Suspected opioid-induced hyperalgesia in an infant

Area of Science:

• Pediatric Critical Care
• Pain Management
• Neonatology

Background:

• Opioid-induced hyperalgesia (OIH) is a known phenomenon that can diminish opioid analgesic efficacy.
• Gastroschisis is a congenital defect requiring extensive surgical management and often prolonged intensive care.

Observation:

• A neonate with gastroschisis developed escalating pain scores and signs of hyperalgesia and allodynia despite increasing opioid doses.
• The infant exhibited irritability, photophobia, and increased pain upon handling, unresponsive to further opioid escalation.

Findings:

• This case represents the first documented instance of opioid-induced hyperalgesia in an infant.
• Opioid de-escalation, rotation to hydromorphone, and the addition of ketamine led to a rapid reduction in pain scores and irritability.
• Successful weaning from opioid infusions and sedatives was achieved after managing OIH.

Implications:

• This report underscores the importance of recognizing OIH in infants, even in the context of complex surgical conditions.
• It suggests that opioid de-escalation and multimodal analgesia strategies, including non-opioid agents like ketamine, are crucial for managing OIH in neonates.
• Further research is warranted to understand the pathophysiology and optimal management of OIH in pediatric populations.