Pain in cognitively impaired children: a focus for general pediatricians

Relationship Between Postural Asymmetry, Balance, and Pain in Children With Spastic Cerebral Palsy

BACKGROUND

Primary symptoms of cerebral palsy (CP), such as spasm and weakness, can lead to secondary musculoskeletal problems. Exploring the interplay and impact of secondary symptoms is essential in CP management.

METHODS

A total of 56 children (32 males and 24 females) aged eight to 12 years in level I to III of Gross Motor Function Classification System (GMFCS) completed The Pediatric Balance Scale and Wong-Baker Faces Scale and the Posture and Postural Ability Scale. Relationships between the three groups were examined using the Kruskal-Wallis test, Tukey test, gamma coefficient, De Somers D, phi coefficient, Cramér V, and one-way analysis of variance.

RESULTS

There was a significant correlation between balance and postural asymmetry (P < 0.001), and no significant difference in balance was there between the severe and moderate asymmetry groups (P = 0.759) and between the mild asymmetry and no asymmetry groups (P = 0.374). Furthermore, there was a significant relationship between postural asymmetry and each of the variables of pain (P < 0.001) and gross motor function (P = 0.002). Although a meaningful correlation was identified between balance and gross motor function (P < 0.001), the relationship between postural asymmetry and balance in GMFCS levels was not found (P = 0.052, P = 0.052, P = 0.233). Conversely, no significant relationship was detected between pain and gross motor function (P = 0.072).

SIGNIFICANCE

Postural asymmetry negatively impacts balance and correlates with pain intensity. Addressing postural problems can contribute to pain management and improved balance.

Timeline of diagnosed pain causes in children with severe neurological impairment

Objective

Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children.

Methods

We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years).

Results

Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001).

Conclusions

Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.

The mitochondrial-related effect of the 905 nm photobiomodulation therapy on 50B11 sensory neurons

Photobiomodulation therapy (PBMT) is known as a complementary tool to alleviate pain sensation in patients, nevertheless, there is still a gap of knowledge on its mechanism of action, thus limiting its clinical employment. In this study, a possible molecular mechanism of the 905 nm PBMT (0.25 W/cm2 ; 3, 6, 12, and 18 J/cm2 , 5 Hz) analgesic effect was tested on 50B11 cells, by investigating its impact on mitochondria. A decrement of adenosine triphosphate was detected, moreover, an increment of total reactive oxygen species and mitochondrial superoxide anion was found after PBMT with all protocols tested. PBMT at 18 J diminished the mitochondrial membrane potential, and influenced mitochondrial respiration, decreasing the oxygen consumption rate. Finally, a decrement of extracellular signal-regulated kinase 1/2 phosphorylation was observed with the protocol using 12 J. Taken together these findings highlighted the intracellular effects, mainly correlated to mitochondrial, induced by 905 nm PBMT in sensory neurons, indicating the central role of this organelle in the cellular response to 905 nm near-infrared laser light.

Chronic Pain in Young People With Cerebral Palsy: Activity Limitations and Coping Strategies

PURPOSE

To describe the effect of chronic pain on the activities of children and adolescents with cerebral palsy, to describe coping strategies, and to examine associations between effect of pain on activities, coping strategies, and level of pain.

METHODS

Using an online survey, 27, 8- to 18-year-olds with cerebral palsy and chronic pain or their parents reported pain intensity, distribution, activity limitations (using the Child Activity Limitations Interview-21), and coping strategies (using the Pediatric Pain Coping Inventory).

RESULTS

Pain intensity ranged from 3 to 10, and 89% reported pain in multiple areas, principally the lower limbs. Individuals reporting higher pain intensity had more activity limitations and were more likely to use catastrophizing coping strategies.

CONCLUSIONS

Coping strategies may be an important mediator between pain and its effect on activities in children with cerebral palsy. Individualized pain management should be based on routine pain assessment.

Pain burden in children with cerebral palsy (CPPain) survey: Study protocol

Pain is a significant health concern for children living with cerebral palsy (CP). There are no population‐level or large‐scale multi‐national datasets using common measures characterizing pain experience and interference (ie, pain burden) and management practices for children with CP. The aim of the CPPain survey is to generate a comprehensive understanding of pain burden and current management of pain to change clinical practice in CP. The CPPain survey is a comprehensive cross‐sectional study. Researchers plan to recruit approximately 1400 children with CP (primary participants) across several countries over 6‐12 months using multimodal recruitment strategies. Data will be collected from parents or guardians of children with CP (0‐17 years) and from children with CP (8‐17 years) who are able to self‐report. Siblings (12‐17 years) will be invited to participate as controls. The CPPain survey consists of previously validated and study‐specific questionnaires addressing demographic and diagnostic information, pain experience, pain management, pain interference, pain coping, activity and participation in everyday life, nutritional status, mental health, health‐related quality of life, and the effect of the COVID‐19 pandemic on pain and access to pain care. The survey will be distributed primarily online. Data will be analyzed using appropriate statistical methods for comparing groups. Stratification will be used to investigate subgroups, and analyses will be adjusted for appropriate sociodemographic variables. The Norwegian Regional Committee for Medical and Health Research Ethics and the Research Ethics Board at the University of Minnesota in USA have approved the study. Ethics approval in Canada, Sweden, and Finland is pending. In addition to dissemination through peer‐reviewed journals and conferences, findings will be communicated through the CPPain Web site (www.sthf.no/cppain), Web sites directed toward users or clinicians, social media, special interest groups, stakeholder engagement activities, articles in user organization journals, and presentations in public media.

CHRONIC PAIN AND PHYSICAL THERAPY IN CHILDREN WITH PARALYTIC SYNDROMES: ARE THERE ANY CHANGES DURING LOCKDOWN?

OBJECTIVE

The aim: To evaluate an influence of physical therapy on chronic pain in children with paralytic's syndrome and to maternal emotional status on lockdown time during the COVID-19 pandemic.

PATIENTS AND METHODS

Materials and methods: Data from 96 children and their mothers (96 persons) were included in the study. On-site services of physical therapists before the pandemic (2018- 2019) were received by 64 children and by 32 children during quarantine measures due to COVID-19 pandemic (2020). The age of the children ranged from 1 to 6 years, the median age was 3 years and 3 months.

RESULTS

Results: We note that there were more boys with paralytic syndromes. Among the leading paralytic syndromes, the most common was spastic tetraparesis. The frequency of children with level III-V motor disorders prevailed.

CONCLUSION

Conclusions: The authors consider that physical rehabilitation in children with paralytic syndromes reduces the incidence of moderate chronic pain and improves the emotional state of parents. But, these changes do not occur during the pandemic.

Caregiver perspectives of managing chronic pain in children and adolescents with dyskinetic and mixed dyskinetic/spastic CP with communication limitations

PURPOSE

Caregivers provide unique insights into managing chronic pain in children and adolescents with dyskinetic and mixed dyskinetic/spastic cerebral palsy with communication limitations. This study explored the personal challenges caregivers face in supporting their child's everyday pain management, including barriers and facilitators to effective chronic pain management.

METHODS

Semi-structured interviews were undertaken with ten caregivers (all mothers) of children with either dyskinetic or mixed dyskinetic/spastic cerebral palsy. All children had chronic pain (> 3 months), were aged from 5 to 15 years, had significant functional limitations, and had either limited or no capacity to self-report their pain. Interpretative phenomenological analysis was used to explore caregivers' subjective experiences of managing their child's chronic pain within family, school, and healthcare contexts.

RESULTS

Five superordinate themes emerged: 1. the continual challenge of problem solving pain and dyskinesia; 2. the pursuit of a solution; 3. unfulfilled preferences within pain management; 4. all-encompassing effects on families; and 5. the ongoing impacts of pain and dyskinesia with age.

CONCLUSION

There is a need for structured pain education and resources targeted towards caregivers and support workers that account for the complex overlay of dyskinesia. There is a further need to ensure caregiver preferences for non-pharmacological pain treatments are met within family-centred care models.

Validity of the Rotterdam Elderly Pain Observation Scale for institutionalised cognitively impaired Dutch adults

BACKGROUND

The Rotterdam Elderly Pain Observation Scale (REPOS) has not yet been validated for institutionalised cognitively impaired adults. To fill this gap of knowledge, we tested psychometric properties of the REPOS when used for pain assessment in this population.

METHODS

In this multicentre observational study, residents were filmed during a possibly painful moment and at rest. Healthcare professionals were asked to rate residents' pain by means of a Numeric Rating Scale (NRS)-proxy. Two researchers assessed pain with the REPOS and the Chronic Pain Scale for Non Verbal Adults with Intellectual Disabilities (CPS-NAID) from video-recordings.

RESULTS

In total, 168 observations from 84 residents were assessed. Inter-observer reliability between the two researchers was good, with Cohen's kappa 0.72 [95% confidence interval (CI) 0.64 to 0.79]. Correlation between the REPOS and CPS-NAID for a possibly painful moment was 0.73 (95% CI 0.65 to 0.79). Sensitivity (85%) and specificity (61%) for the detection of pain were calculated with REPOS ≥ 3 and NRS ≥ 4 as a reference value. Item response theory analysis shows that the item grimace displayed perfect discrimination between residents with and without pain.

CONCLUSION

The REPOS is a reliable and valid instrument to assess pain in cognitively impaired individuals.

Validity and Reliability of the Caregiving Difficulty Scale in Mothers of Children with Cerebral Palsy

This study was conducted to determine the construct validity and reliability of the Caregiving Difficulty Scale, a tool developed to measure difficulties experienced by parents of children with cerebral palsy. To this end, a survey was conducted with 215 mothers of children with cerebral palsy, and the resultant data were analyzed. A confirmatory factor analysis was performed to verify the construct validity of this scale, and the intra-item fit value was calculated for reliability analysis. Validity analysis confirmed that a bi-factor model comprising four sub-factors, Concern for the Child, Impact on Self, Support for Caregiving, and Social and Economic Strain, was suitable for the Caregiving Difficulty Scale. In addition, the reliability analysis results showed that the reliability coefficients of three of these areas, excluding Social and Economic Strain, and the reliability of the entire scale were acceptable. Therefore, the Caregiving Difficulty Scale is an appropriate tool to measure the burden of caregiving for children with cerebral palsy, and the findings emphasize the need to improve its reliability by comparing sub-factors’ reliability.

Paediatricians' Views on Pain in Children with Profound Intellectual and Multiple Disabilities

Pain is a frequent issue in children with profound intellectual and multiple disabilities (PIMD). Its identification and treatment can prove highly challenging for primary care physicians, mainly because of the children’s limited communication abilities. We used an online survey to explore paediatricians’ views regarding the experience and management of pain in children with PIMD and invited 480 professionals working in the canton of Vaud, Switzerland, to take part. We received 121 responses (participation rate 25.5%). A large majority of respondents provided care to children with PIMD. All paediatricians considered that these children feel pain at least as much as typically developing children. However, paediatricians had mixed views on their tolerance to pain. More than 90% held the view that their pain is under-assessed and undertreated. The principal barriers they reported to appropriate management were communication limitations with the child, difficulties in pain assessment, lack of knowledge about children with disabilities and lack of experience. Paediatricians have complex opinions regarding how children with PIMD experience pain and how to manage this problem. Professional education and training on the specificities of children with PIMD, including how to address their pain, seem necessary to foster paediatricians’ ability and confidence in approaching this complex issue.

Pain is frequent in children with cerebral palsy and negatively affects physical activity and participation

AIM

The aim was to identify the prevalence of long-lasting pain among children with cerebral palsy (CP) and to investigate the association between pain and participation in physical leisure activities.

METHODS

This is a cross-sectional study based on data from the National Danish Clinical Quality Database of children with CP. The study population consisted of 960 children aged 2-11 years across all Gross Motor Function Classification System (GMFCS) levels. Data were collected at children's regular clinical visits in 2016 or 2017. Information about pain and participation in physical leisure activities were obtained. The association was estimated as odds ratios (OR) and 95% confidence intervals (95% CI) by logistic regression adjusted for age and sex.

RESULTS

We included data from 817 children (59% boys) median age 6 years, 52% classified as GMFCS level I. A total of 36% reported pain, and the most frequent pain locations were hips, feet and knees. Children reporting pain had lower odds for participation in physical leisure activities (OR 0.71, 95% CI 0.53-0.96).

CONCLUSION

A large proportion of children with CP reported pain. There is an indication that long-lasting pain influences participation in physical leisure activities. Pain-relieving interventions are important to decrease pain-related suffering and facilitate participation.

Practical Approaches and Knowledge Gaps in the Care for Children With Leukodystrophies

Leukodystrophies are a group of neurodegenerative genetic disorders that affect approximately 1 in 7500 individuals. Despite therapeutic progress in individual leukodystrophies, guidelines in neurologic care are sparse and consensus among physicians and caregivers remains a challenge. At patient advocacy meetings hosted by Hunter's Hope from 2016-2018, multidisciplinary experts and caregivers met to conduct a literature review, identify knowledge gaps and summarize best practices regarding neurologic care. Stages of severity in leukodystrophies guided recommendations to address different levels of need based on a newly defined system of disease severity. Four core neurologic domains prioritized by families were identified and became the focus of this guideline: sleep, pain, seizures/epilepsy, and language/cognition. Based on clinical severity, the following categories were used: presymptomatic, early symptomatic, intermediate symptomatic, and advanced symptomatic. Across the leukodystrophies, neurologic care should be tailored to stages of severity while accounting for unique aspects of every disease and multiple knowledge gaps present. Standardized tools and surveys can help guide treatment but should not overburden families.

Clinician Perspectives of Chronic Pain Management in Children and Adolescents with Cerebral Palsy and Dyskinesia

AIMS

To explore perspectives of clinicians from interdisciplinary teams on the barriers and facilitators to chronic pain management for children and adolescents with cerebral palsy and dyskinesia.

METHODS

Interdisciplinary focus groups (n = 2) were conducted at two Australian tertiary pediatric hospitals. Twenty-five experienced clinicians took part, including ten physiotherapists, six pediatricians, four rehabilitation physicians, four occupational therapists, and one speech and language therapist. An external moderator conducted the focus groups and data were analyzed using inductive thematic analysis.

RESULTS

Four key themes emerged: "balancing the intersection of pain and dyskinesia," "difficulty communicating between so many providers," "uncertainty surrounding chronic pain education," and "differing priorities." Key barriers were identified including a lack of access to some interdisciplinary team members and formalized guidance for health professionals regarding chronic pain education.

CONCLUSION

Key issues were reported to impact the delivery of coordinated inter-disciplinary chronic pain management at the tertiary level for children and adolescents with cerebral palsy and dyskinesia. In the absence of strong evidence, a strategy for implementing effective chronic pain management for children and adolescents with cerebral palsy and dyskinesia and gaining clinician consensus regarding the best practice management are recommended.

Pain in children with dyskinetic and mixed dyskinetic/spastic cerebral palsy

AIM

To evaluate pain prevalence and characteristics in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) cerebral palsy (CP) motor types.

METHOD

Seventy-five participants with a diagnosis of CP and confirmed dyskinetic or mixed (dyskinetic/spastic) motor type took part in a multisite cross-sectional study. The primary outcome was carer-reported pain prevalence (preceding 2wks) measured using the Health Utilities Index-3. Secondary outcomes were chronicity, intensity, body locations, quality of life, and activity impact.

RESULTS

Mean participant age was 10 years 11 months (SD 4y 2mo, range 5-18y). There were 44 males and 31 females and 37 (49%) had predominant dyskinetic CP. Pain was prevalent in 85% and it was chronic in 77% of participants. Fifty-two per cent experienced moderate-to-high carer-reported pain intensity, which was significantly associated with predominant dyskinetic motor types (p=0.008). Pain occurred at multiple body locations (5 out of 21), with significantly increased numbers of locations at higher Gross Motor Function Classification System levels (p=0.02). Face, jaw, and temple pain was significantly associated with predominant dyskinetic motor types (p=0.005). Poorer carer proxy-reported quality of life was detected in those with chronic pain compared to those without (p=0.03); however, chronic pain did not affect quality of life for self-reporting participants.

INTERPRETATION

Pain was highly prevalent in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) motor types, highlighting a population in need of lifespan pain management.

WHAT THIS PAPER ADDS

Chronic pain prevalence in children and adolescents with predominant dyskinetic and mixed (dyskinetic/spastic) motor types is high. Pain occurs across multiple body locations in predominant dyskinetic and mixed (dyskinetic/spastic) motor types. Less recognized locations of pain include the face, jaw, and temple for predominant dyskinetic motor types.

Assessing pain in children with autism spectrum disorders: findings from a preliminary validation study

AIMS

Assessing pain in children with autism spectrum disorders (ASDs) can be extremely challenging, since many cannot self-report pain. This study aims to test the validity of the Non-Communicating Children's Pain Checklist - Revised (NCCPC-R) in identifying pain in children and adolescents affected by ASDs.

MATERIALS AND METHODS

A two-phase validation study based on (a) the translation and cultural adaptation of the NCCPC-R to Italian and to ASD-specific needs and context; and (b) the validation of a modified, 32-item version of the NCCPC-R. In all, 141 carers of children aged 6-16 years with ASDs were asked to recall an in-pain episode and a not-in-pain episode of their child and to rate on a 3-point scale (0 = not at all, 3 = very often) each behaviour included in the tool. Internal consistency (Cronbach's α), explorative and confirmative factorial structure, as well as concurrent and discriminant validity, were all assessed.

RESULTS

Confirmatory factor analysis established the revised version of the NCCPC-R for children with ASDs (named = NCCPC-R_ASD ), formed from 10 of the original 30 items categorised into three factors ('Changing in mood', 'Increasing in tension' and 'Alerting reaction') to have an acceptable level of reliability. The tool was internally consistent (α = 0.741 during in-pain episodes, α = 0.790 during not-in-pain episodes) and was able to discriminate between in-pain episodes (13.36 out of 40; CI 95% 12.34-14.39) and not-in-pain episodes (7.84 out of 40; CI 95% 6.86-8.82, p < 0.001).

CONCLUSIONS

These results provide preliminary evidence that the 10-item version of the NCCPC-R_ASD is a reliable and valid tool for assessing pain in children with ASD.

The lived experience of chronic pain and dyskinesia in children and adolescents with cerebral palsy

BACKGROUND

To explore the lived experience of chronic pain and dyskinesia in children and adolescents with cerebral palsy.

METHODS

A convergent parallel mixed methods design was undertaken. First, a quantitative cross-sectional study of participants able to self-report their quality of life was undertaken. This study characterised pain chronicity, intensity, body locations, and quality of life. Second, semi-structured interviews were undertaken with a subset of children and adolescents experiencing chronic pain.

RESULTS

Twenty-five children and adolescents took part in the cross-sectional study, 23 of whom experienced chronic pain and 13 of moderate intensity. Pain was often located in multiple bodily regions (6/21), with no trends in quality of life outcomes detected. Eight participated in semi-structured interviews, which identified three key themes including 'lives embedded with dyskinesia', 'real world challenges of chronic pain', and 'still learning strategies to manage their pain and dyskinesia'.

CONCLUSIONS

A high proportion of children and adolescents with cerebral palsy and dyskinesia who were able to self-report experienced chronic pain. The physical and emotional impacts of living with chronic pain and dyskinesia existed along a spectrum, from those with lesser to greater extent of their impacts. Children and adolescents may benefit from targeted chronic pain education and management within bio-psychosocial models.

Sedation and analgesia in children with cerebral palsy: a narrative review

BACKGROUND

Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications.

DATA SOURCES

We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as 'cerebral palsy and children and pain' or 'sedation and cerebral palsy and children'.

RESULTS

While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation.

CONCLUSIONS

Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.

Interventions in pain management for persons with an intellectual disability

Pain is a multidimensional and subjective experience, and an ideal pain management regime needs to be comprehensive, integrative and involve all relevant persons. Multimodal interventions may include pharmacological, physical, social, psychological and spiritual approaches in order to address pain management at a molecular, functional, behavioural, cognitive and affective levels. Pain management interventions will vary according to pain aetiology, patient characteristics and preferences. In keeping with best practice guidelines for effective pain management, a structured approach incorporating an effective assessment of pain by the healthcare professional, identification of the source and type of pain and accurate documentation is essential. This article focuses on pharmacological and non-pharmacological pain management for individuals with intellectual disability.

Prevalence and characteristics of pain in children and young adults with cerebral palsy: a systematic review

AIM

The primary aim of this review is to evaluate the evidence for pain prevalence in children and young adults with cerebral palsy. Secondary aims are to identify pain characteristics and types of pain measurement used in this population.

METHOD

Ovid MEDLINE, Embase, CINAHL Plus, and PubMed were searched in October 2016 and updated in November 2017. Two authors independently screened studies according to Preferred Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pain outcomes were categorized within a biopsychosocial pain framework, with pain prevalence extracted for all recall periods and measurement types.

RESULTS

One hundred and six publications from 57 studies met inclusion criteria. Pain prevalence varied widely from 14 per cent to 76 per cent and was higher in females, older age groups, and those classified within Gross Motor Function Classification System level V. Pain was most frequent in the lower limbs, back, and abdomen and associated with reduced quality of life or health status. The influence of pain on psychological functioning, interference, and participation was inconclusive.

INTERPRETATION

Variation exists in reported pain prevalence because of sampling bias, inconsistent measurement, varying recall periods, and use of different participant age ranges.

WHAT THIS PAPER ADDS

Pain prevalence varies from 14 per cent to 76 per cent in children and young adults with cerebral palsy. Pain is more prevalent in females, older age groups, and children in Gross Motor Function Classification System level V.

Understanding pain physiology and its application to person with intellectual disability

The issue of pain warrants attention as, by virtue of having an intellectual disability, a person may have associated medical or physical conditions and associated factors increasing their risk of pain disorders. People with intellectual disability experiencing pain need to be provided with the best possible care. The focus of this article is on the exploration of pain: physiology and types; manifestations and responses in the context of intellectual disability in order to promote effective, knowledgeable assessment and management of pain for this client group. Pain is a subjective, complex, physiological and psychological phenomenon that can be acute or chronic and may be classified according to its cause. Within the experience of pain, the concept of total pain describes the physical, psychological, social and spiritual factors that influence the experience of pain.

Validity and reliability of Italian version of the Non-Communicating Children's Pain Checklist: revised version

BACKGROUND

The Non-Communicating Children Pain Check List-Revised (NCCPC-R) is a clinical assessment tool used to assess and measure pain in children aged 3 to 18 years, with mental and intellectual disabilities, incapable to speak.

AIM

Aim of our study was to test the validity and reliability of the Italian version of the NCCPC-R in children with cognitive impairment, in order to obtain a valid tool for pain assessment in these children.

DESIGN

Prospective observational study.

SETTING

Pediatric Outpatient of Physical and Rehabilitative Medicine Department, and Pediatrics, Child Neurology and Psychiatry Department, Sapienza University, Rome.

POPULATION

55 non-communicating children, with severe intellectual disability, aged 3-18 years.

METHODS

The guidelines for "translation, adaptation, and validation of instruments or scales for cross-cultural healthcare research" were used to translate the scale, which was administered by the parents/caregivers twice for 2 consecutive days, in association with NRS (Numerical Rating Scale). The reliability of the scale was evaluated using the intra and inter-class correlation coefficient (ICCs); Cronbach alpha coefficient was used to test the internal validity of the scale; "Receiver Operating Characteristic" (ROC) curves were used to compare pain-free scores with pain scores, determining threshold scores; Pearson correlation between NCCPC-R and NRS values was measured.

RESULTS

The InterCC between the first and the second interviewer at T0 was 0,97, the IntraCC of the first interviewer at T0-T1 was 0,89, showing a high correlation; the Cronbach alpha coefficient at T0 was 0,97, showing a high scale's validity. Pearson correlation between NRS and NCCPC-R values at T0 was 0,54 showing a medium level of agreement (P<0,0001). AUC (area under the curve) obtained by ROC curve at T0 was 0,807 (P=0,001), with sensitivity 95,2 and specificity 55,6, while a T1 AUC was 0,814 (P<0,001), with sensitivity 86,49, specificity 78,57.

CONCLUSIONS

The Italian version of NCCPC-R scale could be used to asses pain in non-communicating patients with mental and intellectual disabilities, showing a good correlation when compared to the NRS.

CLINICAL REHABILITATION IMPACT

The use of NCCPC-R scale in daily life made parents/caregivers able to discriminate the presence/absence of pain in non-communicating children, based on the scores obtained with the questionnaire.

'Total Pain' in Children with Severe Neurological Impairment

Many children with palliative care needs experience difficulty in managing pain. Perhaps none more so than those with severe neurological impairment. For many years; behaviours in these children were misunderstood. As a result; pain was poorly recognised and inadequately managed. Significant advances have been made in the assessment and management of pain in this challenging group of patients. We summarise these advances; drawing on our own experience working with infants; children and young adults with palliative care needs within a UK tertiary paediatric palliative care service. We expand on the recent understanding of 'Total Pain'; applying a holistic approach to pain assessment and management in children with severe neurological impairment.

Initial psychometric validation of the questionnaire on pain caused by spasticity (QPS)

BACKGROUND

The Questionnaire on Pain caused by Spasticity (QPS) is a modular patient- and observer-reported outcome measure of spasticity-related pain (SRP) in children with cerebral palsy (CP). Originally developed for an English-speaking population, we conducted a psychometric validation of a recently developed Chinese language version of the QPS.

METHODS

This was a prospective, observational study involving 137 children/adolescents with CP and upper and/or lower limb spasticity and their parents at three sites in China. Six QPS modules were used, three each for upper and lower limb SRP assessment: a patient self-report module; an interviewer-administered module used by site staff based on the cognitive, communicative, and motor abilities of a patient; and a parent/caregiver module administered for all children as an observer-reported outcome to complement the patient-reported outcome. If no assessment by the patient was possible because of age or cognitive impairments, only the parent/caregiver module was completed. Two visits with a 3-week interval provided data to evaluate and establish administrative ease of use, scoring of the QPS (factor analyses, Rasch analyses), reliability (Cronbach's α, intraclass correlation coefficient), validity (correlations with quality of life [PedsQL™], motor impairment [Gross Motor Function Classification System, Gross Motor Function Measure-66, Manual Ability Classification System], and spasticity [Ashworth Scale, Modified Tardieu Scale]).

RESULTS

For most children, clinic staff reported no difficulties associated with general QPS use or deciding which module to use. Children (and parents) who reported more demanding activities also reported higher levels of associated SRP (or observed SRP behavior). Activity-related SRP items were combined for a total QPS score. Cronbach's α was low for child self-report, but was acceptable for interviewer-administered and parent reports on SRP. Test-retest reliability was high for all modules. Moderate-strong associations were frequently seen between QPS and quality of life, and were particularly strong in the child self-report group. Relatively weak associations were observed between QPS and motor impairment and spasticity.

CONCLUSIONS

This first study was successful in providing initial evidence for the psychometric properties. Clinic staff were able to administer the QPS modules easily, and both children and parents were able to complete the designated QPS appropriately.

Measuring Musculoskeletal Pain in Infants, Children, and Adolescents

Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.

Fever in Children: Pearls and Pitfalls

Fever in children is a common concern for parents and one of the most frequent presenting complaints in emergency department visits, often involving non-pediatric emergency physicians. Although the incidence of serious infections has decreased after the introduction of conjugate vaccines, fever remains a major cause of laboratory investigation and hospital admissions. Furthermore, antipyretics are the most common medications administered to children. We review the epidemiology and measurement of fever, the meaning of fever and associated clinical signs in children of different ages and under special conditions, including fever in children with cognitive impairment, recurrent fevers, and fever of unknown origin. While the majority of febrile children have mild, self-resolving viral illness, a minority may be at risk of life-threatening infections. Clinical assessment differs markedly from adult patients. Hands-off evaluation is paramount for a correct evaluation of breathing, circulation and level of interaction. Laboratory markers and clinical prediction rules provide limited help in identifying children at risk for serious infections; however, clinical examination, prudent utilization of laboratory tests, and post-discharge guidance ("safety netting") remain the cornerstone of safe management of febrile children.

Validation of the Italian version of the Non-Communicating Children's Pain Checklist-Postoperative Version

Background

This study evaluated the validity and reliability of the Italian version of the Non-Communicating Children’s Pain Checklist-Postoperative version (I-NCCPC-PV).

Methods

The original NCCPC-PV version was translated into Italian following the guidelines for “the translation, adaptation, and validation of instruments or scales for cross-cultural healthcare research”. We tested the Italian NCCPC-PV version (I-NCCPC-PV) in 40 children (3–18 years of age) with severe to profound Intellectual Disability and no verbal communication. Each child’s behavior was observed by a parent or caregiver and by an external observer in a quiet situation and a painful one. They independently assessed the child’s level of pain using the translated Italian version of the NCCPCPV (I-NCCPC-PV).

Results

The results from 80 assessments showed that children’s behavioral signs differed significantly between painful and calm situations (p < 0.001). The inter-rater reliability was poor in a quiet condition (ICC 0.62) and fair in a painful situation (ICC 0.77). The inter-rater agreement was good in both calm and painful conditions (72.50% and 77.50% respectively).

Conclusion

The Italian version of the NCCPC-PV (I-NCCPC-PV) can be used for pain assessment in children with Intellectual Disability who lack verbal communication.

Associations between recurrent musculoskeletal pain and visits to the family doctor (GP) and specialist multi-professional team in 74 Norwegian youth with cerebral palsy

BACKGROUND

Musculoskeletal pain in cerebral palsy (CP) is common, but probably undertreated. The aim of the study was to explore if recurrent musculoskeletal pain (RMP) related to the CP condition was associated with visits to the family doctor [general practitioner (GP)] and specialist habilitation centre in youth with CP.

METHODS

Seventy-four youth with CP (mean age 16.5 years, 40 boys) from the same geographical area were assessed by clinical examination, semi-structured interview on pain (adolescent and parent together), the two questions on pain from the Child Health Questionnaire (parents only) and a structured interview on health care services. Gross Motor Function Classification System was level I 39%, level II 23%, level III 8% and levels IV and V 30%.

RESULTS

Thirty-five participants (47%) had visited their GP last year, and 49 (66%) had visited the specialist habilitation centre. The presence of RMP (n = 58; 78%) was not significantly associated with having visited the GP or the specialist habilitation centre. Still, in participants with RMP, increasing pain severity was associated with having visited the GP. Rest, massage, change of position and oral drugs were the most common measures taken to relieve RMP. Three adolescents with RMP did not take any measures to relieve pain.

CONCLUSION

Youth with RMP do take measures to relieve pain, but usually not in the direction of consulting the health care services available unless the pain is severe. Both youth with CP and their caregivers should be encouraged to discuss RMP with their professional network of care.

d. Putten AAJ. Pain and hospital admissions are important factors associated with quality of life in nonambulatory children

AIM

This was the first study to investigate the factors associated with health-related quality of life (HRQoL) in nonambulatory children with cerebral palsy (CP), based on a HRQoL measure specifically developed for this population.

METHODS

The Dutch version of the Caregiver Priorities and Child Health Index of Life with Disabilities (CPCHILD-DV) was used to measure HRQoL. It was completed by 66 parents of 47 boys and 19 girls with nonambulatory CP aged between five and 18 years with gross motor function classification system (GMFCS) levels of IV and V. Factors measured were the child's motor and cognitive impairments, comorbidities, pain, parents' education and occupations and family structure. Multiple linear regression analyses were used to determine the significant factors and the relative contribution of these factors to the CPCHILD-DV scores.

RESULTS

The most important factors associated with poorer HRQoL scores were pain and hospital admissions in the previous six months. Other factors were as follows: increased GMFCS level, feeding by gastrostomy tube, inability to communicate verbally, cognitive impairment, poor seizure control and higher parents' educational qualifications.

CONCLUSION

Pain and hospital admissions were the most important factors that were negatively associated with HRQoL in nonambulatory children with CP between five to 18 years.

Current concepts in management of pain in children in the emergency department

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Evidence and consensus based guideline for the management of delirium, analgesia, and sedation in intensive care medicine. Revision 2015 (DAS-Guideline 2015) - short version

In 2010, under the guidance of the DGAI (German Society of Anaesthesiology and Intensive Care Medicine) and DIVI (German Interdisciplinary Association for Intensive Care and Emergency Medicine), twelve German medical societies published the “Evidence- and Consensus-based Guidelines on the Management of Analgesia, Sedation and Delirium in Intensive Care”. Since then, several new studies and publications have considerably increased the body of evidence, including the new recommendations from the American College of Critical Care Medicine (ACCM) in conjunction with Society of Critical Care Medicine (SCCM) and American Society of Health-System Pharmacists (ASHP) from 2013. For this update, a major restructuring and extension of the guidelines were needed in order to cover new aspects of treatment, such as sleep and anxiety management. The literature was systematically searched and evaluated using the criteria of the Oxford Center of Evidence Based Medicine. The body of evidence used to formulate these recommendations was reviewed and approved by representatives of 17 national societies. Three grades of recommendation were used as follows: Grade “A” (strong recommendation), Grade “B” (recommendation) and Grade “0” (open recommendation). The result is a comprehensive, interdisciplinary, evidence and consensus-based set of level 3 guidelines. This publication was designed for all ICU professionals, and takes into account all critically ill patient populations. It represents a guide to symptom-oriented prevention, diagnosis, and treatment of delirium, anxiety, stress, and protocol-based analgesia, sedation, and sleep-management in intensive care medicine.

Chronic Pain Assessment Tools for Cerebral Palsy: A Systematic Review

BACKGROUND AND OBJECTIVE

Chronic pain in children with cerebral palsy (CP) is underrecognized, leading to detriments in their physical, social, and mental well-being. Our objective was to identify, describe, and critique pediatric chronic pain assessment tools and make recommendations for clinical use for children with CP. Secondly, develop an evidence-informed toolbox to support clinicians in the assessment of chronic pain in children with disabilities.

METHODS

Ovid Medline, Cumulative Index to Nursing and Allied Health Literature, and Embase databases were systematically searched by using key terms "chronic pain" and "clinical assessment tool" between January 2012 and July 2014. Tools from multiple pediatric health conditions were explored contingent on inclusion criteria: (1) children 1 to 18 years; (2) assessment focus on chronic pain; (3) psychometric properties reported; (4) written in English between 1980 and 2014. Pediatric chronic pain assessment tools were extracted and corresponding validation articles were sought for review. Detailed tool descriptions were composed and each tool underwent a formal critique of psychometric properties and clinical utility.

RESULTS

Of the retrieved 2652 articles, 250 articles met eligibility, from which 52 chronic pain assessment tools were retrieved. A consensus among interprofessional working group members determined 7 chronic pain interference tools to be of importance. Not all tools have been validated with children with CP nor is there 1 tool to meet the needs of all children experiencing chronic pain.

CONCLUSIONS

This study has systematically reviewed and recommended, through expert consensus, valid and reliable chronic pain interference assessment tools for children with disabilities.

A comparison of three scales for measuring pain in children with cognitive impairment

AIM

Pain is a neglected problem in children with cognitive impairments, and few studies compare the clinical use of specific pain scales. We compared the Non-Communicating Children's Pain Checklist Postoperative Version (NCCPC-PV), the Echelle Douleur Enfant San Salvador (DESS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The first two were developed for children with cognitive impairment, and the third is a more general pain scale.

METHODS

Two external observers and the child's caregiver assessed 40 children with cognitive impairment for pain levels. We assessed inter-rater agreement, correlation, dependence on knowledge of the child's behaviour, simplicity and adequacy in pain rating according to the caregiver for all three scales.

RESULTS

The correlation between the NCCPC-PV and the DESS was strong (Spearman correlation coefficient = 0.76) and better than between each scale and the CHEOPS. Although the DESS showed better inter-rater agreement, it was more dependent on familiarity with the child and was judged more difficult to use by all observers. The NCCPC-PV was the easiest use and the most appropriate for rating the child's pain.

CONCLUSION

The NCCPC-PV was the easiest to use for pain assessment in cognitively impaired children and should be adopted in clinical settings.

Qualitative development of the 'Questionnaire on Pain caused by Spasticity (QPS),' a pediatric patient-reported outcome for spasticity-related pain in cerebral palsy

PURPOSE

To develop a patient-reported outcome measure for spasticity-related pain in children/adolescents (age 2-17 years) with cerebral palsy (CP), the 'Questionnaire on Pain caused by Spasticity (QPS).'

METHODS

Using a semi-structured interview guide, concept elicitation interviews on spasticity-related pain in upper and lower limbs were conducted in 21 children and caregiver pairs. Data were used to modify initial QPS modules and develop six draft modules, which were subsequently refined and finalized in four consecutive cognitive interview waves (12 children and caregiver pairs).

RESULTS

To accommodate the broad range in the children's communication skills, QPS child/adolescent modules were developed in both interviewer-administered and self-administered formats. With the additional parent modules, three QPS modules were developed for each of the upper and lower limb applications. Information gained from the parent/caregiver modules complements the child/adolescent assessment. Parents report observed signs and frequency of pain in the same situations used to capture the child/adolescent reports of pain severity (e.g., rest, usual daily activities, active mobilization, and physically difficult activities). Participating children/adolescents and parents/caregivers reported that the final QPS instruments were comprehensive, relevant to the child's spasticity-related experience, and easy to understand and complete.

CONCLUSIONS

The QPS is a novel instrument for the assessment of spasticity-related pain in children/adolescents with CP that was developed with direct patient input. Its modules allow the use of this instrument in children/adolescents with varied levels of impairment and communication skills.

Novel cAMP binding protein-BP (CREBBP) mutation in a girl with Rubinstein-Taybi syndrome, GH deficiency, Arnold Chiari malformation and pituitary hypoplasia

Background

Rubinstein-Taybi syndrome (RTS) is a rare autosomal dominant disorder (prevalence 1:125,000) characterised by broad thumbs and halluces, facial dysmorphism, psychomotor development delay, skeletal defects, abnormalities in the posterior fossa and short stature. The known genetic causes are point mutations or deletions of the cAMP-response element binding protein-BP (CREBBP) (50-60% of the cases) and of the homologous gene E1A-binding protein (EP300) (5%).

Case presentation

We describe, for the first time in literature, a RTS Caucasian girl, 14-year-old, with growth hormone (GH) deficiency, pituitary hypoplasia, Arnold Chiari malformation type 1, double syringomyelic cavity and a novel CREBBP mutation (c.3546insCC).

Conclusion

We hypothesize that CREBBP mutation we have identified in this patient could be responsible also for RTS atypical features as GH deficiency and pituitary hypoplasia.