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Choueiry J, Chartrand J, Harrison D, Don A. Pain care for children with cognitive impairment: A parent-nurse partnership. J Pediatr Nurs 2024; 77:e139-e149. [PMID: 38599999 DOI: 10.1016/j.pedn.2024.04.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 03/14/2024] [Accepted: 04/01/2024] [Indexed: 04/12/2024]
Abstract
PURPOSE To explore nurses' experiences of establishing partnerships with parents for pain care of hospitalized children with cognitive impairment (CI) and identify related facilitators and barriers. DESIGN AND METHODS In this qualitative, interpretive descriptive study, individual semi-structured interviews were conducted via videoconferencing with pediatric nurses from inpatient wards in a Canadian pediatric quaternary hospital. Verbatim transcripts were analyzed using an inductive, data-driven thematic analysis approach. RESULTS Eleven nurses were interviewed. The overarching theme was Assessing Pain as an Outsider: "A Complete Guessing Game". Seven major themes were identified.: Relying on Parent Expertise for Pain Assessment, Brainstorming with Parents for Pain Treatment, Supporting Parents as Advocates for Pain Care, Individualizing Pain Care with Parents, Involving the Child in Pain Care: A Spectrum, Barriers to Partnership in Pain Care and Facilitators to Partnership in Pain Care. CONCLUSIONS Nurses described the many ways they involve parents as partners in pain care. However, nurses shared strong feelings of uncertainty associated with pain care in children with CI. Consequently, nurses felt the need to rely on parents for appropriately assessing and treating pain in children with CI. Findings highlighted the practice and education gaps that may contribute to nurses' uncertainty and reliance on parents. PRACTICE IMPLICATIONS By identifying related practice and education gaps, healthcare organizations can implement strategies to further support nurses in establishing partnerships and potentially optimize pain care practices.
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Affiliation(s)
- Juliana Choueiry
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada; Children's Hospital of Eastern Ontario, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada.
| | - Julie Chartrand
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; Children's Hospital of Eastern Ontario Research Institute, 401 Smyth Road, Ottawa, Ontario K1H 8L1, Canada
| | - Denise Harrison
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; Department of Nursing, Melbourne School of Health Sciences, The University of Melbourne, 161 Barry Street, Carlton, Victoria 3053, Australia; Murdoch Children's Research Institute, Royal Children's Hospital, 50 Flemington Road, Parkville, Victoria 3053, Australia
| | - Anna Don
- School of Nursing, University of Ottawa, 451 Smyth Road, Ottawa, Ontario K1H 8M5, Canada; Department of Nursing, School of Health, and Community Studies, Algonquin College, 1385 Woodroffe Ave, K2G 1V8 Ottawa, Ontario, Canada
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Sierra-Núñez D, Bosch-Alcaraz A, Falcó-Pegueroles A, Segura-Matute S, García-Godoy C, Otero-Arús C, Corral-Partearroyo C, Zuriguel-Pérez E. Multicenter study. Nursing professionals' perception of training needs in pain assessment in pediatric patients with cognitive dysfunction. ENFERMERIA INTENSIVA 2024; 35:161-170. [PMID: 37968141 DOI: 10.1016/j.enfie.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Pediatric patients with cognitive dysfunction are at greater risk of pain than typically developing children. Pain assessment in these patients is complex and could generate uncertainty in health professionals about what the key aspects are. AIM To determine the training needs perceived by nursing professionals regarding acute pain assessment in pediatric patients with cognitive dysfunction. METHODS A descriptive, cross-sectional, and multicenter study was performed using a survey addressed to nursing professionals who work in pediatrics during the months of August and September 2022. RESULTS 163 responses were obtained. Most of the professionals who responded were female (92.6%, n = 151), with a mean age of 38.98 ± 10.40 years. The most frequent work unit was the pediatric intensive care unit (PICU), in 36% (n = 58). Most of the participants reported not having previously received training on pain assessment in pediatric patients with cognitive disabilities (85.9%, n = 139). However, 70.4% (n = 114) considered it "very necessary" for the development of their work to receive specific training on this topic. Knowing how to assess acute pain in this population (85.3%, n = 139) and knowing the clinical and behavioral manifestations of pain in this type of patient (84.7%, n = 138) were the aspects that obtained higher scores. CONCLUSION This research notes more than 90% of participants consider "quite necessary" and "strong necessary" to be training in pediatric cognitive dysfunction patients pain assessment. Furthermore, work experience, academic education and to be pediatric specialist obtain statistical significance data.
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Affiliation(s)
| | - A Bosch-Alcaraz
- Departamento de Enfermería de Salud Pública, Salud Mental y Maternoinfantil, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain
| | - A Falcó-Pegueroles
- Departamento de Enfermería Fundamental y Médico Quirúrgica, Escuela de Enfermería, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, Spain
| | - S Segura-Matute
- Unidad de Cuidados Intensivos Pediátrica, Hospital Sant Joan de Deú, Barcelona, Spain
| | - C García-Godoy
- Uriach Consumer Healthcare, Sant Cugat del Vallès, Barcelona, Spain
| | - C Otero-Arús
- Unidad de Cuidados Intensivos Pediátrica, Hospital Sant Joan de Deú, Barcelona, Spain
| | - C Corral-Partearroyo
- Health Technology Assessment in Primary Care and Mental Health (PRISMA) Research Group, Teaching, Research & Innovation Unit, Parc Sanitari Sant Joan de Déu, Barcelona, Spain
| | - E Zuriguel-Pérez
- Investigación en Enfermería, Grupo de Investigación Multidisciplinar de Enfermería, Hospital Universitario Vall Hebrón, Barcelona, Spain
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Rowe S, Best KM. Individualized Numeric Rating Scale to Assess Pain in Critically Ill Children With Neurodevelopmental Disabilities. Am J Crit Care 2024; 33:280-288. [PMID: 38945815 DOI: 10.4037/ajcc2024343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/02/2024]
Abstract
BACKGROUND Pain is a significant burden for children with neurodevelopmental disabilities but is difficult for clinicians to identify. No pain assessment tools for children with neurodevelopmental disabilities have been validated for use in pediatric intensive care units. The Individualized Numeric Rating Scale (INRS) is an adapted 0-to-10 rating that includes parents' input on their child's pain indicators. OBJECTIVES To evaluate the reliability, validity, and feasibility and acceptability of use of the INRS for assessing pain in critically ill children with neurodevelopmental disabilities. METHODS This observational study enrolled critically ill patients with neurodevelopmental disabilities aged 3 to 17 years in 2 pediatric intensive care units at a children's hospital using a prospective repeated-measures cohort design. Structured parent interviews were used to populate each patient's INRS. Bedside nurses assessed pain using the INRS throughout the study. The research team completed independent INRS ratings using video clips. Participating parents and nurses completed feasibility and acceptability surveys. Psychometric properties of the INRS and survey responses were evaluated with appropriate statistical methods. RESULTS For 481 paired INRS pain ratings in 34 patients, interrater reliability between nurse and research team ratings was moderate (weighted κ = 0.56). Parents said that creating the INRS was easy, made them feel more involved in care, and helped them communicate with nurses. CONCLUSIONS The INRS has adequate measurement properties for assessing pain in critically ill children with neurodevelopmental disabilities. It furthers goals of patient- and family-centered care but may have implementation barriers.
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Affiliation(s)
- Shaneel Rowe
- Shaneel Rowe is a study coordinator, Clinical Research Support Office, Children's Hospital of Philadelphia, Penn-sylvania
| | - Kaitlin M Best
- Kaitlin M. Best is a nurse practitioner, Cardiac Critical Care Unit, the Hospital for Sick Children, Toronto, Ontario, Canada
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Oulton K, Gibson F, Kenten C, Russell J, Carr L, Hassiotis A, Kelly P, Kerry S, Tuffrey-Wijne I, Whiting M, Wray J. Being a child with intellectual disabilities in hospital: The need for an individualised approach to care. JOURNAL OF APPLIED RESEARCH IN INTELLECTUAL DISABILITIES 2024; 37:e13153. [PMID: 37792824 DOI: 10.1111/jar.13153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 08/08/2023] [Accepted: 08/13/2023] [Indexed: 10/06/2023]
Abstract
BACKGROUND There is limited qualitative research focussed specifically on what it is like for children and young people with intellectual disabilities coming into hospital, with much of the evidence-base being about those with Autism Spectrum Condition or adults with intellectual disabilities. AIM To share rich detail of the emotional and physical impact on children and young people with intellectual disabilities of attending hospital, from their own and their parent's perspective. METHODS Talking Mats interviews, sticker survey and photography with children and young people with intellectual disabilities, and in-depth interviews, hospital diaries and photography with their parents. RESULTS AND CONCLUSIONS The multiple and compounding layers of complexity surrounding hospital care of children and young people with intellectual disabilities resulted in challenges associated with loss of familiarity and routine, undergoing procedures, managing sensory overload, managing pain and having a lack of safety awareness. An individualised approach to their care is needed.
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Affiliation(s)
- Kate Oulton
- School of Health Sciences, University of Surrey, Guildford, UK
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Faith Gibson
- School of Health Sciences, University of Surrey, Guildford, UK
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Charlotte Kenten
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jessica Russell
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Lucinda Carr
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Angela Hassiotis
- UCL Division of Psychiatry, University College London, London, UK
| | - Paula Kelly
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Sam Kerry
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | - Mark Whiting
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hertfordshire, UK
| | - Jo Wray
- Centre for Outcomes and Experience Research in Children's Health, Illness and Disability, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
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Alzubaidi MA, Drummond BK, Wu J, Jones A, Tahmassebi JF, Aggarwal VR. Predictors of Intra-Operative and Post-Operative Pain Associated with Routine Dental Procedures in Children: A Systematic Review and Meta-Analysis. Dent J (Basel) 2023; 12:4. [PMID: 38248212 PMCID: PMC10814801 DOI: 10.3390/dj12010004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 12/18/2023] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Background: Understanding predictors of pain associated with paediatric dental procedures could play an important role in preventing loss of cooperation, which often leads to the procedure having to be performed under general anaesthesia. Aim: We aimed to identify predictors of intra-operative and post-operative pain associated with routine dental procedures in children. Materials and Methods: A systematic review of observational studies was performed using electronic searches on MEDLINE, EMBASE, PsycINFO, Global Health via OVID, PubMed, Scopus, and SciELO. The NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to evaluate the quality of the included studies, which were meta-analysed to estimate the impact of dental procedures and anxiety on children's pain perception. A meta-regression analysis was also performed to determine the relative effect of predictors on children's pain perception measured as mean differences on a visual analogue scale (VAS). Results: The search identified 532 articles; 53 were retrieved for full-text screening; 6 studies were included in the review; and 4 were eligible for the meta-analysis. The meta-analysis showed the types of procedures that predicted intra-operative pain, with dental extractions being the most painful (Mean VAS Difference [MD] 46.51 mm, 95% confidence interval [CI] 40.40 to 52.62 mm). The meta-regression showed that pain scores for dental extractions were significantly higher than polishing (the least painful procedure (reference category)) by VAS MD = 23.80 mm (95% CI 5.13-42.46 mm, p-value = 0.012). It also showed that highly anxious children reported significantly higher pain scores during dental procedures by a 12.31 mm MD VAS score (95% CI 5.23-19.40 mm, p-value = 0.001) compared to those with low anxiety levels. Conclusions: This systematic review demonstrates that the strongest predictors of intra-operative pain associated with paediatric dental procedures are dental extractions followed by drilling. Children with high anxiety also reported more pain for similar procedures. Tailoring interventions to reduce pain associated with paediatric dental procedures should be a priority for future research, as reducing pain can impact compliance and could reduce the need for general anaesthesia in dental treatment.
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Affiliation(s)
- Mohammed A. Alzubaidi
- Department of Preventive Dentistry, Faculty of Dentistry, Taif University, P.O. Box 11099, Taif 21944, Saudi Arabia;
| | - Bernadette K. Drummond
- Faculty of Medicine & Health, School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; (B.K.D.); (J.W.); (J.F.T.)
| | - Jianhua Wu
- Faculty of Medicine & Health, School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; (B.K.D.); (J.W.); (J.F.T.)
| | - Adam Jones
- Faculty of Medicine & Health, School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; (B.K.D.); (J.W.); (J.F.T.)
| | - Jinous F. Tahmassebi
- Faculty of Medicine & Health, School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; (B.K.D.); (J.W.); (J.F.T.)
| | - Vishal R. Aggarwal
- Faculty of Medicine & Health, School of Dentistry, University of Leeds, Leeds LS2 9JT, UK; (B.K.D.); (J.W.); (J.F.T.)
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Keane OA, Ourshalimian S, Odegard M, Goldstein RY, Andras LM, Kim E, Kelley-Quon LI. Prescription Opioid Use for Adolescents With Neurocognitive Disability Undergoing Surgery: A Pilot Study. J Surg Res 2023; 291:237-244. [PMID: 37478647 PMCID: PMC10578681 DOI: 10.1016/j.jss.2023.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Revised: 05/17/2023] [Accepted: 06/12/2023] [Indexed: 07/23/2023]
Abstract
INTRODUCTION Parents frequently report retaining unused opioid pills following their child's surgery due to fear of untreated postoperative pain. Assessment of pain in adolescents with neurocognitive disability is challenging. We hypothesized that parents of adolescents with neurocognitive disability may report less opioid use and higher opioid pill retention. METHODS Adolescents (13-20 y) undergoing elective surgery (posterior spinal fusion, hip reconstruction, arthroscopy, tonsillectomy) were prospectively enrolled from a tertiary children's hospital from 2019 to 2020. Only adolescents prescribed opioids at discharge were included. Parents completed a preoperative survey collecting sociodemographic characteristics and two postoperative surveys at 30- and 90-d. Neurocognitive disability was determined at time of enrollment by caregiver report, and included adolescents with cerebral palsy, severe autism spectrum disorder, and discrete syndromes with severe neurocognitive disability. RESULTS Of 125 parent-adolescent dyads enrolled, 14 had neurocognitive disability. The median number of opioid pills prescribed at discharge did not differ by neurocognitive disability (29, interquartile range {IQR}: 20.0-33.3 versus 30, IQR: 25.0-40.0, P = 0.180). Parents of both groups reported similar cumulative days of opioid use (7.0, IQR: 3.0-21.0 versus 6.0, IQR:3.0-10.0, P = 0.515) and similar number of opioid pills used (4, IQR: 2.0-4.5 versus 12, IQR: 3.5-22.5, P = 0.083). Parents of both groups reported similar numbers of unused opioid pills (17, IQR: 12.5-22.5 versus 19, IQR: 8.0-29.0, P = 0.905) and rates of retention of unused opioids (15.4% versus 23.8%, P = 0.730). CONCLUSIONS The number of opioid pills prescribed did not differ by neurocognitive disability and parents reported similar opioid use and retention of unused opioid pills. Larger studies are needed to identify opportunities to improve postoperative pain control for children with neurocognitive disability.
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Affiliation(s)
- Olivia A Keane
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California.
| | - Shadassa Ourshalimian
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California
| | - Marjorie Odegard
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Rachel Y Goldstein
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Lindsay M Andras
- Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Jackie and Gene Autry Orthopedic Center, Children's Hospital Los Angeles, Los Angeles, California
| | - Eugene Kim
- Division of Pain Medicine, Children's Hospital Los Angeles, Los Angeles, California
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, California; Department of Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California; Department of Population and Public Health Sciences, Keck School of Medicine of University of Southern California, Los Angeles, California
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Arabiat D, Mörelius E, Hoti K, Hughes J. Pain assessment tools for use in infants: a meta-review. BMC Pediatr 2023; 23:307. [PMID: 37337167 DOI: 10.1186/s12887-023-04099-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 05/28/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Identifying pain in infants is challenging due to their inability to self-report pain, therefore the availability of valid and reliable means of assessing pain is critical. OBJECTIVE This meta-review sought to identify evidence that could guide the selection of appropriate tools in this vulnerable population. METHODS We searched Scopus, Medline, Embase, CINAHL, MIDRIS, EMCare and Google Scholar for eligible systematic reviews. Eligible reviews documented psychometric properties of available observational tools used to assess pain in infants. RESULTS A total of 516 reviews were identified of which 11 met our inclusion criteria. We identified 36 pain assessment tools (evaluated in 11 reviews) of which seven were reported in at least three reviews. The level of evidence reported on the psychometric properties of pain assessment tools varied widely ranging from low to good reliability and validity, whilst there are limited data on usability and clinical utility. CONCLUSIONS Currently, no observer administered pain assessment tool can be recommended as the gold standard due to limited availability and quality of the evidence that supports their validity, reliability and clinical utility. This meta-review attempts to collate the available evidence to assist clinicians to decide on what is the most appropriate tool to use in their clinical practice setting. It is important that researchers adopt a standard approach to evaluating the psychometric properties of pain assessment tools and evaluations of the clinical utility in order that the highest level of evidence can be used to guide tool selection.
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Affiliation(s)
- Diana Arabiat
- Maternal and Child Nursing Department, Faculty of Nursing, The University of Jordan, Amman, Jordan.
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia.
| | - Evalotte Mörelius
- School of Nursing and Midwifery, Edith Cowan University, Joondalup, Western Australia, Australia
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Kreshnik Hoti
- Faculty of Medicine, University of Prishtina, Pristina, Kosovo
| | - Jeffery Hughes
- Curtin Medical School, Faculty of Health Sciences, Curtin University, Bentley, WA, Australia
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Freedman Z, AuBuchon J, Montana M. A single-center descriptive account of the use of pectoral nerve I and II nerve blocks for post-operative pain relief following pediatric sternotomy. PAEDIATRIC & NEONATAL PAIN 2023; 5:16-22. [PMID: 36911785 PMCID: PMC9997121 DOI: 10.1002/pne2.12092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 10/05/2022] [Accepted: 11/11/2022] [Indexed: 12/12/2022]
Abstract
Regional anesthesia between the pectoralis major and minor was first described in 2011 as an alternative method to paravertebral blocks or epidurals for post-operative mastectomies. Since then, the use of pectoral nerve (PECS) blocks for post-operative pain management following thoracotomy, sternotomy, and other procedures in the anterior thorax has increased. While experience with this block is growing, the current understanding of its use in pediatric patients is limited. We reviewed pediatric cases at a single institution and provide a descriptive account of our use of PECS I and II blocks for post-operative pain management following operations involving sternotomy in pediatric patients. We performed a retrospective database analysis of the use of PECS I and II blocks following procedures requiring sternotomy from 2018 to 2021 at St. Louis Children's Hospital. Patients 21 years old and younger who received either a PECS I or II block following a sternotomy for a cardiac procedure were included in the analysis. Patient's demographics, pre-, intra-, and post-operative medications, operative time, extubation status, pain evaluations, and hospital course were assessed from the electronic medical record. From 2018 to 2021, 73 ultrasound-guided PECS blocks were performed for pain relief for pediatric sternotomy. The most commonly performed operations were atrial septal defect closure (n = 12), mitral valve repair (n = 8), and ventricle septal defect closure (n = 8). Out of the 73 patients, 47 received a PECS I block and 26 received a PECS II Block. 70 of the blocks were administered after closure of the sternum while 3 were done before incision. The time to perform blocks took on average of 6 (±4) min. Mean operating room time was 7.5 h. Local anesthetics used for the blocks were as follows: Ropivacaine 0.2% (n = 54), Ropivacaine 0.5% (n = 18), and Bupivacaine 0.25% (n = 1). Twenty-five out of 73 patients did not experience severe pain, defined as ≥7/10 on a numeric pain scale, at any point in the first 24 h following surgery. We describe the of use PECS I and II nerve block following pediatric sternotomy. Blocks were straight forward to perform, and typically took a short amount of time to administer (6 min), when compared to the total operating room time (7.5 h). While this study did not include a comparative group that did not receive a block, 34 percent of patients did not suffer from severe pain in the first 24 h following surgery. Further prospective studies are needed to assess the effectiveness of PECS blocks for pain relief following sternotomy in pediatric patients when compared to current standard of care. PECS blocks may be beneficial for a range of cardiac surgeries that typically result in severe postoperative pain.
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Affiliation(s)
| | - Jacob AuBuchon
- Department of Anesthesiology Washington University in St. Louis and St. Louis Children's Hospital St. Louis Missouri USA
| | - Michael Montana
- Department of Anesthesiology Washington University in St. Louis and St. Louis Children's Hospital St. Louis Missouri USA
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Abstract
This clinical report provides pediatricians evidence-based information on the developmentally appropriate, comprehensive clinical care for hospitalized adolescents. Included in this report are opportunities and challenges facing pediatricians when caring for specific hospitalized adolescent populations. The companion policy statement, “The Hospitalized Adolescent,” includes detailed descriptions of adolescent hospital admission demographics, personnel recommendations, and hospital setting and design advice, as well as sections on educational services, legal and ethical matters, and transitions to adult facilities.
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Sierra-Núñez D, Zuriguel-Pérez E, Bosch-Alcaraz A. Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review. Dev Med Child Neurol 2022; 64:1085-1095. [PMID: 35490248 DOI: 10.1111/dmcn.15259] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 02/20/2022] [Accepted: 04/04/2022] [Indexed: 01/13/2023]
Abstract
AIM To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity. METHOD The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years. RESULTS Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale. INTERPRETATION The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment. WHAT THIS PAPER ADDS Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.
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Affiliation(s)
- Débora Sierra-Núñez
- Paediatric Surgery Unit, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Esperanza Zuriguel-Pérez
- Department of Knowledge Management and Evaluation, Vall d'Hebron University Hospital, Barcelona, Spain.,Multidisciplinary Nursing Research Group, Vall d'Hebron Research Institute, Barcelona, Spain
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Rea BJ, Davison A, Ketcha MJ, Smith KJ, Fairbanks AM, Wattiez AS, Poolman P, Kardon RH, Russo AF, Sowers LP. Automated detection of squint as a sensitive assay of sex-dependent calcitonin gene-related peptide and amylin-induced pain in mice. Pain 2022; 163:1511-1519. [PMID: 34772897 PMCID: PMC9085964 DOI: 10.1097/j.pain.0000000000002537] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 11/03/2021] [Indexed: 11/26/2022]
Abstract
ABSTRACT We developed an automated squint assay using both black C57BL/6J and white CD1 mice to measure the interpalpebral fissure area between the upper and lower eyelids as an objective quantification of pain. The automated software detected a squint response to the commonly used nociceptive stimulus formalin in C57BL/6J mice. After this validation, we used the automated assay to detect a dose-dependent squint response to a migraine trigger, the neuropeptide calcitonin gene-related peptide, including a response in female mice at a dose below detection by the manual grimace scale. Finally, we found that the calcitonin gene-related peptide amylin induced squinting behavior in female mice, but not males. These data demonstrate that an automated squint assay can be used as an objective, real-time, continuous-scale measure of pain that provides higher precision and real-time analysis compared with manual grimace assessments.
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Affiliation(s)
- Brandon J. Rea
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Abigail Davison
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Martin-Junior Ketcha
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Kylie J. Smith
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Aaron M. Fairbanks
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Anne-Sophie Wattiez
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Iowa VA Medical Center, Iowa City, IA, United States
| | - Pieter Poolman
- Center for the Prevention and Treatment of Visual Loss, Iowa VA Medical Center, Iowa City, IA, United States
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, United States
- FaceX LLC, Iowa City, IA, United States
| | - Randy H. Kardon
- Center for the Prevention and Treatment of Visual Loss, Iowa VA Medical Center, Iowa City, IA, United States
- Department of Ophthalmology and Visual Sciences, University of Iowa, Iowa City, IA, United States
- FaceX LLC, Iowa City, IA, United States
| | - Andrew F. Russo
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Iowa VA Medical Center, Iowa City, IA, United States
- Department of Neurology, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
| | - Levi P. Sowers
- Department of Molecular Physiology and Biophysics, Carver College of Medicine, University of Iowa, Iowa City, IA, United States
- Center for the Prevention and Treatment of Visual Loss, Iowa VA Medical Center, Iowa City, IA, United States
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12
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Guard A, Konz M, Smith RO, Engel JM, Keating T. The development of an iPad application for the pain assessment of individuals with developmental disabilities and complex communication needs. Assist Technol 2021; 33:178-189. [PMID: 31169462 DOI: 10.1080/10400435.2019.1612797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Aims: Develop a new pain assessment for youth with communication challenges. The Guard-Putzer Pain Assessment Domains (gPAD) mobile application (app) was designed and tested as a universally accessible way for youth, ages 7-12 years, with a developmental disability (DD) to express their pain experiences through self-report. Methods: A two-phase process developed the design for an app, created an interactive prototype, and tested its face validity and user interface. This work included a comprehensive scoping review of current assessments and pain apps as well as a survey to obtain descriptive data on the clinical practicality of the gPAD to guide the app design. Additionally, 15 therapists reviewed the gPAD assessment. Results: Thirteen respondents (87%) agreed to the statement that they would use the gPAD for this population. School-based practitioners seemed to highlight the most significant needs for the app. Conclusions: Advancement of this app could mainstream the assessment of pain in youth with DD, and other potential populations.
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Affiliation(s)
- Alyssa Guard
- Occupational Therapy, University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Michelle Konz
- Occupational Therapy, University of Wisconsin-Milwaukee, Oshkosh, Wisconsin, USA
| | - Roger O Smith
- University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Joyce M Engel
- University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
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de Araújo Vitor CA, de Oliveira Lira Ortega A, Ferreira ACFM, da Silva CAAL, Gallottini MHC, Santos MTBR. Pressure pain threshold of masticatory muscles in children and adolescents with and without intellectual disability: a pilot study. Eur Arch Paediatr Dent 2021; 22:587-593. [PMID: 33389623 DOI: 10.1007/s40368-020-00593-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/26/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Pain is considered a stressful experience, related to real or possible tissue damage with emotional, sensory, social and cognitive components. The aim of the study was to evaluate and compare, using a digital algometer, the pressure pain threshold of temporal and masseter muscles of children and adolescents with and without intellectual disability. METHODS A cross-sectional study was conducted. Data regarding gender and age were collected from the caregiver of children and adolescents with and without intellectual disability. The evaluations followed this sequence: pressure pain threshold of the masseter and temporal muscles, evaluation of pain on touch using the visual analog scale and signs and symptoms of Temporomandibular disorder. The χ2 test, the Kolgomorov-Smirnov test, Student t test and Mann-Whitney test were performed. The significance level was set at 5%. RESULTS Two homogeneous groups by gender (P = 0.258) and age (P = 0.727) were evaluated, of which 25 children and adolescents presented intellectual disability and another 25 did not have intellectual disability. No significant difference was observed between groups on the pressure pain threshold of the masseter and temporal muscles, nor pressure average or exam time (P > 0.05). Regarding Temporomandibular dysfunction, no difference in signs or symptoms frequency was found (P > 0.05). However, the range of maximum mouth opening was smaller in the intellectual disability group (P = 0.006). CONCLUSION Children and adolescents with intellectual disability and preserved basic functionalities do not present alterations in pain perception when evaluated with computerized pressure algometer and visual analog scale. They present similar threshold of pain to pressure as those reported by normative children and adolescents. These results emphasize the importance to treat these children and adolescents with intellectual disability with respect to their pain threshold.
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Affiliation(s)
- C A de Araújo Vitor
- Postgraduate Program in Dentistry, Cruzeiro do Sul University, Rua Galvão Bueno, 868 Liberdade, São Paulo, SP, Brazil
| | - A de Oliveira Lira Ortega
- Pediatric Dentistry, Postgraduate Program in Dentistry, Cruzeiro do Sul University, Rua Galvão Bueno, 868 Liberdade, São Paulo, SP, Brazil
| | - A C F M Ferreira
- Postgraduate Program in Dentistry, Cruzeiro do Sul University, Rua Galvão Bueno, 868 Liberdade, São Paulo, SP, Brazil
| | - C A-A L da Silva
- Postgraduate Program in Dentistry, Cruzeiro do Sul University, Rua Galvão Bueno, 868 Liberdade, São Paulo, SP, Brazil
| | - M H C Gallottini
- The Discipline of Oral Pathology, Faculty of Dentistry, University of São Paulo, Av. Prof. Lineu Prestes, 2227 Butantã, São Paulo, SP, Brazil
| | - M T B R Santos
- Individuals with Special Needs, Postgraduate Program in Dentistry, Cruzeiro do Sul University, Rua Galvão Bueno, 868 Liberdade, São Paulo, SP, Brazil. .,Cruzeiro do Sul University, Rua Constantino de Sousa, 454, apto 141, São Paulo, SP, 04605-001, Brazil.
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14
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Utilization of pain rating scales in pediatric care among health professionals in a children’s hospital in Kenya. INTERNATIONAL JOURNAL OF AFRICA NURSING SCIENCES 2021. [DOI: 10.1016/j.ijans.2021.100298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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15
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Abdelbaser II, Mageed NA. Analgesic efficacy of ultrasound guided bilateral transversus thoracis muscle plane block in pediatric cardiac surgery: a randomized, double-blind, controlled study. J Clin Anesth 2020; 67:110002. [DOI: 10.1016/j.jclinane.2020.110002] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/01/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
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16
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Liu J, Chen LL, Shen S, Mao J, Lopes M, Liu S, Kong X. Challenges in the Diagnosis and Management of Pain in Individuals with Autism Spectrum Disorder. REVIEW JOURNAL OF AUTISM AND DEVELOPMENTAL DISORDERS 2020. [DOI: 10.1007/s40489-020-00199-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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17
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Shah P, Siu A. Considerations for neonatal and pediatric pain management. Am J Health Syst Pharm 2020; 76:1511-1520. [PMID: 31504147 DOI: 10.1093/ajhp/zxz166] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
PURPOSE Current literature and clinical practice guidelines on pediatric pain management are reviewed. SUMMARY Acute pain is commonly present in neonatal and pediatric patients due to underlying disease states or procedures. Especially in institutions with limited pediatric pain services, it is imperative to describe the appropriate management of pain and pharmacotherapy options that are effective and safe in pediatric patients. Despite the knowledge of pain being an important aspect in the management of children, barriers exist, leading to suboptimal treatment. Addressing these barriers through education of healthcare practitioners, families, and patients will lead to optimizing the patient pain experience. Tools for pain assessment vary depending on the type of pain, the child's age and understanding of pain, and the clinical situation. Pharmacotherapy options for pain management in neonates and pediatric patients include opioid and nonopioid agents. Efficacy and safety data on the use of medications for the treatment of pain in pediatric patients is described. The delivery of medication encompasses patient-specific factors and preferences. Strategies for opioid stewardship and management of iatrogenic withdrawal pose a unique challenge in pediatric patients. CONCLUSION The management of acute pain in neonates and pediatric patients should be a priority for all practitioners caring for these patients. Use of age-appropriate pain assessment tools and understanding of the mechanisms of action and roles in therapy of various nonopioid and opioid therapies can help optimize treatment of pain in neonatal and pediatric patients.
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Affiliation(s)
- Pooja Shah
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers University, the State University of New Jersey, Piscataway, NJ, and Department of Clinical Pharmacy Services, Hackensack University Medical Center, Hackensack, NJ
| | - Anita Siu
- Department of Pharmacy Practice and Administration, Ernest Mario School of Pharmacy at Rutgers University, the State University of New Jersey, Piscataway, NJ, and Department of Clinical Pharmacy Services, Jersey Shore University Medical Center, Neptune, NJ
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Rabach I, Peri F, Minute M, Aru E, Lucafò M, Di Mascio A, Cozzi G, Barbi E. Sedation and analgesia in children with cerebral palsy: a narrative review. World J Pediatr 2019; 15:432-440. [PMID: 31098933 DOI: 10.1007/s12519-019-00264-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2019] [Accepted: 05/01/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients with cognitive impairment due to cerebral palsy experience pain more often than healthy peers and frequently require diagnostic and therapeutic painful procedures. Analgesia and procedural sedation outside the operating room are often required, but they may not adequately be provided because of the inability to accurately recognize and classify the state of pain and for the perceived higher risk of complications. DATA SOURCES We reviewed the available literature to highlight the specific risk factors and area of criticism, that should be further improved. We searched the Cochrane Library, Medline, Pubmed from 1987 to September 2018 using key words such as 'cerebral palsy and children and pain' or 'sedation and cerebral palsy and children'. RESULTS While different pain scales are useful in recognizing pain expressions, anxiety scales are not available. Moreover, studies on non-pharmacological techniques do not always have comparable results. Several risk factors, from anatomic abnormalities to liver and kidney functioning, should be kept in mind before proceeding with sedation. CONCLUSIONS Large trials are needed to assess the impact of non-pharmacological techniques and to evaluate which pain control strategy (pharmacological and non-pharmacological) should be used in different settings.
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Affiliation(s)
- Ingrid Rabach
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, 34100, Trieste, Italy
| | - Francesca Peri
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, 34100, Trieste, Italy. .,University of Trieste, Trieste, Italy.
| | - Marta Minute
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, 34100, Trieste, Italy
| | | | - Marianna Lucafò
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | | | - Giorgio Cozzi
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, 34100, Trieste, Italy
| | - Egidio Barbi
- Institute for Maternal and Child Health, IRCCS 'Burlo Garofolo', Via dell'Istria 65/1, 34100, Trieste, Italy.,University of Trieste, Trieste, Italy
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Cascella M, Bimonte S, Saettini F, Muzio MR. The challenge of pain assessment in children with cognitive disabilities: Features and clinical applicability of different observational tools. J Paediatr Child Health 2019; 55:129-135. [PMID: 30264421 DOI: 10.1111/jpc.14230] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2017] [Revised: 05/23/2018] [Accepted: 08/27/2018] [Indexed: 11/27/2022]
Abstract
Children with cognitive disabilities are at greater risk of experiencing pain. It has been shown that this paediatric population often receive inadequate pain management. Pain may be very difficult to assess, especially in a defined subgroup with non-communicating intellectual disability or severe cognitive disability. Accordingly, several observational pain assessment tools have been proposed to overcome this issue. Due to the absence of an ideal measurement tool, accurate pain assessment requires, after a case-by-case analysis, selecting the more appropriate tool or a variety of combined instruments. The aim of this work is to provide a comprehensive review of the pain assessment tools commonly used in cognitively impaired children. Critical discussion on features and clinical applicability may suggest how to overcome this difficult challenge. Furthermore, this review will help further research aiming to design new instruments and to improve already-in-use tools.
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Affiliation(s)
- Marco Cascella
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori - IRCCS, Naples, Italy
| | - Sabrina Bimonte
- Division of Anesthesia, Department of Anesthesia, Endoscopy and Cardiology, Istituto Nazionale Tumori - IRCCS, Naples, Italy
| | - Francesco Saettini
- Department of Pediatrics, Fondazione MBBM, University of Milan-Bicocca, Monza, Italy
| | - Maria Rosaria Muzio
- Division of Infantile Neuropsychiatry, UOMI - Maternal and Infant Health, Naples, Italy
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Fox MA, Ayyangar R, Parten R, Haapala HJ, Schilling SG, Kalpakjian CZ. Self-report of pain in young people and adults with spastic cerebral palsy: interrater reliability of the revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) scale ratings. Dev Med Child Neurol 2019; 61:69-74. [PMID: 30051908 DOI: 10.1111/dmcn.13980] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2018] [Indexed: 11/28/2022]
Abstract
AIM People with cerebral palsy (CP) are often unable to express pain owing to cognitive or speech impairments. Reports that rely on observation can be inaccurate, because behaviours such as grimacing, common in people with spastic CP, resemble pain expressions. We examined preliminary validity and reliability of the revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) scale in people with spastic CP. METHOD Forty-eight young people and adults (35 females, 13 males; mean [SD] age 29y 2mo [13y]) were video-recorded during a standard examination, rating their pain (0-10) afterwards. Two raters completed the r-FLACC using the video recordings. Interrater reliability was assessed with an unconditional cross-classified random-effects model and item response theory approach; Pearson correlations measured agreement between raters and participants. RESULTS Mean (SD) participant (n=48) pain scores were 2.48 (2.5) and mean (SD) r-FLACC scores were 1.46 (1.68). There was moderate agreement between raters (intraclass coefficient 0.41 and 0.57 respectively) but low agreement between participants and raters (r=0.26). There were no significant effects for raters (lay observers, nurses, physicians, and inexperienced raters). INTERPRETATION Results provide mixed support for the interrater reliability of the r-FLACC in people with spastic CP. WHAT THIS PAPER ADDS The revised Face, Legs, Activity, Cry, and Consolability (r-FLACC) scale can be reliably used by experts and lay raters for people with spastic cerebral palsy (CP). Support is mixed for interrater reliability of the r-FLACC scale used with people with spastic CP.
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Affiliation(s)
- Margaret A Fox
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA.,School of Nursing, University of Michigan, Ann Arbor, MI, USA
| | - Rita Ayyangar
- Department of Physical Medicine and Rehabilitation, and, Pediatric Palliative Care Medicine, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Rebecca Parten
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Heidi J Haapala
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - Claire Z Kalpakjian
- Department of Physical Medicine and Rehabilitation, Michigan Medicine, University of Michigan, Ann Arbor, MI, USA
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21
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Murgia M, Izzo R, Bettinelli A, Di Maggio C, De Angelis M, Mangone M, Paoloni M, Bernetti A, Torquati A, Leuzzi V, Santilli V. Validity and reliability of Italian version of the Non-Communicating Children's Pain Checklist: revised version. Eur J Phys Rehabil Med 2018; 55:89-94. [PMID: 30160437 DOI: 10.23736/s1973-9087.18.05314-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The Non-Communicating Children Pain Check List-Revised (NCCPC-R) is a clinical assessment tool used to assess and measure pain in children aged 3 to 18 years, with mental and intellectual disabilities, incapable to speak. AIM Aim of our study was to test the validity and reliability of the Italian version of the NCCPC-R in children with cognitive impairment, in order to obtain a valid tool for pain assessment in these children. DESIGN Prospective observational study. SETTING Pediatric Outpatient of Physical and Rehabilitative Medicine Department, and Pediatrics, Child Neurology and Psychiatry Department, Sapienza University, Rome. POPULATION 55 non-communicating children, with severe intellectual disability, aged 3-18 years. METHODS The guidelines for "translation, adaptation, and validation of instruments or scales for cross-cultural healthcare research" were used to translate the scale, which was administered by the parents/caregivers twice for 2 consecutive days, in association with NRS (Numerical Rating Scale). The reliability of the scale was evaluated using the intra and inter-class correlation coefficient (ICCs); Cronbach alpha coefficient was used to test the internal validity of the scale; "Receiver Operating Characteristic" (ROC) curves were used to compare pain-free scores with pain scores, determining threshold scores; Pearson correlation between NCCPC-R and NRS values was measured. RESULTS The InterCC between the first and the second interviewer at T0 was 0,97, the IntraCC of the first interviewer at T0-T1 was 0,89, showing a high correlation; the Cronbach alpha coefficient at T0 was 0,97, showing a high scale's validity. Pearson correlation between NRS and NCCPC-R values at T0 was 0,54 showing a medium level of agreement (P<0,0001). AUC (area under the curve) obtained by ROC curve at T0 was 0,807 (P=0,001), with sensitivity 95,2 and specificity 55,6, while a T1 AUC was 0,814 (P<0,001), with sensitivity 86,49, specificity 78,57. CONCLUSIONS The Italian version of NCCPC-R scale could be used to asses pain in non-communicating patients with mental and intellectual disabilities, showing a good correlation when compared to the NRS. CLINICAL REHABILITATION IMPACT The use of NCCPC-R scale in daily life made parents/caregivers able to discriminate the presence/absence of pain in non-communicating children, based on the scores obtained with the questionnaire.
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Affiliation(s)
- Massimiliano Murgia
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Rosanna Izzo
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy -
| | - Alessandra Bettinelli
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Chiara Di Maggio
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Martina De Angelis
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Massimiliano Mangone
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Marco Paoloni
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Andrea Bernetti
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Andrea Torquati
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
| | - Vincenzo Leuzzi
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University, Rome, Italy
| | - Valter Santilli
- Department of Physical Medicine and Rehabilitation, Sapienza University, Rome, Italy
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Sangari TS, Martin TW. Managing Postoperative Pain in Pediatric Patients with Developmental Delay. PAIN MEDICINE 2018; 19:646-647. [DOI: 10.1093/pm/pny035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Taran S Sangari
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
| | - Timothy W Martin
- Department of Anesthesiology, University of Florida, Gainesville, Florida, USA
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Abstract
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.
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Martin P. Pain in Rett syndrome: peculiarities in pain processing and expression, liability to pain causing disorders and diseases, and specific aspects of pain assessment. ADVANCES IN AUTISM 2017. [DOI: 10.1108/aia-02-2017-0003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Peter Martin
- Epilepsiezentrum Kork, Seguin-Klinik, Kehl-Kork, Germany
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Hauer J, Houtrow AJ, Feudtner C, Klein S, Klick J, Linebarger J, Norwood KW, Adams RC, Brei TJ, Davidson LF, Davis BE, Friedman SL, Hyman SL, Kuo DZ, Noritz GH, Yin L, Murphy NA. Pain Assessment and Treatment in Children With Significant Impairment of the Central Nervous System. Pediatrics 2017; 139:peds.2017-1002. [PMID: 28562301 DOI: 10.1542/peds.2017-1002] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Julie Hauer
- Complex Care Service, Division of General Pediatrics, Boston Children’s Hospital, Assistant Professor, Harvard Medical School, Boston Massachusetts
- Seven Hills Pediatric Center, Groton, Massachusetts; and
| | - Amy J. Houtrow
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, Pediatric Rehabilitation Medicine, Rehabilitation Institute, Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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Developing a Sense of Knowing and Acquiring the Skills to Manage Pain in Children with Profound Cognitive Impairments: Mothers' Perspectives. Pain Res Manag 2017; 2017:2514920. [PMID: 28458591 PMCID: PMC5385219 DOI: 10.1155/2017/2514920] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2016] [Revised: 02/11/2017] [Accepted: 03/09/2017] [Indexed: 11/18/2022]
Abstract
Children with profound cognitive impairment (PCI) are a heterogenous group who often experience frequent and persistent pain. Those people closest to the child are key to assessing their pain. This mixed method study aimed to explore how parents acquire knowledge and skills in assessing and managing their child's pain. Eight mothers completed a weekly pain diary and were interviewed at weeks 1 and 8. Qualitative data were analysed using thematic analysis and the quantitative data using descriptive statistics. Mothers talked of learning through a system of trial and error (“learning to get on with it”); this was accomplished through “learning to know without a rule book or guide”; “learning to be a convincing advocate”; and “learning to endure and to get things right.” Experiential and reflective learning was evident in the way the mothers developed a “sense of knowing” their child's pain. They drew on embodied knowledge of how their child usually expressed and responded to pain to help make pain-related decisions. Health professionals need to support mothers/parents to develop their knowledge and skills and to gain confidence in pain assessment and they should recognise and act on the mothers' concerns.
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Conner ER, Musser ED, Colpitts KM, Laochamroonvorapongse DL, Koh JL. Perioperative opioid administration in children with and without developmental delay undergoing outpatient dental surgery. J Clin Anesth 2017; 37:92-96. [DOI: 10.1016/j.jclinane.2016.12.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2015] [Revised: 11/02/2016] [Accepted: 12/07/2016] [Indexed: 11/26/2022]
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Navigating Uncertainty: Health Professionals' Knowledge, Skill, and Confidence in Assessing and Managing Pain in Children with Profound Cognitive Impairment. Pain Res Manag 2016; 2016:8617182. [PMID: 28096710 PMCID: PMC5209615 DOI: 10.1155/2016/8617182] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Accepted: 11/28/2016] [Indexed: 11/18/2022]
Abstract
There is limited evidence to underpin the assessment and management of pain in children with profound cognitive impairment and these children are vulnerable to poor pain assessment and management. Health professionals working with children with profound cognitive impairment from a single paediatric tertiary referral centre in England were interviewed to explore how they develop and acquire knowledge and skills to assess and manage pain in children with cognitive impairment. The interviews were transcribed and subjected to thematic analysis. Nineteen health professionals representing different professional groups and different levels of experience participated in the study. A metatheme “navigating uncertainty; deficits in knowledge and skills” and two core themes “framing as different and teasing things out” and “the settling and unsettling presence of parents” were identified. Uncertainty about aspects of assessing and managing the pain of children with cognitive impairment tended to erode professional confidence and many discussed deficits in their skill and knowledge set. Uncertainty was managed through engaging with other health professionals and the child's parents. Most health professionals stated they would welcome more education and training although many felt that this input should be clinical and not classroom oriented.
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Care-related pain and discomfort in children with motor disabilities in rehabilitation centres. Ann Phys Rehabil Med 2016; 59:314-319. [DOI: 10.1016/j.rehab.2016.04.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2015] [Revised: 04/07/2016] [Accepted: 04/09/2016] [Indexed: 11/22/2022]
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MENDONÇA JGA, DAHER A, CORRÊA-FARIA P, COSTA LR. Is pain during pediatric dental sedation associated with children’s pre-operative characteristics? An exploratory study. REVISTA DE ODONTOLOGIA DA UNESP 2016. [DOI: 10.1590/1807-2577.09416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract Introduction Little is known about the factors associated with the pain of children in dental treatment under conscious sedation. Objective To investigate the association between preoperative characteristics and pain during pediatric dental treatment under sedation. Material and method This exploratory study was conducted with 27 children in restorative treatment under sedation. Information on age, sex and experience of the children with previous dental treatment was obtained through interviews with parents. Oral health status, determined from the presence of dental caries, was verified using the dmf-t index. Pain was assessed by analyzing videos of the dental treatments by two previously calibrated examiners, using the items “legs”, “activity” and “crying” of the observational scale “face, legs, activity, consolability and crying” (FLACC). Data were analyzed using bivariate tests. Result Most of the children (n=14, 51.8%) had no pain during dental treatment under sedation. Among the other children, lower or moderate pain scores (median 1.1; minimum 0 to 3.8) were observed. The FLACC scores did not vary according to sex (P=0.38), previous experience with dental treatment (P=0.32) and history with local anesthesia (P=0.96). The FLACC scores did not correlate significantly with age (Spearman rho= -0.08, P=0.67) and dmf-t (Spearman rho= -0.04, P=0.84). Conclusion In this group of children, pain during dental treatment under sedation was of low frequency and intensity and did not associate with age, sex, oral condition and previous dental experience.
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Abstract
Although nursing leaders call for theory utilization in research, use remains low within the discipline. The purpose of this article is to explore the application of interdisciplinary integration of models and theories to nursing research. An example of theory integration for the purposes of guiding a study relevant to school nursing is described. A conceptual-theoretical-empirical structure based on the Neuman's systems model, a nursing theory, integrated with the social communication model of pain, a psychology model, was developed to guide the study to examine pain assessment for schoolchildren with intellectual and developmental disabilities.
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Kjeldgaard Pedersen L, Nikolajsen L, Rahbek O, Uldall Duch B, Møller-Madsen B. Epidural analgesia is superior to local infiltration analgesia in children with cerebral palsy undergoing unilateral hip reconstruction. Acta Orthop 2016; 87:176-82. [PMID: 26541479 PMCID: PMC4812081 DOI: 10.3109/17453674.2015.1113375] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Treatment of postoperative pain in children with cerebral palsy (CP) is a major challenge. We investigated the effect of epidural analgesia, high-volume local infiltration analgesia (LIA), and an approximated placebo control on early postoperative pain in children with CP who were undergoing unilateral hip reconstruction. PATIENTS AND METHODS Between 2009 and 2014, we included 18 children with CP. The first part of the study was a randomized double-blind trial with allocation to either LIA or placebo for postoperative pain management, in addition to intravenous or oral analgesia. In the second part of the study, the children were consecutively included for postoperative pain management with epidural analgesia in addition to intravenous or oral analgesia. The primary outcome was postoperative pain 4 h postoperatively using 2 pain assessment tools (r-FLACC and VAS-OBS) ranging from 0 to 10. The secondary outcome was opioid consumption over the 21-h study period. RESULTS The mean level of pain 4 h postoperatively was lower in the epidural group (r-FLACC: 0.7; VAS-OBS: 0.6) than in both the LIA group (r-FLACC: 4.8, p = 0.01; VAS-OBS: 5.2, p = 0.02) and the placebo group (r-FLACC: 5.2, p = 0.01; VAS-OBS: 6.5, p < 0.001). Corrected for body weight, the mean opioid consumption was lower in the epidural group than in the LIA group and the placebo group (both p < 0.001). INTERPRETATION Epidural analgesia is superior to local infiltration analgesia for early postoperative pain management in children with cerebral palsy who undergo unilateral hip reconstruction.
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Quinn BL. ‘It's Not Easy’: School Nurse Pain Assessment Practices for Students with Special Needs. Pain Manag Nurs 2016; 17:119-31. [DOI: 10.1016/j.pmn.2016.01.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 01/29/2016] [Accepted: 01/29/2016] [Indexed: 11/30/2022]
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Pedersen LK, Rahbek O, Nikolajsen L, Møller-Madsen B. Assessment of pain in children with cerebral palsy focused on translation and clinical feasibility of the revised FLACC score. Scand J Pain 2015; 9:49-54. [DOI: 10.1016/j.sjpain.2015.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 06/26/2015] [Indexed: 10/23/2022]
Abstract
Graphical Abstract
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Affiliation(s)
- Line Kjeldgaard Pedersen
- Department of Children’s Orthopaedics , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
| | - Ole Rahbek
- Department of Children’s Orthopaedics , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
| | - Lone Nikolajsen
- Danish Pain Research Center , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
| | - Bjarne Møller-Madsen
- Department of Children’s Orthopaedics , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
- Orthopaedic Research Laboratory, Department of Orthopaedic Surgery , Aarhus University Hospital , Nørrebrogade 44, 8000 Aarhus C , Denmark
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The revised FLACC score: Reliability and validation for pain assessment in children with cerebral palsy. Scand J Pain 2015; 9:57-61. [DOI: 10.1016/j.sjpain.2015.06.007] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Accepted: 06/26/2015] [Indexed: 12/31/2022]
Abstract
Graphical Abstract
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Valkenburg AJ, de Leeuw TG, van Dijk M, Tibboel D. Pain in Intellectually Disabled Children: Towards Evidence-Based Pharmacotherapy? Paediatr Drugs 2015; 17:339-48. [PMID: 26076801 PMCID: PMC4768233 DOI: 10.1007/s40272-015-0138-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
This critical opinion article deals with the challenges of finding the most effective pharmacotherapeutic options for the management of pain in intellectually disabled children and provides recommendations for clinical practice and research. Intellectual disability can be caused by a wide variety of underlying diseases and may be associated with congenital anomalies such as cardiac defects, small-bowel obstructions or limb abnormalities as well as with comorbidities such as scoliosis, gastro-esophageal reflux disease, spasticity, and epilepsy. These conditions themselves or any necessary surgical interventions are sources of pain. Epilepsy often requires chronic pharmacological treatment with antiepileptic drugs. These antiepileptic drugs can potentially cause drug-drug interactions with analgesic drugs. It is unfortunate that children with intellectual disabilities often cannot communicate pain to caregivers. Although these children are at high risk of experiencing pain, researchers nevertheless often have to exclude them from trials on pain management because of ethical considerations. We therefore make a plea for prescribers, researchers, patient organizations, pharmaceutical companies, and policy makers to study evidence-based, safe and effective pharmacotherapy in these children through properly designed studies. In the meantime, parents and clinicians must resort to validated pain assessment tools such as the revised FLACC scale.
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Affiliation(s)
- Abraham J Valkenburg
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands.
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands.
| | - Tom G de Leeuw
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Anesthesiology, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Monique van Dijk
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Division of Neonatology, Department of Pediatrics, Erasmus University Medical Center-Sophia Children's Hospital, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Dick Tibboel
- Intensive Care and Department of Pediatric Surgery, Erasmus University Medical Center-Sophia Children's Hospital, Dr. Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands
- Pain Expertise Center, Erasmus University Medical Center, Rotterdam, The Netherlands
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Terwee CB, Prinsen CAC, Ricci Garotti MG, Suman A, de Vet HCW, Mokkink LB. The quality of systematic reviews of health-related outcome measurement instruments. Qual Life Res 2015; 25:767-79. [PMID: 26346986 PMCID: PMC4830864 DOI: 10.1007/s11136-015-1122-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Systematic reviews of outcome measurement instruments are important tools for the selection of instruments for research and clinical practice. Our aim was to assess the quality of systematic reviews of health-related outcome measurement instruments and to determine whether the quality has improved since our previous study in 2007. METHODS A systematic literature search was performed in MEDLINE and EMBASE between July 1, 2013, and June 19, 2014. The quality of the reviews was rated using a study-specific checklist. RESULTS A total of 102 reviews were included. In many reviews the search strategy was considered not comprehensive; in only 59 % of the reviews a search was performed in EMBASE and in about half of the reviews there was doubt about the comprehensiveness of the search terms used for type of measurement instruments and measurement properties. In 41 % of the reviews, compared to 30 % in our previous study, the methodological quality of the included studies was assessed. In 58 %, compared to 55 %, the quality of the included instruments was assessed. In 42 %, compared to 7 %, a data synthesis was performed in which the results from multiple studies on the same instrument were somehow combined. CONCLUSION Despite a clear improvement in the quality of systematic reviews of outcome measurement instruments in comparison with our previous study in 2007, there is still room for improvement with regard to the search strategy, and especially the quality assessment of the included studies and the included instruments, and the data synthesis.
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Affiliation(s)
- C B Terwee
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands.
| | - C A C Prinsen
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | | | - A Suman
- Department of Public Health and the EMGO+ Institute for Health and Care Research, VU University Medical Center, Amsterdam, The Netherlands
| | - H C W de Vet
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - L B Mokkink
- Department of Epidemiology and Biostatistics and the EMGO+ Institute for Health and Care Research, VU University Medical Center, P.O. Box 7057, 1007 MB, Amsterdam, The Netherlands
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