Clinical utility of PPPM and FPS-R to quantify post-tonsillectomy pain in children

Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study

BACKGROUND

Adenotonsillectomy is associated with severe postoperative pain. The parent's postoperative pain measure (PPPM), a 15-item instrument to measure a child's pain at home, has been validated with a seven-point faces scale in children 7-12 years and with the parents' global report of pain in children 2-6 years.

AIMS

Our primary objective was to validate the PPPM with a recommended age-appropriate pain scale in children 2-12 years after adenotonsillectomy. Our secondary objective was to reduce the PPPM components and validate this reduced PPPM.

METHODS

We recruited 319 children out of the 563 adenotonsillectomies performed between December 19, 2017, and December 18, 2018. Parents recorded administration of analgesics and their child's pain scores twice daily for 14 days: PPPM for all children and either the face, legs, arms, crying, consolability (FLACC) pain scale for children 2-3 years or the faces pain scale-revised (FPS-R) for children 4-12 years. In addition, parents recorded analgesics.

RESULTS

Among the 354 eligible children, 9% of parents declined. 252 (79%) families submitted pain diaries. The median age was 2.9 [2.5-3.3] years for FLACC (n = 114) and 5.6 [4.5-7.2] years for FPS-R (n = 138). Across the 14-day recovery period, Cronbach's alpha for PPPM was 0.77 to 0.87. Generalized linear mixed models evaluated the association between PPPM and reference pain scales after adjustment for potential confounders. Time of day and postoperative days were included as predictors in the models. PPPM was strongly associated with FLACC and FPS-R (beta coefficient = 0.4; p < 0.0001). The association decreased over time, and the reduction was more significant for FPS-R than FLACC (beta coefficient = -0.13 vs. -0.04, respectively; p < 0.0001). There was a positive association between PPPM and the use of analgesics. A reduction analysis eliminated items from the original PPPM: four for FLACC and five for FPS-R, suggesting age-related differences. The reduced PPPM instruments achieved similar associations with their respective reference pain scales (beta coefficient = 0.5; p < 0.0001).

CONCLUSIONS

This study extends previous work by validating the PPPM in children as young as 2 years with a recommended age-appropriate pain scale over 14-day convalescence after adenotonsillectomy. The reduced PPPM instruments differed in the two age groups. Future studies might explore these age-appropriate reduced PPPM instruments to assess pain at home following adenotonsillectomy.

Pain in children undergoing tonsillotomy with alternating ibuprofen and paracetamol - a prospective observational study

BACKGROUND

The optimal pain therapy for children undergoing tonsillotomy remains unknown. Our aim was to evaluate a standard pain therapy including the alternating application of ibuprofen and paracetamol.

METHODS

Pain intensity of 81 in-patients after tonsillotomy aged 2-12 years was evaluated three times daily (mean observation 3.85 days) using the Children's and Infants' Postoperative Pain Scale (CHIPPS) in children <5 years, or with the Faces Pain Scale-Revised (FPS-R) in older children. Parents completed the Parents' Postoperative Pain Measure (PPPM-D) in addition. Exceeding the cut-off value in one of the scores implied the indication for an opioid rescue medication (RM). Endpoints were number of children with indication for the RM, course of pain, concordance between pain scales, and adverse events.

RESULTS

Overall, 45.7% of children needed the RM either in the recovery room or on the ward. The rate of children having an indication for RM on the ward was 30.9%. The highest proportion of affected children was identified on the day of surgery (32.1%). Most indications were detected with the PPPM-D only. A comparison with an earlier study showed less affected children compared to ibuprofen monotherapy on the day of surgery and the first postoperative day. Eleven children (13.6%) developed fever.

CONCLUSION

Although our pain therapy concept was effective from postoperative day 1 onwards, it needs improvement for the day of surgery. The overall concordance between the PPPM-D and CHIPPS or FPS-R was low. Fever might be a confounder for the pain intensity measurement with the PPPM-D.

Does ibuprofen, prednisolone, or amoxicillin reduce post-tonsillectomy pain in children? A prospective randomized controlled trial

OBJECTIVE

To evaluate whether the use of anti-inflammatory or antibiotic in the postoperative period modifies pain in children undergoing tonsillectomy.

METHODS

225 children who underwent cold knife tonsillectomy ± adenoidectomy were randomized into five groups, receiving #1 metamizole/acetaminophen, #2 amoxicillin, #3 ibuprofen, #4 prednisolone, or #5 amoxicillin plus prednisolone. All groups received oral analgesics (metamizole/acetaminophen) to use as needed. Pain was monitored during the 7 days following surgery using the Parents' Postoperative Pain Measurement (PPPM) and the Faces Pain Scale - Revised (FPS-R). Pain was also indirectly evaluated by the dose of analgesics administered on each day and by the time needed to return to a solid diet.

RESULTS

After losses (24%), 170 individuals were submitted for analysis. Multiple comparisons demonstrated that the evolution of pain between the different groups, as matched day-per-day, was not significantly different by either PPPM or FPS-R (p > 0.05). The instances of analgesic intake were also similar in all the groups (p > 0.05), as was the return to solid food ingestion (p = 0.41). All groups presented a similar standard of clinical improvement at intervals of 2 days (p < 0.01). Independent of postoperative pain management, patients developed significant pain up to the day 4 following surgery.

CONCLUSION

The addition of amoxicillin, ibuprofen, prednisolone, or amoxicillin and prednisolone does not modify postoperative pain in children undergoing cold-knife tonsillectomy. Special pain control should be performed on the first 4 days following tonsillectomy in children.

Subtotal intracapsular tonsillectomy may be the first choice for tonsillectomy in children

Objective

To investigate the effect and prognosis of subtotal intracapsular tonsillectomy.

Methods

All children (n=162) with tonsillar hypertrophy and chronic tonsillitis were randomly divided into two groups: tonsillectomy (n=75) and subtotal intracapsular tonsillectomy (n=87). Tonsillectomy: the tonsillar tissue was completely removed along with the tonsillar capsule. Subtotal intracapsular tonsillectomy: 80% to 90% of the tonsils and the complete epithelium of the tonsillar crypts were removed without damaging the tonsillar capsule. The Face, Legs, Activity, Cry, and Consolability (FLACC) and parents’ postoperative pain measure (PPPM) scales were used to evaluate postoperative pain, and the obstructive sleep apnea (OSA)-18 questionnaire was used to assess the children’s postoperative quality of life. The patients were followed-up for 2 years.

Results

1. The FLACC and PPPM scales indicated that the children’s postoperative pain after subtotal intracapsular tonsillectomy was significantly less than that of children undergoing tonsillectomy. 2. The OSA-18 scale scores indicated that subtotal intracapsular tonsillectomy significantly improved the children’s quality of life. 3. Two years after subtotal intracapsular tonsillectomy, no patients required reoperation.

Conclusion

Subtotal intracapsular tonsillectomy may be the first choice for tonsillar hypertrophy and chronic tonsillitis patients.

Dipyrone as pre-emptive measure in postoperative analgesia after tonsillectomy in children: a systematic review

Introduction

Tonsillectomy is the 2nd most common outpatient surgery performed on children in the United States of America. Its main complication is pain, which varies in intensity from moderate to severe. Dipyrone is one of the most widely used painkillers in the postoperative period in children. Its use, however, is controversial in the literature, to the point that it is banned in many countries due to its potential severe adverse effects. Because of this controversy, reviewing the analgesic use of dipyrone in the postoperative period of tonsillectomy in children is essential.

Objective

The aim of this study was to review the analgesic use of dipyrone in the postoperative period of tonsillectomy in children.

Methods

Systematic review of the literature, involving an evaluation of the quality of articles in the databases MEDLINE/Pubmed, EMBASE and Virtual Health Library, selected with a preestablished search strategy. Only studies with a randomised clinical trial design evaluating the use of dipyrone in the postoperative period of tonsillectomy in children were included.

Results and conclusion

Only 2 randomised clinical trials were found. Both compared dipyrone, paracetamol, and placebo. We were unable to carry out a metanalysis because the studies were too heterogenous (dipyrone was used as pre-emptive analgesic in one and only postoperatively in another). The analgesic effect of dipyrone, measured by validated pain scales in childhood, was shown to be superior to placebo and similar to paracetamol. It appears that dipyrone exhibits a profile suitable for use in children. However, the scarcity of randomised clinical trials evaluating its analgesic effect in this age group leads to the conclusion that more well-designed studies are still needed to establish the role of dipyrone in the postoperative period of tonsillectomy in children.

Single dose of intraoperative intravenous morphine for analgesia in children undergoing tonsillectomy: Randomized, double-blind clinical trial

INTRODUCTION

Children undergoing tonsillectomy have severe pain in the postoperative period. One of the pharmacological options for analgesia is opioids, such as morphine. However, the risks of adverse effects, such as increased recovery time from anesthesia and respiratory depression, can limit its use.

OBJECTIVES

To evaluate the use of intraoperative intravenous morphine to reduce immediate postoperative pain in children undergoing tonsillectomy.

METHODS

In this double-blind randomized study, children aged 3-10 years were submitted to tonsillectomy, with or without adenoidectomy, and divided into two groups. Children in group M received 0.1 mg/kg of intravenous morphine during anesthetic induction, while those in the control group received conventional anesthesia without morphine. Postoperative pain perceptions were assessed at 30, 60, 120, 180 and 240 min after recovery from anesthesia, by the children themselves and also by their parents or guardians, using a facial pain scale.

RESULTS

A total of 57 children were included, 30 in the group with morphine and 27 in the group without morphine. According to the children themselves, the postoperative pain was less at the evaluations performed at 30 min after awakening from anesthesia (p =  0.023), while according to their parents/guardians, the pain was less intense in the evaluations performed at 30 (p =  0.002), 60 (p =  0.006) and 180 min (p =  0.007) after awakening. Moreover, postoperative analgesics were less requested by children in the morphine group. No observed side effects were associated with the use of morphine.

CONCLUSION

A single dose of intravenous morphine during anesthetic induction reduced the intensity of immediate postoperative pain in children undergoing tonsillectomy, without increasing the time of awakening from anesthesia and with lower consumption of rescue analgesics.

Postoperative morbidity after adenotonsillectomy versus adenopharyngoplasty in young children with obstructive sleep apnea: an RCT

Purpose

In our previous randomized controlled trial (RCT), comparing adenotonsillectomy (ATE) with adenopharyngoplasty (APP) in children with severe obstructive sleep apnea (OSA), there were no differences in respiratory sleep parameters or quality of life. The purpose of the present report was to evaluate postoperative morbidity from this RCT.

Methods

The study was a blinded RCT in 83 children (ATE = 47; APP = 36), 2–4 years of age, with an obstructive apnea–hypopnea index of ≥ 10. Pain was assessed from the first until the tenth day after surgery with a logbook that reported pain by child (FPS-R, Faces Pain Scale-Revised) and caregiver (visual analogue scale), analgesic use, return to normal diet, and weight change. Bleeding, infection, satisfaction with treatment, speech, and swallowing were assessed with a questionnaire and medical records 6 months after surgery.

Results

Sixty-four children (77%) returned the logbook and 65 (78%) answered the questionnaire. The median (interquartile range) day the children graded themselves as pain free (FPS-R = 0) was 7 (6–10) after ATE, compared with 9 (7 to > 10) after APP (p = 0.018). There were no other significant differences between the groups regarding any other pain-related outcomes, bleeding, infection, satisfaction, swallowing, or speech, but three children (11%) reported impaired speech after APP compared to none after ATE (p = 0.067).

Conclusion

The results regarding postoperative morbidity were in favor of ATE and the results from our previous report showed no advantages of APP. Therefore, APP should not be recommended in young, otherwise healthy children with OSA.

The validity of simplified self-report pain intensity assessment tools in preschool-age children undergoing adenotonsillectomy

PURPOSE

To assess the validity of simplified pain scales, including the Simplified Faces Pain Scale (S-FPS) and Simplified Concrete Ordinal Scale (S-COS) in preschool-age children who underwent adenotonsillectomy (T&A) by comparing the values of simplified pain scales with the Faces Pain Scale-Revised (FPS-R) and the Faces, Legs, Activity, Cry, Consolability (FLACC) observational pain scale.

METHODS

The present study consisted of 100 pediatric patients between the ages of 3 and 6 years old who had T&A. A two-step pain assessment approach with S-FPS and S-COS and FPS-R and FLACC pain scales was performed with children with the help of their parents or caregivers at the 1st, 6th and 12th hours, and over the 7 days after surgery.

RESULTS

The mean scores of S-FPS and S-COS were higher than the mean FPS-R scores for each time point for all age groups. The total number of children reporting no pain was higher for FPS-R than S-FPS and S-COS for each age group and the difference was significant for 3-, 4- and 5- year olds. S-FPS, S-COS and FPS-R showed a moderate correlation with FLACC in all age groups, whereas the correlation values were not significantly different between the tests.

CONCLUSION

In the present study, we found that S-FPS and S-COS were valid options for estimating pain in preschool children including 3- and 4-year-olds who underwent T&A.

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.

Postoperative pain and bleeding after adenotonsillectomy versus adenotonsillotomy in pediatric obstructive sleep apnea: an RCT

Purpose

Our previous randomized controlled trial (RCT) of children with obstructive sleep apnea (OSA) showed no significant differences between adenotonsillectomy (ATE) and adenotonsillomy (ATE) in improving nocturnal respiration and symptoms after one year. This is the continuous report with the evaluation of postoperative morbidity concerning bleeding and pain.

Methods

A double-blinded RCT including 79 children, aged 2–6 years, with moderate to severe OSA, randomized to either ATE (n = 40) or ATT (n = 39). From one to ten days postoperatively, parents filled in a logbook with six pain-related outcomes (parent and child grading pain at different levels, days of analgesic use and return to normal diet). Peri- and postoperative bleeding were also registered.

Results

63 patients (80%) returned the logbook. There were significant differences between groups in only two of the six pain-related outcomes in favor of the ATT group; first day when the children graded themselves as pain free (p = 0.021, Log Rank Test), and first day the caregiver estimated pain VAS ≤ 5 (p = 0.007, Log Rank Test). Two (5%) cases of postoperative bleeding occurred in the ATE group, one of which needed a return to theatre. No case of postoperative bleeding was seen in the ATT group.

Conclusions

The results from this RCT are in line with previous comparative studies between ATT and ATE. Children operated with ATT had significantly less postoperative pain in one-third of the outcomes, and less bleeding than ATE. However, as the differences in morbidity between the surgical methods were minor the clinical significance is uncertain.

Trial registration

This study was approved by the Swedish Regional Ethics Board in Stockholm, Sweden (Dnr 2011/925-32 and 2013/2274-32) and registered at ClinicalTrials.gov (Trial registration number NCT01676181).

Acetaminophen, ibuprofen, and tramadol analgesic interactions after adenotonsillectomy

BACKGROUND

The impact of tramadol in children given acetaminophen-ibuprofen combination therapy is uncertain in acute pediatric pain management. A model describing the interaction between these three drugs would be useful to understand the role of supplemental analgesic therapy.

METHODS

Children undergoing tonsillectomy were given oral paracetamol and ibuprofen perioperatively. Blood was taken for paracetamol and ibuprofen drug assay on up to six occasions over 6 h after the initial dose. Tramadol was administered by caregivers for unacceptable postoperative pain. Pain was measured using the Parent's Postoperative Pain Measurement rating two hourly on the first postoperative day. A first-order absorption, one-compartment linear model with first-order elimination was used to describe acetaminophen and ibuprofen disposition. Analgesia was described using an E_MAX model extended for three drugs, assuming additive effects. Curve fitting was performed using nonlinear mixed effects models.

RESULTS

Pharmacodynamic parameter estimates, expressed using fractional Hill equation, were maximum effect (E_MAX ) 0.65 (95%CI 0.54, 0.74), the concentration of acetaminophen associated with 50% of the maximal drug effect (C_50,ACET ) 7.06 (95%CI 7.03, 7.72) mg/L, and the ibuprofen C₅₀ (C_50,IBU ) 3.95 (95%CI 2.57, 7.53) mg/L. The Hill coefficient was 1.48 (95%CI 0.92, 2.62) and an interaction term was fixed at zero (additivity). The half-time (t_1/2 keo) for equilibration between the plasma and effect site was 0.34 hour (95%CI 0.23, 1.98) for acetaminophen and 1.04 hour (95%CI 0.75, 1.77) for ibuprofen. Tramadol had a C_50,TRAM of 0.07 (95%CI 0.048, 1.07) mg/L with a t_1/2 keo,_TRAM 1.78 hour (95%CI 1.06, 1.96).

CONCLUSION

Ibuprofen has an EC₅₀ for analgesia in children similar to that of adults (3.95 mg/L; 95%CI 2.57-7.53, vs 5-10 mg/L adults). The maximum effect from combination therapy (ie, 65% reduction in pain score) achieves satisfactory analgesia with commonly used doses but increased dose adds little additional benefit. The addition of tramadol to this analgesic mixture prolongs analgesia duration.

In-hospital usability and feasibility evaluation of Panda, an app for the management of pain in children at home

BACKGROUND

Postoperative pain in children is often poorly managed at home, leading to slower functional recovery, poor oral intake, sleep disturbances, and behavioral changes. Panda is a smartphone application (app) designed to support parents in assessing their child's pain and managing medications.

AIMS

The aim of this study was to evaluate the Panda app's usability and feasibility in hospital prior to testing the app at home.

METHODS

The study comprised two phases. Phase I evaluated Panda's usability with nurses, parents, and adolescents using simulated scenarios. Usability was measured by task completion rate, user error rates, and the Computer Systems Usability Questionnaire. Phase II evaluated Panda's feasibility by observing parents/guardians of pediatric patients using the app on the postsurgical ward. Feasibility was measured using response frequency and delay following app notifications from an audit trail of app function, and parental satisfaction from an interview. Feedback was used to guide iterative app improvements.

RESULTS

In Phase I, 13 nurses, 12 parents, and 5 adolescents evaluated the app. A total of 103 usability issues were identified, analyzed, and addressed. In Phase II, 29 parents responded to a total of 151 app notifications, with 84% responding within 1 hour in the final round of testing; 93% of participants reported the app was easy to use, and rated the app with a median [interquartile range] Computer Systems Usability Questionnaire score of 2 [1-4]. Significant barriers to use included lack of flexibility in the medication scheduling, low volume of alert sounds, and the extra time spent on medication safety checks.

CONCLUSION

Panda's usability was improved and its feasibility demonstrated in the controlled hospital environment. The next step is to evaluate its feasibility for use at home.

Scaling properties of pain intensity ratings in paediatric populations using the Faces Pain Scale-revised: Secondary analyses of published data based on the item response theory

BACKGROUND

The Faces Pain Scale-revised (FPS-r) has been developed as an interval scale. For other pain measurement instruments, several studies found evidence for and against an interval level of measurement.

OBJECTIVES

The primary aim of the current study was to evaluate the scale properties of the FPS-r using an item response theory approach.

DESIGN

Secondary analysis of published data.

SETTING

Three studies; Study 1 and study 2: One university hospital; Study 3: international pain registry.

PARTICIPANTS

Study 1: n = 246, female: 41%, age: 11-18 years, 3 pain items; Study 2: n = 240, female: 43%, age: 11-18 years, 9 pain items; Study 3: n = 2266, female: 41%, age: 4-18 years, 3 pain items.

METHODS

The rating scale model (interval scale), the graded response model (no interval scale, ordered response categories) and the partial credit model (no interval scale) were used to scale the data.

RESULTS

In all three studies, the rating scale model was outperformed by the graded response model or the partial credit model in terms of model fit. Overlapping response categories were found in items associated with less pain. Response category widths were wider for categories associated with low pain intensity and smaller for categories associated with high pain intensities. Smallest response categories were 1%-67% smaller compared to the widest response category of the same item.

CONCLUSION

According to these findings, the interval scale properties of the FPS-r may be questioned. Item response theory methods may help to solve the problem of missing linearity in pain intensity ratings using FPS-r.

Assessment and management of pain in pediatric otolaryngology

INTRODUCTION

Pain is a disease by itself and it's a public health concern of major implication in children, not just because of the emotional component of the child and his family, but also due to the potential morbidity and mortality involving it. A proper assessment of pain it's a challenge in the pediatric population, due to their lack of understanding and verbalization of hurt. Additionally, a satisfactory treatment of pediatric pain can be arduous due to a lack of clinical knowledge, insufficient pediatric research, and the fear to opioid side effects and addiction.

OBJECTIVES

The aim of this review is to address the current definitions of pain, its physiological mechanisms and the consequences of its inadequate management, as well as, to guide the clinicians in the assessment and management of pain in the pediatric population at otolaryngology services.

METHODOLOGY

Narrative review by selective MeSH search terms: Children, Pediatrics, Otolaryngology, Pain measurement, Pain Management, Analgesics and Analgesia, from databases: MEDLINE/PubMed, Cochrane, ISI, Current Contents, Scielo and LILACS, between January 2000 and May 2016.

RESULTS

129 articles were reviewed according to the requirements of the objectives. Pain measurement is a challenge in children as there are no physical signs that constitute an absolute or specific indicator of pain, and its diagnosis must rely on physiological, behavioral and self-report methods. Regarding treatment, a suitable alternative are the non-pharmacological cognitive/behavioral therapies helped by pharmacological therapies tailored to the severity of pain and the child's age. We provide evidence-based recommendations on pain treatment, including non-opioid analgesics, opioid analgesics and adjuvant medicines to improve the management of pain in children in otolaryngology services.

CONCLUSIONS

We present a global review about assessment and management of pain in pediatric otolaryngology, which leads to future specific reviews on each topic. Research gaps on pain assessment and pharmacological interventions in neonates, infants and children are very wide and it should be promoted ethical and safe research on pain control in this population.

[Validation of the Spanish version of Parent's Postoperative Pain Management pain scale]

INTRODUCTION

Assessment of postoperative pain is a fundamental aspect of post-surgical care. When surgery is performed as an outpatient, the parents are mainly responsible for the assessment of pain, but they may not always correctly evaluate their children's pain. This makes it necessary to have tools that help them to assess postoperative pain reliably. The Parent's Postoperative Pain Measurement (PPPM) is a behavioral measurement tool of post-operative pain developed to help parents to assess their children's post-operative pain. The purpose of this work was to translate this scale into Spanish, and validate the psychometric properties of the Spanish version of the scale.

METHOD

Participants were 111 children aged 2 to 12 years, who had undergone surgery, and one of their parents. After the operation, the children's level of pain was assessed, and the parents completed the PPPM scale in Spanish.

RESULTS

The PPPM items in Spanish showed good internal consistency (Cronbach alpha between 0.784 and 0.900) and the scale scores were closely related to the global pain assessment (Spearman's rho correlation between 0.626 and 0.431). The score on the scale decreased between the day of the operation and the next day, and discriminated well between children undergoing surgery qualified as low/moderate pain and high pain.

CONCLUSIONS

We conclude that the Spanish version of the PPPM scale evaluated in this study, has good psychometric properties to assess postoperative pain by parents at home.