American Academy of Pediatrics (AAP) Update

Rita Agarwal, MD
Chair, AAP Section on Anesthesiology and Pain Medicine (SOA)

Jennifer Riefe, M.Ed
Manager, AAP Section on Anesthesiology and Pain Medicine

Members of the AAP and the SPA have many goals and interests in common, but have different approaches to addressing them. The AAP works with Pediatricians and Pediatric Subspecialists (including surgical subspecialists) on education and advocacy for children’s health issues. This has been a particularly productive time for us, in large part due to the many contributions of Dr. Joseph Tobias - immediate Past Chair of the AAP SOA, and Dr. Connie Houck - former Chair of the SOA, member of the Committee on Drugs and current Chair of the AAP Surgical Advisory Panel. Connie has been at the forefront of the new American College of Surgeons initiative to stratify and credential pediatric levels of care in hospitals. She was also very involved with the FDA consensus statement on anesthesia neurotoxicity and the developing brain.

In 2015 the AAP Section on Anesthesiology and Pain Medicine released a NEW Manual on Procedural Sedation for Infants, Children, and Adolescents authored by Drs. Joseph Tobias and Joseph Cravero. It is directed at pediatricians and other non-anesthesia personnel who perform sedation and can be purchased here.

In October 2015, the AAP submitted a formal letter to the FDA in response to a request for comments on the international scheduling of the drug Ketamine, published in the Federal Register on October 5, 2015 (Docket No. FDA–2015–N–0045).  The AAP asserted that Ketamine is an essential agent for sedation in children in the United States and throughout the world. 

On January 25, 2016, a revised Policy Statement on “Prevention and Management of Procedural Pain in the Neonate,” co-authored by the AAP Committee on Fetus and Newborn and the AAP Section on Anesthesiology and Pain Medicine (SOA) was released.  The full document can be accessed here. Dr. Navil Sethna was a co-author on this effort.

As part of work related to the Providers' Clinical Support System for Opioid Therapies Grant from SAMHSA, the Section is working to develop a 6-part webinar series with the AAP Committee on Substance Abuse aimed at preventing, identifying, and treating opioid dependence. The first webinar was offered in July 2015, and it focused on the Neurobiology of Pain. Dr. Genevieve D’Souza was the speaker for the webinar. The second webinar, offered in August 2015, focused on Strategies for Pain Management. Drs. Brenda Golianu, Cora Breuner, and Genevieve D’Souza were the speakers for that webinar. Four additional webinars will be offered in the near future; work is currently underway on the two webinars for 2016 which will focus on patients with co-occurring diseases. The goal is to pair an Addiction Specialist with a Pain Management Specialist for each of these sessions.  Archived webinars can be viewed here.

There are several statements, policies, guidelines currently under revision, or consideration. Some are close to completion, others still require substantial work. These include:

• The Policy Statement on “The Assessment and Management of Acute Pain in Infants, Children, and Adolescents”
• New Policy Statement on “Care of Pediatric Patients with Chronic Pain”
• New Clinical Report on “Codeine and the Potential for Toxicity in the Pediatric Patient,” a joint Report with the Committee on Drugs (in final stages)
• Revision of the 2006 AAP/AAPD “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures” (close to completion)
• A statement on “Caring for Patients with OSA Undergoing Anesthesia” (joint statement with the Section on Otolaryngology/Head and Neck Surgery, the Section on Pediatric Pulmonology and Sleep Medicine, and the Section on Allergy and Immunology).

A new online CME course on pediatric pain management is currently under development and will be made available on PediaLink, the AAP’s online learning platform, by late summer/early fall 2016. The course is being designed to meet the needs of pediatricians in states where pain management CME is required for re-licensure.  The course has been made possible by a grant from the AAP’s Friends of Children Fund. The AMA is currently working to develop a CME product for primary care providers on the topic of opioids.  Our SOA Chairperson, Rita Agarwal, is participating as the AAP’s representative to the AMA Pain Management Expert Panel charged with managing this project. Their initial meeting took place in July 2015.

In December 2015, the U.S. Food and Drug Administration (FDA) held a joint meeting of its Pulmonary-Allergy Drugs Advisory Committee and its Drug Safety and Risk Management Advisory Committee. During the portion of the meeting dedicated to public stakeholder input, Chair of the AAP’s Surgical Advisory Panel, Connie Houck, testified before the joint panel, sharing the AAP’s recommendation that codeine and codeine-containing products be removed from the over-the-counter (OTC) cough and cold monograph for the treatment of cough in children, and that codeine be contraindicated for the treatment of both cough and pain in all children. The joint panel discussed the available data on the safety of codeine in children in three age groups – 0-6 years of age; 6-12 years of age; and 12-18 years of age – for both pain and cough. Following the discussion, the panel took votes on three questions related to the use of codeine in children, and the votes were overwhelmingly in favor of AAP’s recommendations.

Please consider joining the AAP SOA if you are interested in finding out more about these efforts, or if you are interested in helping with these or other future statements. There is still a lot of work to be done to optimize anesthetic and critical care for children, and we are looking forward to working with more of you. You don’t have to be a pediatrician to join and/or make contributions, you don’t even have to be a full time pediatric anesthesiologist. Click here for more information.