Paediatric pain management in low-income and middle-income countries

Pain management in hospitalized children: A cross-sectional study

OBJECTIVE

To characterize pain management in hospitalized children.

METHOD

This is an observational, cross-sectional, retrospective and descriptive study of quantitative approach, carried out in a secondary hospital in the city of São Paulo, through analysis of 1,251 medical records of children admitted to the pediatric department. Data were tabulated and analyzed through descriptive statistics.

RESULTS

A total of 88.8% of children were assessed for pain with standardized instruments and 86% had analgesia prescribed. Among the assessments, 37.8% of the children had pain; of these, 26% had severe pain, greater in orthopedic conditions; 18.3% were not medicated, even with the presence of pain and prescribed analgesia; 4.3% had no analgesics prescribed; only 0.4% received non-pharmacological measures, and 40.3% had a report of reassessment. Professionals provided greater analgesia to children with surgical and orthopedic conditions compared to clinical conditions (p < 0.05).

CONCLUSION

Pain management in hospitalized children is ineffective, from initial assessments to reassessments after interventions, with prioritization of medication actions guided by professional judgment in the face of pain complaints.

Translation, adaptation and psychometric properties of the Arabic version of the numerical rating scale when used with children and adolescents

OBJECTIVE

The 0-10 Numerical Rating Scale (NRS-11) is widely used with Arabic-speaking pediatric populations. However, there is no data about its validity or reliability. Thus, the aims of this research were to translate the NRS-11 into Arabic and study its dimensionality and construct (convergent and discriminant) validity, and reliability.

METHODS

A group of 190 Lebanese students between 8 and 18 years old participated. Participants were interviewed online and asked to imagine themselves in a hypothetical painful situation and rate the expected pain intensity using the NRS-11-Arabic and an Arabic version of the Visual Analogue Scale (VAS-Arabic). They were also requested to respond to the pediatric Arabic version of the Pain Catastrophizing Scale (PCS-Arabic). Data collection lasted for a month.

RESULTS

Data showed that the NRS-11-Arabic and the VAS-Arabic scores measure the same common construct. In addition, they showed strong statistically significant correlations between NRS-11 and VAS (ranging from 0.83 for the whole sample and 0.83 and 0.84 for the 8-12-year-olds and the 13-18-year-olds, which support its construct validity). These correlations were higher than those between the NRS-11-Arabic and the PCS-Arabic, which support the discriminant validity of NRS-11-Arabic scores. Test-retest reliability was 0.86 for the whole sample, and 0.89 and 0.82 for the 8-12-year-olds and the 13-18-year-olds, respectively, which shows the reliability of the NRS-11-Arabic scores.

CONCLUSIONS

The data provide preliminary evidence of the unidimensionality, validity and reliability of the NRS-11-Arabic scores, thus supporting its use in clinical and research activities involving Arabic-speaking pediatric samples.

25% Dextrose Versus 24% Sucrose for Heel Lancing in Preterm Infants: A Noninferiority RCT

OBJECTIVES

To compare the efficacy of 25% dextrose with 24% sucrose for heel-lance analgesia in preterm infants admitted to the NICU.

METHODS

In this noninferiority, double-blind, randomized controlled trial, preterm infants born at 28 weeks and 0 days to 35 weeks and 6 days of gestation who were due for a scheduled heel-lance procedure were enrolled. Infants randomly assigned to the intervention arm received 0.5 mL 25% dextrose, whereas infants in the active control group received 0.5 mL 24% sucrose orally just 2 minutes before the heel-lance procedure. The primary outcome was Premature Infant Pain Profile (PIPP) score 30 seconds after the procedure. Secondary outcomes included PIPP scores at 60 and 120 seconds, PIPP-Revised scores at 30, 60, and 120 seconds, and any adverse events.

RESULTS

Sixty-four infants were enrolled (32 in each group). The mean (SD) PIPP score at 30 seconds was 6.41 (2.56) in the dextrose group and 7.03 (2.23) in the sucrose group (mean difference, -0.63 (95% confidence interval, -1.85 to 0.60; P = .31). The upper margin of the confidence interval did not cross the predefined noninferiority margin of 2. The mean PIPP scores at 60 (5.03 [2.18] vs 5.39 [1.48]) and 120 (4.75 [1.97] vs 4.94 [1.46]) seconds were also similar. The PIPP-Revised scores between the 2 groups at all time intervals were comparable. One infant in the intervention group had a transient coughing episode.

CONCLUSIONS

In preterm infants under intensive care, 25% dextrose is noninferior to 24% sucrose for heel-lance analgesia as assessed by PIPP score.

Manejo da dor em crianças hospitalizadas: Estudo transversal

RESUMO Objetivo: Caracterizar o manejo da dor em crianças hospitalizadas. Método: Estudo observacional do tipo transversal, com abordagem quantitativa, de caráter retrospectivo e descritivo, realizado em um Hospital secundário do Município de São Paulo, por meio de análise de 1.251 prontuários de crianças internadas na divisão pediátrica. Os dados foram tabulados e analisados por meio de estatística descritiva. Resultados: Um total de 88,8% das crianças foi avaliado para dor com instrumentos padronizados e 86% tinham analgesia prescrita. Dentre as avaliações, 37,8% das crianças apresentaram dor; dessas, 26% apresentaram dor intensa, maior nas afecções ortopédicas; 18,3% não foram medicadas, mesmo com presença de dor e analgesia prescrita; 4,3% não tinham analgésicos prescritos; apenas 0,4% receberam medidas não farmacológicas e 40,3% tinham registro de reavaliação. Os profissionais propiciaram maior analgesia a crianças com afecções cirúrgicas e ortopédicas em comparação às afecções clínicas (p < 0,05). Conclusão: O manejo da dor em crianças hospitalizadas mostra-se ineficaz, desde as avaliações iniciais até as reavaliações após intervenções, com priorização de ações medicamentosas guiadas pelo julgamento profissional frente a queixa álgica.

Efficacy and safety of pharmacological, physical, and psychological interventions for the management of chronic pain in children: a WHO systematic review and meta-analysis

ABSTRACT

Chronic pain in childhood is an international public health problem. We conducted a systematic review and meta-analysis to provide a summary of the published evidence of pharmacological, physical, and psychological therapies for children with chronic pain conditions. We searched CENTRAL, MEDLINE, EMBASE, and PsycINFO from inception to April 2020; clinical trial registries; and other sources for randomised controlled trials or comparative observational trials. We extracted critical outcomes of pain intensity, quality of life, physical functioning, role functioning, emotional functioning, sleep, and adverse events. We assessed studies for risk of bias and certainty of the evidence using GRADE. We included 34 pharmacological (4091 participants), 25 physical therapy (1470 participants), and 63 psychological trials (5025 participants). Participants reported a range of chronic pain conditions. Most studies were assessed to have unclear or high risk of bias across multiple domains. Pharmacological, physical, and psychological therapies showed some benefit for reducing pain, posttreatment, but only physical and psychological therapies improved physical functioning. We found no benefit of any treatment modality for health-related quality of life, role functioning, emotional functioning, or sleep. Adverse events were poorly reported, particularly for psychological and physical interventions. The largest evidence base for the management of chronic pain in children supports the use of psychological therapies, followed by pharmacological and physical therapies. However, we rated most outcomes as low or very low certainty, meaning further evidence is likely to change our confidence in the estimates of effects. This protocol was registered on PROSPERO (CRD42020172451).

Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study

The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.