Children's pain: a mandate for change

Associations between attachment and pain: From infant to adolescent

Pain experience is a negative complex phenomenon influenced by several mechanisms. Attachment processes may affect the way in which individuals experience and signal pain. Hence, in the last two decades, the role of attachment quality has drawn attention in pain research and practice. However, previous reviews on this topic focused on adulthood and/or specific types or pain. We conducted a narrative review examining the association between attachment and different pain conditions from infancy to adolescence. Two independent researchers searched scientific databases for relevant papers. A total of 17 articles were included. Results highlight the following: (a) children and adolescents with chronic idiopathic pain showed low rates of attachment security compared to control groups; (b) pain conditions are consistently associated with elevated rates of at-risk pattern of attachment and information processing; and (c) the presence of unresolved trauma or loss is higher in children and adolescent who experienced pain compared to healthy controls. Despite the significance of these empirical evidences, the impact of caregiving environment and interpersonal context on pain experience in infancy and preschool age is poorly investigated compared to adulthood. Research on pain and attachment needs to be extended since the majority of the studies are limited to specific pain conditions. Future research should investigate the role of anxious attachment on procedural pain and transition from acute to chronic pain, testing new conceptual models. These findings shed light on the importance of relational factors and psychosocial vulnerabilities in pain clinical practice. An attachment-informed approach to pain will help health professionals to offer adequate support during procedures and to increase effectiveness of interventions. A developmental perspective is needed to integrate familial and relational contribution into a multimodal assessment and treatment of pain. Longitudinal studies are recommended.

[Opinions and attitudes of clinical staff on systems for the assessment and treatment of children's pain]

INTRODUCTION

Many factors affect the assessment and treatment of pain, among them being the knowledge and attitudes of clinical staff. The goal of this work was to determine the opinions and attitudes of clinical staff from two hospitals on the different aspects of the assessment and treatment of children's pain.

METHOD

A cross-sectional, descriptive study was conducted using a self-administered questionnaire issued to clinical staff. The questionnaire was given to the professionals, doctors, and nursing staff of the paediatric services of two hospitals, and to an incidental sample of paediatric doctors.

RESULTS

Of the 146 questionnaires sent out, 105 were completed. Participants indicated that standardised scales and physiological recordings were the least frequently used methods to assess children's pain. Participants considered that pharmacological techniques for the treatment of pain were used more frequently than non-pharmacological techniques, at all ages. Participants acknowledged being significantly more knowledgeable about pharmacological methods to relieve paediatric pain than about non-pharmacological methods.

CONCLUSIONS

There is margin for improvement in systems for the assessment and treatment of children's pain as regards the more frequent and standardised use of techniques and standardised tools for the assessment of pain, and the greater administration of non-pharmacological strategies for its treatment.

Pain assessment for children: overcoming challenges and optimizing care

There is growing evidence that children have short- and long-term physical, physiological, and psychological effects due to untreated acute pain. Because the majority of children who seek care in an emergency department present with pain or experience pain during the evaluation and treatment in the emergency department, optimal assessment and treatment of pain are paramount for this population. This review will highlight the many complexities of the assessment of pain for the pediatric patient. In addition, a variety of factors that affect the self-report of pain in children will be identified. Optimizing the utility of a pain assessment remains a challenge for the health care provider in the emergency setting. The common goal of a decreased experience of pain for children through improved analgesic administration remains.

Children's perceptions on the implementation of methods for their postoperative pain alleviation: An interview study

The purpose of this study was to reveal the 8-12-year-old children's perceptions on the use of methods for pediatric postoperative pain alleviation by themselves, their parents and nurses. Face-to-face structured interviews were conducted with 59 subjects who had undergone surgical procedures in three provincial hospitals in Fujian Province, China in 2004. Content analysis and descriptive statistics were used to analyse the data. According to the children's perceptions, they commonly used rest/sleeping, a physical method (positioning) and a strategy of emotional support (requiring presence of their parents); their parents frequently used helping with daily activities and all strategies of emotional support; the nurses mostly used a strategy of emotional support (comforting) and a physical method (positioning). Children's suggestions mainly concerned the application of non-pharmacological methods, especially presence of caregivers. In conclusion, pain-relieving methods were not sufficiently used although children suffered from intense postoperative pain, which calls for health-care providers' future attention.

Social Response in Children with Severe Cognitive Impairments: Factors in Craniofacial Surgery Decision-Making

BACKGROUND

The controversy over whether certain pediatric craniofacial operations primarily address "functional" versus "aesthetic" goals has fostered tensions among insurance companies, patients and families, and treatment teams. The authors posit that such operations have objectives and outcomes that can be categorized as "functionally aesthetic" and describe the empirical basis for this assertion. Furthermore, the authors apply this concept to the difficult surgical decision-making process associated with treating children with severe cognitive impairments.

METHODS

When patients have severe cognitive impairments, the social benefits of treatment may be less clear than for other patients, increasing the complexity of surgery decision-making. The authors discuss the nature of cognitive impairment, its prevalence in patients with craniofacial anomalies, links between social functioning and both cognitive development and appearance, and the importance of social integration for psychological and cognitive functioning. Special issues involved in working with cognitively impaired children are covered, including parent and patient expectations for surgical outcome and the difficulties involved in pain assessment and control. Potential linkages are described for craniofacial surgery, appearance, social functioning, and cognitive development.

CONCLUSIONS

A craniofacial operation directed at reconstruction of a congenital defect in a child should not be dismissed as simply and purely cosmetic. The authors document and outline the potential ethical issues and social and cognitive benefits that should be considered by insurance companies, patients and families, and treatment teams when determining treatment options for cognitively impaired children with craniofacial anomalies.

'I had this horrible pain': the sources and causes of pain experiences in 4- to 11-year-old hospitalized children

Researchers have relied, almost without exception, on adults for qualitative information about children's pain. However, adults may provide only a limited view of children's pain experience. The purpose of this article is to describe the events considered painful by children. Forty-four children participated in the study. They had been admitted for different reasons into different wards of a university hospital. The data consisted of qualitative child interviews and was analysed using inductive content analysis. The pain experience of children came from four main sources: 1. pain as a symptom of a diagnosed illness, 2. pain caused by medical and diagnostic procedures and basic nursing, 3. pain caused by accidents and 4. inexplicable pain not caused by a particular illness or injury. Children are able to report and describe their pain. Children should be regarded as experts on their pain in order to maximize the options for pain management.