Young children's ability to report on past, future, and hypothetical pain states: a cognitive-developmental perspective

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Virtual reality vs. tablet for procedural comfort using an identical game in children undergoing venipuncture: a randomized clinical trial

Introduction

Recent research has explored the effectiveness of interactive virtual experiences in managing pain and anxiety in children during routine medical procedures, compared to conventional care methods. However, the influence of the specific technology used as an interface, 3-dimensions (D) immersive virtual reality (VR) vs. 2D touch screens, during pediatric venipuncture, remains unexamined. This study aimed to determine if immersive VR is more effective than a tablet in reducing pain and anxiety during short procedures.

Methods

An interactive game was designed by clinicians and psychologists, expert in pain theory, hypnosis, and procedural pain and anxiety relief, and was tailored for both VR and tablet use. Fifty patients were randomly assigned to either the Tablet or VR group. The primary outcome measures were pain and anxiety levels during the procedure. Secondary outcome measures included the need for physical restraint, duration of the procedure, enjoyment levels, and satisfaction ratings from both parents and nurses.

Results

Participants, in both groups, had low levels of pain and anxiety. Physical restraint was infrequently used, procedures were brief, and high satisfaction levels were reported by patients, parents, and nurses.

Discussion

This study suggests that the type of technology used as a support for the game has a minimal effect on the child's experience, with both groups reporting low pain and anxiety levels, minimal physical restraint, and high enjoyment. Despite immersive VR's technological advancements, this study underscores the value of traditional tablets with well-designed interactive games in enhancing children's wellbeing during medical procedures.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT05065307].

Content validity of the electronic faces thermometer scale for pain in children: is a picture worth more than a thousand words?

Introduction

Early recognition of pain in children is crucial, and their self-report is the primary source of information. However, communication about pain in healthcare settings can be challenging. For non-verbal communication regarding different symptoms, children prefer digital tools. The electronic Faces Thermometer Scale (eFTS) utilizes a universal design with colors, face emojis, and numbers on an 11-point scale (0-10) for pain assessment. The aim of this study was to establish content validity of the eFTS for pain assessments in children.

Methods

A mixed methods design was used. The study took place at a university hospital in eastern Sweden, involving 102 children aged 8-17 years who visited outpatient clinics. Participants were presented with 17 pictures representing varying pain levels and asked to assess hypothetical pain using the eFTS. A think-aloud approach was employed, prompting children to verbalize their thoughts about assessments and the eFTS. Quantitative data were analyzed using descriptive and comparative statistics, together with a qualitative approach for analysis of think-aloud conversations.

Results

A total of 1,734 assessments of hypothetical pain using the eFTS were conducted. The eFTS differentiated between no pain (level 0-1) and pain (level 2-10). However, no clear agreement was found in the differentiation between hypothetical pain intensity levels (level 2-10). The analysis revealed that children utilized the entire scale, ranging from no pain to high pain, incorporating numbers, colors, and face emojis in their assessments.

Discussion

The variability in assessments was influenced by prior experiences, which had an impact on the statistical outcome in our study. However, employing the think-aloud method enhances our understanding of how children utilize the scale and perceive its design, including the incorporation of emotion-laden anchors. Children express a preference for using the eFTS to assess their pain during hospital visits.

Psychometric evaluation of the electronic faces thermometer scale for pain assessment in children 8-17 years old: A study protocol

It is often a challenge for a child to communicate their pain, and their possibilities to do so should be strengthened in healthcare settings. Digital self-assessment provides a potential solution for person-centered care in pain management and promotes child participation when a child is ill. A child's perception of pain assessment differs when it is assessed using digital or analog formats. As we move into the digital era, there is an urgent need to validate digital pain assessment tools, including the newly developed electronic Faces Thermometer Scale (eFTS). This study protocol describes three studies with the overall aim to evaluate psychometric properties of the eFTS for assessing pain in children 8-17 years of age. A multi-site project design combining quantitative and qualitative methods will be used for three observational studies. Study 1: 100 Swedish-speaking children will report the level of anticipated pain from vignettes describing painful situations in four levels of pain and a think-aloud method will be used for data collection. Data will be analyzed with phenomenography as well as descriptive and comparative statistics. Study 2: 600 children aged 8-17 years at pediatric and dental settings in Sweden, Denmark, Iceland, and USA will be included. Children will assess their pain intensity due to medical or dental procedures, surgery, or acute pain using three different pain Scales for each time point; the eFTS, the Faces Pain Scale Revised, and the Coloured Analogue Scale. Descriptive and comparative statistics will be used, with subanalysis taking cultural context into consideration. Study 3: A subgroup of 20 children out of these 600 children will be purposely included in an interview to describe experiences of grading their own pain using the eFTS. Qualitative data will be analyzed with content analysis. Our pilot studies showed high level of adherence to the study procedure and rendered only a small revision of background questionnaires. Preliminary analysis indicated that the instruments are adequate to be used by children and that the analysis plan is feasible. A digital pain assessment tool contributes to an increase in pain assessment in pediatric care. The Medical Research Council framework for complex interventions in healthcare supports a thorough development of a new scale. By evaluating psychometric properties in several settings by both qualitative and quantitative methods, the eFTS will become a well-validated tool to strengthen the child's voice within healthcare.

Validation of an instrument for dentists' perception of pain in patients with communication difficulties

Pain is present in the dental clinic, whether due to oral problems such as dental caries and its complications or related to dental procedures. Pain evaluation in patients with communication difficulties (PCDs) is challenging for dentists, potentially compromising treatment. The aim of this study was to develop and validate an instrument to assess the perception of dentists about pain in PCDs. This study followed a quantitative methodological approach involving constructing and validating an instrument administered to 50 dentists. The initial instrument consisted of 29 items divided into four domains. Content and construct validity and internal consistency were confirmed. Content validation was performed by judges using the Content Validity Index. The instrument underwent construct validation and internal consistency assessments through exploratory factor analysis and confirmatory factor analysis using Cronbach's α, Kaiser-Meyer-Olkin, and Bartlett's sphericity tests. The final instrument consisted of 21 items divided into three domains, with a high Cronbach's α for one domain and moderate values for the others. The total variance accounted for was above 46.03%. Each factor retained at least three items, with factor loadings greater than 0.3, commonalities greater than 0.2, and eigenvalues >1. Despite the study's limitations, the instrument demonstrated its applicability and potential in evaluating the perception and management of pain in PCDs.

Pain and discomfort in children with gastrostomy tubes - In the context of hematopoietic stem cell transplantation

BACKGROUND

In children with malignant and severe non-malignant disorders undergoing hematopoietic stem cell transplantation (HSCT), treatment related pain and discomfort are common. Food consumption may become troublesome, making the use of a gastrostomy tube (G-tube) necessary and resulting in complications, why the purpose was to explore pain and discomfort during the transplantation and post-transplantation time.

METHODS

This was a mixed methods study where data were collected along the child's total health-care process between 2018 and 2021. Questions with fixed answer options were used, simultaneously, semi-structured interviews were performed. In total, sixteen families participated. Descriptive statistics and content analysis were used to describe analysed data.

FINDINGS

Intense pain was common during the post-surgery phase, especially in conjunction with G-tube care, which is why the children needed support to manage the situation. After the post-surgery phase when the skin has healed, most of the children experienced minor to no pain or bodily discomfort, why the G-tube became a well-functioning and supportive tool in daily life.

CONCLUSIONS

This study describes variations in and experiences of pain and bodily discomfort in conjunction with G-tube insertion in a unique sample of children who had undergone HSCT. In conclusion, the children's comfort in daily life after the post-surgery phase seemed to be only marginally affected by G-tube insertion. Children with severe non-malignant disorders seemed to experience a higher frequency and intensity of pain and bodily discomfort due to the G-tube than children with malignant disorders.

PRACTICE IMPLICATIONS

The paediatric care team need competence in assessing G-tube related pain and awareness that experiences may differ depending on the child's disorder.

Diagnostic criteria for temporomandibular disorders-INfORM recommendations: Comprehensive and short-form adaptations for children

BACKGROUND

The Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) are used worldwide in adults. Until now, no adaptation for use in children has been proposed.

OBJECTIVE

The aim of this study was to present comprehensive and short-form adaptations of Axis I and Axis II of the DC/TMD for adults that are appropriate for use with children in clinical and research settings.

METHODS

Global Delphi studies with experts in TMDs and in pain psychology identified ways of adapting the DC/TMD for children.

RESULTS

The proposed adaptation is suitable for children aged 6-9 years. Proposed changes in Axis I include (i) adapting the language of the Demographics and the Symptom Questionnaires to be developmentally appropriate for children, (ii) adding a general health questionnaire for children and one for their parents, (iii) replacing the TMD Pain Screener with the 3Q/TMD questionnaire and (iv) modifying the clinical examination protocol. Proposed changes in Axis II include (i) for the Graded Chronic Pain Scale, to be developmentally appropriate for children, (ii) adding anxiety and depression assessments that have been validated in children and (iii) adding three constructs (stress, catastrophising and sleep disorders) to assess psychosocial functioning in children.

CONCLUSION

The recommended DC/TMD, including Axis I and Axis II, for children aged 6-9 years, is appropriate for use in clinical and research settings. This adapted the first version for children includes changes in Axis I and Axis II changes requiring reliability and validity testing in international settings. Official translations to different languages according to INfORM requirements will enable a worldwide dissemination and implementation.

A Brief Mindfulness Intervention for Parents and Children before Pediatric Venipuncture: A Randomized Controlled Trial

BACKGROUND

Routine needle procedures can be distressing for parents and children. Mindfulness interventions may be helpful for parents and children but have not been examined for pediatric needle procedures despite showing benefits in the context of pediatric chronic pain and in lab-based pain tasks.

METHODS

This preregistered (NCT03941717) two-arm, parallel-group randomized controlled trial examined the effects of a 5 min mindfulness intervention before pediatric venipuncture for parents and children (aged 7-12) compared to a control group on primary outcomes of child pain and fear, secondary outcomes of parent distress, and tertiary outcomes of parent ratings of child pain and fear. Moderators of parent and children's responses to the intervention were examined: state catastrophizing, trait mindfulness, and experiential avoidance.

RESULTS

Sixty-one parent-child dyads were randomized (31 mindfulness; 30 control). Parents and children completed measures, listened to a 5 min audio recording (mindfulness or control), and parents accompanied their child during routine venipuncture. The mindfulness intervention involved breathing and encouraging nonjudgmental attention to one's experiences, while the control condition involved an unfocused attention task. Three between-subject MANCOVAs assessed for group differences. Child pain and fear rated by children and their parents did not differ between groups. Parents in the mindfulness group were less distressed during the venipuncture than the controls. Parent state catastrophizing may have moderated the intervention effects, such that parents with moderate and high catastrophizing levels had lower distress following the mindfulness intervention versus control.

CONCLUSIONS

The intervention did not reduce child pain or fear but reduced parent distress. It appeared most helpful for parents catastrophizing about their child's pain, which is noteworthy as these children are prone to worse outcomes.

Let's (Not) Talk About Pain: Mothers' and Fathers' Beliefs Regarding Reminiscing About Past Pain

Children's memories for past pain set the stage for their future pain experiences. Parent-child reminiscing about pain plays a key role in shaping children's pain memories. Parental beliefs about the functions of reminiscing are associated with parental reminiscing behaviors. To date, no studies have investigated parental beliefs regarding the functions of reminiscing about past pain or the associations between parental beliefs and reminiscing about past pain. This study aimed to fill these gaps. One-hundred and seven parents (52% fathers) of young children were asked about their beliefs regarding reminiscing about past pain. Interview data were first analyzed using inductive reflexive thematic analysis. A coding scheme was created based on the generated themes to quantitatively characterize parental beliefs. Parents also reminisced with their children about unique past events involving pain. Parent-child reminiscing narratives were coded to capture parent reminiscing behaviors. Inductive reflexive thematic analysis generated three major themes representing parental beliefs regarding reminiscing about past pain: “reminiscing to process past pain,” “reminiscing as a learning tool,” and “avoiding reminiscing about past pain.” Parents who endorsed avoiding reminiscing used fewer optimal reminiscing elements (i.e., open-ended questions) when reminiscing about past painful experiences with children. Parents who endorsed reminiscing to process past pain used more emotion-laden language when reminiscing about past pain. Mothers and fathers of boys and girls endorsed the reminiscing functions to a similar degree. Parents of older, vs. younger, children endorsed reminiscing to process past pain to a greater degree. Developmental considerations and clinical implications of the findings are discussed.

A Memory-Reframing Intervention to Reduce Pain in Youth Undergoing Major Surgery: Pilot Randomized, Controlled Trial of Feasibility and Acceptability

Background

Three to 22% of youth undergoing surgery develop chronic postsurgical pain (CPSP). Negative biases in pain memories (i.e., recalling higher levels of pain as compared to initial reports) are a risk factor for CPSP development. Children’s memories for pain are modifiable. Existing memory-reframing interventions reduced negatively biased memories associated with procedural pain and pain after minor surgery. However, not one study has tested the feasibility and acceptability of the memory-reframing intervention in youth undergoing major surgery.

Aims

The current pilot randomized clinical trial (RCT; NCT03110367; clinicaltrials.gov) examined the feasibility and acceptability of, as well as adherence to, a memory reframing intervention.

Methods

Youth undergoing a major surgery reported their baseline and postsurgery pain levels. Four weeks postsurgery, youth and one of their parents were randomized to receive control or memory-reframing instructions. Following the instructions, parents and youth reminisced about the surgery either as they normally would (control) or using the memory-reframing strategies (intervention). Six weeks postsurgery, youth completed a pain memory interview; parents reported intervention acceptability. Four months postsurgery, youth reported their pain.

Results

Seventeen youth (76% girls, M_age = 14.1 years) completed the study. The intervention was feasible and acceptable. Parents, but not youth, adhered to the intervention principles. The effect sizes of the intervention on youth pain memories (η_p² = 0.22) and pain outcomes (η_p² = 0.23) were used to inform a larger RCT sample size.

Conclusions

Memory reframing is a promising avenue in pediatric pain research. Larger RCTs are needed to determine intervention efficacy to improve pain outcomes.

Pain in Tourette Syndrome-Children’s and Parents’ Perspectives

Tourette Syndrome (TS) is a neurodevelopmental condition characterized by the presence of tics and associated behavioral problems. Yale Global Tic Severity Scale (YGTSS), The PedsQL Pediatric Pain Questionnaire, and Pediatric Pain Coping Inventory were used to assess the severity of tics, the severity of the pain, the location of the pain and pain coping strategies both from children’s and parents’ perspectives. Sixty percent of children demonstrated pain (past or present); the pain was reported by 72% of parents raising children with TS. The pain most commonly was cervical, throat, shoulder, ocular, and joint pain; most children declared pain located in more than one part of the body. Consistency between the declarations of children and their parents in coping with pain was observed. Pain should be recognized as a common comorbid aspect of tic disorders in childhood and therapeutic treatment must include the reduction of pain caused by tics.

Lifetime Prevalence of Nonspecific Low Back Pain in Adolescents: A Cross-sectional Epidemiologic Survey

BACKGROUND

Many nonconclusive studies have been conducted on low back pain (LBP) in adolescents and associated factors.

OBJECTIVE

The aim was to assess the lifetime prevalence and associated factors of LBP in adolescents.

MATERIALS AND METHODS

A questionnaire was administered in high school students (14-19-yr-old participants) in Veneto region (Italy). The self-administered, structured questionnaire included anthropometric data; psychologic factors and lifestyle; presence, intensity, and family history of LBP; referral to professional health care for LBP; and a short version of the International Physical Activity Questionnaire.

RESULTS

A total of 6281 adolescents were recruited; 5204 questionnaires were included in the final analysis. A total of 2549 (48.98%) students reported one or more LBP episodes and 723 (13.89%) reported nonspecific disabling lumbar pain (i.e., no underlying pathology); 1040 (41.11%) subjects with LBP consulted a healthcare professional. A significant association emerged for LBP with sex (female), positive family history, time spent sitting or using electronic devices, sleep deprivation (<5 hrs/night), and low level of physical activity.

CONCLUSION

In a large sample of adolescents, LBP lifetime prevalence is high and often associated with disabling pain and sedentary lifestyle, requiring professional care. These findings may support the development of prevention and treatment strategies of LBP in adolescents, reducing the risk of developing chronic pain.

Ability of 3- to 5-year-old children to use simplified self-report measures of pain intensity

Little is known about self-report pain intensity scales best suited for young children. We tested the ability of preschool children to use two simplified scales (concrete ordinal and faces). Three- to 5-year-olds (n = 123) were asked to make binary discriminations ('less' vs 'more' pain) between response options using the Simplified Faces Pain Scale and Simplified Concrete Ordinal Scale and to complete a seriation task. Eighty participants were also asked to use the Simplified Concrete Ordinal Scale, with modified verbal anchors, to rate the loudness of tones and to assess practice effects. Binary discrimination accuracy and seriation ability improved with age. When using the Simplified Concrete Ordinal Scale to rate the loudness of tones, even the 3-year-olds performed significantly better than chance, and performance was better in 4- and 5-year-olds. Little evidence supported the ability of 3-year-olds to use either of the simplified tools in the pain context. The 4-year-olds demonstrated greater accuracy in using the Simplified Concrete Ordinal Scale than the Simplified Faces Pain Scale, suggesting that the Simplified Concrete Ordinal Scale may be more appropriate for this age group.

Father- and Mother-Child Reminiscing About Past Pain and Young Children's Cognitive Skills

Objective Painful experiences are common, distressing, and salient in childhood. Parent-child reminiscing about past painful experiences is an untapped opportunity to process pain-related distress and, similar to reminiscing about other distressing experiences, promotes children's broader development. Previous research has documented the role of parent-child reminiscing about past pain in children's pain-related cognitions (i.e., memories for pain), but no study to date has examined the association between parent-child reminiscing about past painful experiences and children's broader cognitive skills. Design and Methods One hundred and ten typically developing four-year-old children and one of their parents reminisced about a past painful autobiographical event. Children then completed two tasks from the NIH Toolbox Cognitive Battery, the Flanker Inhibitory Control & Attention Test and the Picture Sequence Memory Test, to measure their executive function and episodic memory, respectively. Results Results indicated that the relation between parental reminiscing style and children's executive function was moderated by child sex, such that less frequent parental use of yes-no repetition questions was associated with boys' but not girls', greater performance on the executive function task. Children displayed greater episodic memory performance when their parents reminisced using more explanations. Conclusions The current study demonstrates the key role of parent-child reminiscing about pain in children's broader development and supports the merging of developmental and pediatric psychology fields. Future longitudinal research should examine the directionality of the relation between parent-child reminiscing about past pain and children's developmental outcomes.

Using an App to monitor postoperative pain at home in pediatric patients

A prospective comparative study was conducted in 487 pediatric patients (69% male, mean age = 6.4 ± 4.0) to evaluate (a) the incidence, intensity, and characteristics of pain in pediatric patients at home during the first 24 hours and 5 days after surgery and (b) the factors associated with higher pain intensity, including the impact of an application (App) compared to the paper-and-pencil approach. Postoperative pain was assessed by patients or their parents at home using the 'Bambino Gesù' Children's Hospital (Ospedale Pediatrico Bambino Gesù, OPBG) tool for participants aged 4-17 years or the Faces, Legs, Arms, Cry, and Consolability scale for participants less than four years old. Participants were assigned to two groups: those who used the paper-and-pencil version of the pain scale and those who used the App. Overall, 209 of the 472 (44%) participants reported pain during the first 24 hours, and 92 of the 420 (22%) reported pain between one and five days after surgery. Higher pain intensity scores were associated with being in the App group, directly assessing own pain, and using the OPBG tool. The App was effective in facilitating pain assessment. Health professionals could empower pediatric patients and their parents in assessing pain at home through a dedicated App.

Communicating with Youth about Pain: Developmental Considerations

BACKGROUND

Pain experiences can negatively impact children and adolescents, leading to trauma symptoms and nonadherence to important health behaviors. Developmentally-tailored communication strategies may mitigate this risk.

METHODS

This article reviews cognitive and linguistic developmental factors, within the familial and cultural context, that are important to consider when communicating with youth about acute, procedural, and/or chronic pain.

RESULTS

Youth undergoing acute or procedural pain benefit from pain education, truthful information about the procedure, and advance preparation. The use of analogies may be particularly helpful for patient understanding of chronic pain development, maintenance, and treatment. Youth with developmental disabilities may express pain differently than their normative peers, requiring adaptation of communication strategies.

CONCLUSION

Developmentally-tailored pain communication is an important tool for caregivers and healthcare providers that may foster adaptive functioning in youth who experience pain.

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.

Development of a web-based assessment tool that evaluates the meal situation when a child has a percutaneous endoscopic gastrostomy

BACKGROUND

Children with cancer often suffer side effects from their treatment, for example nausea and vomiting, which can lead to malnutrition. If a child cannot eat orally, a percutaneous endoscopic gastrostomy (PEG) can improve his or her well-being, psychosocial development and growth by enabling the supply of nourishment and facilitating the administration of necessary medicines. Few data exist on children's comfort when using a PEG. The aim of this study was firstly to develop three versions of a web-based assessment tool in which children, families, and healthcare professionals would be able to register their observations and assessments for evaluating the meal situation when a child has a PEG and secondly to validate the content of the tool.

METHODS

A qualitative design was chosen with purposive sampling of participants. Five children with cancer, five parents, five registered nurses and five paediatricians participated first in an interview and then in a member check of the web-based tool. The data were analysed with manifest qualitative content analysis.

RESULTS

The results highlighted four categories of issues which needed to be revised in the web-based tool: words which were difficult for the participants to understand, items which contained several questions, items which needed to be split into more items to be answerable and the layout of the questionnaire. The web-based tool was revised according to the categories, and then a member check evaluated and finally confirmed the revisions.

CONCLUSIONS

A web-based tool may be able to evaluate the meal situation when a child with cancer has a PEG. The tool may be able to detect early failures of the PEG, facilitating early action from the healthcare professionals in supporting the child and his or her parents in their care of the PEG. In the long run, this web-based tool may also be able to increase the quality of care of children living with a PEG.

Efficacy of Non-pharmacological Methods of Pain Management in Children Undergoing Venipuncture in a Pediatric Outpatient Clinic: A Randomized Controlled Trial of Audiovisual Distraction and External Cold and Vibration

PURPOSE

Venipuncture generates anxiety and pain in children. The primary aim of the study was to evaluate two non-pharmacological techniques, vibration combined with cryotherapeutic topical analgesia by means of the Buzzy® device and animated cartoons, in terms of pain and anxiety relief during venipuncture in children.

DESIGNS AND METHODS

150 children undergoing venipuncture were randomized into four groups: the 'no method' group, the Buzzy® device group, the animated cartoon group and the combination of Buzzy® and an animated cartoon group. Children's pain and anxiety levels along with parents' and nurses' anxiety levels were evaluated by means of validated grading scales.

RESULTS

Overall children's pain increased less in the non-pharmacological intervention groups as compared to the group without intervention. Notably, the difference was statistically significant in the animated cartoon group for children's perception of pain. Children's anxiety and parents' anxiety decreased more in non-pharmacological interventions groups as compared to the group without intervention.

CONCLUSIONS

The study showed the effectiveness of non-pharmacological methods of pain management during venipuncture. Notably, distraction with animated cartoons was superior in terms of children's perception of pain when compared to Buzzy®, and to the combination of cartoons and Buzzy®. Buzzy® was significantly effective at the secondary analysis for children younger than 9. Children's and parents' anxiety is decreased by non-pharmacological methods. Furthermore, nurses' involvement in pediatric care can be enhanced.

PRACTICE IMPLICATIONS

Non-pharmacological methods of pain management during venipuncture represent an easy way to achieve an increased level of compliance among children and parents.

Development and validation of the self-reported PROMIS pediatric pain behavior item bank and short form scale

Pain behaviors are important indicators of functioning in chronic pain; however, no self-reported pain behavior instrument has been developed for pediatric populations. The purpose of this study was to create a brief pediatric measure of patient-reported pain behaviors as part of the Patient-Reported Outcome Measurement Information System (PROMIS). A pool of 47 candidate items for this measure had been previously developed through qualitative research. In this study, youth with chronic pain associated with juvenile fibromyalgia, juvenile idiopathic arthritis, or sickle cell disease (ages 8-18 years) from 3 pediatric centers completed all 47 candidate items for development of the pain behavior item bank along with established measures of pain interference, depressive symptoms, fatigue, average pain intensity, and pain catastrophizing. Caregivers reported on sociodemographic information and health history. Psychometric properties of the pain behavior items were examined using an item response theory framework with confirmatory factor analysis and examination of differential item functioning, internal consistency, and test information curves. Results were used along with expert consensus and alignment with the adult PROMIS pain behavior items to arrive at an 8-item pediatric pain behavior short form, and all 47 items were retained in a calibrated item bank. Confirmatory factor analysis and correlations with validated measures of pain, pain interference, and psychosocial functioning provided support for the short form's reliability and validity. The new PROMIS pediatric pain behavior scale provides a reliable, precise, and valid measure for future research on pain behavior in school-aged children with chronic pain.

Is caregiver refusal of analgesics a barrier to pediatric emergency pain management? A cross-sectional study in two Canadian centres

What is known about the topic?

Children’s pain in the emergency department (ED) continues to be under-recognized and sub-optimally managed.

What did this study ask?

We sought to evaluate the frequency of caregiver/child acceptance of analgesia offered in the ED.

What did this study find?

Of the 743 children who presented to the ED with a painful condition, 408 (54.9%) were offered analgesia. If offered in the ED, analgesia was accepted by 91% (373/408) of the caregivers/children.

Why does this study matter to clinicians?

This study suggests that caregiver/child refusal of analgesia is a not a major barrier to optimal pain management and highlights the importance of ED personnel in encouraging adequate analgesia.

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.

Measuring Musculoskeletal Pain in Infants, Children, and Adolescents

Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.

Systematic Review of Self-Report Measures of Pain Intensity in 3- and 4-Year-Old Children: Bridging a Period of Rapid Cognitive Development

Claims are made for the validity of some self-report pain scales for 3- and 4-year-old children, but little is known about their ability to use such tools. This systematic review identified self-report pain intensity measures used with 3- and/or 4- year-old participants (3-4yo) and considered their reliability and validity within this age span. The search protocol identified research articles that included 3-4yo, reported use of any pain scale, and included self-reported pain intensity ratings. A total of 1,590 articles were screened and 617 articles met inclusion criteria. Of the included studies, 98% aggregated self-report data for 3-4yo with data for older children, leading to overestimates of the reliability and validity of self-report in the younger age group. In the 14 studies that provided nonaggregated data for 3-4yo, there was no evidence for 3-year-old and weak evidence for 4-year-old children being able to use published self-report pain intensity tools in a valid or reliable way. Preschool-age children have been reported to do better with fewer than the 6 response options offered on published faces scales. Simplified tools are being developed for young children; however, more research is needed before these are adopted.

PERSPECTIVE

Some self-report pain scales have been promoted for use with 3- and 4-year-old children, but this is on the basis of studies that aggregated data for younger and older children, resulting in overestimates of reliability and validity for the preschool-age children. Scales with fewer response options show promise, at least for 4-year-old children.

The influence of pain memories on children's and adolescents' post-surgical pain experience: A longitudinal dyadic analysis

OBJECTIVE

Although children's pain memories have been shown to be a powerful predictor of subsequent pain experiences in acute procedural and experimental pain settings, little is known about the influence of children's and parents' pain memories on children's future pain experiences in other painful contexts. This study used a dyadic approach to examine the roles of children's and parents' memories of pain on their subsequent reporting of postsurgical pain several months after the child underwent a major surgical procedure.

METHOD

The sample included 66 parent-child dyads (Mage youth = 14.73 years, SD = 2.01) recruited from 2 tertiary level pediatric hospitals. At baseline, children and parents reported on their catastrophic thinking about the child's pain. Parent and child reports of child pain were collected at approximately 1 month and 5 months postsurgery. At 2-4 months postsurgery, children's and parents' memories for postsurgical pain were assessed.

RESULTS

Results revealed that children's, but not parents', pain memories were a strong predictor of subsequent pain experienced at 5 months postsurgery. Children's and parents' memories for pain did not influence each others' subsequent pain reporting.

CONCLUSIONS

Findings suggest that children's pain memories influence their continued recovery from postsurgical pain and may contribute to pain persistence. Implications for intervention and prevention are discussed. (PsycINFO Database Record