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In search of the optimal pain management strategy for children undergoing cleft lip and palate repair: A systematic review and meta-analysis

      Background

      Postoperative pain following pediatric cleft lip and palate repair provide unique challenges. As no guidelines presently exist, we sought to identify the most effective and safe perioperative pain management strategies for children undergoing primary cleft lip and palate repair.

      Methods

      A systematic search of MEDLINE, Embase, Cochrane library, Scopus, and Web of Science databases was conducted. A total of 230 unique titles were then assessed. Pooled analysis of variables was conducted, and data pertaining to common approaches in decreasing postoperative analgesia were compared.

      Results

      A total of 39 studies involving 583 and 1445 patients undergoing cleft lip and palate repair, respectively, were included. In children undergoing cleft palate repair, palatine block demonstrated the greatest latency to first analgesia (F(8,325) = 210, p<0.0001), but it was not associated with a decrease in total opioid consumption. In cleft lip, bilateral infraorbital nerve blocks resulted in the greatest increase in latency to first analgesia (215.76 min, 95% CI, 83.26 to 448.26, p<0.005) and demonstrated a mean decrease in morphine consumption of 0.2 mg/kg/d (95% CI, -0.20 to -0.20, p<0.00001). No significant intervention-related complications were identified.

      Conclusions

      A variety of effective methods exist to decrease postoperative pain. In this review, palatine nerve block demonstrates the greatest effectiveness in palate repair, while bilateral infraorbital nerve block demonstrates an opioid-sparing effect and increased the latency to first analgesia in cleft lip repair. All studied interventions demonstrated safety in this pediatric cohort. The results of this review should be interpreted in the context of certain limitations, including the number and nature of comparison studies, and significant reporting heterogeneity.

      Keywords

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      References

        • Cobourne M.T.
        The complex genetics of cleft lip and palate.
        Eur J Orthod. 2004; 26: 7-16https://doi.org/10.1093/ejo/26.1.7
        • Carr L.
        • Gray M.
        • Morrow B.
        • Brgoch M.
        • Mackay D.
        • Samson T.
        Opioid sparing in cleft palate surgery.
        Cleft Palate-Craniofacial J. 2018; 55: 1200-1204https://doi.org/10.1177/1055665618764516
        • Suresh S.
        • Barcelona S.L.
        • Young N.M.
        • Seligman I.
        • Heffner C.L.
        • Coté C.J.
        Postoperative pain relief in children undergoing tympanomastoid surgery: is a regional block better than opioids?.
        Anesth Analg. 2002; https://doi.org/10.1097/00000539-200204000-00015
        • Anand K.J.S.
        • Brown M.J.
        • Causon R.C.
        • Christofides N.D.
        • Bloom S.R.
        • Aynsley-Green A.
        Can the human neonate mount an endocrine and metabolic response to surgery?.
        J Pediatr Surg. 1985; 20: 41-48https://doi.org/10.1016/S0022-3468(85)80390-0
        • Doyle E.
        • Hudson I.
        Anaesthesia for primary repair of cleft lip and cleft palate: a review of 244 procedures.
        Pediatr Anesth. 1992; https://doi.org/10.1111/j.1460-9592.1992.tb00189.x
        • Henriksson Valdemar T.Skoog T-G
        Identification of children at high anaesthetic risk at the time of primary palatoplasty.
        Scand J Plast Reconstr Surg Hand Surg. 2001; 35: 177-182https://doi.org/10.1080/028443101300165318
        • Antony A.K.
        • Sloan G.M.
        Airway obstruction following palatoplasty: analysis of consecutive operations.
        Cleft Palate-Craniofacial J. 2002; 39: 145-148https://doi.org/10.1597/1545-1569(2002)039<0145:AOFPAO>2.0.CO;2
        • Henriksson Mats
        • Eriksson T.-.G.
        Risk factors in children having palatoplasty.
        Scand J Plast Reconstr Surg Hand Surg. 2001; 35: 279-283https://doi.org/10.1080/028443101750523186
        • Chiono J.
        • Raux O.
        • Bringuier S.
        • et al.
        Bilateral suprazygomatic maxillary nerve block for cleft palate repair in children.
        Anesthesiology. 2014; 120: 1362-1369https://doi.org/10.1097/ALN.0000000000000171
        • Kamath M.R.
        • Mehandale S.G.
        • Us R.
        Comparative study of greater palatine nerve block and intravenous pethidine for postoperative analgesia in children undergoing palatoplasty.
        Indian J Anaesth. 2009; 53: 654-656
        • Prabhu K.P.K.
        • Wig J.
        • Grewal S.
        Bilateral infraobital nerve block is superior to peri-incisional infiltration for analgesia after repair of cleft lip.
        Scand J Plast Reconstr Surg Hand Surg. 1999; 33: 83-87https://doi.org/10.1080/02844319950159668
        • McHugh M.L.
        Interrater reliability: the kappa statistic.
        Biochem Medica. 2012; : 276-282https://doi.org/10.11613/BM.2012.031
        • Jonnavithula N.
        • Durga P.
        • Madduri V.
        • et al.
        Efficacy of palatal block for analgesia following palatoplasty in children with cleft palate.
        Pediatr Anesth. 2010; 20: 727-733https://doi.org/10.1111/j.1460-9592.2010.03347.x
        • Abu Elyazed M.M.
        • Mostafa S.F
        Bilateral suprazygomatic maxillary nerve block versus palatal block for cleft palate repair in children: a randomized controlled trial.
        Egypt J Anaesth. 2018; 34: 83-88https://doi.org/10.1016/j.egja.2018.05.003
        • Parameswaran A.
        • Ganeshmurthy M.V.
        • Ashok Y.
        • Ramanathan M.
        • Markus A.F.
        • Sailer H.F.
        Does sphenopalatine ganglion block improve pain control and intraoperative hemodynamics in children undergoing palatoplasty? A randomized controlled trial.
        J Oral Maxillofac Surg. 2018; 76: 1873-1881https://doi.org/10.1016/j.joms.2018.03.037
        • Sola C.
        • Raux O.
        • Savath L.
        • Macq C.
        • Capdevila X.
        • Dadure C.
        Ultrasound guidance characteristics and efficiency of suprazygomatic maxillary nerve blocks in infants: a descriptive prospective study.
        Pediatr Anesth. 2012; 22: 841-846https://doi.org/10.1111/j.1460-9592.2012.03861.x
        • Obayah G.M.
        • Refaie A.
        • Aboushanab O.
        • Ibraheem N.
        • Abdelazees M.
        Addition of dexmedetomidine to bupivacaine for greater palatine nerve block prolongs postoperative analgesia after cleft palate repair.
        Eur J Anaesthesiol. 2010; 27: 280-284https://doi.org/10.1097/EJA.0b013e3283347c15
        • Mireskandari S.M.
        • Makarem J.
        Effect of rectal diclofenac and acetaminophen alone and in combination on postoperative pain after cleft palate repair in children.
        J Craniofac Surg. 2011; 22: 1955-1959https://doi.org/10.1097/SCS.0b013e31822ea7fd
        • Fenlon S.
        • Somerville N.
        Comparison of codeine phosphate and morphine sulphate in infants undergoing cleft palate repair.
        Cleft Palate-Craniofac J. 2007; 44: 528-531https://doi.org/10.1597/06-206.1
        • Coban Y.K.
        • Senoglu N.
        • Oksuz H.
        Effects of preoperative local ropivacaine infiltration on postoperative pain scores in infants and small children undergoing elective cleft palate repair.
        J Craniofac Surg. 2008; 19: 1221-1224https://doi.org/10.1097/SCS.0b013e31848432e4
        • Mostafa M.F.
        • Herdan R.
        • Elshazly M.
        Comparative study of levobupivacaine and bupivacaine for bilateral maxillary nerve block during pediatric primary cleft palate surgery: a randomized double-blind controlled study.
        Korean J Anesthesiol. 2018; 71: 135-140https://doi.org/10.4097/kjae.2018.71.2.135
        • Bremerich D.H.
        • Neidhart G.
        • Heimann K.
        • Kessler P.
        • Behne M.
        Prophylactically-administered rectal acetaminophen does not reduce postoperative opioid requirements in infants and small children undergoing elective cleft palate repair.
        Anesth Analg. 2001; 92: 907-912https://doi.org/10.1097/00000539-200104000-00020
        • Nour C.
        • Ratsiu J.
        • Singh N.
        • et al.
        Analgesic effectiveness of acetaminophen for primary cleft palate repair in young children: a randomized placebo controlled trial.
        Pediatr Anesth. 2014; 24 (Anderson B, ed.): 574-581https://doi.org/10.1111/pan.12393
        • Binet A.
        • Thinnes J.
        • Amory C.
        • et al.
        Role of bilateral suprazygomatic maxillary nerve block in primary surgery for soft palate cleft and soft-hard palate cleft.
        Pediatr Anesth Crit Care J. 2015; 3: 111-117https://doi.org/10.14587/paccj.2015.23
        • Mesnil M.
        • Dadure C.
        • Captier G.
        • et al.
        A new approach for peri-operative analgesia of cleft palate repair in infants: the bilateral suprazygomatic maxillary nerve block.
        Pediatr Anesth. 2010; 20: 343-349https://doi.org/10.1111/j.1460-9592.2010.03262.x
        • Jha A.K.
        • Bhardwaj N.
        • Yaddanapudi S.
        • Sharma R.K.
        • Mahajan J.K.
        A randomized study of surgical site infiltration with bupivacaine or ketamine for pain relief in children following cleft palate repair.
        Pediatr Anesth. 2013; 23 (Bosenberg A, ed.): 401-406https://doi.org/10.1111/pan.12124
        • Nicodemus H.F.
        • Ferrer M.J.R.
        • Cristobal V.C.
        • de Castro L.
        Bilateral infraorbital block with 0.5% bupivacaine as post-operative analgesia following cheiloplasty in children.
        Scand J Plast Reconstr Surg Hand Surg. 1991; 25: 253-257https://doi.org/10.3109/02844319109020629
        • Takmaz S.A.
        • Uysal H.Y.
        • Uysal A.
        • Kocer U.
        • Dikmen B.
        • Baltaci B.
        Bilateral extraoral, infraorbital nerve block for postoperative pain relief after cleft lip repair in pediatric patients.
        Ann Plast Surg. 2009; 63: 59-62https://doi.org/10.1097/SAP.0b013e3181851b8e
        • Gaonkar V.
        • Daftary S.
        Comparison of preoperative infraorbital block and peri-incisional infiltration for postoperative pain relief in cleft lip surgeries.
        Indian J Plast Surg. 2004; 37: 105
        • Rajamani A.
        • Kamat V.
        • ponnambalam Rajavel vardaraja
        • Murthy J.
        • Hussain syed Altaf
        A comparison of bilateral infraorbital nerve block with intravenous fentanyl for analgesia following cleft lip repair in children.
        Pediatr Anesth. 2007; 17: 133-139https://doi.org/10.1111/j.1460-9592.2006.02032.x
        • Simion C.
        • Corcoran J.
        • Iyer A.
        • Suresh S.
        Postoperative pain control for primary cleft lip repair in infants: is there an advantage in performing peripheral nerve blocks?.
        Pediatr Anesth. 2008; 18: 1060-1065https://doi.org/10.1111/j.1460-9592.2008.02721.x
        • Grewal G.
        • Garg K.
        • Grewal A.
        Bilateral infraorbital nerve block versus intravenous pentazocine: a comparative study on post-operative pain relief following cleft lip surgery.
        J Clin Diagnostic Res. 2015; 9: UC04-UC06https://doi.org/10.7860/JCDR/2015/11953.5984
        • Mady R.
        • Zanaty O.
        • Shafshaak W.
        • Arida E.-.D.
        • Habib A.
        Bilateral greater palatine nerve block for perioperative analgesia in children undergoing palatoplasty.
        Res Opin Anesth Intensive Care. 2018; 5: 335https://doi.org/10.4103/2356-9115.247404
        • Malamed S.F.
        • Trieger N.
        Intraoral maxillary nerve block: an anatomical and clinical study.
        Anesth Prog. 1983; 30: 44-48
        • Bosenberg A.T.
        • Kimble F.W.
        Infraorbital nerve block in neonates for cleft lip repair: anatomical study and clinical application.
        Br J Anaesth. 1995; 74: 506-508https://doi.org/10.1093/bja/74.5.506
        • Reena Bandyopadhyay KH
        • Paul A
        Postoperative analgesia for cleft lip and palate repair in children.
        J Anaesthesiol Clin Pharmacol. 2016; https://doi.org/10.4103/0970-9185.175649
        • Takemura H.
        • Yasumoto K.
        • Toi T.
        • Hosoyamada A.
        Correlation of cleft type with incidence of perioperative respiratory complications in infants with cleft lip and palate.
        Pediatr Anesth. 2002; 12: 585-588https://doi.org/10.1046/j.1460-9592.2002.00906.x
        • Busman M.
        • Fleeger T.
        • Leach E.
        • et al.
        Sphenopalatine ganglion block for the treatment of acute headache: an old treatment revisited.
        Am J Emerg Med. 2021; 49: 402-403https://doi.org/10.1016/j.ajem.2021.02.007
        • Selim M.A.
        Comparative study of bilateral suprazygomatic maxillary and bilateral greater palatine nerve block for perioperative analgesia in children undergoing palatoplasty.
        Anesth Analg. 2016; 123: 343-344https://doi.org/10.1213/01.ane.0000492662.35217.8c
        • Kadar A.A.
        • Obaid M.A.
        Effect on postoperative pain after local application of Bupivacaine in the Tonsillar Fossa; a prospective single blind controlled trial.
        J Pak Med Assoc. 2003; 59: 422-426
        • Awad I.T.
        • Moore M.
        • Rushe C.
        • Elburki A.
        • O'Brien K.
        • Warde D
        Unplanned hospital admission in children undergoing day-case surgery.
        Eur J Anaesthesiol. 2004; 21: 379-383https://doi.org/10.1017/S0265021504005058
        • Lyons B.
        Postanaesthetic shivering in children.
        Anaesthesia. 1996; 51: 442-445https://doi.org/10.1111/j.1365-2044.1996.tb07788.x
        • Bashir M.M.
        • Qayyum R.
        • Saleem M.H.
        • Siddique K.
        • Khan F.A.
        Effect of time interval between tumescent local anesthesia infiltration and start of surgery on operative field visibility in hand surgery without tourniquet.
        J Hand Surg Am. 2015; 40: 1606-1609https://doi.org/10.1016/j.jhsa.2015.03.034
        • Bateman M.C.
        • Conejero J.A.
        • Mooney E.K.
        • Rothkopf D.M.
        Short-stay cleft palate surgery with intraoperative dexamethasone and marcaine.
        Ann Plast Surg. 2006; 57: 245-247https://doi.org/10.1097/01.sap.0000221468.54751.09
        • Berde C.B.
        • Sethna N.F.
        Analgesics for the treatment of pain in children.
        N Engl J Med. 2002; 347 (Wood AJJ, ed.): 1094-1103https://doi.org/10.1056/NEJMra012626
        • Feriani G.
        • Hatanaka E.
        • Torloni M.R.
        • da Silva E.M.
        Infraorbital nerve block for postoperative pain following cleft lip repair in children.
        in: da Silva EM Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd, Chichester, UK2014https://doi.org/10.1002/14651858.CD011131
        • Takmaz S.A.
        • Uysal H.Y.
        • Uysal A.
        • Kocer U.
        • Dikmen B.
        • Baltaci B.
        Bilateral extraoral, infraorbital nerve block for postoperative pain relief after cleft lip repair in pediatric patients.
        Ann Plast Surg. 2009; 63: 59-62https://doi.org/10.1097/SAP.0b013e3181851b8e
        • Blount R.L.
        • Loiselle K.A.
        Behavioural assessment of pediatric pain.
        Pain Res Manag. 2009; 14: 47-52https://doi.org/10.1155/2009/348184
        • Agrawal K.
        • Panda K.
        A modified surgical schedule for primary management of cleft lip and palate in developing countries.
        Cleft Palate-Craniofacial J. 2011; 48: 1-8https://doi.org/10.1597/09-226
        • ACPA
        Parameters for evaluation and treatment of patients with cleft lip/palate or other craniofacial differences.
        Cleft Palate Craniofac J. 2018; 55: 137-156https://doi.org/10.1177/1055665617739564