Parental administration of analgesic medication in children after a limb injury

Pain management in children and young adults with minor injury in emergency departments in the UK and Ireland: a PERUKI service evaluation

BACKGROUND

Management of acute pain should commence at the earliest opportunity, as it has many short-term and long-term consequences. A research priority of Paediatric Emergency Research in the UK and Ireland (PERUKI) was to examine paediatric pain practices.

OBJECTIVE

To describe the outcomes for paediatric pain management of minor injuries presenting to emergency departments (EDs) across PERUKI.

METHODS

A retrospective service evaluation was performed over a 7-day period in late 2016/early 2017 across PERUKI sites, and analysis performed using an adapted Donabedian framework. Patients under 16 years presenting with minor trauma were eligible, and data were collected on prehospital management, pain assessment, analgesia administered and injury diagnosed.

RESULTS

Thirty-one sites submitted data on 3888 patients. There were 111 missed cases (missed rate 3.6%). The most common injuries were sprains, lacerations, contusions/abrasions and fractures. Documentation of receiving analgesia before arrival in ED occurred in 21% of patients (n=818). A pain assessment was documented in 57.5% of patients (n=2235) during their ED visit, and 3.5% of patients had their pain reassessed (n=138). Of the patients who presented in severe pain (pain score 7-10 or rated severe), 11% were reassessed. Site variability of initial pain assessment ranged from 1.4% to 100% (median 62%). The characteristics of the top quartile performing centres against the bottom quartile performing centres based on completion rate of initial pain scores were identified.

CONCLUSION

Pain assessment was documented in under 60% of children with minor injury, re-assessment of pain was almost completely absent, data and outcomes were missing in a substantial volume of patients, indicating that pain management and the associated outcomes have not been adequately addressed and prioritised within existing network structures and processes.

Management of Pain After Pediatric Trauma

OBJECTIVES

The primary objective of this study was to evaluate the management of pain after traumatic injury in the pediatric emergency department (ED) as measured by time to analgesic administration and pain resolution, stratified by triage acuity level.

METHODS

This is a retrospective descriptive study evaluating the management of children who presented with pain after injury to an urban level 1 trauma center. Consecutive enrollment of 1000 patients identified by ICD-9 codes that included all injuries or external causes for injury (700-999 and all E codes) and who had pain identified by triage pain assessment was performed. For analysis, patients were grouped according to triage level.

RESULTS

Fifty-one percent (511/1000) of patients achieved pain resolution, and an additional 20% (200/1000) of patients had documented improvement in pain score during their ED visit. Triage acuity level 1 group received medications the fastest with a median time of 12 minutes (interquartile range, 10-53 minutes); 65.3% of patients (653/1000) received a pain medication during their ED visit; 54.3% of these patients received oral medications only. Average time to intravenous line placement was 2 hours 35 minutes (SD, 2 hours 55 minutes). Only 1.9% of patients received any medications prior to arrival.

CONCLUSIONS

Higher-acuity patients received initial pain medications and had initial pain score decrease before lower-acuity patients. Given the retrospective nature of the study, we were unable to clearly identify barriers that contributed to delay in or lack of pain treatment in our patient population.

Prehospital Analgesic Administration by Parents for Pain Relief in Children

PURPOSE

Undertreatment of pain by caregivers before presentation to the pediatric emergency department (ED) has been well documented. What has yet to be elucidated are the reasons why caregivers fail to adequately treat pain before arrival in the ED and whether there are differences based on ethnic background or age of the child. The objectives of this study were to determine the barriers to giving pain medication for injuries before ED arrival and to determine if there are any ethnic- or age-related variations to giving pain relief at home.

METHODS

This prospective descriptive study was conducted in the ED at a tertiary care, freestanding children's hospital with a current annual census of approximately 80,000. An anonymous prospective questionnaire was given to caregivers of children between 2 and 17 years of age presenting to the ED between August 2013 and September, 2014. The study population was obtained as a convenience sample. All were self-referred with chief complaints of head, ear, or extremity pain. The questionnaire asked about pain medications and doses given at home as well as the reasons parents gave medication or refused to give pain medication before arrival. Charts were then abstracted to obtain demographic information and care received in the ED.

RESULTS

A total of 154 (45.6%) of the 338 patients enrolled did not receive pain relief before coming to the ED. There were no differences in pain medication received at home based on ethnicity (P = 0.423) or age (P = 0.580). Parents could choose from a list of multiple reasons as to why pain medications were given and/or free text their own answer. The main reasons given by parents were that the accident did not happen at home (28.6%) and that they did not have time to give pain relief before coming to the ED (13%). Other common answers were "had no pain relievers at home" (12.4%) or "afraid it would be wrong/harmful/did not want to mask symptoms" (9.2%). Seventeen parents responded that their child did not complain of pain. Overall, only 28.1% of participants stated lack of pain medications at home.

CONCLUSIONS

In this study, approximately half of all children receive an analgesic for their painful condition before coming to the ED. Continued education regarding pain relief before coming to the ED is needed. Future studies will focus on educating parents to provide analgesia at home.

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.

A Web-based module and online video for pain management education for caregivers of children with fractures: A randomized controlled trial

IntroductionOver 80% of children experience compromise in functioning following a fracture. Digital media may improve caregiver knowledge of managing fracture pain at home.

OBJECTIVES

To determine whether an educational video was superior to an interactive web-based module (WBM) and verbal instructions, the standard of care (SOC).

METHODS

This randomized trial included caregivers of children 0-17 years presenting to the emergency department (ED) with non-operative fractures. Primary outcome was the gain score (pre-post intervention) on a 21-item questionnaire testing knowledge surrounding pain recognition and management for children with fractures. Secondary outcomes included survey of caregiver confidence in managing pain (five-item Likert scale), number of days with difficulty sleeping, before return to a normal diet, and work/school missed.

RESULTS

We analyzed 311 participants (WBM 99; video 108; SOC 104) with a mean (SD) child age of 9.6 (4.2) years, of which 125/311 (40.2%) were female. The video (delta=2.3, 95% CI: 1.3, 3.3; p<0.001) and WBM (delta=1.6; 95% CI: 0.5, 2.6; p=0.002) groups had significantly greater gain scores than the SOC group. The mean video gain score was not significantly greater than WBM (delta=0.7; 95% CI: -0.3, 1.8; p=0.25). There were no significant differences in caregiver confidence (p=0.4), number of absent school days (p=0.43), nights with difficulty sleeping (p=0.94), days before return to a normal diet (p=0.07), or workdays missed (p=0.95).

CONCLUSIONS

A web-based module and online video are superior to verbal instructions for improving caregiver knowledge on management of children's fracture pain without improvement in functional outcomes.

Personal Distress and Sympathy Differentially Influence Health Care Professional and Parents' Estimation of Child Procedure-Related Pain

Objective

Caregivers’ pain estimations may have important implications for pediatric pain management decisions. Affective responses elicited by facing the child in pain are considered key in understanding caregivers’ estimations of pediatric pain experiences. Theory suggests differential influences of sympathy versus personal distress on pain estimations; yet empirical evidence on the impact of caregivers’ feelings of sympathy versus distress upon estimations of pediatric pain experiences is lacking. The current study explored the role of caregiver distress versus sympathy in understanding caregivers’ pain estimates of the child’s pain experience.

Design, Setting, Subjects and Methods

Using a prospective design in 31 children undergoing consecutive lumbar punctures and/or bone marrow aspirations at Ghent University Hospital, caregivers’ (i.e., parents, physicians, nurses, and child life specialists) distress and sympathy were assessed before each procedure; estimates of child pain were obtained immediately following each procedure.

Results

Results indicated that the child’s level of pain behavior in anticipation of the procedure had a strong influence on all caregivers’ pain estimations. Beyond the impact of child pain behavior, personal distress explained parental and physician’s estimates of child pain, but not pain estimates of nurses and child life specialists. Specifically, higher level of parental and physician’s distress was related to higher child pain estimates. Caregiver sympathy was not associated with pain estimations.

Conclusions

The current findings highlight the important role of caregivers’ felt personal distress when faced with child pain, rather than sympathy, in influencing their pain estimates. Potential implications for pain management are discussed.

How Safe Are Common Analgesics for the Treatment of Acute Pain for Children? A Systematic Review

Background. Fear of adverse events and occurrence of side effects are commonly cited by families and physicians as obstructive to appropriate use of pain medication in children. We examined evidence comparing the safety profiles of three groups of oral medications, acetaminophen, nonsteroidal anti-inflammatory drugs, and opioids, to manage acute nonsurgical pain in children (<18 years) treated in ambulatory settings. Methods. A comprehensive search was performed to July 2015, including review of national data registries. Two reviewers screened articles for inclusion, assessed methodological quality, and extracted data. Risks (incidence rates) were pooled using a random effects model. Results. Forty-four studies were included; 23 reported on adverse events. Based on limited current evidence, acetaminophen, ibuprofen, and opioids have similar nausea and vomiting profiles. Opioids have the greatest risk of central nervous system adverse events. Dual therapy with a nonopioid/opioid combination resulted in a lower risk of adverse events than opioids alone. Conclusions. Ibuprofen and acetaminophen have similar reported adverse effects and notably less adverse events than opioids. Dual therapy with a nonopioid/opioid combination confers a protective effect for adverse events over opioids alone. This research highlights challenges in assessing medication safety, including lack of more detailed information in registry data, and inconsistent reporting in trials.

Pain Management of Pediatric Musculoskeletal Injury in the Emergency Department: A Systematic Review

Background. Pain management for children with musculoskeletal injuries is suboptimal and, in the absence of clear evidence-based guidelines, varies significantly. Objective. To systematically review the most effective pain management for children presenting to the emergency department with musculoskeletal injuries. Methods. Electronic databases were searched systematically for randomized controlled trials of pharmacological and nonpharmacological interventions for children aged 0-18 years, with musculoskeletal injury, in the emergency department. The primary outcome was the risk ratio for successful reduction in pain scores. Results. Of 34 studies reviewed, 8 met inclusion criteria and provided data on 1169 children from 3 to 18 years old. Analgesics used greatly varied, making comparisons difficult. Only two studies compared the same analgesics with similar routes of administration. Two serious adverse events occurred without fatalities. All studies showed similar pain reduction between groups except one study that favoured ibuprofen when compared to acetaminophen. Conclusions. Due to heterogeneity of medications and routes of administration in the articles reviewed, an optimal analgesic cannot be recommended for all pain categories. Larger trials are required for further evaluation of analgesics, especially trials combining a nonopioid with an opioid agent or with a nonpharmacological intervention.

Pediatric musculoskeletal pain in the emergency department: a medical record review of practice variation

OBJECTIVE

Musculoskeletal (MSK) injuries are a common, painful pediatric presentation to the emergency department (ED). The primary objective of this study was to describe current analgesic administration practices for the outpatient management of children's MSK pain, both in the ED and postdischarge.

METHODS

We reviewed the medical records of consecutive pediatric patients evaluated in either a pediatric or a general ED (Edmonton, Alberta) during four evenly distributed calendar months, with a diagnosis of fracture, dislocation, strain, or sprain of a limb. Abstracted data included demographics, administered analgesics, pain scores, discharge medication advice, and timing of clinical care.

RESULTS

A total of 543 medical records were reviewed (n  =  468 pediatric ED, n  =  75 general ED). Nineteen percent had documented prehospital analgesics, 34% had documented in-ED analgesics, 13% reported procedural sedation, and 24% documented discharge analgesia advice. Of those children receiving analgesics in the ED, 59% (126 of 214) received ibuprofen. Pain scores were recorded for 6% of patients. At discharge, ibuprofen was recommended to 47% and codeine-containing compounds to 21% of children. The average time from triage to first analgesic in the ED was 121 ± 84 minutes.

CONCLUSIONS

Documentation of the assessment and management of children's pain in the ED is poor, and pain management appears to be suboptimal. When provided, ibuprofen is the most common analgesic used for children with MSK pain. Pediatric patients with MSK pain do not receive timely medication, and interventions must be developed to improve the "door to analgesia" time for children in pain.

Pain management of musculoskeletal injuries in children: current state and future directions

BACKGROUND

Pain is the most common reason for seeking health care in the Western world and is a contributing factor in up to 80% of all emergency department (ED) visits. In the pediatric emergency setting, musculoskeletal injuries are one of the most common painful presentations. Inadequate pain management during medical care, especially among very young children, can have numerous detrimental effects. No standard of care exists for the management of acute musculoskeletal injury-related pain in children. Within the ED setting, pain from such injuries has been repeatedly shown to be undertreated.

OBJECTIVES

Upon completion of this CME article, the reader should be better able to (1) distinguish multiple nonpharmacological techniques for minimizing and treating pain and anxiety in children with musculoskeletal injuries, (2) apply recent medical literature in deciding pharmacological strategies for the treatment of children with musculoskeletal injuries, and (3) interpret the basic principles of pharmacogenomics and how they relate to analgesic efficacy.

RESULTS

Pediatric musculoskeletal injuries are both common and painful. There is growing evidence that, in addition to pharmacological therapy, nonpharmacological methods can be introduced to improve analgesia in the ED and after discharge. Traditionally, acetaminophen with codeine has been used to treat moderate orthopedic injury-related pain in children. Other oral opioids (hydrocodone, oxycodone) are gaining popularity, as well. Current data suggest that ibuprofen is at least as effective as acetaminophen-codeine and codeine alone. Medication compliance might be improved if adverse effects were minimized, and ibuprofen has been shown to have a similar or better adverse effect profile than the oral opioids to which it has been compared. Pharmacogenomic data show that nearly 50% of individuals have at least 1 reduced functioning allele resulting in suboptimal conversion of codeine to active analgesic, so it is not surprising that codeine analgesic efficacy is not optimal. At the same time, nonpharmacological therapies are emerging as commonly used treatment options by parents and adjuncts to analgesic medication. The efficacy and role of techniques (massage, music therapy, transcutaneous electrical nerve stimulation), although promising, require further clarification in the treatment of orthopedic injury pain.

CONCLUSIONS

There is a need to optimize the measurement, documentation, and treatment of pain in children. There is growing evidence that nonpharmacological methods can be introduced to improve analgesia in the ED, and efforts to help parents implement these methods at home might be advantageous to optimize outpatient treatment plans. In pharmacotherapy, ibuprofen has emerged as an appropriate first-line choice for mild-moderate orthopedic pain. Other oral opioids (hydrocodone, oxycodone) are gaining popularity over codeine, because of the current understanding of the pharmacogenomics of such medications.

Presentation, evaluation, and treatment of clavicle fractures in preschool children presenting to an emergency department

Clavicle fractures are a common injury among pediatric patients. Few data exist regarding specific etiologies and their management in the preadolescent patient. Our objective was to determine the specific source of injury and treatment techniques used in the youngest patient population.

METHODS

Study Design. A multicenter retrospective chart review study. Setting. Twenty New Jersey and New York emergency departments from January, 2000 to February, 2007. Subjects. Consecutive patients younger than 2 years with the primary or secondary diagnosis of "clavicle fracture" according to the International Classification of Diseases, Ninth Revision. A manual chart review was performed for specific data points.

RESULTS

Two hundred twenty-eight patients met the inclusion criteria. Complete charts were available for 189 patients: 0 to 6 months (n = 14), 6 to 12 months (n = 41), 12 to 18 months (n = 53), and 18 to 24 months (n = 81). Males comprised 56% of the patients. The 3 most common etiologies of clavicle fractures were as follows: fall from bed/crib, 34%; playful activity, 17%; and fall not otherwise specified (NOS), 16%. Analgesic medications were reported in 32% of children while in the emergency department, and 51% were given a prescription on discharge. The most common immobilization technique was sling in 43% of patients. No immobilization was performed 37% of the time. Two patients (1%) were reported to the Division of Youth and Family Services.

CONCLUSIONS

In the youngest patient population, falling from a crib or bed is the most common etiology of clavicle fractures. Treatment for these injuries was found to be highly variable.

The squeaky wheel gets the grease: parental pain management of children treated for bone fractures

OBJECTIVES

The purpose of this study was to examine parental pharmacological and nonpharmacological pain management practices after extremity fractures.

METHODS

Parents of children aged 5 to 10 years who were diagnosed with a fractured limb and treated in an emergency department were recruited and completed pain records at home for 2 days.

RESULTS

The findings demonstrated that on the day after the fracture, 20% of children received no analgesia and 44% received 1 dose. On day 2, 30% received no analgesia and 37% received 1 dose. The correlation between analgesia and child report of pain increased from day 1 (r = 0.4, P < 0.05) to day 2 (r = 0.52, P < 0.05) as did parental impression that increased from day 1 (r = 0.43, P < 0.05) to day 2 (r = 0.6, P < 0.05). Correlations between pain scores, however, decreased from day 1 (r = 0.6, P < 0.05) to day 2 (r = 0.41, P < 0.05). Although most children received analgesia based on exhibiting active, loud behaviors such as crying (r = 0.63, P < 0.001), children exhibited quiet behaviors more frequently than crying (59.4 % vs. 31.2%, P < 0.001).

CONCLUSIONS

Based on these findings, it was concluded that children received few doses of analgesia at home after a fracture. Although quiet, withdrawn behaviors were exhibited more frequently, parents provided more analgesia if children exhibited active, loud behaviors. Future intervention should be developed to assist parents in recognizing the unique pain cues children exhibit and instructions for safe and effective pain management.

Emergency Department Crowding Is Associated With Poor Care for Patients With Severe Pain

STUDY OBJECTIVE

We study the impact of emergency department (ED) crowding on delays in treatment and nontreatment for patients with severe pain.

METHODS

We performed a retrospective cohort study of all patients presenting with severe pain to an inner-city, teaching ED during 17 months. Poor care was defined by 3 outcomes: not receiving treatment with pain medication while in the ED, a delay (>1 hour) from triage to first pain medication, and a delay (>1 hour) from room placement to first pain medication. Three validated crowding measures were assigned to each patient at triage. Logistic regression was used to test the association between crowding and outcomes.

RESULTS

In 13,758 patients with severe pain, the mean age was 39 years (SD 16 years), 73% were black, and 64% were female patients. Half (49%) of the patients received pain medication. Of those treated, 3,965 (59%) experienced delays in treatment from triage and 1,319 (20%) experienced delays from time of room placement. After controlling for factors associated with the ED treatment of pain (race, sex, severity, and older age), nontreatment was independently associated with waiting room number (odds ratio [OR] 1.03 for each additional waiting patient; 95% confidence interval [CI] 1.02 to 1.03) and occupancy rate (OR 1.01 for each 10% increase in occupancy; 95% CI 0.99 to 1.04). Increasing waiting room number and occupancy rate also independently predicted delays in pain medication from triage (OR 1.05 for each waiting patient, 95% CI 1.04 to 1.06; OR 1.18 for each 10% increase in occupancy; 95% CI 1.15 to 1.21) and delay in pain medication from room placement (OR 1.02 for each waiting patient, 95% CI 1.01 to 1.03; OR 1.06 for each 10% increase in occupancy, 95% CI 1.04 to 1.08).

CONCLUSION

ED crowding is associated with poor quality of care in patients with severe pain, with respect to total lack of treatment and delay until treatment.