Validation of the parent's postoperative pain measure with an age-appropriate reference pain scale for children 2-12 years old during a 14-day recovery after tonsillectomy: A prospective cohort study

New postoperative pain instrument for toddlers-Secondary analysis of prospectively collected assessments after tonsil surgery

BACKGROUND

The Children's and Infant's Postoperative Pain Scale (CHIPPS) and the German version of the Parent's Postoperative Pain Measure (PPPM-D) are used to assess postoperative pain intensity in preschool children. However, they have shown low concordance in previous prospective studies on quality improvement.

AIMS

Our secondary analysis aimed to estimate the association strength between the pain score items and indication for rescue medication defined as CHIPPS ≥4 and/or PPPD-D ≥ 6. Thus, we intended to create a further developed pain instrument with fewer variables for easier routine use.

METHODS

We analyzed 1067 pain intensity assessments of hospitalized children for the development of our novel tool in two steps using modern statistical and machine-learning methods: (1) Boruta variable selection to analyze the association strength between CHIPPS score, PPPM-D items, age, weight, and elapsed time after surgery, including their interactions and pattern stability, and the binary outcome (analgesics required yes/no). (2) Symbolic regression to generate a short formula with the least number of variables and highest accuracy for rescue medication indication.

RESULTS

Additional analgesics were required in 19.96% of pain intensity assessments, whereby the PPPM-D showed higher variance than CHIPPS. Boruta identified PPPM-D score, CHIPPS score, 9 of the 15 PPPM-D variables, and time of assessment as associated with the indication for RM. Symbolic regression revealed that additional analgesics are required if CHIPPS is ≥4 OR PPPM-D item "less energy than usual" AND one of the items "more easily cry" or "more groan/moan" are answered with "yes." These PPPM-D items were not redundant and showed nonlinear course over time. The cross-validated accuracy for this assessment tool was 94.94%.

CONCLUSIONS

The new instrument is easy to use and may improve postoperative pain intensity assessment in children. However, it requires prospective validation in a new cohort.

A service evaluation of the impact of parental information provision on analgesia administration at home posttonsillectomy

INTRODUCTION

Tonsillectomy and adenotonsillectomy are together the most common pediatric surgical procedure and are increasingly performed as day cases. Postoperative pain is commonly severe for 1-2 weeks, but parental analgesia concerns lead to poor analgesia prescription compliance and under administration. This service evaluation assessed parental compliance with analgesia, elicited parental concerns, and obtained parental suggestions for improving the current written advice.

METHODS

Telephone questionnaires were completed on postoperative Days 3/4 and 7 with 42 parents of pediatric (adeno)-tonsillectomy patients over a 6-month period, peri-pandemic. The questionnaire collected categorical data on: analgesia prescribed and administered, the child's symptoms, and healthcare resource use. Qualitative data on barriers to analgesia administration and suggestions for written advice improvement were grouped thematically.

RESULTS

Sore throats were reported by 93.3% parents between discharge and Day 3/4 but only 43.3% parents had 100% compliance with regular paracetamol and ibuprofen in the same time period. Parents frequently avoided morphine administration, expressing concerns about side effects, addiction, and previous experience. Parents were also concerned about using ibuprofen, discrepancies between weight-based and bottle instruction doses, and the length of the analgesia course. Parents would like further written information and reassurance on these topics as well as guidance on tapering or stopping analgesics and whether to wake their child at night.

CONCLUSION

The breadth of unmet information needs identified in this service evaluation, alongside parental suggestions, will be used to improve the current written advice with the aim to improve the postoperative pain experience at home. These include information on length of analgesic course, safety of ibuprofen and paracetamol coadministration for analgesia, and details about morphine administration, including safety, side effects, and indication.

Parents' perspective on recovery at home following adenotonsillectomy: a prospective single-centre qualitative analysis

PURPOSE

In North America, pediatric adenotonsillectomy (TA) is conducted as an ambulatory procedure, thus shifting the burden of postoperative care to parents. The purpose of this study was to describe this parental experience.

METHODS

We conducted a prospective single-centre qualitative study, recruiting the families of children (n = 317) undergoing elective TA in 2018. Parents were invited to submit written comments to two open-ended questions. We coded the comments from 144 parents in a grounded theory analysis and report representative exemplars. Themes and subthemes for the problems encountered, and strategies employed by parents, were developed. We then coded and classified factors that helped/hindered parents and developed models of the experience.

RESULTS

Some parents felt ill-prepared for the severity and duration of pain. Specific findings included a lack of strategies to manage pain at night, refusals, and night terrors. Parents identified the use of pain scales, pain diaries, and liaison with the research team as helpful supports at home. Inconsistent messaging was a barrier. The odynophagia associated with elixirs of acetaminophen and ibuprofen was a barrier to achieving analgesia.

CONCLUSIONS

The findings from this qualitative analysis provide insight into the challenges faced by parents when caring for their children at home following TA; these challenges included difficulties managing physical needs and pain. The analysis suggests that educational content should be standardized and include the use of pain scales and diaries, and both pharmacologic and nonpharmacologic strategies. Development of support at home, including a practicable liaison with health care providers, seems to be warranted.

STUDY REGISTRATION

ClinicalTrials.gov (NCT03378830); registered 20 December 2017.