CE: Assessing a Child's Pain

Pain care for children with cognitive impairment: A parent-nurse partnership

PURPOSE

To explore nurses' experiences of establishing partnerships with parents for pain care of hospitalized children with cognitive impairment (CI) and identify related facilitators and barriers.

DESIGN AND METHODS

In this qualitative, interpretive descriptive study, individual semi-structured interviews were conducted via videoconferencing with pediatric nurses from inpatient wards in a Canadian pediatric quaternary hospital. Verbatim transcripts were analyzed using an inductive, data-driven thematic analysis approach.

RESULTS

Eleven nurses were interviewed. The overarching theme was Assessing Pain as an Outsider: "A Complete Guessing Game". Seven major themes were identified.: Relying on Parent Expertise for Pain Assessment, Brainstorming with Parents for Pain Treatment, Supporting Parents as Advocates for Pain Care, Individualizing Pain Care with Parents, Involving the Child in Pain Care: A Spectrum, Barriers to Partnership in Pain Care and Facilitators to Partnership in Pain Care.

CONCLUSIONS

Nurses described the many ways they involve parents as partners in pain care. However, nurses shared strong feelings of uncertainty associated with pain care in children with CI. Consequently, nurses felt the need to rely on parents for appropriately assessing and treating pain in children with CI. Findings highlighted the practice and education gaps that may contribute to nurses' uncertainty and reliance on parents.

PRACTICE IMPLICATIONS

By identifying related practice and education gaps, healthcare organizations can implement strategies to further support nurses in establishing partnerships and potentially optimize pain care practices.

Deep learning-guided postoperative pain assessment in children

ABSTRACT

Current automated pain assessment methods only focus on infants or youth. They are less practical because the children who suffer from postoperative pain in clinical scenarios are in a wider range of ages. In this article, we present a large-scale Clinical Pain Expression of Children (CPEC) dataset for postoperative pain assessment in children. It contains 4104 preoperative videos and 4865 postoperative videos of 4104 children (from 0 to 14 years of age), which are collected from January 2020 to December 2020 in Anhui Provincial Children's Hospital. Moreover, inspired by the dramatic successful applications of deep learning in medical image analysis and emotion recognition, we develop a novel deep learning-based framework to automatically assess postoperative pain according to the facial expression of children, namely Children Pain Assessment Neural Network (CPANN). We train and evaluate the CPANN with the CPEC dataset. The performance of the framework is measured by accuracy and macro-F1 score metrics. The CPANN achieves 82.1% accuracy and 73.9% macro-F1 score on the testing set of CPEC. The CPANN is faster, more convenient, and more objective compared with using pain scales according to the specific type of pain or children's condition. This study demonstrates the effectiveness of deep learning-based method for automated pain assessment in children.

Transforming acute pain management in children: A concept analysis to develop a new model of nurse, child and parent partnership

OBJECTIVES

To identify the core components of acute pain management in children, re-conceptualise the process and update the existing model to inform nursing research and clinical practice.

BACKGROUND

Acute pain in hospitalised children remains suboptimal, despite extensive nursing research and education. Improvements require a patient-centred approach and a conceptual model which includes the role of parents and partnership.

DESIGN

Using Rodgers' Evolutionary method, a concept analysis was conducted to define the core components for effective acute pain management in children.

METHODS

A scoping review of peer-reviewed literature from 1990 through 2020 was conducted using the terms "pain management," "pain control," "pain treatment," "multi modal," and "concept*". Abstracts from 85 articles were initially reviewed with 30 articles retained for analysis. Core concepts were identified, defined and synthesised. The PRISMA 2020 checklist was used.

RESULTS

A new model was developed from a synthesis of past work which incorporates the role of parents, the complexity of the process and definitions for shared decision-making. Trust, safety, collaborative communication and genuine partnership were identified as the core components for effective pain management in children, with the triadic relationship of nurses, patients and parents in genuine partnership foundational to the nursing process.

CONCLUSION

The new model for acute pain management in children transforms the nurse's role from gatekeeper to facilitator, shifting the process from nurse driven to patient-centred. The new collaborative model will promote shared decision-making for individualised pain assessments, interventions and evaluations.

RELEVANCE TO CLINICAL PRACTICE

Establishing the nurse, child, parent partnership as an essential foundation to pain management has the potential to expand pain assessments, optimise treatment selections, advancing clinical practice, patient outcomes and nursing science. No Patient or Public Contributions were included in this paper as this was a concept analysis pulling from past works.

Current State of Analgesia and Sedation in the Pediatric Intensive Care Unit

Critically ill pediatric patients often require complex medical procedures as well as invasive testing and monitoring which tend to be painful and anxiety-provoking, necessitating the provision of analgesia and sedation to reduce stress response. Achieving the optimal combination of adequate analgesia and appropriate sedation can be quite challenging in a patient population with a wide spectrum of ages, sizes, and developmental stages. The added complexities of critical illness in the pediatric population such as evolving pathophysiology, impaired organ function, as well as altered pharmacodynamics and pharmacokinetics must be considered. Undersedation leaves patients at risk of physical and psychological stress which may have significant long term consequences. Oversedation, on the other hand, leaves the patient at risk of needing prolonged respiratory, specifically mechanical ventilator, support, prolonged ICU stay and hospital admission, and higher risk of untoward effects of analgosedative agents. Both undersedation and oversedation put critically ill pediatric patients at high risk of developing PICU-acquired complications (PACs) like delirium, withdrawal syndrome, neuromuscular atrophy and weakness, post-traumatic stress disorder, and poor rehabilitation. Optimal analgesia and sedation is dependent on continuous patient assessment with appropriately validated tools that help guide the titration of analgosedative agents to effect. Bundled interventions that emphasize minimizing benzodiazepines, screening for delirium frequently, avoiding physical and chemical restraints thereby allowing for greater mobility, and promoting adequate and proper sleep will disrupt the PICU culture of immobility and reduce the incidence of PACs.

Complementarity of pain assessment instruments in children with central nervous system impairment

ABSTRACT Objective: To evaluate the complementarity of the revised Face, Legs, Activity, Cry, Consolability scale and of the Inventory of Pain Behavior in Neurological Disability for the assessment of pain in children with severe neurological impairment. Method: Cross-sectional study conducted in pediatric units of a university hospital in the southern region of Brazil. The sample consisted of 26 children with severe neurological impairment, hospitalized from January to August 2019, and their caregivers. The data were analyzed by descriptive statistics; Kappa Coefficient, Fisher’s Exact Test and Spearman’s Coefficient were used (p≤0,05). Results: Most children primary diagnosis was cerebral palsy (80.8%). Pain was present in 50.0% of children with the application of the scale and in 34.6% with that of the inventory. Considering the two instruments, there was good agreement (84.6%) between respondents (k=0.692; 95% CI 0.437-0.967; p=0.000). Conclusion: The instruments can be used complementarily to assess pain in children with this profile.

Assessment and pain management during the triage phase of children with extremity trauma. A retrospective analysis in a Pediatric Emergency Room after the introduction of the PIPER recommendations

Background and aim of the work:

Pain is one of the most common symptoms in children who access the Pediatric Emergency Room (PER). However, many studies show that it is poorly evaluated and treated during the triage phase and that in many cases algometric scales aren’t used for its evaluation. Faced with this, the Piacenza PER (Italy) implemented the Pain in Pediatric Emergency Room (PIPER) recommendations for the assessment and management of pain from the 1st July 2017. The aim of this study was to detect the possible differences in the trend of the outcomes for the detection and treatment of pain in July-October 2016, 2017, 2018.

Methods:

A retrospective observational study was chosen. 811 discharge letters of extremity traumatized children aged 0-9 years were analyzed, of which 309 referred to the 2016 quarter, 243 to the 2017 quarter and 259 to the 2018 quarter.

Results:

In 2016, the pain of 12 patients was assessed out of a total of 309, in 2017 of 227 out of 243 and in 2018 of 245 out of 259. The Chi Square test about assessed and not assessed pain, gave statistically significant value (p = 1.36E-98), comparing 2016vs2017 and gave not significant value comparing 2017vs2018 (p = 0.58). 4 patients were treated during the triage phase in 2016, 68 in 2017 and 70 in 2018.

Conclusions:

Recommendations introduction has increased the frequency of pain algometric measurements during the triage phase by leading to an improvement in the nursing care outcomes in terms of pediatric pain management. (www.actabiomedica.it)

Pain management in children has significantly improved in the Italian emergency departments

AIM

Pain in children is often poorly assessed and treated in Italian emergency departments (EDs) as found in a survey conducted among the centres of the "Pain in Pediatric Emergency Room (PIPER)" Study Group in 2010. Our aim was to evaluate the changes in pain management in Italian EDs in the last years.

METHOD

A structured questionnaire about pain assessment, protocols, use of local anaesthetics before venipuncture, opioids and adjuvants was mailed to 46 Italian EDs between November 2017 and April 2018.

RESULTS

Pain was always assessed at triage in 34 centres (73.9%). Algometric scales were used in over 90% of EDs. Triage protocols were available in 37 centres (80.4%). Local anaesthetics before venipuncture were always used in six centres (13.0%). Protocols included opioids and adjuvants in 73.0% and 47.2%, respectively. Triage pain assessment was always done in 91.0% of the centres joining the PIPER Study Group up to 2015 and 56.5% in ones that joined the Group after 2015 (P = .017). Local anaesthetics before venipuncture were given in 39.1% of the centres joining until up to 2015 and 13.0% in ones that joined the Group after 2015 (P = .003).

CONCLUSION

Paediatric pain management has significantly improved in Italian EDs in the last 8 years. The centres joining the PIPER Study Group for longer time have shown better results for the indicators considered in the survey.

The Efficacy of Distraction Cards and Kaleidoscope for Reducing Pain During Phlebotomy: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to determine the efficacy of distraction cards and a kaleidoscope in reducing pain during phlebotomy procedures among children aged 6 to 12.

DESIGN

This randomized controlled study involved intervention groups and a control group.

METHODS

Data were obtained by the use of an information form and the visual analog scale. Data were analyzed with descriptive statistics as well as Kruskal-Wallis, Wilcoxon, and post hoc tests.

FINDINGS

During the phlebotomy, children in the control group experienced more pain than children in the distraction cards group and kaleidoscope group (P < .001). There was no significant difference between pain scores of the two intervention groups (P > .05). Both methods were found to be effective in reducing pain.

CONCLUSIONS

It may be helpful to inform children and parents about the process before procedural interventions. Nurses would likely benefit from education on the use of distraction cards and kaleidoscope to be used during procedural interventions.