A Debate on the Proposition that Self-report is the Gold Standard in Assessment of Pediatric Pain Intensity

Self-reported pain during different phases of orthodontic treatment with fixed appliance: A multi-centre randomized controlled trial in adolescents with crowding

OBJECTIVES

To compare self-reported pain levels across various treatment phases using passive self-ligating (Damon) and conventional (Victory) standardized fixed appliance systems.

MATERIALS AND METHODS

Adolescents (12-17 years old) with crowding and displaced teeth, planned for non-extraction treatment, were recruited from four orthodontic clinics. They were randomized into stratified blocks (1:1 ratio) using concealed allocation to receive Damon Q™ (34 boys, 28 girls) or Victory™ (39 boys, 31 girls). Pain and analgesic intake were assessed on seven different occasions with validated self-report questionnaires using a 10-grade scale.

RESULTS

Of the 132 patients included, six were lost to follow up. Clinically relevant mean pain scores (≥4) were registered in both groups after bonding upper and lower arches and after insertion of 0.019 × 0.025 stainless steel archwire. The highest mean scores were reported on day two after bonding the upper arch (Damon 5.96, Victory 7.18, P = .011). In both groups, at least 40% reported taking analgesics during various treatment phases. The Damon group reported a lower intake of analgesics on days one and two (P = .042 and .037) after treatment initiation. In the entire sample, boys reported significantly higher mean pain scores than girls on the second and third days after bonding (P = .008 and .026, respectively).

CONCLUSIONS

Lower pain levels were reported from the Damon group after bonding. In general, boys reported higher pain than girls did. Clinicians and adolescents need to be aware that clinically relevant pain levels can be expected not only after bonding but also in later phases.

Clinical Assessment of Osteoarthritis Pain: Contemporary Scenario, Challenges, and Future Perspectives

The multifaceted nature of osteoarthritis (OA) pain presents a challenge in understanding and managing the condition. The diverse pain experiences, progression rates, individual responses to treatments, and complex disease mechanisms contribute to heterogeneity in the clinical studies outcomes. The lack of a standardized methodology for assessing and classifying OA pain challenges healthcare practitioners. This complicates the establishment of universally applicable protocols or standardized guidelines for treatment. This article explores the heterogeneity observed in clinical studies evaluating OA pain treatments, highlighting the necessity for refined methodologies, personalized patient categorization, and consistent outcome measures. It discusses the role of the multidimensional nature of OA pain, underlying pain mechanisms, and other contributing factors to the heterogeneity in outcome measures. Addressing these variations is crucial to establishing a more consistent framework for evidence-based treatments and advancing care of the patient with OA pain.

A Study on the Effect of Lidocaine-Assisted Non-Coring Needle Placement Using Painless Encircling Puncture in Children with Totally Implantable Venous Access Device

Purpose

This study aimed to investigate the maintenance effect of two puncture methods using non-coring needles in children with totally implantable venous access device (TIVAD).

Methods

The 110 children who received TIVAD implantation for short bowel syndrome and solid tumors in our department from 2021.12 to 2022.12 were selected as the study subjects. Blinded method was used and divided into experimental group and control group according to random number table The experimental group underwent painless surround puncture method to place the needles and compound lidocaine ointment for topical anesthesia, while the control group underwent traditional puncture method to complete this operation. The effects of the two puncture methods on pain, catheter seal fluid volume, and catheter occlusion rate were evaluated using the Facial Pain Scale Revised, Behavioral Assessment Scale, and in vitro digital subtraction angiography test.

Results

In the control group, the degree of puncture pain was mild in 5 patients, moderate in 19 patients, and severe in 28 patients; the amount of catheter sealing solution was 9.32 ± 1.32 mL, and the catheter occlusion rate was 25.00%. In the experimental group, the degree of puncture pain was mild in 16 patients, moderate in 22 patients, and severe in 16 patients; the amount of sealing solution was 7.66 ± 1.08 mL, and the blocking rate was 9.26%. The total pain score in the experimental group was lower than that in the control group (5.23±6.17 VS 7.89±2.38). The difference between the two groups had statistical significance (P < 0.05).

Conclusion

The use of the painless surround puncture method can effectively reduce the pain experienced by children during puncture, decrease the volume of catheter sealing fluid, reduce the rate of catheter blockage, provide a valuable basis for enhancing the maintenance effect of TIVAD in clinical practice for children.

Experiencing Pain Invalidation is Associated with Under-Reporting of Pain: A Social Psychological Perspective on Acute Pain Communication

Pain invalidation involves the dismissal or lack of understanding of another's pain, undermining their subjective experience. Frequent exposure to invalidation negatively impacts mental and physical health as well as pain-related behaviors, potentially leading people to conceal their pain from others in the future and/or withdraw from potential sources of support. It is therefore possible that experiencing pain invalidation may also impact pain-reporting behavior in clinical settings. Across 2 separate samples of emerging adults, we examined whether exposure to invalidation of one's pain was associated with cognizant modulation of one's subjective acute pain ratings within routine medical and dental settings. Drawing upon social psychological theories of impression management and self-presentation, we hypothesized that exposure to pain invalidation would be associated with the under-rating of one's pain. In Study 1, previous experiences of invalidation were associated with under-rating of one's pain when visiting the doctor and the dentist. Study 2 found that invalidation from family and medical professionals-but not from friends-was associated with under-rating pain in both settings. Findings provide further evidence for the harmful effects of pain invalidation, particularly for emerging adults, as the dismissal of one's subjective experience may sow self-doubt while reinforcing cultural stigmas against pain, leading to alterations in pain communication that ultimately creates barriers to efficacious clinical treatment and care and increase pain-related suffering. PERSPECTIVE: Pain invalidation imparts harm to those who already suffer from pain, be it mentally, physically, and/or behaviorally. We show that people who have encountered invalidation are more likely to under-rate their pain when seeking care, impeding assessment and treatment, and further highlighting the importance of clinical validation of pain experiences.

Impact of Facility Dog and Certified Child Life Specialist Dyad on Children's Pain and Anxiety During Needlestick Procedures in a Pediatric Hematology Oncology Clinic Setting

BACKGROUND

Pediatric Hematology Oncology patients undergo frequent needlestick procedures, often leading to negative outcomes including pain and anxiety. Animal-assisted therapy has been shown to minimize pediatric patient distress; however, its utilization by a Certified Child Life Specialist (CCLS) to reduce patient distress has not been widely studied.

METHODS

Pediatric patients receiving needlesticks in the Hematology Oncology Clinic were enrolled between March 2018 and May 2021. Patients who had scheduled visits when the facility dog was present were assigned to the intervention group. Patients were assigned to the control group if the facility dog was not present. The primary objective was to use the Children's Anxiety and Pain Scale to determine whether the CCLS and facility dog dyad minimized patient pain and anxiety during procedures.

RESULTS

A total of 285 patients, 5 to 17 years of age, were enrolled. One hundred forty-three patients were assigned the intervention and received procedural support from the CCLS and facility dog; 142 patients were assigned the control group and received support from the CCLS only. Patient-reported pain scores were significantly lower among patients who received the intervention ( P =0.033).

CONCLUSIONS

Utilization of a CCLS and facility dog dyad during painful needlestick procedures decreases patient-reported pain compared with utilization of CCLS support alone.

Comparison of the Novel Digital Multi-dimension Botong Score with the Brief Pain Inventory for Evaluating Cancer-Related Pain: A Randomized Crossover Trial

INTRODUCTION

Pain is a common symptom in patients with cancer, and comprehensive assessments of pain are crucial for decision-making of treatment regimens. This study aimed to compare the practicality of the novel digital multi-dimension Botong score (BTS) and the brief pain inventory (BPI) for evaluating cancer-related pain.

METHODS

This randomized crossover trial enrolled patients with cancer-related pain at the Affiliated Cancer Hospital of Shandong First Medical University between July and December 2022. The participants were randomized 1:1 to BTS evaluation followed by BPI or vice versa. The consistency of BTS and BPI was analyzed, including pain score and the impact of pain on emotions and sleep. The convenience, patient preference, and the filling time of the two tools were compared. The accuracy of BTS in detecting breakthrough pain and neuropathic pain was analyzed.

RESULTS

A total of 308 patients with cancer-related pain were screened and 233 were finally included in the analysis. The Pearson correlation coefficients of pain score for BTS and BPI (4 relevant questions) were 0.583 for the worst pain score within 24 h, 0.394 for the mildest pain score within 24 h, 0.551 for the average pain score within 24 h, and 0.511 for the current pain score, respectively (all P < 0.01), indicating a positive correlation between the BTS and BPI pain scores. BTS was superior to BPI for filling time, convenience, and patient preference (191.03 vs. 256.76, 7.70 vs. 6.78, 7.58 vs. 6.70; all P < 0.01). The accuracy of BTS in detecting breakthrough pain and neuropathic pain was 98.28% and 97.42%, respectively.

CONCLUSION

Pain scores evaluated by BTS have a positive correlation with those evaluated by BPI. BTS reduces the filling time, is more convenient to use, and is more favored by patients. In addition, BTS could help identify breakthrough pain and neuropathic pain.

CLINICAL TRIAL REGISTRATION

Chictr.org.cn, identifier: ChiCTR220062624.

Pain communication in children with autism spectrum disorder: A scoping review

Children with autism spectrum disorder (ASD) experience social interaction and communication challenges and often display repetitive, restricted patterns of behavior, activities, and interests. The concept of pain is regarded as one of the most complex human stressors due to its subjective and personal nature and the influences of multiple internal and external factors. Due to the complexity of this disorder, it remains concerning how children with ASD communicate their pain and how observers (i.e., parents, carers, and health care practitioners) respond to these children's pain communication. This scoping review aimed to identify how children with ASD communicate or express their pain. Ten studies met the inclusion criteria for further data extraction. Through reflexive thematic analysis, two main themes were identified: verbal and nonverbal responses used by children with ASD to communicate their pain that could influence pain assessment and management strategies. This review highlighted that children with ASD utilized various verbal and nonverbal methods to communicate their pain experiences and that these methods differed compared to children without disabilities. Furthermore, this review emphasizes the importance of holistic pain assessment strategies as well as additional pictorial support for children with ASD. This review recommends that future research should focus on understanding how the inclusion of different stakeholders in pain assessment for children with ASD, can contribute to holistic pain assessment.

Exploring reported distress before and pain during needle insertion into a venous access port in children with cancer

BACKGROUND

Venous access port is commonly used during cancer treatment in children, yet little is known about how children experience such needle insertion procedures.

AIM

To study distress before and pain after venous access port needle insertion among children and adolescents with cancer. A second aim was to explore associations between their self-report of procedure-related distress and pain with proxy reports by parents and nurses.

METHOD

The sample included 43 children/adolescents, aged 1-16 years with cancer, treated at two Norwegian university hospitals. The patient, parent(s), and the nurse performing the procedure completed developmentally appropriate 11-point distress and pain scales before and immediately after the venous access port procedure. Data were analysed using descriptive statistics and non-parametric correlations.

ETHICAL ISSUES

The ethical code of conduct was followed and conformed to the ethical guidelines adopted by the Regional Committee for Medicine and Health Research and the data protector officer at the hospitals.

RESULTS

For the youngest children (1-5 years), the median distress proxy score was 8 (range 0-9) and pain proxy score 4 (range 0-10). Median distress and pain scores for children aged 6-12 years were 3 (range 0-9) and 1 (range 0-10), respectively, and for the adolescents (age 13-16) 0 (range 0-6) and 1 (range 0-5), respectively. Patients' self-reported distress and pain correlated highly with parents' (distress: rho = 0.83, p < 0.001, pain: rho = 0.92, p < 0.001) and with nurses' proxy ratings (distress: rho = 0.89, p < 0.001, pain: rho = 0.88, p < 0.001).

CONCLUSION

There were individual age differences in experienced distress/pain associated with venous access port needle insertion, with a trend for younger children to experience higher levels of distress/ pain than the older children. Children's self-report of distress/ pain concurred with both parental and nurse proxy reports.

Exploring Non-Invasive Salivary Biomarkers for Acute Pain Diagnostics: A Comprehensive Review

Pain is one of the most common complaints leading to a pediatric emergency department visit and is associated with various painful procedures, leading to increased anxiety and stress. Assessing and treating pain in children can be challenging, so it is crucial to investigate new methods for pain diagnosis. The review aims to summarize the literature on non-invasive salivary biomarkers, such as proteins and hormones, for pain assessment in urgent pediatric care settings. Eligible studies were those that included novel protein and hormone biomarkers in acute pain diagnostics and were not older than 10 years. Chronic pain studies were excluded. Further, articles were divided into two groups: studies in adults and studies in children (<18 years). The following characteristics were extracted and summarized: study author, enrollment date, study location, patient age, study type, number of cases and groups, as well as tested biomarkers. Salivary biomarkers, such as cortisol, salivary α-amylase, and immunoglobulins, among others, could be appropriate for children as saliva collection is painless. However, hormonal levels can differ among children in different developmental stages and with various health conditions, with no predetermined levels of saliva. Thus, further exploration of biomarkers in pain diagnostics is still necessary.

Parents' perceptions of their child's pain assessment in hospital care: A cross-sectional study

PURPOSE

A prerequisite for successful pain management is identifying the pain and assessing its intensity. The aim of this study was to describe parents' perceptions of their child's pain assessment in hospital care.

DESIGN AND METHODS

This study was a descriptive cross-sectional study. A questionnaire was completed by parents (n = 261) whose child was hospitalized in one of the pediatric units (n = 6) of the University Hospital in Finland. Quantitative data were analyzed using statistical methods; open-ended data were analyzed using inductive content analysis.

RESULTS

Parents reported that their children experienced moderate (36%) to severe pain (42%) during hospitalization. The most intense pain experienced by the children was associated with needle-related procedures (41%). A large proportion of parents (83%) were involved in their child's pain assessment. Parents were satisfied with their child's pain assessment but perceived some shortcomings. Parents hoped that a variety of methods would be used to assess their child's pain and that the parents' and child's views on pain would be taken into account.

CONCLUSIONS

Most children experience moderate to severe pain during hospitalization. Parents are often involved in pain assessment but are rarely instructed to use pain scales.

PRACTICE IMPLICATIONS

Child's pain should be assessed regularly and frequently enough. It is important that the child and parents are involved in shared decision-making about pain assessment and treatment, and they have opportunities to ask questions. Guidance should be offered to parents about the use of pain assessment scales.

The Effects of Preoperative Pain Education on Pain Severity in Cardiac Surgery Patients: A Pilot Randomized Control Trial

BACKGROUND

There is minimal research on the effect of individualized preoperative education on postoperative pain and postoperative pain medication intake.

AIM

The study objective was to assess the effect of individually tailored preoperative education on postoperative pain severity, number of pain breakthroughs, and use of pain medication in participants receiving the intervention compared to controls.

METHODS

A pilot study with 200 participants was conducted. The experimental group received an informational booklet and discussed their ideas surrounding pain and pain medication with the researcher. Controls received no intervention. Postoperative pain severity was measured by a Numerical Rating System (NRS), which was divided into mild (NRS 1-3), moderate (NRS 4-6), and severe (NRS 7-10).

RESULTS

In the participant cohort, 68.8% of participants were male, and the average age was 60.48±10.7. Average postoperative 48-hour cumulative pain scores were lower in those who received the intervention compared to controls; 50.0 (IQR 35.8-60.0) vs. 65 (IQR 51.0-73.0; p < .01) participants who received the intervention had less frequent pain breakthroughs when compared to controls (3.0 [IQR 2.0-5.0] vs. 6.0 [IQR 4.0-8.0; p < .01]). There was no significant difference in the amount of pain medication taken by either group.

CONCLUSIONS

Participants who receive individualized preoperative pain education are more likely to have decreased postoperative pain.

Assessing need for advance imaging among children with back pain using pain intensity as clinical marker

INTRODUCTION

Pediatric back pain evaluation nowadays relies on patient history, physical examination, and plain radiographs to identify underlying pathologies. Constant pain, night pain, radicular pain, and abnormal neurological examination were previously recommended as clinical markers to assess the need for magnetic resonance imaging evaluation. Recent studies have challenged the use of these clinical markers, recommending further studies. This study aimed to assess pain intensity as a predictor of underlying magnetic resonance imaging pathology in children with back pain.

METHODS

An observational cross-sectional study of pediatric patients between 8 and 17 years with back pain for more than 4 weeks from 2009 to 2021 was conducted. A whole spine magnetic resonance imaging was performed on patients with back pain without an identifiable cause and no prior spine treatment. The numerical rating scale questionnaire was administered to each patient, and answers were divided into three groups: mild (1-3), moderate (4-6), and severe (7-10) numerical rating scale score. Student's t-test and chi-square analysis were used to correlate differences between continuous and categorical values, respectively.

RESULTS

Of 590 patients (70% female and a mean age of 15.25 years), there were 35.1% of patients had a magnetic resonance imaging underlying pathology. No association was found between severe numerical rating scale score and the presence of underlying MRI pathology (p = 0.666). Patients with low or moderate numerical rating scale scores had similar associations to an underlying magnetic resonance imaging pathology as patients with a severe numerical rating scale score (p = 0.256; p = 0.357, respectively).

CONCLUSIONS

Back pain intensity was not found to be an effective clinical marker for predicting underlying magnetic resonance imaging pathology in pediatric patients with back pain.

Discriminant properties of the Behavioral Pain Scale for assessment of procedural pain-related distress in ventilated children

OBJECTIVES

Children hospitalized in a pediatric intensive care unit (PICU) are frequently exposed to distressing and painful medical procedures and interventions. There is a lack of clinical scales to measure procedural pain-related distress in ventilated children. The Behavioral Pain Scale (BPS) was initially developed to detect procedural pain in critically ill adults. This study aims to assess the BPS's discriminant properties for measuring procedural pain-related distress in ventilated pediatric patients incorporating two instruments validated for pediatric patients.

METHODS

This prospective exploratory study was performed with ventilated children admitted to the interdisciplinary 14-bed PICU of the University Children's Hospital, University Medical Center Hamburg-Eppendorf, Germany. The nurse in charge and an independent observer simultaneously assessed the patients using German versions of the BPS, the COMFORT-B scale (CBS), and the modified Face, Legs, Activity, Cry, Consolability (mFLACC) scale immediately before and during endotracheal suctioning.

RESULTS

We analyzed 170 parallel assessments in n=34 ventilated children. Patients were (mean ± SD) 9.5 ± 4.8 years old. Internal consistency for the BPS was excellent (α=0.93). We found a high rater agreement for all clinical scales (BPS: k=0.73, CBS: k=0.80, mFLACC: k=0.71). Strong correlations were identified between BPS and CBS (r=0.89) and BPS and mFLACC (r=0.79). The BPS cutoff values showed likewise excellent results (area under the curve CBS >16: 0.97; mFLACC >2: 0.91).

CONCLUSIONS

In our population of ventilated children, the BPS was well suited to detect procedural pain-related distress compared with two validated pain scales. Further extensive validation studies should follow to support our findings.

Assessing Pain Research: A Narrative Review of Emerging Pain Methods, Their Technosocial Implications, and Opportunities for Multidisciplinary Approaches

Pain research traverses many disciplines and methodologies. Yet, despite our understanding and field-wide acceptance of the multifactorial essence of pain as a sensory perception, emotional experience, and biopsychosocial condition, pain scientists and practitioners often remain siloed within their domain expertise and associated techniques. The context in which the field finds itself today-with increasing reliance on digital technologies, an on-going pandemic, and continued disparities in pain care-requires new collaborations and different approaches to measuring pain. Here, we review the state-of-the-art in human pain research, summarizing emerging practices and cutting-edge techniques across multiple methods and technologies. For each, we outline foreseeable technosocial considerations, reflecting on implications for standards of care, pain management, research, and societal impact. Through overviewing alternative data sources and varied ways of measuring pain and by reflecting on the concerns, limitations, and challenges facing the field, we hope to create critical dialogues, inspire more collaborations, and foster new ideas for future pain research methods.

Nurses' use of the clinically aligned pain assessment tool: A mixed methods study

BACKGROUND

Assessment of pain in the hospital has often relied on intensity rating alone. To address the gap in meeting patients' pain management expectations, a Midwestern medical center implemented the CAPA (Clinical Aligned Pain Assessment) tool for more comprehensive nursing pain assessments.

AIMS

This research described nurses' experience using CAPA on an adult general medicine unit and their documentation of the tool in the electronic health record (EHR) more than 5 years after CAPA implementation.

DESIGN

Mixed methods exploratory sequential design.

METHODS

A convenience sample of nurses (N = 8) participated in 2 focus groups to describe how they used CAPA, how well it assessed pain, how it determined pain interventions, and the challenges and advantages of using CAPA. Patient EHR data (N = 373) for a 6-month period from the same unit were analyzed to evaluate CAPA documentation.

RESULTS

Qualitative themes included: benefits of using CAPA, CAPA leads to a more comprehensive picture, variation in how CAPA is used, and challenges. Quantitative findings demonstrated most frequent documentation in the comfort domain and earlier, though still delayed, reassessment when a higher level of pain was noted. Mixed methods analysis revealed variation in knowledge and practice regarding which domains to document each shift and during reassessment.

CONCLUSIONS

As patient advocates, nurses are integral to thorough assessment and treatment of pain. Findings identified the need for methodological research of CAPA. As with any assessment tool, when using CAPA, ongoing monitoring is needed to address how it is administered, coded, and used for decision-making about pain management.

Phase 2 Assessment of a New Functional Pain Scale by Comparing It to Traditional Pain Scales

Background

Assessment of pain has always been subjective and is commonly assessed using a numeric pain scale (NPS) or Wong-Baker faces scale. The pain intensity score is not standardized and relies on individuals’ past experiences. The disadvantage of using such pain assessment scales and treating the numbers can lead to overdosing on analgesics leading to unwanted side effects. The Robert Packer Hospital/Functional Pain Scale (RPH/FPS) was developed as a tool for the objective assessment of pain and its impact on a patient’s function. 

Aim

The study aimed to validate the RPH/FPS scale against NPS and Wong-Baker faces scale in medical, surgical, and trauma patients. The patients’ were also asked to rank the scales as one (1) being the most preferred to three (3) being the least preferred.

Design

This prospective, observational cohort study compares the two most common pain scales, the NPS and the Wong-Baker Faces, to the RPH/FPS.

Methods

Spearman correlation was used to test for correlation between the three scales, and Wilcoxon rank-sum test was used to compare means between the RPH/FPS and NPS. The study participants were also asked to rate their preferences for the scales by rating the most preferred of the three scales as one (1) and the least preferred number three (3). 

Results

The RPH/FPS had a strong correlation with both the NPS and Wong-Baker Faces scales (RPH/FPS vs. NPS R=0.69, p<0.001: RPH-FPS vs. Wong-Baker Faces R=0.69, P<0.001). As for preferences, the RPH/FPS was ranked first on 36.9% of the surveys followed by NPS on 35.9%, and the Wong-Baker Faces on 22.3%. There were 4.9% of the surveys missing the preference rankings.

Conclusion

The results validate the RPH/FPS scale against the NPS and Wong-Baker Faces scales. This gives the clinicians a tool for objective assessment of pain and its effect on the recovery process, thereby minimizing the observed disconnect that sometimes happens between the reported pain intensity level and the providers' observation of the patient.

Evaluating the 0–10 Point Pain Scale on Adolescent Opioid Use in US Emergency Departments

Objective: To evaluate trends in national emergency department (ED) adolescent opioid use in relation to reported pain scores. Methods: A retrospective, cross-sectional analysis on National Hospital Ambulatory Medical Care Survey (NHAMCS) data was conducted on ED visits involving patients aged 11–21 from 2008–2017. Crude observational counts were extrapolated to weighted estimates matching total population counts. Multivariate models were used to evaluate the role of a pain score in the reported use of opioids. Anchors for pain scores were 0 (no pain) and 10 (worst pain imaginable). Results: 31,355 observations were captured, which were extrapolated by the NHAMCS to represent 162,515,943 visits nationwide. Overall, patients with a score of 10 were 1.35 times more likely to receive an opioid than patients scoring a 9, 41.7% (CI95 39.7–43.8%) and 31.0% (CI95 28.8–33.3%), respectively. Opioid use was significantly different between traditional pain score cutoffs of mild (1–3) and moderate pain (4–6), where scores of 4 were 1.76 times more likely to receive an opioid than scores of 3, 15.5% (CI95 13.7–17.3%) and 8.8% (CI95 7.1–10.6%), respectively. Scores of 7 were 1.33 times more likely to receive opioids than scores of 6, 24.7% (CI95 23.0–26.3%) and 18.5% (CI95 16.9–20.0%), respectively. Fractures had the highest likelihood of receiving an opioid, as 49.2% of adolescents with a fracture received an opioid (CI95 46.4–51.9%). Within this subgroup, only adolescents reporting a fracture pain score of 10 had significantly higher opioid use than adjacent pain scores, where fracture patients scoring a 10 were 1.4 times more likely to use opioids than those scoring 9, 82.2% (CI95 76.1–88.4%) and 59.8% (CI95 49.0–70.5%), respectively. Conclusions: While some guidelines in the adult population have revised cut-offs and groupings of the traditional tiers on a 0–10 point pain scale, the adolescent population may also require further examination to potentially warrant a similar adjustment.

Prescribing and Administering Opioid Doses Based Solely on Pain Intensity: Update of A Position Statement by the American Society for Pain Management Nursing

The foundation of safe and effective pain management is an individualized, comprehensive pain assessment that includes, but is not limited to, the intensity of pain if the patient is able to report it. An unforeseen consequence of the widespread use of pain intensity rating scales is the practice of prescribing specific doses of opioid analgesics based solely on specific pain intensity ratings. Many factors in addition to pain intensity influence opioid requirements. To date there is no research demonstrating that a specific opioid dose will relieve pain of a specific intensity in all patients or even in the same patient at different times. The official position of the American Society for Pain Management Nursing (ASPMN) maintains that the practice of prescribing doses of opioid analgesics based solely on pain intensity should be prohibited because it disregards the relevance of other essential elements of assessment and may contribute to untoward patient outcomes.

Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale-Revised

OBJECTIVE

This study aimed to assess the agreement between patients presenting to the pediatric emergency department (ED) with acute pain and their caregivers when using the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R).

METHODS

This was a prospective, observational study examining patients 3 to 7.5 years old presenting to a pediatric ED with acute pain. Participants completed the WBF and FPS-R twice during their ED evaluation. Caregivers rated their child's pain using both the WBF and FPS-R at the same time points. Intraclass correlations (ICCs) were calculated between caregiver and child reports at each time point, and Bland-Altman plots were created.

RESULTS

Forty-six subjects were enrolled over 5 months. Mean age was 5.5 ± 1.2 years. Average initial child pain scores were 6.6 ± 2.8 (WBF) and 6.1 ± 3.3 (FPS-R), and repeat scores were 3.3 ± 3.4 (WBF) and 3.1 ± 3.3 (FPS-R). Average initial caregiver pain scores were 6.3 ± 2.4 (WBF) and 6.2 ± 2.3 (FPS-R), and repeat scores were 3.4 ± 2.0 (WBF) and 3.4 ± 2.1 (FPS-R). On initial assessment, ICCs between children and caregivers using the FPS-R and WBF were 0.33 and 0.22, respectively. On repeat assessment, the ICCs were 0.31 for FPS-R and 0.26 for WBF. Bland-Altman plots showed poor agreement but no systematic bias.

CONCLUSION

There was poor agreement between caregivers and children when using the WBF and FPS-R for assessment of acute pain in the ED. Caregiver report should not be used as a substitute for self-report of pain if possible.

How and Why Patient Concerns Influence Pain Reporting: A Qualitative Analysis of Personal Accounts and Perceptions of Others' Use of Numerical Pain Scales

Complex factors influence how people report and interpret numerical pain ratings. Such variability can introduce noise and systematic bias into clinical pain assessment. Identification of factors that influence self-rated pain and its interpretation by others may bolster utility of these scales. In this qualitative study, 338 participants described motivations for modulating their own pain reports relative to a numerical pain scale (0–10), as well as perceptions of others’ pain reporting modulation. Responses indicated that people over-report pain to enhance provider belief/responsiveness or the likelihood of pain relief, and out of fear of future pain or potential illness. Concerns of how one’s pain affects and is perceived by others, and financial concerns motivated pain under-reporting. Unprompted, many participants reported never modulating their pain ratings, citing trust in providers and personal ethics. Similar reasons were assumed to motivate others’ pain ratings. However, participants often attributed others’ over-reporting to internal causes, and their own to external. This bias may underlie common assumptions that patients over-report pain for nefarious reasons, distort interpretation of pain reports, and contribute to pain invalidation. Recognition of patient concerns and one’s own personal biases toward others’ pain reporting may improve patient-provider trust and support precision of numerical pain ratings.

Being heard - Supporting person-centred communication in paediatric care using augmentative and alternative communication as universal design: A position paper

Person-centred care, with its central focus on the patient in partnership with healthcare practitioners, is considered to be the contemporary gold standard of care. This type of care implies effective communication from and by both the patient and the healthcare practitioner. This is often problematic in the case of the paediatric population, because of the many communicative challenges that may arise due to the child's developmental level, illness and distress, linguistic competency and disabilities. The principle of universal design put forth in conventions and legislation means that the design of products and services should be usable by all people, to the greatest extent possible. Augmentative and alternative communication encompasses strategies, for example pictures and apps, that are typically used with people with communication disability. In this position paper, we argue for the universal use of augmentative and alternative communication to support person-centred communication and care for children, regardless of age or potential disability. Clinical examples are shared from three different paediatric care settings where pictorial supports were applied universally. Interviews were conducted with children and adolescents (with and without disabilities), parents and healthcare practitioners, and the principles of universal design were used as a framework to demonstrate how person-centred communication is supported in paediatric care.

Assessment of dental pain in children with intellectual disability using the dental discomfort questionnaire

OBJECTIVE

This study aimed to compare the Dental Discomfort Questionnaire (DDQ) scores in children with and without intellectual disability (ID) and to measure correlation between the total DDQ and the Decayed, Missing, and Filled Teeth (DMFT/dmft) scores, as well as the condition of the tooth causing pain.

METHOD

This cross-sectional study included 81 children with normal intellectual development who attended the Departments of Pediatric Dentistry at two Turkish Universities and 80 children with different levels of intellectual disability who reported dental pain in special education centers. The 12-question DDQ (Turkish version) was applied to the parents of the patients with their consent. The relationship of the DDQ scores with tha of the DMFT/dmft, dental status, and demographic data was evaluated.

RESULTS

When the DDQ scores of children with intellectual disabilities were evaluated, it was found that the majority of the answers given to the questions were statistically similar (p < 0.05) to those of children with normal cognitive level. In the questions in which "pain when eating and brushing teeth" was evaluated, a higher score was obtained, which led to an increase in the total DDQ score (p < 0.001). There was a statistically significant difference between the groups in terms of the distribution of dental conditions (p < 0.001). When compared to the normal cognitive group, patients with mild and severe intellectual disabilities had more deep dentin caries, thoughy, frequent periapical abscess was less common in those groups (p < 0.001 and p = 0.022). There was no statistically significant relationship between DMFTscores.

CONCLUSION

The DDQ was found to be a descriptive, functional, and easy-to-use questionnaire for children with intellectual disabilitiesin terms of detecting the presence of dental pain. No correlation was found between DMFT/dmft, dental status and DDQ scores.

The evidence supporting the association between the use of pain scales and outcomes in hospitalized children: A systematic review

BACKGROUND

Systematic use of pain intensity scales is considered a prerequisite for treatment of pain in hospitalized children, but already a decade ago, attention was called to the lack of robust evidence supporting the presumed positive association between their use and desired outcomes.

OBJECTIVES

To re-evaluate the evidence supporting the association between the use of pain scales and patient and process outcomes in hospitalized children.

DESIGN

Systematic literature review.

DATA SOURCES

The online databases PubMed and Cumulative Index of Nursing and Allied Health Literature (CINAHL) were searched from inception to April 15, 2020.

REVIEW METHODS

We performed single screening of all records followed by duplicate screening of full texts of interest with a disagreement procedure in place. Studies where the authors evaluated outcomes from the use of self-report or behavioral-based pain scales in children 0-18 years in a hospital setting were included. Emergency care settings were excluded.

RESULTS

In a majority of the 32 included studies, complex interventions that included one or more pain scales were evaluated. Process outcomes (e.g., documentation) were most frequently studied. Interventions were commonly associated with improved documentation of pain assessment, while the effect on pain management documentation was inconsistent. However, improvements in process outcomes did not necessarily result in better patient outcomes. In regard to patient outcomes (e.g., pain intensity, side effects, or satisfaction with treatment), some authors reported reduced pain intensity on group level, but the effect on other functional outcomes, child and parent satisfaction, and aspects of safety were inconsistent. Methodological issues, e.g., weak study designs and small samples, biased the results, and it was not possible to determine how pain scales contributed to the overall effects since they were studied as part of complex interventions.

CONCLUSIONS

Although both a theoretically founded understanding of pain and clinical experience suggest that the use of pain scales will make a difference for hospitalized children with pain, there is still limited evidence to support this notion. As pain scales have been almost exclusively studied as an aspect of complex interventions, research that determines the active ingredient(s) in a complex intervention and their joint and individual effects on outcomes that are meaningful for the child (for example reduced pain intensity or improved function) are urgently needed. Tweetable abstract: Limited #research supports association between use of pediatric #pain scales and patient outcomes @_randida @PainPearl.

Manifestation and parental assessment of children's cancer pain at home: An exploratory mixed-methods study

AIMS AND OBJECTIVES

To describe pain manifestation in children with cancer at home and understand how parents assess this pain.

BACKGROUND

Pain is experienced by children with cancer throughout their cancer journey. Short-term, and into survivorship, pain has negative physical and psychological consequences. Changes in treatment location mean children with cancer spend more time at home. Little is known about pain experienced by children at home or how parents assess this pain.

DESIGN

A mixed-methods convergent parallel study was reported using STROBE.

METHOD

Parents of children with cancer on active treatment were recruited from one tertiary cancer centre. Parental attitudes towards pain expression were assessed using surveys. Parents recorded their child's pain manifestation in pain diaries kept for one month. Interviews captured a deeper understanding of pain manifestation and how parents assess this pain at home. Integration occurred after each data collection method was analysed separately.

RESULTS

Predominantly children were not in pain at home. However, most children experienced at least one episode of problematic pain over the pain diary period. Surveys showed parents held misconceptions regarding children's pain expression. Interviews diverge from surveys and suggest parents used a range of information sources to assess pain.

CONCLUSION

Children with cancer may differ from one another in the manifestation of pain at home resulting in multiple pain trajectories. Parents of children with cancer are able to adequately assess their child's pain using information from multiple sources.

RELEVANCE TO CLINICAL PRACTICE

It is not currently possible to predict which children will experience problematic pain at home, so all parents require pain management education prior to discharge. Teaching parents to use bundled approaches to pain assessment may accelerate their learning. Healthcare professionals may benefit from using multiple information sources to assess pain.

Topical Review: State of the Field of Child Self-Report of Acute Pain

OBJECTIVE

Children experience acute pain with routine and emergent healthcare, and untreated pain can lead to a range of repercussions. Assessment is vital to diagnosing and treating acute pain. Given the internal nature of pain, self-report is predominant. This topical review reflects on the state of the field of pediatric acute pain self-report, and proposes a framework for acute pain assessment via self-report.

METHOD

We examine self-report of acute pain in preschool-age children through adolescents, and we detail a three-step process to optimize acute pain assessment.

RESULTS

The first step is to decide between a pain screening or assessment. Several 0-10 self-report scales are available for pain screenings. Assessment requires specification of the goals and domains to target. Core criteria, common features, modulating factors, and consequences of acute pain provide a framework for a comprehensive pain assessment. Whereas there are some measures available to assess aspects of these domains, there are considerable gaps. Last, it is important to integrate the data to guide clinical care of acute pain.

CONCLUSIONS

Self-report of acute pain is dominated by single-item intensity scales, which are useful for pain screening but inadequate for pain assessment. We propose a three-step approach to acute pain assessment in children. However, there is a need for measure development for a comprehensive evaluation of the core criteria, common features, modulating factors, and consequences of pediatric acute pain. In addition, there is limited guidance in merging data found in multifaceted evaluations of pediatric acute pain.

Children's self-reports of fear and pain levels during needle procedures

Aim

The objective was to determine the levels of and potential relationships between, procedure-related fear and pain in children.

Design

Clinical based cross-sectional.

Methods

Ninety children aged between 7-18 years were included consecutively and self-reported levels of pain and fear on a 0-100 mm visual analogue scales (VAS) when undergoing routine needle insertion into a subcutaneously implanted intravenous port following topical anaesthesia.

Results

The needle-related fear level was reported to be as high as the needle-related pain level (mean VAS: 14 mm and 12 mm, respectively, N = 90). With fear as the dependent variable, age and pain were significantly associated and explained 16% of the variance. With pain as the dependent variable, fear was significantly associated and explained 11% of the variance. A post hoc analysis indicated that younger children reported their fear levels to be higher than their pain levels.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

Documentation of breakthrough pain in narrative clinical records of children with life-limiting conditions: Feasibility of a retrospective review

This study explored the feasibility of generating reliable information on the frequency, nature and management of breakthrough pain (BTP) in children with life-limiting conditions and life-threatening illnesses (LTIs) from narrative clinical records. In the absence of standardized ways for documenting BTP, we conducted a consensus exercise to develop a glossary of terms that could denote BTP in the records. Thirteen clinicians who contributed to the records reached consensus on 45 terms which could denote BTP, while emphasizing the importance of contextual information. The results of this approach together with guidance for improving the reliability of retrospective reviews informed a data extraction instrument. A pilot test of this instrument showed poor agreement between raters. Given the challenges encountered, we do not recommend a retrospective review of BTP using narrative records. This study highlighted challenges of data extraction for complex symptoms such as BTP from narrative clinical records. For both clinical and research purposes, the recording of complex symptoms such as BTP would benefit from clear criteria for applying definitions, a more structured format and the inclusion of validated assessment tools. This study also showed the value of consensus exercises in improving understanding and interpretation of clinical notes within a service.

"Seeing Pain Differently": A Qualitative Investigation Into the Differences and Similarities of Pain and Rheumatology Specialists' Interpretation of Multidimensional Mobile Health Pain Data From Children and Young People With Juvenile Idiopathic Arthritis

Background

In contrast to the use of traditional unidimensional paper-based scales, a mobile health (mHealth) assessment of pain in children and young people (CYP) with juvenile idiopathic arthritis (JIA) enables comprehensive and complex multidimensional pain data to be captured remotely by individuals. However, how professionals use multidimensional pain data to interpret and synthesize pain reports gathered using mHealth tools is not yet known.

Objective

The aim of this study was to explore the salience and prioritization of different mHealth pain features as interpreted by key stakeholders involved in research and management of pain in CYP with JIA.

Methods

Pain and rheumatology specialists were purposively recruited via professional organizations. Face-to-face focus groups were conducted for each specialist group. Participants were asked to rank order 9 static vignette scenarios created from real patient mHealth multidimensional pain data. These data had been collected by a researcher in a separate study using My Pain Tracker, a valid and acceptable mHealth iPad pain communication tool that collects information about intensity, severity, location, emotion, and pictorial pain qualities. In the focus groups, specialists discussed their decision-making processes behind each rank order in the focus groups. The total group rank ordering of vignette scenarios was calculated. Qualitative data from discussions were analyzed using latent thematic analysis.

Results

A total of 9 pain specialists took part in 1 focus group and 10 rheumatology specialists in another. In pain specialists, the consensus for the highest pain experience (44%) was poorer than their ranking of the lowest pain experiences (55%). Conversely, in rheumatology specialists, the consensus for the highest pain experience (70%) was stronger than their ranking of the lowest pain experience (50%). Pain intensity was a high priority for pain specialists, but rheumatology specialists gave high priority to intensity and severity taken together. Pain spread was highly prioritized, with the number of pain locations (particular areas or joints) being a high priority for both groups; radiating pain was a high priority for pain specialists only. Pain emotion was challenging for both groups and was only perceived to be a high priority when specialists had additional confirmatory evidence (such as information about pain interference or clinical observations) to validate the pain emotion report. Pain qualities such as particular word descriptors, use of the color red, and fire symbols were seen to be high priority by both groups in interpretation of CYP pain reports.

Conclusions

Pain interpretation is complex. Findings from this study of specialists’ decision-making processes indicate which aspects of pain are prioritized and weighted more heavily than others by those interpreting mHealth data. Findings are useful for developing electronic graphical summaries which assist specialists in interpreting patient-reported mHealth pain data more efficiently in clinical and research settings.

Postoperative pain: factors and tools to improve pain management in children

Outpatient surgery has made it increasingly common for parents to manage pain in the home setting. Studies have shown that parents often under treat pain, leaving children vulnerable to the negative side effects of suboptimal pain management. Multiple factors affect pain management like child’s age and developmental stage, language, cultural values like stoicism, parental beliefs about medication, biological differences among groups, etc. Understanding all the factors involved can help healthcare providers and parents better understand pain and contribute to optimal pain management. Multiple tools and technological interventions have been created to help create a better understanding of pain and a holistic approach to care.

The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period

Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.

The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children

BACKGROUND

Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited.

AIMS

The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples.

DESIGN

Qualitative, descriptive design.

SETTINGS

Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use.

PARTICIPANTS/SUBJECTS

Nurses (N = 22) with ≥1 year experience caring for preverbal children.

METHODS

Individual, semistructured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment.

CONCLUSIONS

Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

The Experience of Pain and Pain Tool Preferences of Hospitalized Youth

BACKGROUND

An accurate holistic pediatric pain assessment is necessary for quality pain management. Evidence continues to be published indicating inadequacies in pediatric pain management. It is important for clinicians to consider the pain assessment process while caring for youth.

AIM

The purpose of this study was to understand the pain experience through focused interviews and to explore how youth use, interpret and understand self-report pain assessment tools including their tool preferences.

DESIGN

A qualitative descriptive study using a research developed semi-structured interview guide was conducted with 40 hospitalized youth, 10-17 years (M: 13yr; S.D. 2.4); 21 (52.5%) female on a medical inpatient unit. Interview questions focused on: current pain experience; pain related symptoms; evaluation of pain treatment and preferences for select pain assessment tools: 0-10 Numeric Rating Scale, The Oucher, Faces Pain Scale-Revised, and Adolescent Pediatric Pain Tool (APPT).

SETTING

Large tertiary and quaternary care pediatric hospital located in northeastern United States.

PARTICIPANTS/SUBJECTS

Hospitalized youth, 10-17 years of age.

RESULTS

Analysis of transcribed interviews yielded 3 themes: My Pain Now, Pain Treatment Expectations, and Telling Healthcare Providers about My Pain. Additionally, pain tools preference, assessment frequency, and discussion of how behavior, activity level, and pain expression was different for each youth. APPT was the preferred pain assessment tool. Descriptive words such as sharp, throbbing, and aching were identified most often. Youth identified that activity and pain level often do not match.

CONCLUSIONS

Because pain is multi-dimensional, assessing each dimension (quality, location, intensity, and meaning) is key to thorough assessment. Results provide insight into youth preferences influencing clinical practice such as offering options for interventions and having a voice in the pain management process. All nurses caring for children should discuss available pain tools preferably before the child is in pain and assure the child knows how to use the tool.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

Nursing people with intellectual disability and dementia experiencing pain: An integrative review

AIMS AND OBJECTIVES

To explore the current evidence of nurses caring for people with intellectual disability and dementia who experience pain.

BACKGROUND

People with intellectual disability are ageing and are experiencing age-related health conditions including dementia and conditions associated with pain, but at an earlier age. Addressing the needs of people with intellectual disability who develop dementia is a new challenge for nurses.

DESIGN

An integrative literature review.

METHODS

A systematic search of databases: CINAHL, MEDLINE, PsycINFO, Cochrane, EMBASE, Academic Search Complete, Scopus and Web of Science between 27 October 2017-7 November 2017. Hand searching and review of secondary references were also undertaken. Quality appraisal (Crowe Critical Appraisal Tool), thematic data analysis (Braun and Clarke, Qualitative Research in Psychology, 3, 2006, 77) and reporting using the PRISMA guidelines.

RESULTS

Seven papers met the inclusion criteria, and three themes emerged from this review: nurses knowledge of ageing, dementia and pain; recognising pain in people with intellectual disability and dementia; and the role of nurse education. People with intellectual disability and dementia have difficulty communicating their pain experience compounded by pre-existing communication difficulties.

CONCLUSIONS

A pain experience can present similar to behavioural and psychological symptoms of dementia, and diagnostic overshadowing often occurs whereby a pain need is misinterpreted as behavioural and psychological symptoms resulting in inappropriate treatment. Nurses need greater knowledge about the presence of pain and potential causes in people with intellectual disability and dementia, and education can be effective in addressing this knowledge deficit.

RELEVANCE TO CLINICAL PRACTICE

Pain assessment tools for people with intellectual disability and dementia need to include behavioural elements, and baseline assessments are required to identify changes in presentation. Nurses need to recognise and respond to pain based on the evidence in order to deliver quality care.

Efficacy of hypnosis on pain, wound-healing, anxiety, and stress in children with acute burn injuries: a randomized controlled trial

No randomized controlled trial has investigated the efficacy of hypnosis for reducing pain and improving wound-healing in children with burns. This randomized controlled trial aimed to investigate whether hypnosis decreases pain, anxiety, and stress and accelerates wound-healing in children undergoing burn wound procedures. Children (4-16 years) with acute burns presenting for their first dressing change were randomly assigned to a Hypnosis Group who received hypnosis plus standard care or a Standard Care Group who received standard pharmacological and nonpharmacological intervention. Repeated measures of pain intensity, anxiety, stress, and wound-healing were taken at dressing changes until ≥95% wound re-epithelialization. Data for 62 children were analyzed on an intent-to-treat basis using Generalized Estimating Equations (n = 35 Standard Care Group; n = 27 Hypnosis Group). An effect on the primary outcomes of pain and wound healing was not supported {self-reported pain intensity largest Mean Difference [MD] = -0.85 (95% confidence interval [CI]: -1.91 to 0.22), P = 0.12; MD for re-epithelialization = -0.46 [95% CI: -4.27 to 3.35], P = 0.81}. Some support was found for an effect on the secondary outcomes of preprocedural anxiety (MD = -0.80 [95% CI: -1.50 to -0.10], P = 0.03 before the second dressing change) and heart rate as a measure of stress (MD = -15.20 [-27.20 to -3.20], P = 0.01 and MD = -15.39 [-28.25 to -2.53], P = 0.02 before and after the third dressing change). Hypnosis may be effective for decreasing preprocedural anxiety and heart rate in children undergoing repeated pediatric wound care procedures but not for reducing pain intensity or accelerating wound healing.

External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol

INTRODUCTION

Needle-related procedures are considered as the most important source of pain and distress in children in hospital settings. Considering the physiological and psychological consequences that could result from these procedures, management of pain and distress through pharmacological and non-pharmacological methods is essential. Therefore, it is important to have interventions that are rapid, easy-to-use and likely to be translated into clinical practice for routine use. The aim of this study will be to determine whether a device combining cold and vibration (Buzzy) is non-inferior to a topical anaesthetic (liposomal lidocaine 4% cream) for pain management of children undergoing needle-related procedures in the emergency department.

METHODS AND ANALYSIS

This study will be a randomised controlled non-inferiority trial comparing the Buzzy device to liposomal lidocaine 4% cream for needle-related pain management. A total of 346 participants will be randomly assigned in a 1:1 ratio to one of the two study groups. The primary outcome will be the mean difference in pain intensity between groups during needle-related procedures. A non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. A Non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. The secondary outcomes will be the level of distress during the procedure, the success of the procedure at first attempt, the occurrence of adverse events, the satisfaction of both interventions and the memory of pain 24 hours after the procedure. The primary outcome will be assessed for non-inferiority and the secondary outcomes for superiority.

ETHICS AND DISSEMINATION

This study protocol was reviewed and approved by the institutional review board of the study setting. Findings of this trial will be disseminated via peer-reviewed publications and conference presentations.

TRIAL REGISTRATION NUMBER

NCT02616419.

Adaptation of pain scales for parent observation: are pain scales and symptoms useful in detecting pain of young children with the suspicion of acute otitis media?

Background

The assessment of ear pain is challenging in young, mostly preverbal children. Our aim was to investigate whether pain scales are useful tools for parents to detect pain in their young children with the suspicion of acute otitis media (AOM), and to assess associations between 16 symptoms and the severity of pain.

Methods

This cross-sectional study included 426 children (6–35 months) with symptoms suggestive of AOM. We surveyed symptoms and pain via parental interview. As part of the interview, parents assessed their child’s pain by using two pain scales: The Faces Pain Scale-Revised (FPS-R) and the Face, Legs, Activity, Cry, Consolability (FLACC) Scale. The outcome of interest was moderate/severe pain. We used the χ² test or Fisher’s test as applicable to compare the severity of pain between three parental pain assessment methods (the parental interview, the FPS-R and the FLACC Scale). We also used multivariable logistic regression models to study the association between the severity of pain and AOM and to study the association between symptoms and the severity of pain.

Results

In children with AOM (n = 201), pain was assessed by parents as moderate/severe in 65% via interview; 90% with the FPS-R; and 91% with the FLACC Scale (P < 0.001). In children without AOM (n = 225), the percentages were 56, 83 and 88%, respectively (P < 0.001). Between children with and without AOM, the occurrence of moderate/severe pain did not differ with any of the pain evaluation methods. Of symptoms, ear pain reported by child and restless sleep were significantly associated with moderate/severe pain, regardless of the pain evaluation method.

Conclusions

It seems that nearly all the children with respiratory tract infection, either with or without AOM, might suffer from moderate/severe pain. Without pain scales, parents may underestimate their child’s pain. Of symptoms, ear pain reported by child and restless sleep might indicate pain in children with respiratory tract infection. We suggest that the adaptation of pain scales for parent observation is a possibility in children with respiratory tract infection which, however, requires further studies.

Trial registration

www.clinicaltrials.gov, identifier NCT00299455. Date of registration: March 3, 2006.

Electronic supplementary material

The online version of this article (10.1186/s12887-018-1361-y) contains supplementary material, which is available to authorized users.

Perceived language proficiency and pain assessment by registered and student nurses in native English-speaking and EAL children aged 4-7 years

AIMS AND OBJECTIVES

To identify the factors that influence decisions made by health professionals when assessing the pain of native English speaking and children whose English is an additional language.

BACKGROUND

Pain assessment in children is often poorly executed following acute injury. Whilst a range of pain assessment tools have been developed, little guidance is provided for assessing pain in children with English as an additional language.

DESIGN

Factorial survey design.

METHODS

Twenty minor injuries unit nurses and 20 children's nursing students participated in an electronic survey to make judgements on 12 scenarios describing a child attending a minor injuries unit following an incident, accompanied by a parent. Respondents had to decide the most important form of pain assessment, and whether they would ask a parent or an interpreter to assess the pain of the child. An open-ended question asked about the difficulties found in making a judgement.

RESULTS

Observation of the child's behaviour was the most common pain assessment reported. The visual analogue scale was significantly associated with children with proficient English. Respondents were significantly more likely to involve parents in the assessment if they could speak English well compared to parents with poor English skills. Moreover, nursing students were significantly more likely than registered nurses to call for support from an interpreter. Thematic analysis identified three themes related to difficulties with pain assessment: contrasting approaches, differing perceptions of pain and overcoming challenges.

CONCLUSIONS

The reduced ability to communicate between child, parent and healthcare professional highlights the need to identify forms of assessment based on individual cases.

RELEVANCE TO CLINICAL PRACTICE

The number of children with English as an additional language has seen a marked rise over the last decade. In situations where communication ability is reduced, assessment of pain should be tailored to meet the needs of the child. This may require timely access to interpreter services.

Adult judgments of children’s pain and fear during venipuncture: The impact of adult and child sex

Background

Low levels of agreement between caregiver and child reports of acute pain are well documented.

Aims

This study builds on prior research through exploring factors that may contribute to low caregiver–child concordance. Specifically, the study examined the influence of adult and child sex on adult judgments of children’s pain and fear during venipuncture and examined whether trait parental pain catastrophizing, empathy, and anxiety predicted judgment accuracy.

Methods

Using a judgment study paradigm, 160 participants (82 women) viewed 20 10-s video clips of children (10 boys, 10 girls) undergoing venipuncture and rated each child’s pain and fear. Adults’ ratings were compared to the children’s own ratings. Adults completed measures of trait parental pain catastrophizing, dispositional empathy, and trait anxiety.

Results

Adults accurately judged boys’ pain and fear significantly more often than that of girls. Further, adults underestimated and overestimated girls’ pain and overestimated girls’ fear significantly more frequently than that of boys. No effects of adult sex or adult by child sex interactions emerged. Parental pain catastrophizing significantly predicted underestimation of girls’ pain, with adults who engaged in more catastrophizing being less likely to underestimate girls’ pain. The variables did not predict adult judgment of child pain for women and men separately and did not predict adult judgment of child fear when examined by adult sex, child sex, or both combined.

Conclusions

Child sex influences adult pain and fear judgments, with girls being more vulnerable to inaccurate assessment than boys. Higher levels of parental pain catastrophizing may buffer against adults’ propensities to underestimate girls’ pain.

Optimizing Numeric Pain Rating Scale administration for children: The effects of verbal anchor phrases

Background: The 0–10 Verbal Numeric Rating Scale (VNRS) is commonly used to obtain self-reports of pain intensity in school-age children, but there is no standard verbal descriptor to define the most severe pain.

Aims: The aim of this study was to determine how verbal anchor phrases defining 10/10 on the VNRS are associated with children’s reports of pain.

Methods and Results: Study 1. Children (N = 131, age 6–11) rated hypothetical pain vignettes using six anchor phrases; scores were compared with criterion ratings. Though expected effects of age and vignette were found, no effects were found for variations in anchors. Study 2. Pediatric nurses (N = 102) were asked how they would instruct a child to use the VNRS. Common themes of “the worst hurt you could ever imagine” and “the worst hurt you have ever had” to define 10/10 were identified. Study 3. Children’s hospital patients (N = 27, age 8–14) rated pain from a routine injection using four versions of the VNRS. Differences in ratings ranging from one to seven points on the scale occurred in the scores of 70% of children when the top anchor phrase was changed. Common themes in children’s descriptions of 10/10 pain intensity were “hurts really bad” and “hurts very much.”

Discussion: This research supports attention to the details of instructions that health care professionals use when administering the VNRS. Use of the anchor phrase “the worst hurt you could ever imagine” is recommended for English-speaking, school-age children. Details of administration of the VNRS should be standardized and documented in research reports and in clinical use.

The Faces Emotional Coping Scale as a self-reporting instrument for coping with needle-related procedures: An initial validation study with children treated for type 1 diabetes

The aim of this study was to determine the concurrent and content validity, sensitivity and inter-rater reliability of the Faces Emotional Coping Scale (FECS) to evaluate the children's anticipation of the level of emotional coping in conjunction with a venepuncture. A total of 153 children with type 1 diabetes and 86 of their parents participated in the study. The age of the children, 76 of whom were boys, ranged from 7 to 18 years. The child and his or her parent reported the child's coping ability, and the child reported the pain intensity and unpleasantness of a venepuncture. The child also wrote a short narrative about his or her experience of the needle procedure. The FECS correlated negatively with the Coloured Analogue Scale and the Facial Affective Scale and positively with the FECS by proxy. The narratives of 90 children correlated negatively with the FECS. Younger children reported significantly lower scores than older children did regarding their ability to cope with a venepuncture. The children's scores on the FECS showed good agreement with the parents' scores. In this study, the FECS was deemed valid for measuring children's ability to cope with their emotions when undergoing needle-related procedures like venepuncture.

Chronic Pain Assessments in Children and Adolescents: A Systematic Literature Review of the Selection, Administration, Interpretation, and Reporting of Unidimensional Pain Intensity Scales

BACKGROUND

Advances in pain assessment approaches now indicate which measures should be used to capture chronic pain experiences in children and adolescents. However, there is little guidance on how these tools should best be administered and reported, such as which time frames to use or how pain scores are categorised as mild, moderate, or severe.

OBJECTIVE

To synthesise current evidence on unidimensional, single-item pain intensity scale selection, administration, interpretation, and reporting.

METHODS

Databases were searched (inception: 18 January 2016) for studies in which unidimensional pain intensity assessments were used with children and adolescents with chronic pain. Ten quality criteria were developed by modifying existing recommendations to evaluate the quality of administration of pain scales most commonly used with children.

RESULTS

Forty-six studies met the inclusion criteria. The highest score achieved was 7 out of a possible 10 (median: 5; IQR: 4-6). Usage of scales varied markedly in administrator/completer, highest anchors, number of successive assessments, and time referent periods used.

CONCLUSIONS

Findings suggest these scales are selected, administered, and interpreted inconsistently, even in studies of the same type. Furthermore, methods of administration are rarely reported or justified making it impossible to compare findings across studies. This article concludes by recommending criteria for the future reporting of paediatric chronic pain assessments in studies.