ASA issued a landmark Statement on the Practice of Pediatric Pain in October 2023, advocating for board-certified, pain physician-lead care for all pediatric pain patients. This is the first official practice statement created to address the topic of pediatric pain care by the society. The statement declared that a “board-certified, pain specialist trained in pediatric pain provides optimal diagnosis and management” and that “pediatric pain medicine training informs on the differences in anatomy, physiology, pharmacology, treatment selection and procedural nuance that can separate a successful procedure or treatment from an unsafe or injurious one” (asamonitor.pub/3VbixMK). The statement further discusses the need for development of a unique skill set and appreciation of multidisciplinary collaboration needed to care for children, who represent some of our most vulnerable patients. In alignment with this statement and given the current undefined landscape for pediatric pain training and practice, it is imperative that our society and members work together to create, define, and standardize pediatric pain care with leadership from physician anesthesiologists.

“The specialty of pediatric pain medicine is still in a formative stage. Understanding the historical context of how pain medicine developed as a specialty offers important points on why change is needed to secure the future of pediatric pain medicine as its own specialty.”

Pediatric pain is a nascent and developing specialty in part because of the difficulty organizing care around a symptom that was largely believed to not exist. Historically, textbooks commonly discounted or denied infant pain sensations, including an often-referenced publication in 1941 by McGraw (Child Dev 1941;12:31-42). Even up to the 1980s, our colleagues may recall regularly conducting surgery in infants with no or minimal analgesia. From that decade onward, advocacy by concerned parents and physicians led to research debunking misconceptions that infants could not sense pain, had no memory for pain, or had no ill effects of inadequately treated pain. Consequently, the development of clinicians specializing in the anesthetic care of pediatric patients in pain did not begin in earnest until the 1980s.

Over the past three decades, research and knowledge of pediatric pain has grown exponentially. Some of the first studies on pain in children affirmed the use of opioids for pediatric pain and described multidisciplinary care of pediatric pain patients (J Pediat 1988;113:421-9; Pain 1987;30:s99). Pediatric intensivists and anesthesiologists frequently took up this mantle, given their practices more frequently encountered pediatric patients with severe pain. The specialty of pediatric pain medicine is still in a formative stage. Understanding the historical context of how pain medicine developed as a specialty offers important points on why change is needed to secure the future of pediatric pain medicine as its own specialty.

Pain medicine has evolved and changed over the past three decades (J Anesth Hist 2020;6:13-6). For comparison, the specialty originally developed certification in 1989, with review by the American Board of Anesthesiology (ABA) and American Board of Medical Specialties over the next two years. Then in 1992, the Accreditation Council for Graduate Medical Education (ACGME) approved specialty certification within the purview of the Anesthesiology Residency Review Committee. The first board certification examination for (then-called) “Pain Management” was offered in 1993. In 2002, the certificate title was changed to “Pain Medicine” to differentiate physician-based from nonphysician-based care. Currently, five ABMS member boards are approved for pain medicine certification, all using the ABA Pain Medicine examination. These include boards for emergency medicine, family practice, physical medicine and rehabilitation, neurology, psychiatry, and radiology. However, pediatric-trained resident applicants are not eligible to take the pain medicine exam. Consequently, applicants with pediatric training are virtually non-existent in ACGME pain medicine fellowships.

Program requirements from the ACGME for pain medicine have adapted to some changes in the specialty but touch on pediatric pain issues only in a general sense. Updates in requirements in 2005 and 2019 emphasized multidisciplinary care across neurology, physical medicine and rehabilitation, and anesthesiology. Yet the current program training requirements only reference one statement on “treatment of pain in pediatric patients” (In (IV.B.1.c).(1).(b).(xi)). As a result, the exposure of pain medicine fellowship trainees to pediatric pain medicine varies considerably, often consisting of minimal exposure and no formal rotation at most programs. A call to action is now upon us to improve the training and subsequent care of pain in pediatric patients.

No formal board certification program exists for the unique field of pediatric pain medicine. Across the United States, eight ACGME-accredited pain fellowship programs offer a defined focus on pediatric pain care (asamonitor.pub/3RgrGRP). These fellowship programs are formed by tight collaborations and strong commitments between pediatric and adult hospital systems. Their educational tracks emphasize expanded time spent in the pediatric hospital, ambulatory clinics, and pain rehabilitation programs during fellowship training. Such programs commonly employ an equal split in time between pediatric and adult didactics and patient care, with training in interventional procedural instruction that meets ACGME standards for pain medicine. Most programs have been developed in the past 10 years and often only accept one or two applicants per year. Due to the emerging nature of program development and the small trainee pool for board-certified physicians, the landscape of physicians who currently practice pediatric pain medicine is mostly made up of specialists who are not board-certified in pain medicine but are nonetheless dedicated to helping their patients experience less pain. The current workforce includes physicians from a variety of specialties, including pediatrics, pediatric intensive care, anesthesiology, physical medicine and rehabilitation, and palliative care, among others. Some physicians do obtain additional non-ACGME training or attend conferences or master classes to improve knowledge to care for pediatric patients; however, these programs are often abbreviated and generally do not offer training in interventional skills. Despite difficulty in obtaining education, trainees in pediatrics appear receptive and express strong interest in improving their pediatric pain management skills (Complement Ther Med 2021;59:102721).

Creation of the ASA Statement on the Practice of Pediatric Pain Medicine serves as a key step in the pathway to developing and advancing the pediatric pain medicine workforce. Even for anesthesiologists who do not specialize in pain or pediatrics, it is important for our entire community to take three key next steps to ensure continued leadership by our specialty to offer exemplary care of children with pain. First, as an organization, we should commit to encouraging research on this topic, promoting educational programs, and developing new avenues to improve pediatric pain medicine training and practice. A second important step includes better characterizing the current landscape of pediatric pain medicine care and clinician training through surveys, focus groups, and other feedback from our colleagues, trainees, and patients. This information will help drive the development of future interventions to improve educational programs in pediatric pain. Third, cultivating and strengthening partnerships between ASA and relevant societies such as the Society for Pediatric Pain Medicine, Society for Pediatric Anesthesia, and the American Academy of Pediatrics are critical to ensure we maintain long-lasting collaborations and build new bridges for training opportunities, especially for pediatric specialty physicians.