Managing procedural pain in pediatric patients

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

Postoperative Pain Management in Children Undergoing Laparoscopic Appendectomy: A Scoping Review

Laparoscopic appendectomy (LA) is one of the most commonly performed surgical procedures in children and is associated with extreme postoperative discomfort due to peritoneal inflammation and infection. The main objective of this study was to investigate the effects of postoperative pain (POP) in children after laparoscopic appendectomy. Articles describing or evaluating the control of POP in children with LA were considered eligible. All available literature such as randomized controls, prospective controls, retrospective as well as clinical studies were considered. A comprehensive search was performed in PubMed, Medline, Embase, Cochrane Library, Clinical trials.gov, and Google scholar. The initial search took place on 23 April 2021, and was updated on 24 August 2021. There were no language or date restrictions. Each of the included articles was evaluated separately by two independent reviewers. Additional papers were found by searching the reference lists of eligible studies. Eighteen papers were considered. All papers, and many of them used different methods to treat POP in children undergoing LA, such as lidocaine infusion, different analgesic approaches, ultrasound-guided transverse abdominis blockade (UGTAP), ultrasound-guided quadratus lumborum blockade (UGQLB), and comparison of open appendectomy (OA) with local anesthetics in relation to POP management in children. Laparoscopic appendectomy is the surgical procedure preferred by clinicians compared with open appendectomy in children. A multimodal analgesic approach is optimal and efficient surgical techniques such as UGBRSB, UGQLB, and UGTAP block might significantly impact POP in children except that there are contraindications. Dexmedetomidine proved to be an effective adjuvant that can enhance the effect of local anesthetics. The lack of a sufficient number of studies may be a factor affecting our confidence in the results of this study. Therefore, further evidence-based randomized control trials with a large sample size are needed to provide clarity.

Parents' from Poland coping with the illness of a child-Preliminary research. Cultural adaptation and evaluation of the psychometric properties of the coping health inventory for parents - polish version

PURPOSE

The goal was to present preliminary research results on how parents cope with the illness of a child using the Coping Health Inventory for Parents (CHIP) after it had been culturally adapted and its psychometric properties evaluated.

DESIGN AND METHODS

Taking part in the study were 459 parents of children with asthma (n = 230) or suffering pain (n = 229).A.

RESULTS

The content validity of the coefficient of variation ratio (CVR) for each item on the scale ranged from 0.84 to 1.00. Exploratory factor analysis by principal components method with Equamax rotation confirmed the three-factor structure of the test. THe theoretical validity of the tool was confirmed by intercorrelation matrix analysis, and the criterion validity of the CHIP test was evaluated based on analysis of intergroup differences regarding individual measurements of coping by parents of children diagnosed with asthma but differentiated by need of regular medication. CHIP has high Cronbach alpha coefficients values: 0.80-0.86. Results indicate that the children's parents rate as moderately helpful the Support (2.23, ± 0.60) and Family (2.17, ± 0.55) styles. Parents rated the Medical style as least helpful in coping (1.75, ± 0,59).

CONCLUSIONS

This study confirms both the accuracy and the reliability of the CHIP test, and the obtained coefficient values indicate that the tool can be used for individual and for scientific research.

PRACTICE IMPLICATIONS

The study shows that assessment of the manner of a parent's coping with the illness of a child is influenced by the child's gender and place of residence.

Investigating the use of physical restraint of children in emergency departments: A Scandinavian survey

AIM

The aim of the study is to describe the current frequency of physical restraint and the use of analgesics and sedatives for treating pediatric pain in emergency departments (EDs) in Scandinavia.

METHODS

We performed a nation-wide electronic survey asking nurses in the emergency departments in Denmark, Norway, and Sweden about their experience treating children in pain.

RESULTS

Responses from 103 Danish, Norwegian and Swedish nurses were included (79% response rate). Physical restraint was reported used at 79% [70.0-85.9] (N = 78) of the surveyed departments (DK: 96%, NO: 67%, SE: 77%) with two participants reporting daily use of physical restraint. Paracetamol was available at all departments and used most frequently. Sedation was available at 88% [78.8-92.0] of the departments with midazolam as the most recurrent sedative (83%, [74.8-89.4]). Seventy-three percent of respondents reported a need for better treatments. Lack of education was the most frequently reported obstacle for providing both pain treatment (29%) and sedation (43%) followed by lack of guidelines.

CONCLUSION

Physical restraint of children during painful procedures is used in the majority of Scandinavian emergency departments (79%). There appears to be a lack of local guidelines for both pain treatment and sedation.

Effect of Distraction Intervention for Needle-Related Pain and Distress in Children: A Systematic Review and Meta-Analysis

A systematic review and meta-analysis conducted to evaluate the combined effect of distraction intervention for needle-related pain in order to provide the basis for developing an effective nursing intervention for children. We searched three electronic databases, PubMed, Embase, and CINAHL, for original articles published in the period from 1 January 2011 to 31 July 2019. In addition, a manual search was performed on the basis of references in the literature and the references of the articles in pursuit of comprehensive data until 10 December 2019. Meta-analysis was performed by the synthesis of the effect size, homogeneity, heterogeneity, and trim-and-fill method using MIX 2.0 Pro. Well-planned RCTs, single-center studies, high-quality studies, participants older than 10 years of age, and visual and clown distraction interventions were effective for needle-related pain and distress management among children. The results showed evidence supporting the effect of distraction interventions for children’s needle-related pain and distress. Through this review, strategies were identified to design better interventions to improve the outcomes.

Pediatric Postoperative Pain Management in Korea: Parental Attitudes Toward Pain and Analgesics, Self-Efficacy, and Pain Management

PURPOSES

This study aimed to explore parental attitudes toward children's pain and analgesic drugs and parental self-efficacy and use of pain relief strategies in children's postoperative pain management in Korea, and to identify the relationships among these variables.

DESIGN AND METHODS

A cross sectional descriptive study was conducted. Participants were 124 parents of hospitalized children (aged 4-9 years) undergoing tonsillectomy in Korea.

RESULTS

A considerable proportion of parents held misconceptions about how children express pain. For example, 87.9% of parents perceived that children always tell their parents when they are in pain. Moreover, parents reported significant attitudinal barriers to analgesic use with 60.5% of parents believed that side effects are something to worry about when giving children pain medication. Parental attitudes to use analgesics were significantly different by children's gender, family income, and length of hospital stay. Emotional support methods such as touch, parental presence, and comfort/reassurance were the frequently used, whereas cognitive-behavioral approaches such as distraction were less frequently used nonpharmacological pain relief strategies. A parent's self-efficacy in managing children's pain significantly correlated with the appropriate use of analgesics and parental use of pain relief strategies.

CONCLUSIONS

Promoting parental self-efficacy in postoperative pain management is important. Educational interventions focused on behavioral changes of parents, including practical guidance for pharmacological and nonpharmacological pain relief strategies, are needed.

PRACTICE IMPLICATIONS

Providing parents with proper, effective education about children's postoperative pain management should not only provide accurate information but should also enhance parents' self-efficacy in assessing and managing children's pain.

Analgesic effects of breast- and formula feeding during routine childhood immunizations up to 1 year of age

BACKGROUND

Data on analgesic effects of breast/formula milk sucking while receiving routine childhood immunizations are available only in early infancy, have rarely been compared in the same study, and are not accompanied by information on mothers' satisfaction/acceptance. Here we aimed to compare the analgesic effect of both methods vs. held-only controls up to 1 year of age, and verify mothers' satisfaction.

METHODS

Two to 12 months children subjected to vaccine were allocated into three groups: breastfed, formula-fed, and held-only controls. A video recording was performed to analyze pain parameters: crying latency/duration and specific scales [FLACC (Face, Legs, Activity, Cry, and Consolability), NIPS (Neonatal Infant Pain Scale)]. After the procedure, mothers filled in a satisfaction questionnaire.

RESULTS

One-hundred and sixty-two children were recruited: 54 breastfed, 35 formula fed, and 73 controls. Breastfed showed the longest crying latency, and together with formula fed, had the shortest duration and lowest pain scores. Most mothers appreciated not only the respective feeding-mediated pain mitigation method used, but also the simply-holding procedure. In all cases, they felt reassured, with an unexpected frequent underestimation of their child's pain during the shot.

CONCLUSIONS

The analgesic effect of breastfeeding during vaccination extends also to children >6 months old, and is obtained by formula too. Embracing the child may help to reassure mothers.

IMPACT

We confirmed the analgesic effect of breastfeeding during the vaccination procedures in early infancy. We show for the first time that this effect is extended also to children up to 1 year of age, and it may be obtained by formula feeding as well. Most mothers appreciated pain mitigation not only through feeding, but also the simply-holding procedure. In all cases, mothers felt reassured, with an unexpected frequent underestimation of their child' pain during the shot. The promotion of these easily feasible and well-accepted strategies should be further encouraged within health professionals during vaccination procedures.

Management of Procedural Pain in Children

In recent years, there has been increased interest in the study of pain in children and its treatment. It is known that when facing diagnostic and therapeutic procedures similar to those performed on adults, children either do not receive specific pain treatment or receive it on a significantly lower scale. However, recent research suggests a change in attitude and an improvement in the current treatment of children's pain. Although current knowledge demonstrates the falsity of many preconceived ideas about pain and its management, our results suggest that attitudinal change towards childhood pain remains slow and that real improvement in the training and practical application of the pediatrician who has to treat childhood pain is urgently needed. In this context, this manuscript has prepared standards and guidelines to improve pain management practices in a large number of national and international professional settings.

[An Integrative Literature Review on Pain Alleviation Interventions for Hospitalized Children]

Purpose

The purpose of this study was to review pain alleviation intervention for Korean pediatric inpatients with reference to Kolcaba's Theory of Comfort.

Methods

Whittemore and Knafl's integrative review methods were used. Articles published in Korean or English were identified through electronic search engines and scholarly web sites. Scientific, peer-reviewed articles published between 2006 and 2019 were included in this review. Twenty-seven articles that met the inclusion criteria were analyzed.

Results

Among the 27 selected studies, three were descriptive, while 24 were interventional studies related to pain alleviation interventions. Pain alleviation interventions showed three attributes: identifying pain triggers and the child's response to pain, effective strategies for pain relief, and nurses' competence in pain management.

Conclusion

The three attributes of pain alleviation interventions using the theory of comfort shown in this study were identified as important factors for obtaining evidence-based data on how to enhance the comfort of hospitalized pediatric patients. In addition, the attributes of pain alleviation interventions should be considered for hospitalized pediatric patients and their family members.

Opioids: A Review of Pharmacokinetics and Pharmacodynamics in Neonates, Infants, and Children

Pain management in the pediatric population is complex for many reasons. Mild pain is usually managed quite well with oral acetaminophen or ibuprofen. Situations involving more severe pain often require the use of an opioid, which may be administered by many different routes, depending on clinical necessity. Acute and chronic disease states, as well as the constantly changing maturational process, produce unique challenges at every level of pediatrics in dosing and management of all medications, especially with regard to high-risk opioids. Although there has been significant progress in the understanding of opioid pharmacokinetics and pharmacodynamics in neonates, infants, children, and adolescents, somewhat limited data exist from which necessary information, concerning the safe and effective use of these agents, may be drawn. The evidence here provided is intended to be helpful in directing the practitioner to patient-specific reasons for preferring one opioid over another. As our knowledge of opioids and their effects has grown, it has become clear that older medications like codeine and meperidine (pethidine) have very limited use in pediatrics. This review provides pharmacokinetic and pharmacodynamic evidence on the currently available opioids: morphine, fentanyl (and derivatives), codeine, meperidine, oxycodone, hydrocodone, hydromorphone, methadone, buprenorphine, butorphanol, nalbuphine, pentazocin, ketobemidone, tramadol, piritramide, naloxone and naltrexone. Morphine, being the most studied opioid analgesic, is the standard against which all others are compared. Pharmacokinetic parameters of morphine that have been found in neonates, i.e., higher volume of distribution, immature metabolic processes that develop at various rates, elimination that is variable based on age and weight, as well as treated and untreated disease processes, are an example of all opioids in the population discussed in this review. Outside the premature and neonatal population, the use of opioids in infants, children, and adolescents quickly begins to resemble the established values found in adults. As such, the concerns (risks) of these medications become comparable to those seen in adults.

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.

Flexible Bronchoscopy Under Bronchoscopist-Administered Moderate Sedation Versus General Anesthesia: A Comparative Study in Children

Background: Flexible bronchoscopy (FB) can be performed under bronchoscopist administered moderate sedation (BAMS) with a midazolam/fentanyl combination or general anesthesia (GA). However, the outcome of BAMS has not been well established in children. Currently, most of the centers prefer FB under GA. Both techniques have their advantages and disadvantages with implications for safety, complications, and diagnostic yield. The primary objective of our study was to evaluate the safety, time efficiency, and cost-effectiveness of FB under BAMS as compared with FB under GA in a similar setting. Methods: We performed a retrospective chart review to compare BAMS versus GA for FB in children. We recruited BAMS children (n = 295) from University of Florida (UF) Health Shands Children's Hospital, and GA children (n = 100) from Penn State Children's Hospital (PSHCH). Both the groups had similar indications, complexities, and procedural environments. Comparisons of various time-intervals including preprocedure time, sedation-induction time, scope time, and post-procedure time among different BAMS versus GA age-groups were the primary outcomes. The secondary outcomes were the determination of the rates of complications, the dosages of sedative/anesthetic, cost-effectiveness, and sedation patterns under BAMS. Results: FB under BAMS required significantly higher preprocedure times and sedation-induction times (P < 0.001** and P < 0.001** respectively) but shorter scope and post-procedure times compared with the GA group times (P < 0.001** and P < 0.001** respectively). Younger children had a deeper level of sedation for an extended period under BAMS. The costs for the sedation services and the complication rates were lower in the BAMS group compared with the GA group. Conclusion: Our study demonstrated the feasibility of BAMS in children. FB under BAMS had an advantage of lower cost and fewer procedural complications compared with FB under GA. Despite that, the safety of BAMS could not be conclusively established from this retrospective study. Moreover, BAMS can potentially compromise the diagnostic yield because the bronchoscopist is also responsible for monitoring sedation and managing the airway.

Evaluating comfort measures for commonly performed painful procedures in pediatric patients

Introduction

Management of pediatric pain from medical procedures is of great importance for improving both patient care and experience. In this study, we investigated methods of managing acute pain in infants and children by studying the correlation between the number of attempts to complete painful procedures, given different comfort measures.

Methods

The study is a retrospective review of 74,276 procedures performed at two pediatric hospitals in an integrated academic children’s health system between 2013 and 2016. We compared three comfort measures most frequently offered: positions of comfort (POC), distraction (DIST), and pharmacological (PHARM). These methods were compared in the setting of four procedures: peripheral intravenous (PIV) catheter insertion, gastrointestinal tube placement, incision procedures, and bladder catheterization. We used the number of attempts needed to complete a procedure as a measure of efficacy minimizing distressing experience in an acutely painful setting (single attempt vs repeat attempts).

Results

Among younger children, DIST appears superior to the other two methods; it performs significantly better for three of the four procedures (PIV catheterization, incision wound, and urinary catheterization) among infants aged <1 year and for PIV catheterization among toddlers aged 1–3 years. For older children, POC tends to perform slightly better than the other two methods, although it is significantly better only for PIV catheterization among adolescents aged 13–21 years and urinary catheterization among children aged 9–12 years.

Conclusion

Results from this study may be used to determine appropriate comfort measures for painful procedures in pediatric setting.

A prospective audit of pain profiles following general and urological surgery in children

BACKGROUND

Postoperative pain is frequently undertreated in children both in hospital and at home following discharge. Pain has both short- and long-term consequences for children, their families, and the healthcare system. A greater understanding of procedure-specific postoperative pain trajectories is required to improve pain management.

AIM

To determine the duration and severity of acute postoperative pain experienced by children undergoing 8 different general and urological procedures (primary outcomes). Behavioral disturbance rates, nausea and vomiting scores, and parental satisfaction were also examined during the follow-up period (secondary outcomes).

METHOD

Families of children (0-18 years) undergoing common general and urological procedures were invited to enroll in the study. Children's pain scores, measured using a parental proxy 0-10 numerical rating scale, were collected by telephone interview until pain was resolved. Analgesia prescribed and given, behavioral disturbance, nausea and vomiting scores, the method of medication education communication, and parental satisfaction were also measured.

RESULTS

Of 360 patients recruited, 326 complete datasets were available. Patients underwent laparoscopic appendicectomy (57), open appendicectomy (19), circumcision (50), cystoscopy (52), hypospadias repair (22), inguinal hernia repair (51), orchidopexy (51), or umbilical hernia repair (24). Postoperative pain peaked on the day of or the day after surgery in all groups, and decreased over time. Pain lasted a median duration of 5 postoperative days following open appendicectomy, and 0-2 postoperative days for other procedures. Behavioral disturbance rates closely followed pain scores. Analgesia administration at home varied widely between and within groups.

CONCLUSION

Pain management was inadequate in most of the groups studied, particularly after appendicectomy or umbilical hernia repair, with most children experiencing at least moderate pain on the day of and day after surgery. There was a need for a standardized management, with increased dual analgesia prescribing, to ensure that children receive adequate postoperative analgesia in hospital and at home.

Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System

Pain is a frequent and significant problem for children with impairment of the central nervous system, with the highest frequency and severity occurring in children with the greatest impairment. Despite the significance of the problem, this population remains vulnerable to underrecognition and undertreatment of pain. Barriers to treatment may include uncertainty in identifying pain along with limited experience and fear with the use of medications for pain treatment. Behavioral pain-assessment tools are reviewed in this clinical report, along with other strategies for monitoring pain after an intervention. Sources of pain in this population include acute-onset pain attributable to tissue injury or inflammation resulting in nociceptive pain, with pain then expected to resolve after treatment directed at the source. Other sources can result in chronic intermittent pain that, for many, occurs on a weekly to daily basis, commonly attributed to gastroesophageal reflux, spasticity, and hip subluxation. Most challenging are pain sources attributable to the impaired central nervous system, requiring empirical medication trials directed at causes that cannot be identified by diagnostic tests, such as central neuropathic pain. Interventions reviewed include integrative therapies and medications, such as gabapentinoids, tricyclic antidepressants, α-agonists, and opioids. This clinical report aims to address, with evidence-based guidance, the inherent challenges with the goal to improve comfort throughout life in this vulnerable group of children.

Management of acute pediatric pain in the emergency department

PURPOSE OF REVIEW

This article provides a summary of recommendations for the multimodal and multidisciplinary approach to acute pediatric pain management and highlights recent research on this topic.

RECENT FINDINGS

Recent literature has focused on updating recommendations for the use of various analgesics in the pediatric population. While codeine is no longer recommended due to increasing evidence of adverse effects, the more liberal use of intranasal fentanyl is now encouraged because of the ease of administration and rapid delivery. The evidence base for the use of ultrasound-guided regional nerve blocks by qualified providers in the acute pediatric pain setting continues to grow.

SUMMARY

The pediatric emergency medicine provider should be able to assess pain and develop individualized pain plans by utilizing a range of nonpharmacologic and pharmacologic strategies. Knowledge of the most recent literature and changes in recommendations for various pain medications is essential.

Nationwide study of headache pain in Italy shows that pain assessment is still inadequate in paediatric emergency care

Aim

Italian national guidelines on pain management were published in 2010, but there is little information on how effective pain management is in paediatric emergency care, with other countries reporting poor levels. Using headache as an indicator, we described pain assessment in Italian emergency departments and identified predictors of algometric scale use.

Methods

All Italian paediatric and maternal and child hospitals participated, plus four general hospitals. Data on all children aged 4–14 years admitted during a one‐month period with headache as their chief complaint were abstracted from clinical records. Multivariable analyses identified predictors of algometric assessment, taking into account the cluster study design.

Results

We studied 470 admissions. During triage, pain was assessed using a standardised scale (41.5%), informally (15.5%) or was not recorded (42.9%). Only 32.1% of the children received analgesia in the emergency department. The odds ratios for predictors of algometric assessment were non‐Italian nationality (3.6), prehospital medication (1.8), admission to a research hospital (7.3) and a more favourable nurses‐to‐admissions ratio of 10.8 for the highest versus lowest tertile.

Conclusion

Despite national guidelines, paediatric pain assessment in Italian emergency care was suboptimal. Hospital variables appeared to be stronger predictors of adequate assessment than patient characteristics.

Improving postoperative pain management in children by providing regular training and an updated pain therapy concept

BACKGROUND

In recent years, children's hospitals have increasingly implemented postoperative pain management protocols to reduce postoperative pain and improve patient satisfaction. The effectiveness and long-term sustainability of such protocols have rarely been studied. Therefore, we conducted a prospective intervention study to assess the impact of regular training and improvement of clinical processes on the quality of postoperative pain management.

METHODS

We conducted an initial assessment of the status quo of postoperative pain management (Audit 1) followed by repeated training and improvement of clinical processes (analgesic pocket card, parents' brochure, modification of the patient chart, bimonthly advanced trainings sessions) and a follow-up review after 3 years (Audit 2). We used a data entry form, a patient survey, and an anonymous questionnaire for the nursing staff as measurement tools.

RESULTS

Our analysis included a total of 93 and 85 patients in the initial and final audits. The return rates of the nursing staff questionnaire were 83% (Audit 1) and 77% (Audit 2). The training and process improvements resulted in significant improvement in the administration of analgesics for pain requiring treatment, the control of pain measurement after the administration of analgesics and the use of non-pharmacological pain therapies. The patients reported faster administration of analgesics for acute pain and improved pain relief following the intervention.

CONCLUSIONS

Repeated training and improvement of clinical processes can significantly improve the long-term quality of postoperative pain management in children with a tolerable amount of effort on the part of health care professionals and institutions.

Procedural pain and patient-reported side effects with weekly injections of subcutaneous methotrexate in children with rheumatic disorders

BACKGROUND

Despite the widespread use of subcutaneous methotrexate in treating pediatric rheumatic disorders, the amount of pain associated with the injections has not been quantified. Our study aims 1) to quantify the amount of pain associated with subcutaneous injections of methotrexate, 2) to explore predictors of pain, 3) to determine the frequency of patient-reported clinical adverse effects of methotrexate, and 4) identify coping strategies of patients and caregivers.

METHODS

Patients aged 4-17 years with rheumatologic diseases who were receiving weekly subcutaneous methotrexate injections for at least 4 weeks were invited to participate in this prospective cohort study. They were trained to use the Faces Pain Scale-Revised (FPS-R) and Faces, Legs, Arms, Cry, Consolability (FLACC) tools to rate pain associated with the injections. All patients underwent focused interviews exploring their experiences with methotrexate injections.

RESULTS

Forty-one patients consented to the study. The mean age was 11.2 years (SD = 3.9 years) and 68% were female. Most patients were diagnosed with JIA (73%). Mean duration of methotrexate therapy was 2.5 years (SD = 2.1 yrs). All but one of the patients used methotrexate 25 mg/ml solution for injection in 1 cc or 3 cc syringe with 30 gauge ½" needle. Median amount of pain was 2/10 on the FPS-R and 1/10 on the FLACC. Higher intensity of pain was significantly associated with presence of side effects (p = 0.004), but not duration of therapy (p = 0.20) or age (p = 0.24). Most participants (61%) experienced at least one adverse effect; nausea (56%) and vomiting (34%) were the most common symptoms reported. Patients and caregivers reported using ice (34%), comfort positions (51%), rewards (49%), reassurance (54%), distraction (51%), and analgesic medications (22%) to cope with the injections.

CONCLUSION

Subcutaneous injections of methotrexate are associated with a mild amount of pain. Presence of side effects may amplify the amount of perceived pain. Clinicians can apply this knowledge when counseling patients and family members about methotrexate therapy.

Pain management policies and practices in pediatric emergency care: a nationwide survey of Italian hospitals

BACKGROUND

Pain experienced by children in emergency departments (EDs) is often poorly assessed and treated. Although local protocols and strategies are important to ensure appropriate staff behaviours, few studies have focussed on pain management policies at hospital or department level. This study aimed at describing the policies and reported practices of pain assessment and treatment in a national sample of Italian pediatric EDs, and identifying the assocoated structural and organisational factors.

METHODS

A structured questionnaire was mailed to all the 14 Italian pediatric and maternal and child hospitals and to 5 general hospitals with separate pediatric emergency room. There were no refusals. Information collected included the frequency and mode of pain assessment, presence of written pain management protocols, use of local anaesthetic (EMLA cream) before venipuncture, and role of parents. General data on the hospital and ED were also recorded. Multiple Correspondence Analysis was used to explore the multivariable associations between the characteristics of hospitals and EDs and their pain management policies and practices.

RESULTS

Routine pain assessment both at triage and in the emergency room was carried out only by 26% of surveyed EDs. About one third did not use algometric scales, and almost half (47.4%) did not have local protocols for pain treatment. Only 3 routinely reassessed pain after treatment, and only 2 used EMLA. All EDs allowed parents' presence and most (17, 89.9%) allowed them to stay when painful procedures were carried out. Eleven hospitals (57.9%) allowed parents to hold their child during blood sampling. Pediatric and maternal and child hospitals, those located in the North of Italy, equipped with medico-surgical-traumatological ED and short stay observation, and providing full assessment triage over 24 hours were more likely to report appropriate policies for pain management both at triage and in ER. A nurses to admissions ratio ≥ median was associated with better pain management at triage.

CONCLUSIONS

Despite availability of national and international guidelines, pediatric pain management is still sub-optimal in Italian emergency departments. Multifaceted strategies including development of local policies, staff educational programs, and parental involvement in pain assessment should be carried out and periodically reinforced.