Judging the effectiveness of analgesia for children and adolescents during vaso-occlusive events of sickle cell disease

Comparison of Side Effects of Nalbuphine and Morphine in the Treatment of Pain in children with Cancer: A Prospective Study

Contemporary pain management regimens in children do not include the use of the middle step of the analgesic ladder, i.e., weak opioids. The aim of this study was to analyse the comparison of side effects and the therapeutic efficacy of morphine and nalbuphine in pain management in children with cancer. We conducted an observational, prospective study and analysed medical records of patients treated at the Clinic of Paediatric Haematology and Oncology of the University Hospital in Wroclaw (Poland), who developed mucositis during treatment. The efficacy and safety of both drugs were analysed, and the efficacy of pain relief and the incidence of adverse effects characteristic of opioid drugs were compared. The cases of 96 of children treated with opioid drugs nalbuphine or morphine were analysed. Nalbuphine therapy was accompanied by a statistically significantly lower incidence of side effects such as skin pruritus, constipation, and micturition disorders compared to morphine (p < 0.05). After the discontinuation of nalbuphine, signs of withdrawal syndrome were much less frequent than after morphine (p < 0.05). In Conclusion, nalbuphine used as a pain killer in children with oncological disorder is a safe drug. It provides stable analgesia in most children. Compared to morphine, the side effects typical of opioid use are less common, and the incidence decreases over time.

Pharmacokinetics and analgesic effects of methadone in children and adults with sickle cell disease

BACKGROUND

Vaso-occlusive episodes (VOEs) are a significant source of morbidity among children and adults with sickle cell disease (SCD). There is little information on methadone use for SCD pain. This investigation evaluated methadone pharmacokinetics in children and adults with SCD, with a secondary aim to assess pain relief and opioid consumption.

PROCEDURE

Participants included children (<18 years) and adults with a VOE requiring hospitalization. Patients were randomly assigned to receive standard care (opioid patient-controlled analgesia; control group) or one dose of intravenous methadone (0.1-0.125 mg/kg) in addition to standard care (methadone group). Venous methadone and metabolite concentrations were measured. Pain scores, pain relief scores, and opioid consumption were recorded.

RESULTS

Twenty-four children (12 methadone, 12 controls) and 23 adults (11 methadone, 12 controls) were studied. In children, the half-life of R- and S-methadone enantiomers was 34 ± 16 and 24 ± 9 hr, respectively. In adults, R- and S-methadone half-lives were 52 ± 17 and 38 ± 12 hr, respectively. Pain scores were lower (P = 0.002) and pain relief scores were higher (P = 0.0396) in children receiving methadone versus controls. There was no difference in pain scores and pain relief in adults receiving methadone versus controls. There was no difference in opioid consumption between methadone and control groups, in both adults and children.

CONCLUSIONS

Intravenous methadone disposition in children and adults with SCD was comparable to that in subjects without SCD from prior studies. Methadone produced more pain relief than standard care in children with SCD. Higher methadone doses may be more effective and should be evaluated in both children and adults with SCD.

Treatment of Pain in Pediatric Patients

A growing body of evidence demonstrates that untreated pain is associated with adverse consequences that can compromise clinical and developmental outcomes in children but that these adverse consequences can be prevented or attenuated by appropriate analgesic therapy. Thus, effective treatment of acute pain must be a clinical priority for children of all ages. Over the past 20 years, extensive pediatric research exploring pain assessment, developmental pharmacology of analgesics, and the clinical use of analgesics has dispelled many myths and misconceptions about pain management in pediatric patients; proven that analgesics can be used safely in neonates, infants, and children; and provided a framework for the development of pediatric pain management guidelines. This article reviews guidelines recommended for managing acute pain in pediatric patients and the treatment options for children experiencing acute pain. Contemporary issues regarding acetaminophen, nonsteroidal anti-inflammatory agents, and opioids are discussed.

Development and validation of a virtual human vignette to compare nurses' assessment and intervention choices for pain in critically ill children

INTRODUCTION

As virtual experiences are increasingly used in health care training and research, it is important that adequate processes are applied for developing valid scenarios. We describe the development and validation of virtual human (VH) vignettes, computer-generated scenarios with animated patients and clinical information, for a mixed-methods study regarding nurses' assessment and intervention choices for critically ill children's pain.

METHODS

We followed the case development and review process for high-fidelity simulation case scenarios, including the use of validated written vignettes and content experts. Forty nurses described their pain assessment and intervention choices for the newly derived VH vignettes and completed a pain questionnaire. Nurses' reports of VH vignette consistency with their professional experience and recognition of VH facial expressions were evaluated to establish face validity. Their pain ratings for the VH and written (questionnaire) vignettes were evaluated for convergent validity. Qualitative content analysis, descriptive statistics, correlations, and paired t tests were used.

RESULTS

Most nurses (68.4%) supported vignette consistency with their professional experience. Facial expression recognition was 98.4%. Smiling children's pain was rated significantly lower than grimacing children in both VH and written vignettes. Pain was rated significantly lower for grimacing children in the VH vignettes than the written vignettes. Virtual human vignette pain ratings were strongly correlated with their written counterparts.

CONCLUSIONS

This process was effective for developing VH vignettes that demonstrated good face validity with participants and convergent validity with written vignettes. Virtual human vignettes may be useful in studying the influence of facial actions on nurses' choices for children's pain assessment and treatment.

PICU Nurses' Pain Assessments and Intervention Choices for Virtual Human and Written Vignettes

The purpose of this concurrent mixed-methods study was to 1) examine the factors pediatric intensive care unit nurses consider when assessing and intervening for children who report severe pain and to 2) determine the effect of child behavior and diagnosis on the nurses' pain ratings and intervention choices for written and virtual human vignettes. Quantitative and qualitative results substantiated that despite recommendations to use self-report, many PICU nurses use behavior as the primary indicator to assess and treat pain, even when a child is old enough to articulate pain intensity and there is sufficient cause for pain to be present.

Pain assessment using the adolescent pediatric pain tool: a systematic review

BACKGROUND

The Adolescent Pediatric Pain Tool (APPT) is a multidimensional pain assessment tool designed to assess pain location (body outline diagram), intensity (word graphic rating scale) and quality (list of pain descriptors) in hospitalized children eight to 17 years of age.

OBJECTIVES

To identify the age range, health conditions, settings and purpose for which APPT has been used; the components of the APPT that have been used; and the reported clinical and research utility of the APPT.

METHODS

A systematic review of published studies using the APPT was performed. Studies were identified through electronic searches in CINAHL, Medline, PubMed, SciELO and PsycInfo.

RESULTS

Twenty-three studies were analyzed. APPT has been used in patients between two and 68 years of age, with various acute and chronic conditions, in and out of hospital. All but six studies used the three components of the APPT. Most of the studies used the total number of sites marked, mean pain intensity and mean number of pain descriptors selected as main outcome measures; however, scoring methods varied. Studies report that the use of the APPT is relevant for clinical practice and for research.

CONCLUSION

Obtaining self-report of pain using the APPT may help clinicians to tailor pain management interventions. It may also be used in studies to provide a deeper understanding of the pain experience and to examine the effectiveness of pain management interventions. However, outcome measures and methods of scoring the different components of the APPT need to be clearly identified.

WITHDRAWN: Pain management for sickle cell disease in children and adults

This review is out of date, and the original authors are no longer available to update it. If you are interested in updating this review, please contact PaPaS: https://papas.cochrane.org/contact‐us

At October 2015, a new author team is preparing a replacement review to focus on acute sickle cell crises in adults.

The editorial group responsible for this previously published document have withdrawn it from publication.

Treating pain in sickle cell disease with opioids: clinical advances, ethical pitfalls

This article explores the ethical principles of prescribing in Sickle Cell Disease. The first two sections of the article provide detailed scientific justification for the last section of the manuscript, which explores and discusses the ethical principles.

Benchmarking pain outcomes for children with sickle cell disease hospitalized in a tertiary referral pediatric hospital

BACKGROUND

Painful vaso-occlusive crisis (VOC) is the most common reason for hospitalization in children with sickle cell disease.

OBJECTIVE

To benchmark pain outcomes in sickle cell disease, including process outcomes (eg, pain assessment and documentation practices, pain management interventions) and clinical outcomes (eg, pain intensity over hospital stay), to identify areas for improvement.

METHODS

A retrospective study was conducted on electronic charts of children hospitalized with a primary diagnosis of VOC between July 2007 and August 2008.

RESULTS

A convenience sample of 50 admissions was used. In terms of clinical outcomes, patients presented to the emergency department with an initial median pain intensity of 9⁄10 (interquartile range 8⁄10 to 10⁄10). Forty-three per cent had not used opioids for pain relief at home. The mean (± SD) length of stay was 4.0±2.3 days. For most patients, median scores for highest daily pain intensity remained moderate to high throughout hospitalization, although scores did decrease significantly per day of hospitalization. In terms of process outcomes, pain intensity was assessed according to hospital standards on 25% of days in both the emergency department and the ward. There was no discrepancy between prescribed and administered opioid doses and medication use. In 95% of cases, strong opioid use was in a subtherapeutic or low therapeutic dosage range.

CONCLUSIONS

The results showed three areas to target for improvement: improved pain assessment and documentation using valid pain tools; more aggressive multimodal management for peak VOC pain; and better education and support for pain management at home. Further studies are required to evaluate optimal pain treatment practices.

Remote monitoring of pain and symptoms using wireless technology in children and adolescents with sickle cell disease

PURPOSE

The purpose of this study was to examine (a) symptoms, (b) pain characteristics (intensity, location, quality), (c) pain medications and nonpharmacological strategies used for pain, (d) thoughts and feelings, and (e) healthcare visits. We also examined the relationship between pain and sleep.

DATA SOURCES

Pain and symptoms were entered on an electronic e-Diary using a smartphone and were remotely monitored by an advanced practice registered nurse (APRN). Sixty-seven children and adolescents (10-17 years) reported mild to severe pain at home that did not require healthcare visits. Symptoms reported were (a) general symptoms such as tiredness/fatigue (34.7%), headache (20.8%), yellowing of the eyes (28.4%); (b) respiratory symptoms such as sniffling (32.9%), coughing (19.1%), changes in breathing (10.0%); and (c) musculoskeletal symptoms such as stiffness in joints (15.8%). A significant negative correlation was found between pain and sleep (r = -.387, p = .024). Factors that predict pain included previous history of sickle cell disease (SCD) related events, symptoms, and negative thoughts.

CONCLUSION

Pain and multiple symptoms entered on a web-based e-Diary were remotely monitored by an APRN and prompted communications, further evaluation, and recommendations.

IMPLICATIONS FOR PRACTICE

Remote monitoring using wireless technology may facilitate timely management of pain and symptoms and minimize negative consequences in SCD.

Increased clearance of morphine in sickle cell disease: implications for pain management

Acute vaso-occlusive painful episodes associated with sickle cell disease (SCD) are frequently treated with morphine. Many SCD individuals require relatively higher doses of morphine to achieve optimal analgesia. We studied pharmacokinetics of morphine in SCD to explore if altered disposition could be a factor contributing to increased requirement of morphine in this population. The study subjects were in steady state of health to avoid the effect of hemodynamic changes associated with vaso-occlusion on morphine disposition. The plasma concentrations of morphine and its major metabolites were measured at timed intervals in 21 SCD subjects after they received a single .1 mg/Kg infusion of morphine sulfate. USCPACK software was used to fit candidate pharmacokinetic models. Noncompartmental pharmacokinetic parameters for morphine were calculated. Morphine clearance was 2.4-3.6 L/h, half-life was .3-.7 hours, AUC(0-∞) was 27.7-42.5 ng∗h/mL, and volume of distribution was .96-3.38 L/kg. Clearance of morphine in the study population was 3-10 folds higher than published estimates in the non-SCD population, with correspondingly lower AUC and half-life. Volume of distribution was similar. This observation suggests that due to increased clearance SCD individuals may require higher dose and frequency of morphine to achieve comparable plasma levels.

PERSPECTIVE

Accelerated clearance of morphine likely related to increased hepatic and renal blood flow may be responsible for increased requirement of morphine in SCD. Although SCD individuals may require higher and more frequent doses of morphine, inter-individual variability of morphine disposition highlights the importance of individualization of the therapy.

Pediatric nurses' beliefs and pain management practices: an intervention pilot

We evaluated feasibility of the Internet-based Relieve Children's Pain (RCP) protocol to improve nurses' management of children's pain. RCP is an interactive, content-focused, and Kolb's experiential learning theory-based intervention. Using a one-group, pretest-posttest design, we evaluated feasibility of RCP and pretest-posttest difference in scores for nurses' beliefs, and simulated and actual pain management practices. Twenty-four RNs completed an Internet-based Pain Beliefs and Practices Questionnaire (PBPQ, alpha=.83) before and after they completed the RCP and an Acceptability Scale afterward. Mean total PBPQ scores significantly improved from pretest to posttest as did simulated practice scores. After RCP in actual hospital practice, nurses administered significantly more ibuprofen and ketorolac and children's pain intensity significantly decreased. Findings showed strong evidence for the feasibility of RCP and study procedures and significant improvement in nurses' beliefs and pain management practices. The 2-hr RCP program is promising and warrants replication with an attention control group and a larger sample.

A systematic review of faces scales for the self-report of pain intensity in children

CONTEXT

Numerous faces scales have been developed for the measurement of pain intensity in children. It remains unclear whether any one of the faces scales is better for a particular purpose with regard to validity, reliability, feasibility, and preference.

OBJECTIVES

To summarize and systematically review faces pain scales most commonly used to obtain self-report of pain intensity in children for evaluation of reliability and validity and to compare the scales for preference and utility.

METHODS

Five major electronic databases were systematically searched for studies that used a faces scale for the self-report measurement of pain intensity in children. Fourteen faces pain scales were identified, of which 4 have undergone extensive psychometric testing: Faces Pain Scale (FPS) (scored 0-6); Faces Pain Scale-Revised (FPS-R) (0-10); Oucher pain scale (0-10); and Wong-Baker Faces Pain Rating Scale (WBFPRS) (0-10). These 4 scales were included in the review. Studies were classified by using psychometric criteria, including construct validity, reliability, and responsiveness, that were established a priori.

RESULTS

From a total of 276 articles retrieved, 182 were screened for psychometric evaluation, and 127 were included. All 4 faces pain scales were found to be adequately supported by psychometric data. When given a choice between faces scales, children preferred the WBFPRS. Confounding of pain intensity with affect caused by use of smiling and crying anchor faces is a disadvantage of the WBFPRS.

CONCLUSIONS

For clinical use, we found no grounds to switch from 1 faces scale to another when 1 of the scales is in use. For research use, the FPS-R has been recommended on the basis of utility and psychometric features. Data are sparse for children below the age of 5 years, and future research should focus on simplified measures, instructions, and anchors for these younger children.

Pediatric nurses' cognitive representations of children's pain

The aim of this mixed methods exploratory study was to describe pediatric nurses' cognitive representations (CRs) of the assessment and management of children's pain and to determine the relationships between their CRs and their choices about pain assessment and morphine administration. We recruited a convenience sample of 87 nurses caring for hospitalized children at 4 institutions. We measured the CRs with the Conceptual Content Cognitive Map (3CM) technique and pain assessment and morphine administration with smiling and grimacing child vignettes. We used content analyses for the 3CM data and fit logistic regression models to predict participants' analgesic choice for each vignette. Nearly all (91%) participants identified the child's behavior as an assessment approach; 48% indicated it as most important. Participants (92%) identified pharmacologic as a management approach; 47% indicated it as most important. Participants' CRs did not predict assessment or morphine administration choices. Significantly more participants chose the appropriate analgesic response for the grimacing child than they did for the smiling child. Nurses with more years of pediatric experience were less likely to select administration of the appropriate morphine dose. The 3CM method provided insights into nurses' thinking about pain that are indicative of gaps, which may be amenable to interventions.

PERSPECTIVE

Findings are from an innovative, unique measure of nurses' knowledge and beliefs about the complex phenomenon of children's pain management. Extensive details about the thought processes of pediatric nurses regarding pain assessment and management surfaced through this analysis, which provide excellent information for direction of future research and practice innovations.

Treatment of uncomplicated vaso-occlusive crises in children with sickle cell disease in a day hospital

BACKGROUND

Day hospital management for patients with sickle cell disease experiencing uncomplicated vaso-occlusive pain crises has been described in adult populations as an alternative care delivery system. The objective of this study was to characterize and descriptively assess the benefits of a day hospital exclusively designed for children.

PROCEDURE

We retrospectively studied all admissions to the Day Hospital at the Texas Children's Sickle Cell Center since its inception in 2000. A Day Hospital admission was defined as a minimum of two consecutive days of aggressive pain management as an outpatient, including intravenous hydration and analgesics, supported by home treatment over night with oral analgesic and anti-inflammatory agents. We gathered data on demographics, incoming pain score, provider type, opioid administration, length of stay, and needs for higher level care.

RESULTS

A total of 35 patients, ages 2-19, accounted for 80 episodes during the study period. The median incoming pain score was 8 on a scale from 1 to 10. The median length of stay was 2 days. The return rate for acute care within 48 hr for persistent symptoms was 7%. Seventy-one percent of patients admitted to the Day Hospital were treated without requiring transfer to inpatient care for escalating pain or medical needs.

CONCLUSIONS

We conclude that a dedicated Day Hospital facility has the potential to provide patient-centered, effective, and timely management of vaso-occlusive crises in children as well as adults.

Quality of life and pain management in sickle-cell disease

Sickle-cell disease is the most common genetic disorder worldwide and is characterized by intermittent severe painful episodes and other complications such as stroke, priapism, cholecystitis and acute chest syndrome. This review outlines the causes and characteristics of pain in children with sickle cell disease, how pain can be assessed and how painful episodes can be prevented. Sickle cell disease can have a significant impact on the patient’s quality of life, and the ways in which this can manifest, how it can be measured and how interventions such as cognitive behavioral therapy can be used to manage it are outlined. Medical management of acute painful episodes both in the community and in the hosptial setting are discussed, including the role of different analgesic and adjuvant agents. Prevention of painful episodes with hydroxycarbamide is discussed.

Pharmacogenetics of morphine: Potential implications in sickle cell disease

Morphine is frequently used to treat painful episodes associated with sickle cell disease (SCD) but may fail to provide adequate analgesia in many patients. This concise review focuses on unique disease related changes in physiologic variables associated with SCD that impacts pharmacokinetics and pharmacodynamics of morphine and may contribute to the variability in analgesia. Emerging evidence suggests that the allelic variants in the genes involving the opioid (UGT2B7, OPRM1, and ABCB1 genes) and nonopioid system (COMT gene) can alter the efficacy of morphine.

UGT2B7 promoter variant -840G>A contributes to the variability in hepatic clearance of morphine in patients with sickle cell disease

The purpose of the study was to determine if UDP-glucuronosyltransferase (UGT) 2B7 allelic variants encoding for UGT2B7, primary enzyme responsible for morphine glucuronidation contribute to the variability in the hepatic clearance of morphine in sickle cell disease (SCD). Twenty-four hour PK study of morphine and UGT2B7 variants genotyping was performed in 20 SCD patients in a steady state of health. Presence of the -840G allele (GG and GA) was associated with lower morphine metabolites/morphine AUC ratio compared with AA genotype (1.8 +/- 0.5 vs. 3.0 +/- 1.8 for M6G/M and 10.1 +/- 2.7 vs. 15.7 +/- 9.4 for M3G/M) (P = 0.03). Presence of UGT2B7 -840G allele is associated with significantly reduced glucuronidation of morphine and thus contributes to the variability in hepatic clearance of morphine in SCD.

Evidence-based assessment of pediatric pain

OBJECTIVE

To conduct an evidence-based review of pediatric pain measures.

METHODS

Seventeen measures were examined, spanning pain intensity self-report, questionnaires and diaries, and behavioral observations. Measures were classified as "Well-established," "Approaching well-established," or "Promising" according to established criteria. Information was highlighted to help professionals evaluate the instruments for particular purposes (e.g., research, clinical work).

RESULTS

Eleven measures met criteria for "Well-established," six "Approaching well-established," and zero were classified as "Promising."

CONCLUSIONS

There are a number of strong measures for assessing children's pain, which allows professionals options to meet their particular needs. Future directions in pain assessment are identified, such as highlighting culture and the impact of pain on functioning. This review examines the research and characteristics of some of the commonly used pain tools in hopes that the reader will be able to use this evidence-based approach and the information in future selection of assessment devices for pediatric pain.

Nurses' perceptions of children's pain: a pilot study of cognitive representations

Despite advances in pain assessment and management, hospitalized children continue to report high levels of pain intensity. Untreated pain can have deleterious effects on multiple body functions, resulting in delayed recovery, prolonged hospitalization, and worsening illness. Prior research demonstrates that nurses administered analgesia that was less than amounts recommended by standards and less than that available by physician order. This study was conducted to better understand how nurses think about and respond to children's pain by examining pediatric nurses' cognitive representations (CRs) and comparing the contents of CRs with standards of practice and with management decisions in case studies. Kaplan's theory of CR guided the research. Twenty registered nurses' CRs were measured by the Conceptual Content Cognitive Map open-ended technique. Descriptive and content analyses revealed that participants have rich and diverse CRs of children's pain. Cognitive map content items (294) were coded by investigators as belonging to an assessment (63%) or management (37%) domain. Items were further coded into multiple subgroups in each domain. For assessment, 65% of participants included the use of children's self-report of pain in their maps while 80% included behavioral manifestations; 50% included both. For management, 75% of participants identified pharmacological approaches, 60% identified nonpharmacological approaches, and 35% identified family involvement; 25% identified all three approaches. Indicators in participants' cognitive maps suggest there may be a relationship between nurses' CRs and choice of analgesic administration. Findings provide the direction for future education and research to improve children's pain relief.

Quantification of analgesic use in children with sickle cell disease

OBJECTIVES

The purposes of this study were: (1) to quantify analgesic use in children with sickle cell disease who were hospitalized for a vaso-occlusive episode, using the Medication Quantification Scale (MQS) and (2) to examine the relationships between pain intensity scores, number of painful areas marked on a body outline diagram, number of word descriptors of pain quality, and amount of analgesic medications administered.

METHODS

Children (5 to 19 y) were asked daily to provide pain intensity ratings and describe the location and quality of their pain. The nursing flowsheets were also reviewed to determine the dose, routes, and the number of times analgesic medications were administered in the previous 24 hours.

RESULTS

Mean worst pain intensity score on the day of admission was 84.0+/-9.9 (range 63.8 to 100) on the 0 to 100 Oucher numeric rating scale. The mean MQS score administered on the day of admission was 15.7+/-4.9 (range 6 to 24). This score decreased significantly by 1.2+/-0.5 (P<0.0001; range 0.9 to 2.5) each day of hospitalization. Significant correlations were found between various pain characteristics and total MQS scores prescribed at time of admission.

DISCUSSION

The MQS was a useful and sensitive measure to quantify analgesic use in patients with sickle cell disease who were hospitalized for an acute painful episode. The MQS score accounted for variations in the types of analgesic medications, routes of administration, dosing schedules, and opioid dosing requirements.

Unique concerns of the pediatric surgical patient: pre-, intra-, and postoperatively

This article focuses on the unique concerns of pediatric surgical patients and emphasizes preparation of the family as an integrated unit. The statement from older standards of the American Nurses' Association that "children have the right to be treated with dignity and respect" remains a valid challenge for nurses caring for these patients.

Pain management for sickle cell disease

BACKGROUND

Sickle cell disease is an inherited genetic disorder characterized by an abnormality of haemoglobin that predisposes to polymerization and consequent deformation ("sickling"). Sickle cell disease can cause episodes of acute severe pain. Chronic pain may also occur. Currently, pain is inadequately managed.

OBJECTIVES

The primary aim of the review was to assess the effectiveness of pharmacological analgesic interventions for pain management in sickle cell disease, including the treatment of acute and chronic pain in children and adults.

SEARCH STRATEGY

A pre-defined search strategy was used to electronically search the MEDLINE and EMBASE databases. Searches were also conducted on the Cochrane Controlled Trial Register (CCTR) and the Oxford pain randomised controlled trials citation database. The search period covered from January 1965 through to June 2002. Bibliographies of retrieved studies were searched for additional references. No language restriction was used.

SELECTION CRITERIA

All randomised controlled trials involving pharmacological treatment of acute or chronic pain in children or adults with sickle cell disease were selected. Patients with haemoglobin SS, haemoglobin S ss thalassaemia and the haemoglobin SC group were included.

DATA COLLECTION AND ANALYSIS

Trials were quality rated using the Oxford quality scale. Continuous measures of outcome were combined using weighted mean differences. Overall effect size was calculated with 95% confidence intervals.

MAIN RESULTS

Nine randomised controlled trials were identified. All studies involved small numbers of patients with acute sickle cell pain only. Interventions included NSAIDs (versus placebo in four studies; versus strong opioids in one study), strong opioids (oral versus parenteral in one study; morphine versus alternate in one study) and corticosteroids (versus placebo in two studies). Lack of data, small patient numbers, variations in study design and outcome measures limited the review. Due to heterogeneity of methodologies and reporting, it was not possible to perform meaningful meta-analyses.

AUTHORS' CONCLUSIONS

There were no studies addressing chronic pain in sickle cell disease. There is limited evidence for analgesic interventions in acute pain crises. Studies have been under-powered. There is not enough data for inter-trial comparisons. In one trial, there was no difference in the efficacy of sustained-release oral versus parenteral morphine, which suggests that oral morphine should be considered for acute pain. Parenteral corticosteroids appear to shorten the period over which analgesics are required and hospital length-of-stay, without producing short-term major adverse effects. More research is needed to improve pain management in sickle cell disease.

Changes in sleep, food intake, and activity levels during acute painful episodes in children with sickle cell disease

As part of a larger study that examined pain experience, pain management, and pain outcomes among children with sickle cell disease, functional status (sleep, food intake, and activity levels) was examined during hospitalization for acute painful episodes. Children were asked to rate the amount of pain they experienced as well as the amount of time they slept, the amount of food they ate, and the amount of activity they had everyday. Children reported high levels of pain, which showed only a small decrease throughout hospitalization, and had disrupted sleep and wake patterns, decreased food intake, and decreased activity levels. Nurses need to routinely monitor functional status during acute painful episodes so that strategies to promote adequate sleep, food intake, and activity may be incorporated to minimize long-term negative outcomes in children with sickle cell disease.

Pain management for the hospitalized pediatric patient

Pediatric hospitalists should make pain assessment and treatment a high priority and a central part of their daily practice. Efforts at improving pain treatment in pediatric hospitals should be multidisciplinary and should involve combined use of pharmacologic and nonpharmacologic approaches. Although available information can permit effective treatment of pain for most children in hospitals, there is a need for more research on pediatric analgesic pharmacology, various nonpharmacologic treatments, and different models of delivery of care.

Multidimensional assessment using the adolescent pediatric pain tool: a case report

PURPOSE

Children's and adolescents' pain experiences are complex and multidimensional. Therefore, assessing a single dimension of pain intensity is in many instances inadequate. The purpose of this case report is to illustrate the benefits of using a multidimensional pain tool to assess vaso-occlusive pain in children and adolescents with sickle cell disease.

CONCLUSIONS

The adolescent pediatric pain tool (APPT) provides a valid multidimensional pain assessment that facilitates individual pain assessments that optimize children's and adolescents' pain relief interventions and outcomes.

PRACTICE IMPLICATIONS

The APPT is particularly valuable when clinicians encounter children and adolescents experiencing complex, difficult to manage pain.

Nurses??? Knowledge, Attitudes, and Practices

PURPOSE

To describe nurses' knowledge and attitudes about relieving children's pain, perceived barriers to optimal pain management, and analgesics administered by nurses in relation to levels of children's pain.

STUDY DESIGN AND METHODS

Data were collected from 67 nurses and 132 children in their care. Outcomes were measured with The Nurses' Knowledge and Attitudes Survey Regarding Pain, the Nurses' Perceived Barriers to Optimal Pain Management for Children Survey, calculations of the ordered analgesia administered by the nurse, and the Oucher scale for intensity of children's pain.

RESULTS

Most nurses demonstrated knowledge and positive attitudes about relieving children's pain but lacked knowledge about the incidence of respiratory depression and thought that children overreport their pain. Inadequate or insufficient physician medication orders for pain were identified by 99% of nurses as the greatest barrier to optimal pain management. The children's mean pain level was 1.63 (scale of 0 to 5). Of the 117 children who reported pain, 74% received analgesia. Nurses administered means of 37.9% of available morphine and 22.8% of available total analgesia.

CLINICAL IMPLICATIONS

Nurses in practice need to become more aware of the adequacy of their analgesic administration, the value of children's self-report of pain, and the limitations of relying on children's behavioral manifestations to judge pain intensity. This study also demonstrates the importance of examining attitudes about children's pain relief and learning more about respiratory depression in children receiving opioids.

The Alternate Forms Reliability of the Oucher Pain Scale

The purpose of this study was to determine the adequacy of the alternate forms reliability of three versions of the Oucher pain scale. Because the original large-sized posters were unwieldy for use by nurses with children in clinical settings, it became necessary to reduce it in size. To determine whether the resulting tools were psychometrically equivalent to the original versions of the Oucher, this study was undertaken. In a group of 3- to 12-year-old children who underwent surgical or dental procedures ( n = 137), scores were obtained after the procedure on small and large versions of the Oucher. The order of presentation of the two different Ouchers was randomized. Findings revealed that correlation coefficients between the scores provided for the small and large versions of the Oucher were strong, positive, and significant for the Caucasian, African-American, and Hispanic versions in 3- to 12-year-old children. These results provided evidence of the adequacy of the alternate forms reliability of these scales.

Home treatment of pain for children and adolescents with sickle cell disease

This ethnographic study examined family caregivers' perceptions of the effectiveness of comfort measures used at home for children with vaso-occlusive episodes (VOE) of sickle cell disease. Interviews were conducted in the hospital while children experienced VOE. Oral analgesics and most nonpharmacologic pain relief methods were rated by caregivers as only partly effective. Major themes that emerged from interview information reflected caregivers' efforts on behalf of their children in avoiding pain episodes, keeping a normal routine, "catching" the pain, getting their minds off the pain, helping the child get through the episode, and staying out of the hospital. Understanding the role of the family caregiver in home settings may assist health care professionals to provide more empathetic care to children with VOE and to their families when children are admitted to the hospital. Findings may encourage professionals to design the most effective methods of home pain management for these families.

Physical and cognitive-behavioral activities used in the home management of sickle pain: a daily diary study in children and adolescents

BACKGROUND

There is little information documenting the use of cognitive-behavioral and physical pain relieving activities by children and adolescents for management of pain related to sickle cell disease (SCD).

METHODS

Thirty-seven subjects (aged 6-21 years) used a daily self-report pain diary for 6 months to 3 years to report their home pain experience and its pharmacologic and non-pharmacologic management.

RESULTS

A total of 514 vaso-occlusive pain episodes (2,592 days) were reported. Cognitive-behavioral or physical pain management activities were used alone on 7.5% of these pain days, and with analgesics on 77%. Female gender (P = 0.003) and increasing pain intensity (P = 0.04) were associated with an increased number of activities used. Increasing pain intensity was also associated with usage of several specific activities.

CONCLUSIONS

Patients and families frequently used cognitive-behavioral and physical activities in addition to oral analgesics to treat sickle cell-related pain at home, and may benefit from additional training and support.

METABOLISM OF OPIOIDS IS ALTERED IN LIVER MICROSOMES OF SICKLE CELL TRANSGENIC MICE

Pain in sickle cell anemia (SCA) is clinically managed with opioid analgesics. There are reports that SCA patients tolerate high doses of these drugs without adequate pain relief. The current study investigated the in vitro hepatic metabolism of opioids in mouse models of sickle cell anemia, with the hypothesis that higher dose requirements in SCA could be explained by an increased metabolism rate of opioids. Various rodent cytochrome P450 substrates, i.e., buprenorphine and codeine, and rodent uridine glucuronosyltransferase substrates, i.e., morphine, buprenorphine, and estradiol, were studied. The three groups used were: 1) control C57BL mice, 2) mice with the human alpha-globin and sickle beta-globin transgenes (SC), and 3) mice with the human alpha-globin and sickle beta-globin transgenes, and homozygous for the murine alpha-globin and heterozygous for the beta(major)-gene knockout (SCKO). In vitro hepatic microsomal incubations were carried out for each substrate, and data were fit to the Michaelis-Menten equation. Morphine formation had a higher V(max) in SCKO microsomes (0.4 +/- 0.009 nmol/min. mg; estimate +/- S.E.) than controls (0.25 +/- 0.007). Morphine-3-glucuronide formation had V(max) estimates of 18.9 +/- 0.6, 25.1 +/- 0.4, and 27.06 +/- 1.1 nmol/min. mg in control, SC, and SCKO microsomes, respectively. The control V(max) for estradiol-3-glucuronide formation was 2-fold greater than in SCKO microsomes. The control V(max) for estradiol 17-glucuronide formation was 3.4- and 2.2-fold greater than in SC and SCKO microsomes. Thus, in vitro metabolism of opioids is altered in SCA mouse models, which may lead to altered clearances of these drugs.

Caregiver report of pain in infants and toddlers with sickle cell disease: reliability and validity of a daily diary

Pain is a hallmark sign of sickle cell disease (SCD) with more than 80% of vaso-occlusive episodes managed at home. This study explored the pyschometric properties of a daily pain and symptom diary and compliance of caregiver report in young children with SCD during a 1- to 2-year period. Compliance for completing diary entries for the first year with 16 caregivers was 90.6% and 86.2% with 19 respondents for the first 2 years. A Cronbach alpha of 0.86 was calculated for 12 items in the diary during a period of 1,450 diary days. Test-retest reliability analysis yielded 99.8% agreement between written entry and stated data entry. Interitem correlations for the 16 respondents ranged from 0.11 to 0.89 (mean, 0.52). Scale reliability estimates were quite strong, ranging from 0.50 to 0.99 (mean, 0.85). Construct validity was supported with significant relationships between caregiver report of giving medications when SCD pain was identified (chi-square = 98.0, P < .0001) and providing other help to relieve SCD pain (chi-square = 8.36, P < .004). The results provide evidence that the Infant/Toddler Diary is a reliable, valid measure of pain and illness report by caregivers of young children with SCD.

Pain management in children with sickle cell disease

Sickle cell disease (SCD) is one of the most common inherited diseases worldwide. The disease is characterized by chronic hemolytic anemia, as well as acute and chronic complications. One of the most intractable problems encountered by children with SCD is the painful episode that results from tissue ischemia due to vaso-occlusion. Pain related to SCD is unique among pain syndromes due to the unpredictable, recurrent, and often persistent nature of the disease, as well as the recurring and essential need for the use of opioids. Painful vaso-occlusive episodes (VOE) are a principal cause of morbidity and account for a significant number of emergency department and hospital admissions. When untreated or inadequately managed, the pain of VOE may cause both short- and long-term consequences. Despite the fact that pain is an almost universal feature of the disease, children with SCD may form one of the most undertreated and understudied populations. One of the factors contributing to poor pain management is conflicting perceptions between patients, their families, and healthcare professionals about pain that is reported and analgesia that is required. Pain management guidelines have recently been published in an effort to overcome barriers in the assessment and management of pain related to SCD. Although there is considerable variability in the way SCD pain is managed, the standard treatment protocol for painful episodes has been rest, rehydration, and analgesia. However, pain control for children with SCD is often a difficult and complex process, and one that requires frequent systematic pain assessments and continuous adjustment of comfort measures, especially analgesics. There are a variety of analgesic agents to choose from, such as acetaminophen (paracetamol), oral or parenteral nonsteroidal anti-inflammatory drugs, and oral or parenteral opioids. Each of these options has advantages and disadvantages to their use. Continuous infusions of analgesics and patient controlled analgesia have been shown to be effective and widely used in hospital settings to manage severe pain. However, the opioid dose required to achieve pain relief varies considerably within each painful episode, from one episode to another, and between individual patients. Although not yet curable in humans, pain related to SCD can be effectively managed in most patients by using a comprehensive approach that incorporates pharmacologic, psychologic, behavioral, and physical pain management strategies.

Management of vaso-occlusive pain in children with sickle cell disease

PURPOSE

A descriptive, longitudinal design was used to evaluate the pain management strategies used in children with sickle cell disease who were experiencing pain during a vaso-occlusive episode.

METHODS

A list of the medications (name, amount, mode of delivery, and frequency) prescribed and administered for pain management for each participant was recorded on the Medication Quantification Scale Worksheet, starting from day 1 of hospitalization to the day of discharge. Children were asked once each evening to provide three separate ratings of how much the pain medication helped them during the day, evening, and night using a 0-to-10 rating scale.

RESULTS

Using patient-controlled analgesia (PCA), children self-administered only 35% of the analgesic medications that were prescribed and reported little pain relief. No significant relationships were found between changes in pain relief scores and the amount of analgesics administered.

CONCLUSIONS

Clinicians need to monitor the amount of analgesics delivered in relationship to pain relief and assist children to titrate PCA administration of analgesics to achieve optimal pain control, or to advocate for changes in the PCA regimen when children cannot assume control of pain management.

Treatment of sickle cell pain

Sickle cell disease affects 70,000 Americans who experience an average of 0.8 painful episodes each year. The pathophysiology of sickle cell pain is not completely understood. The disease is characterized by both acute and chronic pain syndromes. Patients with sickle cell pain often encounter barriers to receiving appropriate care, including lack of continuity of care and perceived opiate addiction. Studies describing pharmacotherapy for sickle cell pain have been primarily retrospective and uncontrolled. In analyzing the available literature regarding pathophysiology, assessment, and treatment of sickle cell pain, we found a need for increased practitioner education and intervention to improve the level of care provided to patients with this disease.

Assessment of sickle cell pain in children and young adults using the adolescent pediatric pain tool

The objectives of this study were to describe and compare the characteristics of pain experienced by children and young adults with sickle cell disease (SCD) in inpatient and outpatient settings. The Adolescent Pediatric Pain Tool (APPT), a multidimensional self-report pain assessment, was completed by African American children and young adults (mean age 15.39 +/- 4.32) with SCD during a clinic visit (n = 52), day hospital visit (n = 29), or during the first 24 hours of an inpatient stay (n = 72). Multiple linear regression revealed that pain intensity, number of body areas with pain, and the quality of pain were related to age, sex, and care setting. Pain intensity, location, and quality were of greater magnitude than previous reports of early postoperative pain in children. Examining the specific dimensions of pain intensity, location, and quality and the influencing factors of age, sex, and care setting may lead to more effective treatments for SCD pain.