throughout all stages of trials.

    View details for DOI 10.1097/MPA.0000000000002105

    View details for Web of Science ID 000891594100005

    View details for PubMedID 36395394

    View details for PubMedCentralID PMC9697224

  • Racial and ethnic differences in pediatric surgery utilization in the United States: A nationally representative cross-sectional analysis JOURNAL OF PEDIATRIC SURGERY Groenewald, C. B., Lee, H. H., Jimenez, N., Ehie, O., Rabbitts, J. A. 2022; 57 (8): 1584-1591


    Children of minority background have reduced access to surgery. This study assessed for racial/ethnic differences in surgical utilization by location.We conducted a cross-sectional analysis of U.S. children (0-17 years of age) participating in the nationally representative Medical Expenditure Panel Survey (MEPS, 2015-2018). Race/ethnicity was the variable of interest. The primary outcome variables were prevalence rates of surgery defined by location of surgical procedure (inpatient, emergency department, hospital outpatient, and office). Covariates included contextual factors that may influence access to and need for healthcare services, including age, sex, insurance status, residential geographic status, usual source of care, and parental reports of child's physical and mental health. We employed multivariate logistic regression models to assess the relationship between outcomes and race/ethnicity.The study population included 31,024 children with an overall surgical rate of 4.8%. Adjusted odds of surgery in an ambulatory location were lower for all racial/ethnic minority groups compared to non-Hispanic White counterparts (non-Hispanic Black aOR = 0.3, 95% CI: 0.2-0.5; Hispanic aOR = 0.4, 95% CI: 0.3-0.6; non-Hispanic Asian aOR = 0.2, 95% CI 0.0-0.5 for hospital outpatient surgery; for office-based setting, non-Hispanic Black aOR = 0.4, 95% CI 0.3-0.6; Hispanic aOR = 0.5, 95% CI: 0.4-0.7; non-Hispanic Asian aOR = 0.4; 95% CI 0.3-0.7). No racial/ethnic differences were observed for surgical procedures in inpatient or emergency department locations.Staggering differences exist in pediatric surgery utilization patterns by racial/ethnic background, even after adjusting for important contextual factors (income, insurance, health status). Our findings in a nationally representative dataset may suggest systemic barriers related to racial/ethnic background for the pediatric surgical population.

    View details for DOI 10.1016/j.jpedsurg.2021.10.011

    View details for Web of Science ID 000853223000024

    View details for PubMedID 34742576

    View details for PubMedCentralID PMC9023599

  • A Brief Measure Assessing Adolescents' Daily In-Hospital Function Predicts Pain and Health Outcomes at Home After Major Surgery PAIN MEDICINE Powelson, E. B., Chandra, N., Jessen-Fiddick, T., Zhou, C., Rabbitts, J. 2022; 23 (9): 1469-1475


    Pain-related function is not routinely assessed in the hospital. This prospective cohort study examined whether patients' daily pain-related function during hospitalization, based on the validated Youth Acute Pain Functional Ability Questionnaire (YAPFAQ), is associated with pain and quality of life.The YAPFAQ is a 12-item measure assessing functional parameters of recovery related to pain and has been validated in children and adolescents with sickle cell disease and after surgery. Adolescents undergoing major musculoskeletal surgery (n = 93) completed the YAPFAQ daily for up to 3 days after surgery. Adolescents self-reported health-related quality of life on the Pediatric Quality of Life Inventory and pain intensity on a numeric rating scale at home 2 weeks after surgery.Higher YAPFAQ scores, representing poorer function, were associated with higher pain intensity (β = 0.2, P = 0.04) and poorer health-related quality of life (β = -0.3, P = 0.01) at home 2 weeks after surgery. This functional measure could be clinically relevant to providers to identify adolescents at risk of difficulty with pain and recovery at home after surgery who might need further intervention to minimize functional impairment and delayed recovery.This article provides conceptual validation of a functional score for pediatric pain, the YAPFAQ, to assess pain intensity and health-related quality of life in the subacute period.

    View details for DOI 10.1093/pm/pnac033

    View details for Web of Science ID 000796640700001

    View details for PubMedID 35201357

    View details for PubMedCentralID PMC9434145

  • Healthcare utilization and costs among pediatric patients with chronic postsurgical pain after major musculoskeletal surgery PEDIATRIC ANESTHESIA Ellyson, A. M., Powelson, E. B., Groenewald, C. B., Rabbitts, J. A. 2022; 32 (4): 577-578

    View details for DOI 10.1111/pan.14402

    View details for Web of Science ID 000761745300001

    View details for PubMedID 35075715

    View details for PubMedCentralID PMC9269163

  • Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine Groenewald, C. B., Rabbitts, J. A., Tham, S. W., Law, E. F., Palermo, T. M. 2021; 17 (11): 2205-2214


    The aim of this study was to estimate the association between insufficient sleep and prescription opioid misuse among US high school students.Participants were 6,884 high school students who self-reported on sleep duration and prescription opioid misuse in the 2019 Youth Risk Behavior Survey. Sleep duration was categorized by the Youth Risk Behavior Survey according to the American Academy of Sleep Medicine guidelines as follows: recommended sleep duration (8-9 hours) vs insufficient sleep (< 8 hours). Participants also reported whether they had any prescription opioid misuse during their lifetime and whether they had prescription opioid misuse within the past 30 days.Most (79.4%) participants reported sleeping less than 8 hours per night. Among all youth, 12.9% reported lifetime prescription opioid misuse and 6.2% reported current prescription opioid misuse. Prevalence of both lifetime and current opioid medication misuse was higher among those also reporting insufficient sleep compared to those reporting recommended sleep duration (14.3% vs 7.7%, P < .0001 for lifetime misuse and 6.6% vs 4.3%, P = .0091 for current misuse). In multivariate models, insufficient sleep was associated with an increased odds of lifetime prescription opioid misuse (adjusted odds ratios = 1.4; 95% confidence interval, 1.1-1.2; P = .006); however, we did not find an association between sleep duration and current prescription opioid misuse in multivariate analysis.Sleep duration is associated with lifetime opioid misuse among US youth. Longitudinal studies are needed to test whether causal relationships exist, and to understand biobehavioral mechanisms that underlie associations between sleep deficiency and opioid misuse in adolescents.Groenewald CB, Rabbitts JA, Tham SW, Law EF, Palermo TM. Associations between insufficient sleep and prescription opioid misuse among high school students in the United States. J Clin Sleep Med. 2021;17(11):2205-2214.

    View details for DOI 10.5664/jcsm.9418

    View details for PubMedID 34019477

    View details for PubMedCentralID PMC8636372

  • Associations between adolescent sleep deficiency and prescription opioid misuse in adulthood. Sleep Groenewald, C. B., Law, E. F., Rabbitts, J. A., Palermo, T. M. 2021; 44 (3)


    The main aim of this study was to estimate the association between sleep deficiency in adolescence and subsequent prescription opioid misuse in adulthood using United States nationally representative longitudinal data.Self-reported data captured in the National Longitudinal Study of Adolescent to Adult Health at baseline (Wave 1; mean age = 16 years) and 12 year follow-up (Wave 4; mean age = 29 years). Participants (n = 12,213) reported on four measures of sleep during adolescence (Wave 1) and on lifetime prescription opioid misuse during adulthood (Wave 4). Associations between adolescent sleep and adult opioid misuse were estimated using multivariate logistic regression analysis controlling for sociodemographics, chronic pain, mental health, childhood adverse events, and a history of substance use.During adolescence, 59.2% of participants reported sleep deficiency. Prospectively, adolescents reporting not getting enough sleep, chronic unrestful sleep, and insomnia were associated with an increased risk for prescription opioid misuse (adjusted odds ratios [OR] = 1.2, p < 0.005 for all three variables). Short sleep duration was not associated with opioid misuse.This is the first study to longitudinally link sleep deficiency as an independent risk factor for the development of prescription opioid misuse. Sleep deficiency could be a driver of the opioid crisis affecting young people in the United States. Future studies should determine whether early and targeted sleep interventions may decrease risk for opioid misuse in high-risk patients prescribed opioids for pain.

    View details for DOI 10.1093/sleep/zsaa201

    View details for PubMedID 32978633

    View details for PubMedCentralID PMC7953216

  • Physical Activity as a Predictor of Chronic Pain Following Pediatric Spinal Surgery CLINICAL JOURNAL OF PAIN Rabbitts, J. A., Holley, A. L., Zhou, C., Chen, L. 2021; 37 (3): 186-193


    (1) Characterize objective physical activity patterns via actigraphy over 4 months postspinal fusion surgery, and (2) examine associations between activity patterns at 2-week and chronic postsurgical pain (CPSP) status at 4 months.Data from 109 youth (10 to 18 y) who underwent spinal fusion surgery at a children's hospital in the Northwestern United States were analyzed. Youth completed questionnaires and actigraphic assessment of physical activity presurgery, and 2 weeks and 4 months postsurgery.Eighteen percent of youth developed CPSP at 4 months. Presurgery physical activity was similar for youth with and without CPSP. At 2 weeks postsurgery, daily activity levels were lower for youth who developed CPSP as compared with those who did not, including lower mean activity (168 vs. 212 counts/min, P=0.01), fewer activity bouts (n=1.7 vs. 2.6, P=0.02), and shorter bout duration (27 vs. 40 min, P=0.02). Differences in activity were maintained at 4 months such that youth with CPSP had lower mean activity (284 vs. 334 counts/min, P=0.03), as well as greater proportion time spent sedentary and lower proportion time in light activity than youth without CPSP. In adjusted models examining 2-week actigraphy as a predictor of 4-month pain status, mean activity (odds ratio=0.99, P=0.04) and number of activity bouts (odds ratio=0.79, P=0.02) were associated with subsequent CPSP status over and above 2-week pain intensity.Lower activity engagement during the initial weeks following spinal fusion surgery was associated with development of CPSP, suggesting early physical activity limitations as a risk factor for CPSP in youth. Understanding recovery patterns is critical for identifying those at risk for chronic pain and implementing early interventions.

    View details for DOI 10.1097/AJP.0000000000000903

    View details for Web of Science ID 000622346700004

    View details for PubMedID 33273273

    View details for PubMedCentralID PMC7867602

  • Epidemiology of Pediatric Surgery in the United States PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B. 2020; 30 (10): 1083-1090


    The epidemiology of pediatric surgery in the United States and whether disparities in access to surgical care exist on a national level remain inadequately described.We determined rates of surgical intervention and associations with sociodemographic factors among children 0-17 years of age in the United States.Analysis of the 2005-2018 National Health Interview Survey samples included 155,064 children. Parents reported on whether their child had a surgery or surgical procedure either as an inpatient or outpatient over the past 12 months. Multivariate logistic regression models, adjusted for age, sex, race and ethnicity, income, language, parent education, region, having a usual source of care, and comorbid conditions, examined odds ratios for sociodemographic factors associated with surgery, analyzing the most recent data (2016-2018; 25 544 children).In the most recent data, 4.7% of children had surgical intervention each year, with an average of 3.9 million surgeries performed annually. Rates of surgery were stable between 2005 and 2018. Minority children had lower adjusted odds (aOR) of surgical intervention as compared to white, non-Hispanic children (aOR = 0.6, 95%CI = 0.5-0.8 for black children, and aOR = 0.7, 95%CI = 0.5-0.9 for Hispanic children). Other sociodemographic factors associated with a lower adjusted odd of surgical intervention included uninsured status (aOR = 0.5; 95%CI = 0.3-0.9), and primary language other than English (aOR = 0.5; 95%CI 0.3-0.9). Income was not associated with surgical intervention.On average, 3.9 million surgeries are performed on children 0-17 years of age in the United States each year. Significant disparities exist in surgical care for children, with black and Hispanic children having lower rates of surgery over and above contribution of other disparity domains. These findings in a nationally representative sample highlight the need for national policies to eliminate disparity of care received by minority children.

    View details for DOI 10.1111/pan.13993

    View details for Web of Science ID 000563639400001

    View details for PubMedID 32777147

    View details for PubMedCentralID PMC7891905

  • Correlates and motivations of prescription opioid use among adolescents 12 to 17 years of age in the United States. Pain Groenewald, C. B., Patel, K. V., Rabbitts, J. A., Palermo, T. M. 2020; 161 (4): 742-748


    Despite significant efforts, the opioid crisis remains a pressing health concern affecting adolescents. The primary aim of this study was to describe recent sociodemographic shifts in the opioid epidemic. We examined whether rates of opioid use, including opioid misuse and opioid use disorder among 12 to 17 year olds in the United States, differ according to sociodemographic factors, physical and mental health, and substance use characteristics using data from the 2015 and 2016 National Survey on Drug Use and Health. We also examined motivations for opioid misuse. The study included 27,857 participants. Black, non-Hispanic adolescents were more likely to both use and misuse opioids as compared to white, non-Hispanic adolescents, a clear difference from previous studies. The main motivation for misuse by adolescents was relief of physical pain (50%, 95% confidence interval 46%-54%). Adolescents who reported pain relief as the major reason for misuse had increased odds of substance use as compared to adolescents who did not report any opioid misuse. However, odds for substance use was greatest among adolescents who reported reasons other than pain relief for opioid misuse. National Survey on Drug Use and Health self-report data suggest recent shifts in opioid misuse with minority adolescents appearing to be at increased risk of opioid misuse compared with white adolescents. Relief of physical pain is the most common motivation for opioid misuse.

    View details for DOI 10.1097/j.pain.0000000000001775

    View details for PubMedID 31815917

    View details for PubMedCentralID PMC7085424

  • Perioperative Care for Adolescents Undergoing Major Surgery: A Biopsychosocial Conceptual Framework ANESTHESIA AND ANALGESIA Rabbitts, J. A., Kain, Z. 2019; 129 (4): 1181-1184

    View details for DOI 10.1213/ANE.0000000000004048

    View details for Web of Science ID 000487076900042

    View details for PubMedID 30720491

    View details for PubMedCentralID PMC6867702

  • Evaluating the psychometric properties of the Widespread Pain Index and the Symptom Severity Scale in youth with painful conditions CANADIAN JOURNAL OF PAIN-REVUE CANADIENNE DE LA DOULEUR Dudeney, J., Law, E. F., Meyyappan, A., Palermo, T. M., Rabbitts, J. A. 2019; 3 (1): 137-147


    Assessing features of centralized pain may prove to be clinically meaningful in pediatric populations. However, we are currently limited by the lack of validated pediatric measures.We examined the psychometric properties of the Widespread Pain Index (WPI) and Symptom Severity (SS) scale, to assess features of centralized pain, in youth with painful conditions from three clinical samples: (1) musculoskeletal surgery, (2) headache, and (3) chronic pain.Participants were 240 youth aged 10-18 years (Mage=14.8, SD=1.9) who completed the WPI and SS scale. Subsets of participants also completed additional measures of pain region, pain intensity, quality of life, pain interference and physical function.Increased features of centralized pain by age were seen for the WPI (r=0.27, p<0.01) and SS scale (r=0.29, p<0.01). Expected differences in sex were seen for the WPI (sex:t132=-3.62, p<0.01), but not the SS scale (sex:t223=-1.73, p=0.09). Reliability for the SS scale was adequate (α=.70). Construct validity was demonstrated through relationships between the WPI and pain regions (r=.57, p<0.01), and between the SS scale and quality of life (r=-.59, p<0.01) and pain interference (r=.56, p<0.01). Criterion validity was demonstrated by differences on the WPI between the surgery sample and the headache and chronic pain samples (F2,237=17.55, p<0.001). Comprehension of the SS scale items was problematic for some youth.The WPI showed adequate psychometric properties in youth; however the SS scale may need to be modified. Our findings support the need to develop psychometrically sound instruments for comprehensive assessment of pain in pediatric samples.

    View details for DOI 10.1080/24740527.2019.1620097

    View details for Web of Science ID 000616374900015

    View details for PubMedID 32051925

    View details for PubMedCentralID PMC7015535

  • Racial differences in opioid prescribing for children in the United States. Pain Groenewald, C. B., Rabbitts, J. A., Hansen, E. E., Palermo, T. M. 2018; 159 (10): 2050-2057


    Racial differences exist in analgesic prescribing for children during emergency department and ambulatory surgery visits in the United States; however, it is unknown whether this is true in the outpatient setting. We examined racial and ethnic differences in outpatient analgesic prescribing using nationally representative data from 113,929 children from the Medical Expenditure Panel Survey. We also examined whether patient-provider race and ethnic concordance was associated with opioid prescription. White children were more commonly prescribed opioids as compared to minorities (3.0% vs 0.9%-1.7%), except for Native American children who had similar rates of opioid prescription (2.6%) as white children. Minorities were more likely to receive nonopioid analgesics than white children (2.0%-5.7% vs 1.3%). Although most white children had race-concordant providers (93.5%), only 34.3% of black children and 42.7% of Hispanic children had race-concordant providers. Among black children, having a race concordant usual source of care provider was associated with a decreased likelihood of receiving an opioid prescription as compared to having a white usual source of care provider (adjusted odds ratio [95% confidence interval] = 0.51 [0.30-0.87]). For all other racial groups, patient-provider race-concordance was not associated with likelihood of opioid prescription. Racial differences exist in analgesic prescriptions to children at outpatient health care visits in the United States, with white children more likely to receive opioids and minorities more likely to receive nonopioid analgesics. Health care providers' race and ethnicity may play a significant role in extant analgesic differences. Further work should focus on understanding the role of provider race and ethnicity in analgesic differences to children in the United States.

    View details for DOI 10.1097/j.pain.0000000000001290

    View details for PubMedID 29794611

    View details for PubMedCentralID PMC6150822

  • Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery ACADEMIC PEDIATRICS Lifland, B. E., Mangione-Smith, R., Palermo, T. M., Rabbitts, J. A. 2018; 18 (4): 376-383


    Monitoring patient-centered health outcomes after hospital discharge is important for identifying patients experiencing poor recovery after surgery. Utilizing parent reports may improve the feasibility of monitoring recovery when children are not available to provide self-report. We therefore aimed to examine agreement between parent and child reports of child pain and health-related quality of life (HRQOL) in children after hospital discharge from inpatient surgery.A total of 295 children aged 8 to 18 years and their parents reported on child pain intensity using an 11-point numerical rating scale and on HRQOL using the 0- to 100-point Pediatric Quality of Life Inventory Version 4.0 Generic Core Scales by phone or online, 4 to 8 weeks after surgery. Agreement between parent and child ratings was assessed by absolute discrepancy scores, Pearson product-moment correlations, 2-way mixed effects intraclass correlation coefficient models, and linear regression models.We found good to excellent agreement between child and parent reports of pain intensity and HRQOL. Average absolute discrepancy scores of pain intensity and HRQOL were 0.6 and 7.8 points, respectively. Pearson product-moment correlation coefficients were 0.74 and 0.80, and intraclass correlation coefficients were 0.72 and 0.79, for pain intensity and HRQOL, respectively. Regression coefficients for models examining pain intensity and HRQOL were 0.93 to 0.98 and 1.0, respectively.Although child and parent reports may both contribute important information, parent report is a valid proxy for child self-reported pain intensity and HRQOL after discharge from inpatient pediatric surgery, which may prove important for better understanding pain experiences and intervention needs.

    View details for DOI 10.1016/j.acap.2017.12.001

    View details for Web of Science ID 000431387700005

    View details for PubMedID 29229566

    View details for PubMedCentralID PMC5936667

  • The Influence of Pain Memories on Children's and Adolescents' Post-Surgical Pain Experience: A Longitudinal Dyadic Analysis HEALTH PSYCHOLOGY Noel, M., Rabbitts, J. A., Fales, J., Chorney, J., Palermo, T. M. 2017; 36 (10): 987-995


    Although children's pain memories have been shown to be a powerful predictor of subsequent pain experiences in acute procedural and experimental pain settings, little is known about the influence of children's and parents' pain memories on children's future pain experiences in other painful contexts. This study used a dyadic approach to examine the roles of children's and parents' memories of pain on their subsequent reporting of postsurgical pain several months after the child underwent a major surgical procedure.The sample included 66 parent-child dyads (Mage youth = 14.73 years, SD = 2.01) recruited from 2 tertiary level pediatric hospitals. At baseline, children and parents reported on their catastrophic thinking about the child's pain. Parent and child reports of child pain were collected at approximately 1 month and 5 months postsurgery. At 2-4 months postsurgery, children's and parents' memories for postsurgical pain were assessed.Results revealed that children's, but not parents', pain memories were a strong predictor of subsequent pain experienced at 5 months postsurgery. Children's and parents' memories for pain did not influence each others' subsequent pain reporting.Findings suggest that children's pain memories influence their continued recovery from postsurgical pain and may contribute to pain persistence. Implications for intervention and prevention are discussed. (PsycINFO Database Record

    View details for DOI 10.1037/hea0000530

    View details for Web of Science ID 000413337600007

    View details for PubMedID 28726472

    View details for PubMedCentralID PMC5620121

  • Postsurgical pain in children: unraveling the interplay between child and parent psychosocial factors PAIN Rabbitts, J. A., Fisher, E. 2017; 158 (10): 1847-1848
  • Validation of the Youth Acute Pain Functional Ability Questionnaire in Children and Adolescents Undergoing Inpatient Surgery JOURNAL OF PAIN Rabbitts, J. A., Aaron, R. V., Zempsky, W. T., Palermo, T. M. 2017; 18 (10): 1209-1215


    Half of children admitted after surgery experience intense pain in hospital, and many experience continued pain and delayed functional recovery at home. However, there is a gap in tools available to measure acute functional ability in pediatric postsurgical settings. We aimed to validate the Youth Acute Pain Functional Ability Questionnaire (YAPFAQ) in a large inpatient pediatric surgical population, evaluate its responsiveness to expected functional recovery, and develop a short form for broad clinical implementation. The YAPFAQ is a self-report measure assessing acute functional ability, developed in children admitted for acute sickle cell pain. We evaluated psychometric properties of the measure in 564 children ages 8 to 18 years admitted after surgery. A sample of 54 participants completed the YAPFAQ daily for 3 days after major surgery to assess responsiveness. The measure showed good reliability (Cronbach α = .96) and construct validity, with expected relationships with physical health-related quality of life (r = -.53, P < .001) and pain intensity (r = .42, P < .001). YAPFAQ scores decreased over time showing good responsiveness to expected recovery. A 3-item short form of the YAPFAQ showed promising psychometric properties. Early assessment of functioning after surgery may identify children at risk for poor functional outcomes and allow targeting of therapies to improve postsurgical recovery.The YAPFAQ showed promising psychometric properties in a pediatric postsurgical population. This study addresses a gap in tools available to monitor functional recovery during hospitalization after pediatric surgery. Early detection of problems with recovery may enable targeted therapies to improve postsurgical outcomes.

    View details for DOI 10.1016/j.jpain.2017.05.004

    View details for Web of Science ID 000412793100006

    View details for PubMedID 28576670

    View details for PubMedCentralID PMC5614820

  • Complementary and Alternative Medicine Use by Children With Pain in the United States ACADEMIC PEDIATRICS Groenewald, C. B., Beals-Erickson, S. E., Ralston-Wilson, J., Rabbitts, J. A., Palermo, T. M. 2017; 17 (7): 785-793


    Chronic pain is reported by 15% to 25% of children. Growing evidence from clinical samples suggests that complementary and alternative medicine (CAM) therapies are desired by families and may benefit some children with pain conditions. The objective of this study was to provide estimates of CAM use by children with pain in the United States.We analyzed data from the 2012 National Health Interview Survey (NHIS) to estimate patterns, predictors, and perceived benefits of CAM use among children 4 to 17 years of age with and without painful conditions in the United States. We used chi-square tests to compare the prevalence rates of CAM use among children with pain to CAM use among children without pain. Multivariable logistic regression was used to examine factors associated with CAM use within the group of children with pain conditions.Parents reported that 26.6% of children had pain conditions (eg, headache, abdominal, musculoskeletal pain) in the past year; of these children, 21.3% used CAM. In contrast, only 8.1% of children without pain conditions used CAM (χ2, P < .001). CAM use among children with pain was associated with female sex (adjusted odds ratio [aOR] = 1.49, P = .005), higher income (aOR = 1.61, P = .027), and presence of 4+ comorbidities (aOR = 2.01, P = .013). Among children with pain who used CAM, the 2 most commonly used CAM modalities were biology-based therapies (47.3%) (eg, special diets and herbal supplements) and manipulative or body-based therapies (46.3%) (eg, chiropractic and massage).CAM is frequently used by children with pain in the United States, and many parents report benefits for their child's symptoms.

    View details for DOI 10.1016/j.acap.2017.02.008

    View details for Web of Science ID 000411921700012

    View details for PubMedID 28232257

    View details for PubMedCentralID PMC5598558

  • A developmental perspective on the impact of chronic pain in late adolescence and early adulthood: implications for assessment and intervention PAIN Rosenbloom, B. N., Rabbitts, J. A., Palermo, T. M. 2017; 158 (9): 1629-1632
  • Temporal daily associations among sleep and pain in treatment-seeking youth with acute musculoskeletal pain JOURNAL OF BEHAVIORAL MEDICINE Holley, A., Rabbitts, J., Zhou, C., Durkin, L., Palermo, T. M. 2017; 40 (4): 675-681


    Sleep is an important health risk factor. In the context of pediatric chronic pain, sleep is often impaired and temporal daily associations link sleep deficiency to subsequent increased pain. It is unknown whether similar temporal relationships exist for youth with acute pain. Thus, we characterized sleep in youth with acute musculoskeletal (MSK) pain to examine daily sleep-pain associations. Participants were 67 youth (10-17 years) with acute MSK pain (<1 month duration). Youth underwent eight nights of actigraphic sleep monitoring and completed twice daily pain diaries. Generalized linear models tested nighttime sleep as a predictor of morning pain, and evening pain as a predictor of nighttime sleep. Shorter sleep duration and poorer sleep quality predicted higher morning pain intensity. However, evening pain did not predict nighttime sleep, suggesting the strongest temporal association is in the direction of sleep deficiency impacting next-day pain, as has been found in prior research in youth with chronic pain.

    View details for DOI 10.1007/s10865-017-9847-x

    View details for Web of Science ID 000405298700015

    View details for PubMedID 28378107

    View details for PubMedCentralID PMC5912262

  • Codeine use among children in the United States: a nationally representative study from 1996 to 2013. Paediatric anaesthesia Livingstone, M. J., Groenewald, C. B., Rabbitts, J. A., Palermo, T. M. 2017; 27 (1): 19-27


    Concerns regarding the safety of codeine have been raised. Cases of life-threatening respiratory depression and death in children have been attributed to codeine's polymorphic metabolic pathway. International health agencies recommend restricted use of codeine in children. Despite these recommendations, the epidemiology of codeine use among children remains unknown.Our objective was to examine patterns of codeine use in the US among children.A cross-sectional analysis of children of age 0-17 years from 1996 to 2013 in the US was performed. Data were extracted from MEPS, a nationally representative set of health care surveys. Prevalence rates of codeine use between 1996 and 2013 were examined. Multivariable logistic regression examined relationships between codeine use and patient demographics.Codeine use remained largely unchanged from 1996 to 2013 (1.08 vs 1.03 million children, respectively). Odds of codeine use was higher in ages 12-17 (OR, 1.40; [1.21-1.61]), outside of the Northeastern US, and among those with poor physical health status (OR, 3.29 [1.79-6.03]). Codeine use was lower in children whose ethnicity was not white and those uninsured (OR, 0.47 [0.34-0.63]). Codeine was most frequently prescribed by emergency physicians (18%) and dentists (14%). The most common condition associated with codeine use was trauma-related pain.Pediatric codeine use has declined since 1996; however, more than 1 million children still used codeine in 2013. Health care providers must be made aware of guidelines advising against the use of codeine in children. Codeine is potentially hazardous and safer alternatives to treat children's pain are available.

    View details for DOI 10.1111/pan.13033

    View details for PubMedID 27779367

    View details for PubMedCentralID PMC5179302

  • Association Between Widespread Pain Scores and Functional Impairment and Health-Related Quality of Life in Clinical Samples of Children JOURNAL OF PAIN Rabbitts, J. A., Holley, A., Groenewald, C. B., Palermo, T. M. 2016; 17 (6): 678-684


    Pain involving several body regions generally represents nervous system pathophysiology shifting from predominantly peripheral to more central. In adults, higher widespread pain scores are clinically meaningful and confer risk for poor response to treatment. It is unknown whether widespread pain is similarly important in children. To address this gap, we conducted an observational study examining 1) associations between widespread pain and functional impairment and health-related quality of life (HRQOL) in clinical pediatric samples, and 2) associations among sociodemographic factors and pain catastrophizing with widespread pain scores. Participants were 166 children aged 10 to 18 years from 3 samples (acute pain, presurgery, chronic pain). Children self-reported pain intensity, pain catastrophizing, functional impairment, and HRQOL. Children indicated pain locations on a body diagram, which was coded using the American College of Rheumatology definition of widespread pain. Results revealed higher widespread pain scores were associated with greater functional impairment with routine activities (F = 3.15, P = .02) and poorer HRQOL (F = 3.29, P = .02), adjusting for pain intensity, study group, and demographic characteristics. Older age (B = .11, P = .02), and Hispanic ethnicity (B = .67, P = .04) were associated with higher widespread pain scores. Findings support incorporating evaluation of widespread pain into pediatric pain assessment. Future research is needed to examine the longitudinal effect of widespread pain on children's treatment outcomes.This article examines the association between widespread pain scores and functional impairment and HRQOL in community and clinical samples of children. Assessment of the spatial distribution of the pain experience provides unique information that may identify children at risk for poorer health.

    View details for DOI 10.1016/j.jpain.2016.02.005

    View details for Web of Science ID 000377628000005

    View details for PubMedID 26924379

    View details for PubMedCentralID PMC4885772

  • Trends in opioid prescriptions among children and adolescents in the United States: a nationally representative study from 1996 to 2012. Pain Groenewald, C. B., Rabbitts, J. A., Gebert, J. T., Palermo, T. M. 2016; 157 (5): 1021-1027


    Prescription opioid misuse is a major public health concern in the United States, yet little is known about national prescription patterns. We aimed to assess trends in opioid prescriptions made to children and adolescents, to their families, and to adults in the United States from 1996 to 2012. The sample was drawn from nationally representative data, the Medical Expenditure Panel Surveys. We used survey design methods to examine trends in prescription opioid use over time and a logistic regression analysis to examine predictors associated with opioid use. Findings indicated that from 1996 to 2012 opioid prescriptions to children and adolescents remained stable and low. In 1996, 2.68% of children received an opioid prescription, and in 2012, 2.91% received an opioid prescription. In contrast, opioid prescriptions to family members of children and adolescents and adults in general significantly increased during this period. The most common opioid prescriptions to children and adolescents in 2012 were codeine, hydrocodone, and oxycodone. Using multivariate logistic regression models, the white non-Hispanic race, older age, health insurance, and parent-reported fair to poor general health were associated with higher rates of opioid prescriptions in children and adolescents. Our main finding was that although the rates of opioid prescriptions have increased among adults in the United States, the rates have not changed among children and adolescents. Recent epidemiologic association studies have identified a strong link between increased opioid prescriptions and increased rates of opioid misuse and abuse in adults. Future studies should assess the association between adult opioid prescriptions and children or adolescent opioid misuse.

    View details for DOI 10.1097/j.pain.0000000000000475

    View details for PubMedID 26716995

    View details for PubMedCentralID PMC4943214

  • Pain and Health-Related Quality of Life After Pediatric Inpatient Surgery JOURNAL OF PAIN Rabbitts, J. A., Palermo, T. M., Zhou, C., Mangione-Smith, R. 2015; 16 (12): 1334-1341


    Around 4 million children undergo inpatient surgery in the United States each year, however little is known about the impact of surgery and postoperative pain on children's health-related quality of life (HRQOL) during the weeks and months after surgery. We measured pain and HRQOL in a large, heterogeneous pediatric postsurgical population from baseline to 1-month follow-up. Over a 20-month period, parents of 915 children age 2 to 18 years (mean = 9.6 years), 50% male, 56% white, admitted to surgical services at a children's hospital enrolled in the study. Parent participants reported on sociodemographics, child HRQOL, and pain characteristics at baseline and 1 month after discharge. Although most of the children recovered to baseline by 1 month after hospital discharge, 23% of children had a significant decline in HRQOL. Logistic regression analyses found that increasing child age (odds ratio = 2.1 for age 13-18 years) and the presence of moderate-severe postsurgical pain at 1 month (odds ratio = 5.7) were significantly associated with deterioration in HRQOL from baseline to 1-month follow-up (P < .05 for each variable). Although HRQOL returns to the baseline level for most children, a sizeable proportion have significant deterioration in HRQOL associated with continued postsurgical pain at 1 month after hospital discharge from surgery.This study addresses an important gap in the literature, examining pain and health-related quality of life in a broad population of children undergoing a wide range of inpatient surgeries. Evaluation of inpatient health services from a patient and family perspective is essential in evaluating outcomes of surgical care.

    View details for DOI 10.1016/j.jpain.2015.09.005

    View details for Web of Science ID 000366443000011

    View details for PubMedID 26416163

    View details for PubMedCentralID PMC4666767

  • Remembering pain after surgery: a longitudinal examination of the role of pain catastrophizing in children's and parents' recall PAIN Noel, M., Rabbitts, J. A., Tai, G. G., Palermo, T. M. 2015; 156 (5): 800-808


    Children's memories for pain play a powerful role in their pain experiences. Parents' memories may also influence children's pain experiences, by influencing parent-child interactions about pain and children's cognitions and behaviors. Pain catastrophizing of children and parents has been implicated as a factor underlying memory biases; however, this has not been empirically examined. The current longitudinal study is the first to examine the role of pain catastrophizing of children and parents in the development of their pain memories after surgery. Participants were 49 youth (32 girls) aged 10 to 18 years undergoing major surgery and their parents. One week before surgery, children and parents completed measures of pain catastrophizing. Two weeks after surgery (the acute recovery period), children and parents completed measures of child pain intensity and affect. Two to 4 months after surgery, children's and parents' memories of child pain intensity and affect were elicited. Hierarchical linear regression models revealed that over and above covariates, parent catastrophizing about their child's pain (magnification, rumination) accounted for a significant portion of variance in children's affective and parents' sensory pain memories. Although parent catastrophizing had a direct effect on pain memories, mediation analyses revealed that child catastrophizing (helplessness) indirectly influenced children's and parents' pain memories through the child's postoperative pain experience. Findings highlight that aspects of catastrophic thinking about child pain before surgery are linked to distressing pain memories several months later. Although both child and parent catastrophizing influence pain memory development, parent catastrophizing is most influential to both children's and parents' evolving cognitions about child pain.

    View details for DOI 10.1097/j.pain.0000000000000102

    View details for Web of Science ID 000354007800007

    View details for PubMedID 25630028

    View details for PubMedCentralID PMC4402244

  • Presurgical Psychosocial Predictors of Acute Postsurgical Pain and Quality of Life in Children Undergoing Major Surgery JOURNAL OF PAIN Rabbitts, J. A., Groenewald, C. B., Tai, G. G., Palermo, T. M. 2015; 16 (3): 226-234


    Limited research has examined presurgical risk factors for poor outcomes in children after major surgery. This longitudinal study examined presurgical psychosocial and behavioral factors as predictors of acute postsurgical pain intensity and health-related quality of life (HRQOL) in children 2 weeks after major surgery. Sixty children aged 10 to 18 years, 66.7% female, and their parent/guardian participated in the study. Children underwent baseline assessment of pain (daily electronic diary), HRQOL, sleep (actigraphy), and psychosocial factors (anxiety, pain catastrophizing). Caregivers reported on parental pain catastrophizing. Longitudinal follow-up assessment of pain and HRQOL was conducted at home 2 weeks after surgery. Regression analyses adjusting for baseline pain revealed that presurgery sleep duration (β = -.26, P < .05) and parental pain catastrophizing (β = .28, P < .05) were significantly associated with mean pain intensity reported by children 2 weeks after surgery, with shorter presurgery sleep duration and greater parental catastrophizing about child pain predicting greater pain intensity. Adjusting for baseline HRQOL, presurgery child state anxiety (β = -.29, P < .05) was significantly associated with HRQOL at 2 weeks, with greater anxiety predicting poorer HRQOL after surgery. In conclusion, child anxiety, parental pain catastrophizing, and sleep patterns are potentially modifiable factors that predict poor outcomes in children after major surgery.This study addresses an important gap in literature, examining presurgical risk factors for poorer acute postsurgical outcomes in children undergoing major surgery. Knowledge of these factors will enable presurgical identification of children at risk for poorer outcomes and guide further research developing prevention and intervention strategies for these children.

    View details for DOI 10.1016/j.jpain.2014.11.015

    View details for Web of Science ID 000351027300004

    View details for PubMedID 25540939

    View details for PubMedCentralID PMC5137504

  • Bidirectional Associations Between Pain and Physical Activity in Adolescents CLINICAL JOURNAL OF PAIN Rabbitts, J. A., Holley, A., Karlson, C. W., Palermo, T. M. 2014; 30 (3): 251-258


    The objectives were to: (1) examine temporal relationships between pain and activity in youth, specifically, whether physical activity affects pain intensity and whether intensity of pain affects subsequent physical activity levels on a daily basis, and (2) examine clinical predictors of this relationship.Participants were 119 adolescents (59 with chronic pain and 60 healthy) aged 12 to 18 years, 71% female. Adolescents completed 10 days of actigraphic monitoring of physical activity and daily electronic diary recordings of pain intensity, medication use, sleep quality, and mood. Linear mixed models assessed daily associations among physical activity and pain. Daily mean (average count/min) and peak (highest daily level) activity were used for analyses. Medication use, sleep quality, and mood ratings were included as covariates, and age, sex, and body mass index percentile were adjusted for.Higher pain intensity was associated with lower peak physical activity levels on the next day (t641=-2.25, P=0.03) and greater medication use predicted lower mean physical activity levels the same day (t641=-2.10, P=0.04). Higher mean physical activity levels predicted lower pain intensity ratings at the end of the day (t705=-2.92, P=0.004), but only in adolescents with chronic pain.Youth experiencing high pain intensity limit their physical activity level on a day-to-day basis. Activity was related to subsequent pain intensity, and may represent an important focus in chronic pain treatment. Further study of the effect of medications on subsequent activity is needed.

    View details for DOI 10.1097/AJP.0b013e31829550c6

    View details for Web of Science ID 000331459400010

    View details for PubMedID 23669450

    View details for PubMedCentralID PMC3766388

  • Response to: the Fontan patient in the non cardiac setting PEDIATRIC ANESTHESIA Mauermann, W., Flick, R., Rabbitts, J. 2013; 23 (8): 763

    View details for DOI 10.1111/pan.12215

    View details for Web of Science ID 000321296900017

    View details for PubMedID 23822184

  • Outcomes of general anesthesia for noncardiac surgery in a series of patients with Fontan palliation PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Mauermann, W. J., Barbara, D. W., Burkhart, H. M., Warnes, C. A., Oliver, W. C., Flick, R. P. 2013; 23 (2): 180-187


    To describe the experience of a single, tertiary care institution in the care of patients with Fontan physiology undergoing anesthesia for noncardiac surgery.The Fontan procedure was developed in 1971 to palliate patients with univentricular cardiac physiology leading to long-term survival of these patients, who may now present as adults for noncardiac surgery.We retrospectively reviewed the medical records of Fontan patients 16 years and older who underwent general anesthesia for noncardiac surgery at Mayo Clinic in Rochester, Minnesota. Preoperative data, perioperative course, intraoperative and postoperative hemodynamic, pulmonary, cardiovascular, and renal complications were described.Thirty-nine general anesthetics were administered to 31 patients for noncardiac surgery after Fontan palliation. Perioperative complications occurred in 12 of the 39 (31%) noncardiac surgeries, and there was one postoperative death that occurred on day 13 after ventral hernia repair. The two patients who had complications that did not resolve (long-term dialysis and death) had ejection fractions well below the mean for the group (22% and 28%).It may be more appropriate for Fontan patients to undergo anesthesia for noncardiac surgery in a tertiary institution, particularly patients with an ejection fraction of <30%. Intraoperative arterial blood pressure monitoring and overnight admission are likely appropriate for most cases.

    View details for DOI 10.1111/pan.12020

    View details for Web of Science ID 000313051800013

    View details for PubMedID 22998356

  • Geographic differences in perioperative opioid administration in children PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Raesaenen, J. 2012; 22 (7): 676-681


    To investigate whether geographic differences exist in perioperative opioid administration to children.  To investigate whether perioperative fentanyl use for cleft lip and palate surgery varies between children of three different geographic regions.Differences have been found in perioperative opioid administration to children of differing ethnicity in the USA. Whether similar differences exist in perioperative opioid administration to children residing in different geographic regions is unknown.We retrospectively reviewed the medical records of ASA I children who underwent surgery under standardized general anesthesia between January 2010 and April 2011 during SMILE Network International mission trips to Africa, India and Central and South America. Perioperative administration of fentanyl was compared between these three locations.We analyzed data from 79 children who underwent surgery in Africa, 76 in India and 153 in Central and South America. Children in Central and South America were given <50% of the intraoperative amount of fentanyl (2.0 ± 1.2 mcg·kg(-1) ) administered to children in Africa (4.1 ± 2.4 mcg·kg(-1) ; P < 0.001) and children in India (4.3 ± 2.2 mcg·kg(-1) ; P < 0.001). Postoperatively, fentanyl was administered in equivalent doses to all groups.Children in Central and South America received less opioid intraoperatively than African and Indian children, under standardized anesthesia for cleft surgeries. Further research is necessary to elucidate the mechanisms underlying these group differences.

    View details for DOI 10.1111/j.1460-9592.2012.03806.x

    View details for Web of Science ID 000304714500009

    View details for PubMedID 22324378

    View details for PubMedCentralID PMC5139618

  • Prevalence of moderate-severe pain in hospitalized children PEDIATRIC ANESTHESIA Groenewald, C. B., Rabbitts, J. A., Schroeder, D. R., Harrison, T. E. 2012; 22 (7): 661-668


      Acute pain management in children is often inadequate. The prevalence of pain in hospitalized children in the US is unknown.  We reviewed clinical characteristics of all pediatric patients admitted to Mayo Eugenio Litta Children's hospital during July 2009. Patients with moderate-severe pain were identified. For patients identified as having moderate-severe pain risk factors, analgesia regimens, and pain outcomes were reviewed.  The prevalence of moderate-severe in-hospital pain was 27% (95% C.I. 23% to 32%). Teenagers and infants experienced higher prevalence rates of moderate-severe pain (38% and 32% respectively) than children (17%, P < 0.001). In addition, patients admitted to medical services had much lower rates of moderate-severe pain (13%) than those admitted to surgical services (44%, P < 0.001). Regional anesthesia was used in eleven (7.2%) of the patients on surgical services. Acetaminophen was administered to 75% of patients with moderate-severe pain. Only 21% of these patients had nonsteroidal anti-inflammatory drugs (NSAIDS) available. Opioids were given scheduled to 36% of patients with moderate-severe pain and as needed to another 40%. Fifty-five percent of patients still had one or more episode of moderate-severe pain on the day following an initial diagnosis; however, this number decreased steadily over subsequent days. Eleven patients (13% of those diagnosed with moderate-severe pain) still had one or more episodes of daily moderate-severe pain by day four.  The prevalence of moderate-severe pain in hospitalized children remains high. Analgesia regimens may not be optimal. Underutilization of regional anesthesia techniques may have contributed to increased pain scores. A large proportion of children diagnosed with moderate-severe pain may have persistent clinically significant pain in subsequent days.

    View details for DOI 10.1111/j.1460-9592.2012.03807.x

    View details for Web of Science ID 000304714500007

    View details for PubMedID 22332912

  • Postural orthostatic tachycardia syndrome and general anesthesia: a series of 13 cases JOURNAL OF CLINICAL ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Jacob, A. K., Low, P. A., Curry, T. B. 2011; 23 (5): 384-392


    To investigate whether patients with postural orthostatic tachycardia syndrome (POTS) developed unexpected perioperative complications.Retrospective case series.Academic medical center.The records of 13 patients with POTS, who underwent surgical procedures during general anesthesia, were studied. Details of disease management, anesthetic induction, hemodynamic response to induction and intubation, intraoperative course, and immediate postoperative management were analyzed.Three patients developed prolonged intraoperative hypotension, which was not associated with induction of anesthesia. All 13 patients were successfully treated and they recovered without complications. There were no unplanned hospital or intensive care admissions.Intraoperative hypotension, but not tachycardia, was observed in three of 13 patients with POTS who received general anesthesia for a variety of surgical procedures using multiple medications and techniques.

    View details for DOI 10.1016/j.jclinane.2010.12.013

    View details for Web of Science ID 000293940000007

    View details for PubMedID 21802629

    View details for PubMedCentralID PMC3349351

  • Perioperative opioid requirements are decreased in hypoxic children living at altitude PEDIATRIC ANESTHESIA Rabbitts, J. A., Groenewald, C. B., Dietz, N. M., Morales, C., Raesaenen, J. 2010; 20 (12): 1078-1083


    To investigate the effect of altitude on perioperative opioid requirements in otherwise healthy children.To investigate whether children living and having surgery at high altitude received different doses of fentanyl than those living and having surgery at sea level.Recent studies in animals (Anesthesiology, 105, 2006 and 715) and children with obstructive sleep apnea (Anesthesiology, 105, 2006 and 665; Anesthesiology 100, 2004 and 806) suggest that analgesic effects of exogenous opioids are enhanced by hypoxia. However, the effects of hypoxia on perioperative narcotic requirements in otherwise healthy children have not been previously reported.We reviewed retrospectively the opioid requirements of pediatric patients who underwent cleft lip or palate surgery during Smile Network International mission trips to Cusco and Lima, Peru between 2007 and 2009. Patients who had surgery at high altitude were compared to those who had surgery at sea level. All patients received a standardized anesthetic with intravenous fentanyl as the only perioperative opioid.Hundred and two patients had surgery at 3399 m above sea level (masl) (Cusco) and 169 patients had surgery at 150 masl (Lima). Patients at high altitude had significantly lower baseline oxygen saturations (92 ± 4% vs 98 ± 3%; P < 0.001) and received 40% less opioid (1.2 ± 0.8 vs 2.0 ± 1.4 μg·kg(-1) per h; P < 0.001) compared to patients at sea level.Opioid administration was reduced in otherwise healthy children with altitude-induced chronic hypoxia when compared to non-hypoxic children undergoing similar operations under similar anesthetic regimens. Whether this difference is due to altitude or altitude-induced hypoxia, requires further study.

    View details for DOI 10.1111/j.1460-9592.2010.03453.x

    View details for Web of Science ID 000284485500003

    View details for PubMedID 21199116

  • Epidemiology of Ambulatory Anesthesia for Children in the United States: 2006 and 1996 ANESTHESIA AND ANALGESIA Rabbitts, J. A., Groenewald, C. B., Moriarty, J. P., Flick, R. 2010; 111 (4): 1011-1015


    There are few data that describe the frequency, anesthetic type, provider, or disposition of children requiring outpatient anesthesia in the United States (US). Since the early 1980s, the frequency of ambulatory surgery has increased dramatically because of advances in medical technology and changes in payment arrangements. Our primary aim in this study was to quantify the number of ambulatory anesthetics for children that occur annually and to study the change in utilization of pediatric anesthetic care over a decade.The US National Center for Health Statistics performed the National Survey of Ambulatory Surgery in 1994 through 1996 and again in 2006. The survey is based on data abstracted from a national sample of ambulatory surgery centers and provides data on visits for surgical and nonsurgical procedures for patients of all ages. We abstracted data for children who had general anesthesia, regional anesthesia, or monitored anesthesia care during the ambulatory visit. We obtained the information from the 2006 and 1996 databases and used population census data to estimate the annual utilization of ambulatory anesthesia per 1000 children in the US.In 2006, an estimated 2.3 million ambulatory anesthesia episodes of care were provided in the US to children younger than 15 years (38 of 1000 children). This amount compares with 26 per 1000 children of the same age group in 1996. In most cases, an anesthesiologist was involved in both time periods (74% in 2006 and 85% in 1996). Of the children, 14,200 were admitted to the hospital postoperatively, a rate of 6 per 1000 ambulatory anesthesia episodes.The number and rate of ambulatory anesthesia episodes for US children increased dramatically over a decade. This study provides an example of how databases can provide useful information to health care policy makers and educators on the utilization of ambulatory surgical centers by children.

    View details for DOI 10.1213/ANE.0b013e3181ee8479

    View details for Web of Science ID 000282310200031

    View details for PubMedID 20802051

  • Influence of endogenous angiotensin II on control of sympathetic nerve activity in human dehydration. The Journal of physiology Rabbitts, J. A., Strom, N. A., Sawyer, J. R., Curry, T. B., Dietz, N. M., Roberts, S. K., Kingsley-Berg, S. M., Charkoudian, N. 2009; 587 (Pt 22): 5441-9


    Arterial blood pressure can often fall too low during dehydration, leading to an increased incidence of orthostatic hypotension and syncope. Systemic sympathoexcitation and increases in volume regulatory hormones such as angiotensin II (AngII) may help to maintain arterial pressure in the face of decreased plasma volume. Our goals in the present study were to quantify muscle sympathetic nerve activity (MSNA) during dehydration (DEH), and to test the hypothesis that endogenous increases in AngII in DEH have a mechanistic role in DEH-associated sympathoexcitation. We studied 17 subjects on two separate study days: DEH induced by 24 h fluid restriction and a euhydrated (EUH) control day. MSNA was measured by microneurography at the peroneal nerve, and arterial blood pressure, electrocardiogram, and central venous pressure were also recorded continuously. Sequential nitroprusside and phenylephrine (modified Oxford test) were used to evaluate baroreflex control of MSNA. Losartan (angiotensin type 1 receptor (AT1) antagonist) was then administered and measurements were repeated. MSNA was elevated during DEH (42 +/- 5 vs. EUH: 32 +/- 4 bursts per 100 heartbeats, P = 0.02). Blockade of AT1 receptors partially reversed this change in MSNA during DEH while having no effect in the control EUH condition. The sensitivity of baroreflex control of MSNA was unchanged during DEH compared to EUH. We conclude that endogenous increases in AngII during DEH contribute to DEH-associated sympathoexcitation.

    View details for DOI 10.1113/jphysiol.2009.176693

    View details for PubMedID 19805740

    View details for PubMedCentralID PMC2793875

  • Sympathetic Neural Mechanisms in Human Cardiovascular Health and Disease Charkoudian, N., Rabbitts, J. A. ELSEVIER SCIENCE INC. 2009: 822-830


    The sympathetic nervous system plays a key role in regulating arterial blood pressure in humans. This review provides an overview of sympathetic neural control of the circulation and discusses the changes that occur in various disease states, including hypertension, heart failure, and obstructive sleep apnea. It focuses on measurements of sympathetic neural activity (SNA) obtained by microneurography, a technique that allows direct assessment of the electrical activity of sympathetic nerves in conscious human beings. Sympathetic neural activity is tightly linked to blood pressure via the baroreflex for each individual person. However, SNA can vary greatly among individuals and that variability is not related to resting blood pressure; that is, the blood pressure of a person with high SNA can be similar to that of a person with much lower SNA. In healthy normotensive persons, this finding appears to be related to a set of factors that balance the variability in SNA, including cardiac output and vascular adrenergic responsiveness. Measurements of SNA are very reproducible in a given person over a period of several months to a few years, but SNA increases progressively with healthy aging. Cardiovascular disease can be associated with substantial increases in SNA, as seen for example in patients with hypertension, obstructive sleep apnea, or heart failure. Obesity is also associated with an increase in SNA, but the increase in SNA among patients with obstructive sleep apnea appears to be independent of obesity per se. For several disease states, successful treatment is associated with both a decrease in sympathoexcitation and an improvement in prognosis. This finding points to an important link between altered sympathetic neural mechanisms and the fundamental processes of cardiovascular disease.

    View details for DOI 10.4065/84.9.822

    View details for Web of Science ID 000269354000009

    View details for PubMedID 19720780

    View details for PubMedCentralID PMC2735432

  • Cardiac risk of noncardiac surgery after percutaneous coronary intervention with drug-eluting stents ANESTHESIOLOGY Rabbitts, J. A., Nuttall, G. A., Brown, M. J., Hanson, A. C., Oliver, W. C., Holmes, D. R., Rihal, C. S. 2008; 109 (4): 596-604


    The American College of Cardiology released a scientific advisory that included a recommendation to delay elective of noncardiac surgery (NCS) for 1 yr after percutaneous coronary intervention (PCI) with a drug-eluting stent (DES).This single-center, retrospective study examined the risk for complications of NCS performed within 2 yr after DES placement and examined whether this risk changed based on the time between procedures. The primary endpoint was major adverse cardiac events (MACEs) during the hospitalization for NCS. Bleeding events were analyzed as a secondary endpoint.From April 22, 2003, to December 31, 2006, a total of 520 patients underwent NCS within 2 yr after PCI with a DES at Mayo Clinic. The majority, 84%, of the DES placed were Cypher stents. The frequency of MACE was not found to be significantly associated with the time between PCI and NCS (rate of MACEs 6.4, 5.7, 5.9, and 3.3% at 0-90, 91-180, 181-365, and 366-730 days after PCI with DES, respectively; P = 0.727 for comparison across groups). Characteristics found to be associated with MACEs in univariate analysis were advanced age (P = 0.031), emergent NCS (P = 0.006), shock at time of PCI (P = 0.035), previous history of myocardial infarction (P = 0.046), and continuation of a thienopyridine (ticlopidine or clopidogrel) into the preoperative period (P = 0.040). The rate of transfusion did not seem to be associated with antiplatelet therapy use.The risk of MACEs with NCS after DES placement was not significantly associated with time from stenting to surgery, but observed rates of MACEs were lowest after 1 yr.

    View details for DOI 10.1097/ALN.0b013e318186de1c

    View details for Web of Science ID 000259521500005

    View details for PubMedID 18813037

  • Mayo Clinic and the origins of blood banking MAYO CLINIC PROCEEDINGS Rabbitts, J. A., Bacon, D. R., Nuttall, G. A., Moore, S. 2007; 82 (9): 1117-1118

    View details for DOI 10.4065/82.9.1117

    View details for Web of Science ID 000249176300014

    View details for PubMedID 17803879

  • Occupational exposure to blood in medical students SAMJ SOUTH AFRICAN MEDICAL JOURNAL Rabbitts, J. A. 2003; 93 (8): 621-624


    To determine the extent of occupational exposure to blood in medical students, details of the circumstances surrounding the incidents and the subsequent experiences of the student.Prospective cohort study.Tygerberg Hospital, the Health Sciences Faculty of the University of Stellenbosch during a 15-week period from 4 February to 19 May 2002.One hundred and thirty-six student interns (SIs), i.e. final-year medical students.All Sis received a questionnaire and a letter motivating them to participate in the study and explaining the procedure. Regular class meetings enabled continuous motivation and ongoing update. In the case of an incident during the 15-week period, the SI filled in the form and placed it in a sealed drop-off box.Specific focus on the preceding events and the situation in which the incidents occurred (department, time of day, procedure performed, and whether the student was on call), exposure to HIV (patient's retroviral status), use of post-exposure prophylaxis (PEP) (whether used, when initiated), and the consequences of the exposure (emotional, on sexual behaviour during the window period, and on career choice).During the 15-week period, 19 incidents were reported; the majority occurred while students were on call, almost half occurred after hours, and a disproportionate number occurred in three departments.Occupational blood exposure is a very real problem and poses a significant risk. SI suggestions should be considered in improving the prevention and management of such incidents.

    View details for Web of Science ID 000185281700032

    View details for PubMedID 14531124