Postoperative Pain Outcomes and Satisfaction in Preschool Versus School-Age Children: A Prospective Multicenter Observational Study

Background Postoperative pain management in children remains a significant challenge due to developmental differences in pain perception, reporting, and communication. However, limited evidence exists regarding age-specific predictors of severe pain and patient satisfaction among preschool and school-age children, particularly when perioperative, psychological, and analgesic-related factors are integrated. Despite advances in multimodal analgesia, a substantial proportion of pediatric patients continue to experience inadequate postoperative pain relief. Objectives To evaluate postoperative pain trajectories, identify predictors of severe pain, and assess factors associated with satisfaction in pediatric patients undergoing elective surgery, with stratification by developmental age groups (preschool versus school-age). Methods This prospective multicenter observational cohort study included 325 children aged three to 12 years undergoing elective surgery under general anesthesia, with or without regional anesthesia (RA). Patients were categorized into preschool (3-6 years, n=175) and school-age (6-12 years, n=150) groups. Pain intensity was assessed at predefined time points during the first 24 postoperative hours using age-appropriate validated scales: the Face, Legs, Activity, Cry, Consolability (FLACC) scale for preschool children and the Numerical Rating Scale (NRS) for school-age children. Severe pain was defined as NRS ≥7/10. Satisfaction with pain management was recorded on a 0-10 scale. Multivariable logistic regression identified independent predictors of severe pain, while linear regression evaluated factors associated with patient satisfaction. Results Pain scores peaked in the early postoperative period and declined significantly over time (P<0.001). Severe pain occurred in 26.5% of patients, with no significant difference between groups (P=0.324). School-age children reported higher pain immediately postoperatively, whereas preschool children exhibited higher pain scores later during recovery. Independent predictors of severe pain included higher early postoperative pain, pain at discharge, preoperative anxiety, and the need for additional analgesia. In contrast, pre-incisional local anesthetic infiltration (LAI), RA, premedication, and preoperative education were associated with lower odds of severe pain (all P<0.05). Satisfaction scores were high (mean 8.1±1.1) and were positively associated with effective pain relief, use of regional techniques, and patient/parent involvement in care. Conversely, persistent severe pain, higher early postoperative pain, and the need for additional analgesia were associated with lower satisfaction. Regression models demonstrated strong predictive performance, with Nagelkerke R² values up to 0.884 and an adjusted R² of 0.434. Conclusion Postoperative pain outcomes in children are predominantly associated with modifiable perioperative factors rather than age alone. Early pain control, multimodal analgesia, RA, and patient-centered strategies, including preoperative education and shared decision-making, are consistently associated with improved pain outcomes and satisfaction. These findings support the development of risk-stratified, individualized approaches to pediatric perioperative pain management.