Agreement Between Parent Proxy Report and Child Self-Report of Pain Intensity and Health-Related Quality of Life After Surgery

Development and validation of the Child Hemophilia Treatment Experience Measure: A new observer-reported outcome measure

INTRODUCTION

The Child Hemophilia Treatment Experience Measure (Child Hemo-TEM) was developed to capture the treatment burden experience of children with haemophilia (CwH).

AIM

Describe the development of this novel haemophilia-specific measure.

METHODS

Interviews were conducted with clinical experts, CwH and CwH's caregivers. Interviews were analysed according to adapted grounded theory principles. Based on the analysis, a preliminary measure was developed and debriefed. Psychometric analyses were performed according to an a priori analysis plan using data collected in a cross-sectional web survey and a final measure was generated.

RESULTS

Interviews with four clinical experts, 25 CwH ages 8 to <12 years, and 25 caregivers of CwH <12 years were conducted. Concepts endorsed by ≥10% of CwH and caregivers were: adherence, ease of use, emotional impacts, physical impacts, treatment concerns, and interference with daily life. Cognitive debriefing assessments were conducted to ensure participant understanding and item relevance. Caregivers found the measure to be understandable, comprehensive, and relevant. However, several issues with CwH completing the measure were identified and it was decided to only develop an observer-reported outcome version. Data for psychometric validation was collected in a web survey (N = 187). Item reduction dropped 12 items. Factor analysis generated a single, 7-item, internally consistent (α = .855) factor, which consisted of items covering all relevant a priori concepts. The majority of a priori convergent and all known groups validity hypotheses were confirmed.

CONCLUSIONS

The study findings provide evidence that the Child Hemo-TEM is a brief, well-designed, and valid and reliable measure of haemophilia treatment burden.

Acceptability and Usability of Smileyscope Virtual Reality for Paediatric Pain Management During Burn Procedures: Perspectives of Patients, Carers and Clinicians

AIM

To explore clinician, child and parent acceptability and usability of the Smileyscope VR device in the context of addressing the unique pain and distress needs of young burn patients.

DESIGN

A survey comprising closed and open-ended questions.

METHOD

Descriptive statistics analysed participant characteristics, pain and analgesia. Qualitative content was collected from April 2022-August 2022 and analysed to identify barriers and enablers. Categories were then mapped onto the Capabilities, Opportunities and Motivation-Behaviour Wheel (COM-B) framework.

RESULTS

Smileyscope was found to be effective for reducing pain and anxiety during dressing changes by both patients (n = 39) and parents (n = 37). Clinicians (n = 35) reported high self-efficacy and willingness to reuse the device. However, concerns arose regarding the device's fit and the need for age-appropriate programmes.

CONCLUSION

Smileyscope demonstrated promise in reducing procedural pain and distress. The device is well accepted by all participants implying ease of implementation. Feedback suggests further program development and fitting optimisation is required.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Improved procedural pain has proven to decrease wound healing times, decreasing possible need for further scar management and long-term consequences after sustaining a burn injury. Smileyscope use in rural hospitals presents valuable opportunities for optimising early paediatric burn pain.

IMPACT

Increased burn pain can delay wound healing and have long term physical and psychological impact on patients. Smileyscope was well received within this cohort; however, improvements in device design and programmes were suggested. This study shows the potential for use of Smileyscope as a non-pharmacological approach to improving paediatric burn pain and distress.

PATIENT OR PUBLIC CONTRIBUTION

While our study included patients, parents and clinicians as research participants, there was no patient or public contribution in the design or conduct of the study, analysis or interpretation of the data.

Paediatric laceration repair in the emergency department: post-discharge pain and maladaptive behavioural changes

BACKGROUND

Paediatric laceration repair procedures are common in the ED; however, post-discharge recovery remains understudied. Perioperative research demonstrates that children exhibit maladaptive behavioural changes following stressful and painful medical procedures. This study examined post-discharge recovery following paediatric laceration repair in the ED.

METHODS

This prospective observational study included a convenience sample of 173 children 2-12 years old undergoing laceration repair in a paediatric ED in Orange, California, USA between April 2022 and August 2023. Demographics, laceration and treatment data (eg, anxiolytic medication), and caregiver-reported child pre-procedural and procedural pain (Numerical Rating Scale (NRS)) were collected. On days 1, 3, 7 and 14 post-discharge, caregivers reported children's pain and new-onset maladaptive behavioural changes (eg, separation anxiety) via the Post Hospitalization Behavior Questionnaire for Ambulatory Surgery. Univariate and logistic regression analyses were conducted to identify variables associated with the incidence of post-discharge maladaptive behavioural change.

RESULTS

Post-discharge maladaptive behavioural changes were reported in 43.9% (n=69) of children. At 1 week post-discharge, approximately 20% (n=27) of children exhibited maladaptive behavioural changes and 10% (n=13) displayed behavioural changes 2 weeks post-discharge. Mild levels of pain (NRS ≥2) were reported in 46.7% (n=70) of children on post-discharge day 1, 10.3% (n=14) on day 7 and 3.1% (n=4) on day 14. An extremity laceration (p=0.029), pre-procedural midazolam (p=0.020), longer length of stay (p=0.043) and post-discharge pain on day 1 (p<0.001) were associated with incidence of maladaptive behavioural changes. Higher pain on post-discharge day 1 was the only variable independently associated with an increased likelihood of maladaptive behavioural change (OR=1.32 (95% CI 1.08 to 1.61), p=0.001).

CONCLUSION

Over 40% of children exhibited maladaptive behavioural changes after ED discharge. Although the incidence declined over time, 10% of children continued to exhibit behavioural changes 2 weeks post-discharge. Pain on the day following discharge emerged as a key predictor, highlighting the potential critical role of proactive post-procedural pain management in mitigating adverse behavioural changes.

Do Caregivers and Patients With Early-Onset Scoliosis Share the Same Perspective on Health-Related Quality of Life? A Comparison of 24-item Early-Onset Scoliosis Questionnaire and 22-item Scoliosis Research Society Questionnaire Scores

OBJECTIVE

The 24-item Early-Onset Scoliosis Questionnaire (EOSQ-24) is validated in patients with early onset scoliosis (EOS) aged 0 to 18 years and the 22-item Scoliosis Research Society (SRS-22) questionnaire is validated in idiopathic scoliosis patients 10 years and older. EOSQ-24 is completed by the caregiver and SRS-22 is completed by the patient. A prior study comparing patient-reported outcome measures completed by older pediatric patients and their parents showed a low level of agreement. Our purpose was to compare EOSQ-24 and SRS-22 scores completed at the same time point and at subsequent time points, in patients aged 5 to 18 years with idiopathic or congenital EOS without developmental delay.

METHODS

This was a multicenter retrospective study. We identified pairs of EOSQ-24 and SRS-22 completed on the same day or within 6 months. Some patients had multiple pairs of surveys over time. EOSQ-24 and SRS-22 questions were matched and domain scores for Pain, Function, Mental Health, and Satisfaction were compared. Patients with a change in treatment between surveys were excluded. Pearson correlation coefficients ( r ) were used to compare domain scores, with r ≥0.7 indicating a strong relationship.

RESULTS

There were 228 patient-caregiver dyads who completed 411 pairs of EOSQ-24 and SRS-22 on the same day. A strong correlation was found only for the Pain domain ( r =0.77). Function, Mental Health, and Satisfaction domains had positive but not strong correlations ( r = 0.58, r = 0.50, r = 0.41, respectively). Subanalysis based on age also showed a strong correlation only for Pain. There were 76 patient-caregiver dyads who completed 134 pairs of surveys with SRS-22 completed within 6 months after an EOSQ-24. All domains demonstrated a positive but not strong correlation, with Pain showing the highest correlation ( r = 0.64).

CONCLUSIONS

EOSQ-24 and SRS-22 had a strong correlation only for Pain when completed at the same time point. EOSQ-24 and SRS-22 completed within 6 months lacked a strong correlation for all domains. Our findings suggest that parents and children with EOS may not share the same perspective on their health. Self-reported questionnaires should be used when possible to assess health-related quality of life in older children and adolescents with EOS who are developmentally neurotypical.

LEVEL OF EVIDENCE

Level III-diagnostic.

Caregiver Burden Associated With Pediatric Chronic Pain: A Retrospective Study Using the Pediatric Electronic Persistent Pain Outcomes Collaboration Database

OBJECTIVES

This retrospective, cross-sectional study investigated the nature and extent of burden experienced by caregivers of children and adolescents with chronic pain, and factors associated with increased caregiver burden.

METHODS

The Pediatric Electronic Persistent Pain Outcomes Collaboration database provided prospectively collected data from 1929 families attending 9 pediatric chronic pain services across Australia and New Zealand. Data included demographic information, responses to child pain and functioning measures, caregiver work impairment, and psychosocial functioning.

RESULTS

Caregivers of children with chronic pain reported work impairment associated with their child's pain (mean: 15% ± SD 25 absenteeism; 38% ± SD 29 productivity lost), significantly worse than published international population norms (large-scale community survey data), most other caregiver samples of adults and children with other chronic conditions, and adult samples with various pain conditions. Caregivers reported considerable burden in multiple psychosocial functioning domains, particularly leisure functioning, pain-related catastrophizing, and adverse parenting behaviors (with greater pain-related avoidance). Caregiver psychosocial burden was significantly associated with child psychosocial functioning (β = -0.308, P < 0.01), school absenteeism (β = 0.161, P < 0.01), physical disability (β = 0.096, P < 0.05), and pain duration (β = 0.084, P < 0.05), but not pain intensity. Caregiver work productivity loss was significantly associated with school absenteeism (β = 0.290, P < 0.01), child physical disability (β = 0.148, P < 0.01), child health care utilization (β = 0.118, P < 0.05), and worst pain intensity (β = 0.101, P < 0.05).

DISCUSSION

These results highlight the significant and varied impacts experienced by caregivers of children with chronic pain. This work is novel in reporting significant work impairment and confirms psychosocial burden in a larger sample than previous studies.

Exploring camouflaging by the Chinese version Camouflaging Autistic Traits Questionnaire in Taiwanese autistic and non-autistic adolescents: An initial development

LAY ABSTRACT

Camouflaging is a coping strategy used by some autistic and other neurodivergent people to fit in neurotypical social contexts. The self-reported Camouflaging Autistic Traits Questionnaire has been validated for use in research with adults in some Western societies, but not in non-Western cultural-ethnic groups. We translated Camouflaging Autistic Traits Questionnaire into traditional Chinese and examined the use of this measure in Taiwanese adolescents via both self-report and caregiver-report in 100 autistic and 105 non-autistic adolescents. Both self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire were composed of two factors (i.e. a "compensation-masking" subscale and an "assimilation" subscale). Both adolescent self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire total score and subscales were reliable in measurement, and they highly correlated with each other. Taiwanese autistic adolescents were more likely to camouflage than non-autistic adolescents, especially on assimilation. Female autistic adolescents showed higher assimilation than male autistic adolescents. Higher camouflaging, especially assimilation, was associated with higher stress in autistic and non-autistic adolescents alike. Both self-reported and caregiver-reported Chinese version Camouflaging Autistic Traits Questionnaire were reliable and offered meaningful information to help us understand the social coping experiences of autistic and non-autistic adolescents.

Development and expansion of a pediatric transitional pain service to prevent complex chronic pain

The prevention of chronic pain is a key priority in North America and around the world. A novel pediatric Transitional Pain Service (pTPS) at the Hospital for Sick Children was established to address four main areas of need, which the authors will describe in more detail: (1) provide comprehensive multi-modal pain management and prevention techniques to children at-risk for the development of chronic pain, (2) provide opioid stewardship for children at-risk for chronic pain and their families at home after discharge, (3) facilitate continuity of pain care for children across transitions between inpatient and outpatient care settings, and (4) support caregivers to manage their child's pain at home. The pTPS works with healthcare providers, patients, and their families to address these areas of need and improve quality of life. Furthermore the service fills the gap between inpatient acute pain services and outpatient chronic pain services (accessible only once pain has persisted for >3 months). In pediatric patients who experience pain in hospital and who have been prescribed opioids, discharge to home or rehabilitation may represent a vulnerable time in which pain may persist and during which analgesic requirements may change. This offers an important opportunity to address and prevent the development of chronic pain, and to monitor opioids while ensuring alternative pain therapy is available. The authors will outline risk factors for persistent postsurgical pain, the development and implementation of a pTPS, present initial clinical outcomes andsuggest areas for future research in this evolving area of care.

Differences in the child, mother, and nurses' pain score measurements during pediatric venipuncture

BACKGROUND

Self-reporting is the gold standard for measuring pain in adult pain management; however, this issue is unique and different in children. Accurate pain assessment for the appropriate management of children's pain is important.

PURPOSE

This study was conducted to assess the pain level by the child, mother, and nurse during intravenous line insertion in preschool children, candidates for surgery in Tabriz Children's Hospital.

DESIGN AND METHODS

This is descriptive observational study. A total of 140 eligible children were included in the study using convenience and sequential methods. The intravenous line was inserted by an experienced nurse and pain assessment was performed by the child, mother, and nurse immediately after procedure, using the Wong-Baker face scale (WBFS). The data were analyzed through descriptive statistics and repeated measures ANOVA test using SPSS version 13 software.

RESULTS

The difference between child-mother and nurse-mother mean scores was not statistically significant; however, there was a statistically significant difference between the score measured by the child and the nurse (P = 0.017).

CONCLUSION

The children's pain assessment score during venipuncture was higher than that of mothers and nurses. The mothers' score was more closely related to the children's score. As a result, a mother's assessment can be considered a reliable estimation of proper pain management in young children and mothers can act as a moderator and actualize the nurses' score. Consequently, establishing a three-way communication between mother, child, and nurses is necessary to precisely estimate the child's actual pain and take appropriate measures to reduce it.

A Multisite Study Investigating Child and Parent Proxy Reported Quality of Life in Children With Cleft Lip and/or Palate

This observational, multisite cohort study explored health-related quality of life (HRQoL) in children with cleft lip and/or palate (CL/P), including interrater agreement and ratings for this group relative to clinical cutoff scores and published means for healthy and chronically ill children.

Participants (338 children ages 8-10 years, 45.9% male and their parents, 82.0% female) across 6 sites completed the Pediatric Quality of Life Inventory Generic Core Scales (PedsQL).

Intraclass correlation revealed poor interrater agreement for most HRQoL domains. Although ratings were generally higher than those expected for children with a chronic illness, child ratings were below healthy means for school functioning, and parent proxy ratings were below healthy means for all domains except physical functioning. Lower ratings consistent with chronic illness means were found for self-reported emotional and psychosocial functioning in children with cleft lip and palate (CLP), as well as parent proxy-reported emotional, school, and psychosocial functioning for children with cleft palate (CP). Scores were most likely to be in the clinical range for children with CP for social, school, and total functioning.

Although parent proxy report provides important information about observed functioning, poor interrater agreement indicates that both child and parent proxy reported HRQoL should be included in outcomes assessment for CL/P. HRQoL ratings may be higher for children with CL/P compared to youth with other chronic illnesses, but psychosocial functioning may be negatively impacted when compared with healthy youth, particularly for emotional, social, and school functioning in children with CLP or CP.

Prevalence of Temporomandibular Disorders Based on a Shortened Symptom Questionnaire of the Diagnostic Criteria for Temporomandibular Disorders and Its Screening Reliability for Children and Adolescents Aged 7-14 Years

The prevalence and adequacy of diagnostic approaches for temporomandibular disorders (TMD) in children and adolescents are still matters of debate. This study aimed to determine the prevalence of TMD and oral habits in children and adolescents aged 7-14 years and evaluate the consistency between self-reported TMD symptoms and clinical findings using a shortened Axis I of Diagnostic Criteria for TMD (DC/TMD). Children (aged 7-10) and adolescents (aged 11-14) of both sexes were invited to participate in this study (n = 1468). Descriptive statistics for all observed variables and Mann-Whitney U-Tests for the clinical examination were performed. A total of 239 subjects participated in the study (response rate 16.3%). The self-reported prevalence of TMD was found to be 18.8%. The most frequently reported oral habit was nail biting (37.7%), followed by clenching (32.2%) and grinding (25.5%). Self-reported headache increased with age, while clenching and grinding decreased. Based on the answers to the DC/TMD Symptom Questionnaire, subgroups of asymptomatic and symptomatic participants (n = 59; 24.7%) were established and randomly selected for the clinical examination (f = 30). The shortened Symptom Questionnaire showed a sensitivity of 0.556 and a specificity of 0.719 for pain during the clinical examination. Although the Symptom Questionnaire exhibited high specificity (0.933), its sensitivity (0.286) for temporomandibular joint sounds was low. Disc displacement with reduction (10.2%) and myalgia (6.8%) were the most common diagnoses. In conclusion, the self-reported prevalence of TMD in children and adolescents in this study was comparable to that reported in the literature for adults. However, the accuracy of the shortened Symptom Questionnaire as a screening tool for TMD-related pain and jaw sounds in children and adolescents was found to be low.

Symptoms in the acute phase of SARS-CoV-2 infection among Danish children aged 0-14 years

Objectives

To investigate the prevalence and burden of proxy-reported acute symptoms in children in the first 4 weeks after detection of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection, and factors associated with symptom burden.

Methods

Nationwide cross-sectional survey using parental proxy reporting of symptoms associated with SARS-CoV-2 infection. In July 2021, a survey was sent to the mothers of all Danish children aged 0-14 years with a positive SARS-CoV-2 polymerase chain reaction (PCR) test between January 2020 and July 2021. The survey included 17 symptoms associated with acute SARS-CoV-2 infection and questions about comorbidities.

Results

Of 38,152 children with a positive SARS-CoV-2 PCR test, 10,994 (28.8%) mothers responded. The median age was 10.2 (range 0.2-16.0) years and 51.8% were male. Among participants, 54.2% (n=5957) reported no symptoms, 43.7% (n=4807) reported mild symptoms, and 2.1% (n=230) reported severe symptoms. The most common symptoms were fever (25.0%), headache (22.5%) and sore throat (18.4%). Asthma {odds ratio (OR) 1.91 [95% confidence interval (CI) 1.57-2.32) and OR 2.11 (95% CI 1.36-3.28)}, allergy [OR 1.31 (95% CI 1.14-1.52) and OR 1.70 (95% CI 1.18-2.46], eczema [OR 1.43 (95% CI 1.20-1.71) and OR 2.03 (95% CI 1.38-2.97)] and OCD/anxiety/depression [OR 2.06 (95% CI 1.39-3.06) and OR 3.79 (95% CI 1.80-7.97)] were associated with reporting a higher symptom burden [values indicate outcomes reporting three or more acute symptoms (upper quartile) and reporting a severe symptom burden, respectively]. The highest prevalence of symptoms was found among children aged 0-2 and 12-14 years.

Conclusions

Among SARS-CoV-2-positive children aged 0-14 years, approximately half reported no acute symptoms within the first 4 weeks after a positive PCR test. Most symptomatic children reported mild symptoms. Several comorbidities were associated with reporting a higher symptom burden.

Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery

INTRODUCTION

Our aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs).

METHODS

Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models.

RESULTS

Among 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11-0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10-0.70), and both in combination (RRR:0.08, 95% CI:0.02-0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL.

CONCLUSION

Use of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children.

LEVEL OF EVIDENCE

III.

The feasibility of negative pressure wound therapy versus standard dressings in paediatric hand and foot burns protocol: a pilot, single-centre, randomised control trial

INTRODUCTION

The goal of paediatric hand and foot burn management is hypertrophic scar and/or contracture prevention. The risk of scar formation may be minimised by integrating negative pressure wound therapy (NPWT) as an acute care adjunct as it decreases the time to re-epithelialisation. NPWT has known associated therapeutic burden; however, this burden is hypothesised to be outweighed by an increased likelihood of hypertrophic scar prevention. This study will assess the feasibility, acceptability and safety of NPWT in paediatric hand and foot burns with secondary outcomes of time to re-epithelialisation, pain, itch, cost and scar formation.

METHODS AND ANALYSIS

This is a single-site, pilot randomised control trial. Participants must be aged ≤ 16 years, otherwise well and managed within 24 h of sustaining either a hand or foot burn. Thirty participants will be randomised to either standard care (Mepitel®-a silicone wound interface contact dressing-and ACTICOAT™-a nanocrystalline silver-impregnated dressing) or standard care plus NPWT. Patients will be reviewed until 3 months post-burn wound re-epithelialisation, with measurements taken at dressing changes to assess primary and secondary outcomes. Surveys, randomisation and data storage will be done via online platforms and physical data storage collated at the Centre for Children's Health Research, Brisbane, Australia. Analysis will be performed using the Stata statistical software.

ETHICS AND DISSEMINATION

Queensland Health and Griffith University Human Research ethics approval including a site-specific assessment was obtained. The findings of this study will be disseminated through clinical meetings, conference presentations and peer reviewed journals.

TRIAL REGISTRATION

Registered with the Australian and New Zealand Clinical Trials Registry (ACTRN12622000044729, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=381890&isReview=true , registered 17/01/2022).

Protocol for a feasibility, acceptability and safety study of the PICO device (negative pressure wound therapy) in acute paediatric burns

INTRODUCTION

Negative pressure wound therapy (NPWT) in acute burn care may decrease the time to re-epithelialisation by more than 20%. Despite this, the perceived burden of use; including therapeutic, physical and financial, have limited the use of NPWT in acute burn care. This might be minimised by using the small, ultraportable, single-use NPWT device PICO as opposed to larger devices, which to date has never been studied in acute burn care. This research will; therefore, primarily assess the feasibility, acceptability and safety of PICO in paediatric burns. Secondary outcomes include time to re-epithelialisation, pain, itch, cost and scar formation.

METHODS AND ANALYSIS

This protocol details a clinical trial methodology and is pre-results. This single site, prospective, pilot randomised controlled trial will be conducted in an Australian quaternary paediatric burns centre. Participants must be aged ≤16 years, otherwise well and managed within 24 hours of sustaining a burn that fits beneath a PICO dressing. Thirty participants will be randomised to one of three groups: group A: Mepitel and ACTICOAT, group B: Mepitel, ACTICOAT and PICO and group C: Mepitel, ACTICOAT Flex and PICO. Patient outcomes will be recorded at each dressing change to assess efficacy and safety outcomes until 3 months postburn wound re-epithelialisation. Surveys, randomisation and data storage will be undertaken via online platforms and physical data storage collated at the Centre for Children's Health Research, Brisbane, Australia. Analysis will be done by using StataSE 17.0 statistical software.

ETHICS AND DISSEMINATION

Ethics has been obtained from Queensland Health and Griffith Human Research Ethics committees including a site-specific approval. These data will be disseminated via clinical meetings, conference presentations and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ACTRN12622000009718.

Agreement of Clinician‐Administered and Modified Parent‐Administered House‐Brackmann Scales in Children with Bell's Palsy

Objective

Currently there is no parent administered scale for facial nerve function in children. We set out to assess the agreement between a newly developed parent-administered modified version of the House-Brackmann (HB) scale and the standard clinician-administered HB scale in children with Bell's palsy.

Study Design

Secondary analysis of a triple-blind, randomized, placebo-controlled trial of corticosteroids to treat idiopathic facial paralysis (Bell's palsy) in children (6 months to <18 years).

Setting

Multicenter study at pediatric hospitals with recruitment in emergency departments.

Methods

Children were recruited within 72 hours of symptom onset and assessed using the clinician-administered and the parent-administered modified HB scales at baseline, and at 1, 3, and 6 months until recovered. Agreement between the 2 scales was assessed using intraclass coefficient (ICC) and a Bland-Altman plot.

Results

Data were available for 174 of the 187 children randomized from at least 1 study time point. The mean ICC between clinician and parent HB scores across all time points was 0.88 (95% confidence interval, CI: 0.86, 0.90). The ICC for the data collected at baseline was 0.53 (95% CI: 0.43, 0.64), at 1 month was 0.88 (95% CI: 0.84, 0.91), at 3 months was 0.80 (95% CI: 0.71, 0.87) and at 6 months was 0.73 (95% CI: 0.47, 0.89). A Bland-Altman plot indicated a mean difference between the 2 scores (clinician-reported minus parent-reported) of only -0.07 (95% limits of agreement -1.37 to 1.23).

Conclusion

There was good agreement between the modified parent-administered and the clinician-administered HB scales.

The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic

BACKGROUND

Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement.

METHODS

This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS^®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™).

STUDY

Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS).

RESULTS

Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size.

CONCLUSION

Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.

Short- and Long-Term Self-Reported Symptoms in Adolescents Aged 12-19 Years after Vaccination against SARS-CoV-2 Compared to Adolescents Not Vaccinated-A Danish Retrospective Cohort Study

This study investigated self-reported short- and long-term symptoms among adolescents receiving the BNT162b2 (Pfizer/BioNTech) vaccine against SARS-CoV-2 and those who did not. A retrospective cohort study based on Danish national survey (collected between 20 July and 15 September 2021) and register data was conducted. Differences in short-term (<14 days) and long-term (>two months) symptoms were explored using logistic regression adjusted for confounders. A total of 747 vaccinated (first dose n = 326; second dose n = 421) and 6300 unvaccinated adolescents were included in analyses of short-term symptoms and 32 vaccinated and 704 unvaccinated adolescents in long-term symptom analyses. In the first 14 days after the first and second vaccine dose the most reported symptoms included headache and muscle or joint symptoms. In both vaccinated and unvaccinated adolescents, the 15−19-year-olds reported significantly higher proportions of all symptoms compared to the 12−14-year-olds. After the second vaccine dose vaccinated 12−14-year-olds reported significantly more headache in adjusted analyses (OR 2.20 (95% CI 1.24; 3.90)). Among the 15−19-year-olds, significantly more vaccinated adolescents reported gastrointestinal symptoms (1.38 (1.06; 1.81)), headache (1.66 (1.24; 2.22)), and tiredness (1.44 (1.08; 1.93)). No differences were found in long-term symptoms. Vaccinated adolescents reported significantly more short-term symptoms including headache, tiredness, and gastrointestinal symptoms after the second vaccine dose than unvaccinated adolescents. Long-term symptom results should be interpreted with caution due to limited sample size.

Consistency of pediatric pain ratings between dyads: an updated meta-analysis and metaregression

Accurate assessment of pediatric pain remains a challenge, especially for children who are preverbal or unable to communicate because of their health condition or a language barrier. A 2008 meta-analysis of 12 studies found a moderate correlation between 3 dyads (child-caregiver, child-nurse, and caregiver-nurse). We updated this meta-analysis, adding papers published up to August 8, 2021, and that included intraclass correlation/weighted kappa statistics (ICC/WK) in addition to standard correlation. Forty studies (4,628 children) were included. Meta-analysis showed moderate pain rating consistency between child and caregiver (ICC/WK = 0.51 [0.39-0.63], correlation = 0.59 [0.52-0.65], combined = 0.55 [0.48-0.62]), and weaker consistency between child and health care provider (HCP) (ICC/WK = 0.38 [0.19-0.58], correlation = 0.49 [0.34-0.55], combined = 0.45; 95% confidence interval 0.34-0.55), and between caregiver and HCP (ICC/WK = 0.27 [-0.06 to 0.61], correlation = 0.49 [0.32 to 0.59], combined = 0.41; 95% confidence interval 0.22-0.59). There was significant heterogeneity across studies for all analyses. Metaregression revealed that recent years of publication, the pain assessment tool used by caregivers (eg, Numerical Rating Scale, Wong-Baker Faces Pain Rating Scale, and Visual Analogue Scale), and surgically related pain were each associated with greater consistency in pain ratings between child and caregiver. Pain caused by surgery was also associated with improved rating consistency between the child and HCP. This updated meta-analysis warrants pediatric pain assessment researchers to apply a comprehensive pain assessment scale Patient-Reported Outcomes Measurement Information System to acknowledge psychological and psychosocial influence on pain ratings.

Fear of illness & virus evaluation (FIVE) COVID-19 scales for children-parent/caregiver-report development and validation

OBJECTIVE

Commonly-used youth anxiety measures may not comprehensively capture fears, worries, and experiences related to the pervasive impact of the COVID-19 pandemic. This study described the development of the Fear of Illness and Virus Evaluation (FIVE) scales and validated the caregiver-report version.

METHOD

After initial development, feedback was obtained from clinicians and researchers, who provided suggestions on item content/wording, reviewed edits, and provided support for the updated FIVE's content and face validity. Factor structure, measurement invariance, and psychometric properties were analyzed using data from a multi-site, longitudinal study of COVID-19-related effects on family functioning with 1599 caregivers from the United States and Canada.

RESULTS

Confirmatory factor analyses indicated a hierarchical five-factor structure best fit the data, resulting in a 31-item measure with four lower-order subscales: (1) Fears about Contamination and Illness; (2) Fears about Social Distancing, (3) Avoidance Behaviors, and (4) Mitigation Behaviors, and a higher-order factor, (5) Total Fears, indicated by the two fear-related lower-order subscales. Measurement invariance by country of residence, child age, and child sex was found. All subscales demonstrated strong internal consistency, appropriate item-scale discrimination, and no floor or ceiling effects. The Total Fears subscale demonstrated appropriate test-retest reliability. Concurrent validity supported by strong correlation with a youth anxiety measure.

DISCUSSION

The FIVE provides a psychometrically-sound measure of COVID-19-related fears and behaviors in youth in a caregiver-report format. Future research is necessary to evaluate correlates and longitudinal symptom patterns captured by the FIVE caregiver-report, as well as the validity and reliability of a youth self-report version of the FIVE.

Long COVID symptoms in SARS-CoV-2-positive children aged 0–14 years and matched controls in Denmark (LongCOVIDKidsDK): a national, cross-sectional study

Background

After the acute phase of SARS-CoV-2 infection, children can develop long COVID symptoms. We aimed to investigate the prevalence of long-lasting symptoms, the duration and intensity of symptoms, quality of life, number of sick days and absences from daycare or school, and psychological and social outcomes in children aged 0–14 years who had been infected with SARS-CoV-2 relative to controls with no history of SARS-CoV-2 infection.

Methods

A nationwide cross-sectional study was conducted including children with a confirmed SARS-CoV-2-positive PCR test (cases) and matched controls from Danish national registers. A survey was sent to mothers (proxy reporting) of children aged 0–14 years who had had a positive SARS-CoV-2 test between Jan 1, 2020, and July 12, 2021, and a control group matched (1:4) by age and sex. The survey included the Pediatric Quality of Life Inventory (PedsQL) and the Children's Somatic Symptoms Inventory-24 (CSSI-24) to capture current overall health and wellbeing, and ancillary questions about the 23 most common long COVID symptoms. Descriptive statistics and logistic regression analysis were used. Clinically relevant differences were defined as those with a Hedges' g score greater than 0·2. This study is registered at ClinicalTrials.gov (NCT04786353).

Findings

Responses to the survey were received from 10 997 (28·8%) of 38 152 cases and 33 016 (22·4%) of 147 212 controls between July 20, 2021, and Sept 15, 2021. Median age was 10·2 years (IQR 6·6–12·8) in cases and 10·6 years (6·9–12·9) in controls. 5267 (48·2%) cases and 15 777 (48·3%) controls were female, and 5658 (51·8%) cases and 16 870 (51·7%) controls were male. Cases had higher odds of reporting at least one symptom lasting more than 2 months than did controls in the 0–3 years age group (478 [40·0%] of 1194 vs 1049 [27·2%] of 3855; OR 1·78 [95% CI 1·55–2·04], p<0·0001), 4–11 years age group (1912 [38·1%] of 5023 vs 6189 [33·7%] of 18 372; 1·23 [1·15–1·31], p<0·0001), and 12–14 years age group (1313 [46·0%] of 2857 vs 4454 [41·3%] of 10 789; 1·21 [1·11–1·32], p<0·0001). Differences in CSSI-24 symptom scores between cases and controls were statistically significant but not clinically relevant. Small clinically relevant differences in PedsQL quality-of-life scores related to emotional functioning were found in favour of cases in the children aged 4–11 years (median score 80·0 [IQR 65·0–95·0]) in cases vs 75·0 [60·0–85·0] in controls; p<0·0001) and 12–14 years (90·0 [70·0–100·0] vs (85·0 [65·0–95·0], p<0·0001). PedsQL social functioning scores were also higher in cases (100·0 [90·0–100·0] than controls (95·0 [80·0–100·0]) in the 12–14 years age group (p<0·0001; Hedges g>0·2).

Interpretation

Compared with controls, children aged 0–14 years who had a SARS-CoV-2 infection had more prevalent long-lasting symptoms. There was a tendency towards better quality-of-life scores related to emotional and social functioning in cases than in controls in older children. The burden of symptoms among children in the control group requires attention. Long COVID must be recognised and multi-disciplinary long COVID clinics for children might be beneficial.

Funding

A P Møller and Chastine Mc-Kinney Møller Foundation.

Agreement between older adult patient and caregiver proxy symptom reports

BACKGROUND

Proxy report is essential for patients unable to complete patient-reported outcome (PRO) measures themselves and potentially beneficial when the caregiver perspective can complement patient report. In this study, we examine agreement between self-report by older adults and proxy report by their caregivers when completing PROs for pain, anxiety, depression, and other symptoms/impairments.

METHODS

Four PROs were administered by telephone to older adults and their caregivers followed by re-administration within 24 h in a random subgroup. The PROs included the PHQ-9 depression, GAD-7 anxiety, PEG pain, and SymTrak multi-dimensional symptom and functional status scales.

RESULTS

The sample consisted of 576 older adult and caregiver participants (188 patient-caregiver dyads, 200 patients without identified caregiver). The four measures had good internal (Cronbach's alpha, 0.76 to 0.92) and test-retest (ICC, 0.63 to 0.92) reliability whether completed by patients or caregivers. Total score and item-level means were relatively similar for both patient and caregiver reports. Agreement for total score as measured by intraclass correlation coefficient (ICC) was better for SymTrak-23 (0.48) and pain (0.58) than for anxiety (0.28) and depression (0.25). Multinomial modeling showed higher (worse) patient-reported scale scores were associated with caregiver underreporting, whereas higher caregiver task difficulty was associated with overreporting.

CONCLUSION

When averaged over individuals at the group level, proxy reports of PRO scores by caregivers tend to approximate patient reports. For individual patients, proxy report should be interpreted more cautiously for psychological symptoms as well as when patient-reported symptoms are more severe, or caregiver task difficulty is high.

Follow up of pain reported by children undergoing outpatient surgery using a smartphone application: AlgoDARPEF multicenter descriptive prospective study

ABSTRACT

In pediatric patients, pain remains the most common complaint after surgery. This French multicenter epidemiological study (AlgoDARPEF) aimed to evaluate the use of a smartphone application (App) to assess the duration and severity of pain experienced by children undergoing outpatient surgery. Children below 18 years of age scheduled for an elective outpatient procedure in one of the participating centers were eligible. Parents were invited to provide daily information for 10 days regarding their child's pain and comfort via a smartphone App using the Parents' Postoperative Pain Measure - Short Form (PPPM-SF). Children over 6 years old could also provide self-assessments of pain using a Numerical Rating Scale (NRS-11). Data regarding pain medication, preoperative anxiety, postoperative nausea and vomiting, and parent satisfaction were also analyzed. Repeated-measures analyses of variance (ANOVAs) were used to compare the self- and hetero-assessments of pain. Eleven centers participated in the study, and 1,573 patients were recruited. Forty-nine percent of parents (n = 772) actually used the App at least once. In all surgeries, the average pain rating on the PPPM-SF scale did not exceed 3/10 throughout the follow-up period, as well as for the four main surgical specialties. Age, visceral surgery, and preoperative anxiety ≥ 4/10 were identified as independent risk factors for experiencing at least one episode of pain ≥ 4/10 during the first 48 postoperative hours. While these findings indicated that postoperative pain management appears to be satisfactory in the families who used the App, some improvements in anxiety management are suggested. This study shows that inviting parents to use a smartphone App to assess and report the quality of postoperative management in pediatric patients, provides useful information. A continuous report is possible, regarding pain and adverse events, over a postoperative ten days period, by a self-reporting or a parent's contribution. Future studies should investigate the ability of live data collection using an App to ensure fast, efficient interactions between patients and physicians.

Potentially unrecognised pain in children: Population-based birth cohort study at 7 years of age

AIM

To estimate agreement in the point prevalence of any pain, high-intensity pain and pain in two or more sites according to parental and child report.

METHODS

We conducted a prospective study of 5639 children from a Portuguese birth cohort - Generation XXI, where parents and 7-year-old children answered the same questions at the same time. We assessed the accuracy of parental report, considering children's self-report as the gold standard.

RESULTS

At 7 years of age, 499 children (8.8% (95% confidence interval (CI) 8.1-9.6)) reported having pain at the time of the interview. Of those, 44.1% had high-intensity pain (3.9% (95% CI 3.4-4.4) of the whole sample) and 12.4% reported pain in two or more sites (1.1% (95% CI 0.8-1.4) of the whole sample). In this community setting, pain prevalence and intensity were lower when collected from parents. Parental report had sensitivity below 20% and specificity above 95% but its positive predictive value was at most 25%.

CONCLUSION

Our findings support that, outside acute care, parents have a specific but not sensitive report of children's pain at the age of 7 years. Their report seemed useful to exclude major complaints but limited to screen children's pain. This limitation was higher for more severe pain, that is two or more sites or high-intensity pain. Children should be asked directly about pain to avoid under-estimating paediatric pain.

Old Drug, New Pain. Roles and Challenges of Methadone Therapy in Pediatric Palliative Care: A Systematic Review

BACKGROUND

Pediatric palliative care (PPC) is defined as the prevention and relief from suffering of families and children with life-limiting (LLDs) or life-threatening diseases (LTDs). These patients often experience pain, with morphine being the most widely used drug to treat it. Few studies investigated the role of methadone in PPC patients, although it is considered among the most effective and underutilized drugs in PPC.

OBJECTIVES

Our aim was to evaluate the efficacy, safety, and dosage of methadone in PPC.

METHODS

Between August and October 2021 PubMed, Scopus and the Cochrane Library were searched for studies on the use of methadone in children with LLDs and LTDs. Articles were included if they met the following criteria: published in the last 10 years, English language, patients aged 0-23 years; children enrolled in a PPC center or receiving declared support from a PPC service; reporting of specific data on methadone in interventional trials, observational studies, or case series on >10 patients. The reporting of the article was guided by the PRISMA guidelines, and a critical appraisal of the included studies was performed using the JBI-tool.

RESULTS

After duplicates removal and full-text assessment, four studies were included and another one was added after checking the references of the retrieved papers. All were retrospective, and the literature is concordant in documenting the lack of evidence. A total of 116 children received methadone in PPC. From our review emerges the poor quality of data collection: in only one study pain was assessed with standardized scales. All studies documented the effectiveness of methadone in treating complex pain, either nociceptive or neuropathic. No serious adverse events were reported, with no cases of cardiac arrhythmias.

CONCLUSION

Our results suggest that methadone could represent a suitable strategy for treating pain in PPC. However, the evidence base is insufficient, and further research is warranted.

Family-Rated Pediatric Health Status Is Associated With Unplanned Health Services Use

OBJECTIVE

Self-rated health is a common self-reported health measure associated with morbidity, mortality, and health care use. The objective was to investigate the association of family-rated health status (FRH) in pediatric care with administrative indicators, patient and respondent features, and unplanned health services use.

PATIENTS AND METHODS

Data were taken from Child-Hospital Consumer Assessment of Healthcare Providers and Systems surveys collected between 2015 and 2019 in Alberta, Canada and linked with administrative health records. Three analyses were performed: correlation to assess association between administrative indicators of health status and FRH, logistic regression to assess respondent and patient characteristics associated with FRH, and automated logistic regression to assess the association between FRH and unplanned health services use within 90 days of discharge.

RESULTS

A total of 6236 linked surveys were analyzed. FRH had small but significant associations with administrative indicators. Models of FRH had better fit with patient and respondent features. Respondent relationship to child, child age, previous hospitalizations, and number of comorbidities were significantly associated with ratings of FRH. Automated models of unplanned services use included FRH as a feature, and poor ratings of health were associated with increased odds of emergency department visits (adjusted odds ratio: 2.15, 95% confidence interval: 1.62-2.85) and readmission (adjusted odds ratio: 2.48, 95% confidence interval: 1.62-2.85).

CONCLUSION

FRH is a simple, single-item global rating of health for pediatric populations that provides accessible and useful information about pediatric health care needs. The results of this article serve as a reminder that family members are valuable sources of information that can improve care and potentially prevent unplanned health services use.

Experiences of Pain and Quality of Life in Pediatric Intracranial Hypertension

OBJECTIVE

To examine psychosocial correlates, specifically pain intensity, pain interference, and quality of life (QOL), in patients with pediatric intracranial hypertension. We hypothesized that parents and children who report higher levels of pain intensity and interference would be associated with lower QOL.

METHODS

Eighty-three patients and their families seen in the pediatric intracranial hypertension clinic of a large pediatric hospital completed self-report and parent proxy measures on QOL, mood, and other psychosocial correlates. Bivariate correlations were conducted between parent proxy and self-reports and regression analyses between pain and psychosocial correlate variables were examined.

RESULTS

Parent proxy and child reports were highly correlated. Body mass index (BMI) was a significant predictor of parent proxy report of pain intensity with higher BMI associated with higher parent proxy ratings of pain intensity. Parents reported significantly higher levels of pain interference for their children compared to child report. Parent ratings of child depression symptoms, BMI, and age were significant predictors of pain interference. Higher BMI and depression symptoms and younger age were associated with more pain interference. Overall QOL was similar to other headache populations but lower than other chronic illness and healthy populations.

CONCLUSIONS

Pediatric intracranial hypertension is associated with decreased QOL. Body mass index was a significant predictor of pain intensity and interference and should be monitored closely in clinic. Clinical care should include psychosocial screening to identify patients who would benefit from interventions to reduce the impact of this condition.

Assessing fatigue in children and adolescents: Psychometric validation of the German version of the PROMIS® Pediatric Short Form v2.0 - Fatigue 10a in school children and pediatric chronic pain patients

Purpose

Fatigue is a common symptom in children and adolescents. Its negative impact on health outcomes is even more pronounced in those with chronic pain. There is currently no fatigue measurement tool in German that is validated for both children and adolescents with and without chronic pain. Therefore, this study aimed to gather quantitative validity evidence to support the use of the German version of the PROMIS^® Pediatric Short Form v2.0 - Fatigue 10a (PROMIS^® F-SF) in the German pediatric general population as well as in German pediatric chronic pain patients.

Methods

The 10-item self-assessment questionnaire was validated in a sample of N = 1348 school children (9–18 years; 52.4% female) and N = 114 pediatric chronic pain patients (8–17 years; 63.3% female). Construct and convergent validity, reliability, and item and scale characteristics were examined.

Results

Confirmatory factor analyses showed sufficient model fit for the 1-factor model of the questionnaire (school sample: CFI = 0.94, RMSEA = 0.10, SRMR = 0.04; patient sample: CFI = 0.90, RMSEA = 0.14, SRMR = 0.05). Convergent validity was supported by weak-to-large significant correlations with sleep quality, health-related quality of life (HRQoL), and pain characteristics. The questionnaire had excellent internal consistency in both samples (α = 0.92 and α = 0.93). Sex differences and age distributions of the PROMIS^® F-SF showed that girls reported significantly higher fatigue than boys and that fatigue increased with age.

Conclusion

The PROMIS^® F-SF is a reliable instrument with good psychometric properties. Preliminary evidence is provided that the questionnaire validly measures fatigue in children and adolescents with and without chronic pain.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11136-021-03032-8.

Associations Between Health Care Professional Communication Practices and Influenza Vaccination of Hospitalized Children

BACKGROUND

Health care professionals (HCPs) (eg, nurses, doctors) play a key role in vaccine uptake. Few studies describe HCP influenza vaccine communication with parents of hospitalized children.

METHODS

This study included English- and Spanish-speaking parents of influenza vaccine-eligible children hospitalized at a tertiary care pediatric hospital between October 2018 and May 2019. A survey was completed online or via telephone 2 to 15 weeks (median 4 weeks) after discharge. It examined parental intent to vaccinate their child during hospitalization and parent-reported inpatient HCP communication practices (eg, vaccine recommendation strength, format for initiating the recommendation). Multivariable logistic regression examined the associations between HCP communication practices and influenza vaccination during hospitalization, adjusting for demographic, clinical, and visit characteristics.

RESULTS

Parents (n = 194; 63.0% response rate) were mostly white (66.8%) and English-speaking (97.4%). Their children were primarily 5 through 17 years (67.0%) with chronic disease (68.6%); 24.7% were vaccinated before discharge. Most parents initially had no plan (55.6%) or planned to decline (31.1%) influenza vaccine for their child during hospitalization. Of these parents, 22.2% decided to accept the vaccine, 66.7% citing a HCP conversation as the main reason for changing their mind. Overall, 75.3% recalled a HCP conversation about influenza vaccination. Of these parents, 61.0% reported a HCP recommendation (53.8% described it as "very strong"; 11.1% noted a presumptive initiation format). A parent-reported HCP conversation (adjusted odds ratio [AOR] 5.23, 95% confidence interval [CI] 1.64-16.68) and recommendation (AOR 5.59, 95% CI 2.01-15.51) were associated with influenza vaccination during hospitalization.

CONCLUSION

This study highlights the importance of discussing and recommending influenza vaccination with parents of hospitalized children.

Mother-reported pain experience between ages 7 and 10: A prospective study in a population-based birth cohort

BACKGROUND

Trajectory studies suggest considerable stability of persistent or recurrent pain in adolescence. This points to the first decade of life as an important aetiologic window for shaping future pain, where the potential for prevention may be optimised.

OBJECTIVES

We aimed to quantify changes in mother-reported pain experience in children between ages 7 and 10 and describe clusters of different pain experiences defined by complementary pain features.

METHODS

We conducted a prospective study using data from 4036 Generation XXI birth cohort participants recruited in 2005-06. Pain history was reported by mothers at ages 7 and 10 using the Luebeck pain screening questionnaire. We tracked changes in six pain features over time using relative risks (RRs) and their 95% confidence intervals (95% CIs). Clusters were obtained using the k-medoids algorithm.

RESULTS

The risk of severe pain at age 10 increased with increasing severity at age 7, with RRs ranging from 2.18 (95% CI 1.90, 2.50) for multisite to 4.43 (95% CI 3.19, 6.15) for high frequency pain at age 7. A majority of children (59.4%) had transient or no pain but two clusters included children with stable recurrent pain (n = 404, 10.2% of the sample). One of those (n = 177) was characterised by higher probabilities of multisite pain (74.6% and 66.7% at ages 7 and 10, respectively), with psychosocial triggers/contexts (59.3% and 61.0%) and daily-living restrictions (72.2% and 84.6%). Most children in that cluster (58.3%) also self-reported recent pain at age 10 and had more frequent family history of chronic pain (60.5%).

CONCLUSIONS

All pain features assessed tracked with a positive gradient between ages 7 and 10, arguing for the significance of the first decade of life in the escalation of the pain experience. Multisite pain and psychosocial attributions appeared to be early markers of more adverse pain experiences.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Pediatric Pain Assessment in the Intensive Care Unit: An Evidence-Based Algorithm

BACKGROUND

Conducting an adequate pain assessment in the Pediatric Intensive Care Unit (PICU) is multifactorial and complex due to the diversity of the population. It is critical that validated pain assessment methods are used appropriately and consistently to aid in evaluation of pain and pain management interventions.

PURPOSE

The aim of this evidence-based practice project was to improve pain assessment practices in the PICU through a decision-support algorithm.

DESIGN & METHODS

The Iowa Model-Revised was used to guide the development and implementation of an evidence-based decision algorithm. Pre- and postdata were collected via surveys (nursing knowledge and confidence) and documentation audits (nursing pain assessments). Various implementation strategies were used to facilitate the integration and sustainability of the algorithm in practice.

RESULTS

The majority of survey items showed an increase in nursing knowledge and confidence. Audits of pain assessment documentation displayed an increase in appropriate pain assessment documentation related to a child's communicative ability. However, there is a need for reinfusion related to the documentation of sedation assessments.

CONCLUSIONS

The use of an algorithm supported the ability of PICU nurses to critically consider and choose the pain assessment method most appropriate for the patient's condition. The algorithm promotes nursing clinical judgement, prioritizes pain management, and includes patients receiving sedation. The algorithm supports a comprehensive pain assessment in a difficult pediatric patient population. Future research is needed to strengthen and standardize the usage of terms "assume pain present" and "assume pain managed," and to also improve the overall feasibility and effectiveness of the algorithm.

Experience of Registered Nurses of Postoperative Pain Assessment Using Objective Measures among Children at Effia Nkwanta Regional Hospital in Ghana

Introduction: People undergoing surgical operations experience some level of pain. Assessing pain intensity is one of the duties of the nurse and it involves subjective measures (self-report), and objective measures (behavioural and physiological). It has been observed by the researcher that nurses in clinical practice do not assess pain before management more so among children. Also, there is limited research in the area of pain assessment in children who cannot communicate. This study aimed to describe the experiences of registered nurses in assessing postoperative pain among children (0-3 years) using objective measures.

Methods: Descriptive phenomenology was the chosen design. Maximum variation sampling was used to recruit nine registered nurses with experience in nursing children after surgery at Effia Nkwanta Regional Hospital (ENRH) in Ghana. The researchers conducted audio-recorded in-depth interviews, transcribed verbatim and qualitatively analyzed following Colaizzi’s approach to descriptive phenomenology analysis.

Results: The study revealed that the nurses have more experience with using behavioural measures with limited experience with the use of physiological measures. The behavioural measures mostly reported from their experience were changes in facial expression and unusual crying of the child. In general, the nurses do not formally use consistent approaches to assess pain among children.

Conclusion: Given these results, opportunities should be made available for nurses to enhance their skills and utilize evidence-based approaches to formally assess pain among post-operative children.

Parent-child agreement in different domains of child behavior and health

AIM

The present study aimed to investigate and compare parent-child agreement in different domains of child health and behavior.

METHODS

Data were collected between 2011 and 2019 within the framework of the LIFE Child study (Germany). Different subgroups of 10- to 12-year-old children and their parents (n (max) = 692) completed questionnaires on several health behaviors (diet, media use, physical activity, sleep), parameters of health (behavioral strengths and difficulties, psychosomatic complaints), and school grades. Agreement between child and parent reports was evaluated using weighted kappa coefficients. Furthermore, the frequencies of different types of (dis)agreement (parent report > child report, same response, child report > parent report) were assessed and checked for associations with child or parent gender.

RESULTS

Agreement between child and parent reports varied from low to almost perfect, with the greatest levels of agreement for school grades and organized physical activity, and the lowest for dizziness, sleep duration, and the consumption of potatoes. Child gender had no significant effect on parent-child agreement. In contrast, the findings suggest that parent gender had some effect on agreement levels, with higher agreement for certain psychosomatic complaints when parent reports were completed by the mother, and higher agreement for white bread consumption if they were completed by the father. For some of the questionnaire items (especially those relating to behavioral difficulties and psychosomatic complaints, but also to the consumption of individual food products and mobile phone use), the type of (dis)agreement differed depending on child or parent gender.

CONCLUSIONS

The findings suggest that the perceptions and reporting strategies of children and their parents can diverge considerably, in particular for behavior that is not easily observable or measurable.

Content and construct validity of the Diagnostic Criteria for Temporomandibular Disorders Axis I for children

OBJECTIVE

To perform the content and construct validation of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) Axis I, for children 7-11 years old.

MATERIALS AND METHODS

A Delphi process was used to perform the content validity of the DC/TMD Axis I. One hundred eighty-nine 7- to 11-year-old children were assessed with the adapted instrument. Confirmatory factor analysis (CFA) was used to investigate construct validity of the DC/TMD for children. A baseline one-factor model was compared against a two-factor (Model 2) and a seven-factor (Model 3) models based on the original DC/TMD. Root mean squared error of approximation (RMSEA), comparative fit index (CFI), chi-square, change in chi-square and Cronbach's α were used to analyse the data. All analyses were performed in STATA^© version 13.0.

RESULTS

Items of the DC/TMD were reduced, "history time" was changed to 2 weeks, pain intensity was assessed through a face scale, and language was adapted to be better understood by children. The amount of muscle pressure was maintained as in the original DC/TMD Axis I. The CFA led to a two- and a seven-factor model, with good fit. The internal consistency of Model 2 was .91 and of Model 3, .94.

CONCLUSION

The results of this study provide evidence to support a seven-factor representation of the DC/TMD Axis I for 7- to 11-year-old children, as well as a two-factor structure. Such findings will begin to provide researchers with confidence in the properties of this instrument when considering its inclusion in clinical research.

A descriptive analysis of pediatric post-tonsillectomy pain and recovery outcomes over a 10-day recovery period from 2 randomized, controlled trials

Pediatric tonsillectomy involves an often painful and lengthy recovery period, yet the extended recovery process is largely unknown. This article describes postoperative recovery outcomes for 121 children aged 4 to 15 (mean 6.6 years, SD = 2.3) years enrolled in 1 of 2 clinical trials of analgesia safety and efficacy after tonsillectomy. Postoperative analgesia included scheduled opioid analgesic plus acetaminophen/ibuprofen medication use (first 5 days) and “as-needed” use (last 5 days). Clinical recovery as measured daily by the Parents' Postoperative Pain Measure (PPPM; an observational/behavioral pain measure), children's self-reported pain scores, side-effect assessments, need for unanticipated medical care, and satisfaction with recovery over 10 days was assessed. Higher Parents' Postoperative Pain Measure scores were correlated with poorer sleep, receipt of breakthrough analgesics, distressing side effects, higher self-reported pain scores, and need for unanticipated medical care. Higher self-reported pain scores were associated with more distressing adverse events, including nausea, vomiting, insomnia, lower parent satisfaction, and unplanned medical visits and hospitalizations. Pain and symptoms improved over time, although 24% of the children were still experiencing clinically significant pain on day 10. Scheduled, multimodal analgesia and discharge education that sets realistic expectations is important. This study adds to the emerging body of literature that some children experience significant postoperative pain for an extended period after tonsillectomy.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

The Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ): Development and Initial Psychometric Evaluation of a Brief and Comprehensive Measure of Pain and Pain Outcomes in Hospitalized Youth

Pediatric pain assessment in the hospital traditionally involves the patient's self-report of pain intensity using a numeric rating scale, which does not capture the complexity of the pain experience. No valid, comprehensive measure of pain in hospitalized youth exists. This study was designed to develop and conduct initial psychometric testing of the Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ), a comprehensive patient-reported measure of pain and pain outcomes in hospitalized youth. A multidisciplinary group of pediatric pain researchers and clinicians collaborated to adapt the adult APS-POQ Revised to pediatrics, including a patient-report and parent proxy version. The adapted measures were administered to 218 pediatric inpatients (age M = 13.4 years, 56% female) and 214 of their parents (80% mothers) at 4 US children's hospitals. The measure was feasible to administer within the inpatient setting and was acceptable and understandable to pediatric patients and their parents. Internal consistency was adequate for both patient-report and parent proxy (α = 0.77). Confirmatory factor analysis supported the following 6 domains, consistent with the adult measure: pain intensity, functional interference, emotional response, side effects, perceptions of care, and usual pain. Additional research is needed to further support the reliability and validity of this measure in diverse clinical populations. PERSPECTIVE: To reduce the impact of pain on hospitalized youth, pediatric pain assessment must move beyond ratings of pain intensity. The Pediatric APS-POQ provides a brief but comprehensive assessment of pain and pain outcomes in hospitalized children and adolescents, which will allow for greater individualization in hospital-based pain management and quality improvement purposes.

Validating the German version of the Revised Children's Anxiety and Depression Scale in a sample of pediatric chronic pain patients

OBJECTIVE

Many children and adolescents with chronic pain report substantial emotional distress, such as symptoms of anxiety and depression, that need to be assessed for successful chronic pain treatment. In the context of pediatric chronic pain, the Revised Children's Anxiety and Depression Scale has been recommended for the assessment of anxiety and depression symptoms. Therefore, the present study aimed to validate the German version of the Revised Children's Anxiety and Depression Scale in a sample of children and adolescents with chronic pain.

METHODS

Data were collected from N = 300 children and adolescents (age 8-17 years) who presented with headache, abdominal pain and/or musculoskeletal pain at a specialized pediatric pain center for interdisciplinary outpatient pain evaluation.

RESULTS

Cronbach's α for the total and subscales of the Revised Children's Anxiety and Depression scale ranged from 0.73 to 0.95. Sound psychometric properties were found in terms of item properties, factor structure and convergent validity with other measures of anxiety and depression (r ranged from 0.40 to 0.94). Girls reported significantly higher levels of anxiety and depression compared with boys. Higher pain severity was associated with more symptoms of anxiety and depression.

CONCLUSION

This study demonstrated that the German version of the Revised Children's Anxiety and Depression Scale is a reliable and valid measure for the assessment of anxiety and depression symptoms in children and adolescents with chronic pain. Further studies in school and clinical samples are needed to establish German norms and cutoff points for this scale.

Patient-proxy agreement on health-related quality of life in juvenile fibromyalgia syndrome

BACKGROUND

Health-related quality of life (HRQoL) measures serve as important indicators of pain-related physical and psychosocial function in youth with juvenile fibromyalgia syndrome (JFMS). While the administration of parent-proxy reported HRQoL measures in the assessment of JFMS is common, its added clinical value to patient self-reports is unclear. We aimed to determine the level of agreement on HRQoL among patients with JFMS as well as their parent-proxies and to determine factors associated with this agreement.

METHODS

We performed a retrospective, cross-sectional cohort study of children aged 8 to 17 years diagnosed with JFMS and presenting for initial evaluation to a pediatric rheumatology pain clinic between April 2017 and May 2018. All patients and proxies were administered the Pediatric Quality of Life Short Form 15 Generic Core Scales (PedsQL SF-15) as part of routine clinical care. We calculated absolute discrepancy scores (absolute value of parent-proxy score minus patient score) to describe the extent of difference in HRQoL scores between parent-proxies and patients. We examined agreement between parent-proxy report and patient self-report via intraclass correlation coefficients (ICCs), stratified by age and sex, as well as Bland-Altman plots. We also used multivariate regression models to determine factors associated with level of agreement.

RESULTS

A total of 65 patient-proxy pairs were included in this study. ICCs demonstrated good to excellent agreement between all parent-proxy and patient measures of HRQoL irrespective of the patient's age or sex. The level of agreement was not associated with pain duration or pain severity but less agreement on psychosocial HRQoL was associated with older patient age (β = 1.30; p < 0.05).

CONCLUSIONS

This study in youth with JFMS demonstrated good to excellent patient-proxy agreement across all domains of the PedsQL SF-15 irrespective of patient's age or sex. Our findings suggest that parent-proxy reports do not provide additional information beyond that obtained from the patient self-report of HRQoL according to the PedsQL SF-15. In order to facilitate children and adolescents with JFMS becoming partners in their own healthcare, and to decrease the burden of multiple questionnaires, we propose focusing on patients' own perceptions of HRQoL in the clinical setting.