Pain experiences and non-pharmacological strategies for pain management after tonsillectomy: a qualitative interview study of children and parents

Factors Influencing Parental Decision-Making Regarding Analgesia for Children with Musculoskeletal Injury-Related Pain: A Qualitative Study

OBJECTIVES

To explore and understand parental decision-making relating to acute pain management for their children presenting to the emergency department.

STUDY DESIGN

This study employed one-on-one semistructured interviews. Parents of children with acute musculoskeletal injuries were recruited from 3 Canadian pediatric emergency departments. Interviews were conducted via telephone from June 2019 to March 2021. Verbatim transcription and thematic analyses occurred concurrently with data collection, supporting data saturation and theory development considerations.

RESULTS

Twenty-seven interviews were completed. Five major themes regarding pain care emerged: (1) my child's comfort is a priority, (2) every situation is unique, (3) opioids only if necessary, (4) considerations when choosing opioids, and (5) pain research is important. Overall, parents were highly comfortable with their assessment of their child's pain. Participants' willingness to use opioid analgesia for their children was primarily dependent on perceptions of injury and pain severity. Opioid-averse and opioid-accepting families had similar considerations when making analgesic decisions but weighed risks and benefits differently.

CONCLUSIONS

Parents assess and manage their children's pain globally and multimodally, with comfort being prioritized. For most parents, the desire to relieve their children's pain outweighed concerns of substance use disorder, misuse, and adverse events when making decisions about opioid analgesia for short-term use. These results can inform evidence-based family-centered approaches to co-decision-making of analgesic plans for children with acute pain.

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.

Experiences of pain in paediatric chronic fatigue syndrome/myalgic encephalomyelitis: a single-centre qualitative study

BACKGROUND

Moderate to severe pain affects up to two-thirds of children with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) and is associated with worse fatigue and physical functioning. This research aims to gain a greater insight into pain experienced by these children.

METHODS

Thematic analysis of qualitative data from semistructured interviews with 13 children with CFS/ME (mean age=15.3 years, 67% female) was completed.

RESULTS

Thematic analysis enabled construction of three themes: children's wide-ranging experiences of pain, negative impact of pain and lack of effective treatment for pain and nine subthemes. The first theme demonstrated highly varied pain experiences, ranging from 'like [being]… on fire', like 'being stabbed' to 'like…lead'. Children experienced pain in multiple sites and with wide-ranging frequency and severity. The second theme highlighted the profound negative impact of pain on multiple aspects of children's lives. Physical activity was severely impaired; some children 'couldn't leave bed' or 'couldn't…brush [their] own hair'. Abdominal pain meant some would 'go…days without eating'. Pain substantially impacted on mental health, leaving children feeling 'agitated', experiencing 'really bad panic attacks' or making them '[want to] breakdown'. Children felt they 'can't do the things that everyone else can do', had 'missed out' and are 'behind everyone'. Some avoided socialising as they 'don't want to stop everyone else'. The final theme demonstrates the absence of adequate treatment for pain, with participants reporting 'nothing has ever really got rid of it' and only 'slightly [takes] the edge off' and other experiencing side effects.

CONCLUSIONS

Pain in paediatric CFS/ME is highly variable, common and often results in severe physical limitation and poor mental health. Effective treatments for pain represent an unmet need.

Comparison of celecoxib and acetaminophen for pain relief in pediatric day case tonsillectomy: A randomized double-blind study

OBJECTIVE

Post-tonsillectomy pain is a common morbidity in children. The aim of this study was to compare the efficacy of celecoxib with acetaminophen on pain relief in pediatric day-case tonsillectomy.

METHODS

We compared the analgesic effect of celecoxib (99 patients) with acetaminophen (100 patients) for the management of post-tonsillectomy pain. Post-tonsillectomy pain score was evaluated three times a day for 7 days. In addition, the incidence of post-tonsillectomy bleeding and the rate of patients who returned to regular diet were evaluated.

RESULTS

In the first day, we observed lower mean pain score in the celecoxib group, than the acetaminophen group (P =  0.013). The overall pain score in other days was not significantly different between the two groups. In the celecoxib group, more patients resumed regular amount of oral intake within the first 3 days. Also, the rate of post-tonsillectomy bleeding in the two groups was not statistically different.

CONCLUSION

We recommend celecoxib as a more suitable choice than acetaminophen for post-tonsillectomy pain management in the first day and resuming regular diet within 3 days.Level of Evidence: 1b.

Establishment of resilience in a challenging recovery at home after pediatric tonsil surgery-Children's and caregivers' perspectives

The objective of this study was to explore children's and caregivers’ experiences and management of postoperative recovery at home after tonsil surgery. The study had an explorative qualitative design with an inductive approach. Twenty children (5‐12 years of age) undergoing tonsillectomy or tonsillotomy with or without adenoidectomy participated along with their caregivers in semi‐structured interviews at a mean time of 28 days after surgery. The interviews were analyzed with content analysis. One main category emerged from the interviews: children and caregivers struggle to establish resilience in a challenging recovery. The families’ resilience relied on their situational awareness and capacity to act, which in turn formed a basis for the ability to return to normal daily life. Children and caregivers described the recovery as an evident interruption of daily life which had an impact on the children's physical and psychological well‐being. Both children and caregivers described the pain as a central concern. The families used different pharmacological and complementary strategies to manage the pain, which in some cases were complex. Some families said that the analgesics were insufficient in preventing breakthrough pain, and spoke about a lack of support as well as inadequate and contradictory information from healthcare staff. Caregivers also expressed uncertainty, ambivalence, or anxiety about the responsibility associated with their child's recovery. To optimize and support the recovery after tonsil surgery, it is crucial to obtain knowledge of children's and caregivers’ perspectives of postoperative recovery at home. The results indicate that the postoperative period included several troublesome experiences for which neither the children nor the caregivers were informed or prepared. The experience of pain was significant, and often complex to manage. To increase families’ resilience, the information provided by healthcare professionals needs to be broadened. Multidisciplinary teamwork is necessary to achieve this goal.

Efficacy of Telephone Follow-Up in Children Tonsillectomy with Day Surgery

OBJECTIVE

Day surgery for tonsillectomy has become more and more popular in China. However, many parents face difficulties to cope up with the pain and side effects after surgery. The present study was aimed to examine the efficacy of telephone follow-up on children's post-discharge recovery after tonsillectomy.

METHODS

In this prospective study, the sample consisted of 863 children randomly assigned to receive clinic visit after discharge or 1 to 14 d' telephone follow-up after discharge. During the follow-up, the research nurse or parents assessed each child's status, identified problems, and provided needed follow-up care. Key outcomes were pain intensity, postoperative complication, and unanticipated contact with the health care system.

RESULTS

Compared with clinical visit, children in telephone follow-up group presented with less pain in early stage after surgery and better food and drink intake. The prevalence of hemorrhage, nausea, vomiting, fever and dizziness had no difference between the groups. Telephone follow-up also reduced unanticipated healthcare services.

CONCLUSIONS

The present study suggested that a follow-up telephone call is a safe and cost-effective method of postoperative management for pediatric patients who have undergone tonsillectomy.

Children's views on postsurgical pain in recovery units in Norway: A qualitative study

AIMS AND OBJECTIVES

To explore children's postsurgical experiences with pain and pain management in the recovery unit.

BACKGROUND

Children's pain is underestimated and undertreated. Untreated pain can cause unnecessary suffering, increased complication risks and may lead to chronic pain. Research exploring children's experiences with postoperative pain and pain management is limited.

DESIGN

A qualitative, exploratory study. The study complied with the Consolidated Criteria for Reporting Qualitative Research (COREQ).

METHODS

Children (N = 20), 8-16 years old, took part in semi-structured interviews about their experiences with pain and postoperative pain management while they were in a recovery unit. Data were collected at two university hospitals in Norway. Content analysis was used to analyse the data.

RESULTS

Three themes emerged from the interviews: "children's experiences of what felt unpleasant and painful," "children's experiences with pain management" and "children's recommendations for future pain management". About half of the children reported moderate to severe pain while in the recovery unit and they did not always tell their nurses when they had pain. They also reported experiencing pain in places other than their surgical wounds and stated that nausea and vomiting felt unpleasant and painful. The children indicated that pain medications and the use of nonpharmacological methods helped them cope with their pain and provided several recommendations about how to improve pain management.

CONCLUSION

Paediatric postoperative pain management remains suboptimal. The children in our study provided useful information about their pain experiences, how to improve pain management and explained why they did not tell their nurses when they were in pain.

RELEVANCE TO CLINICAL PRACTICE

These findings should direct further improvements in paediatric postoperative pain management, such as increased use of pain assessment tools and preparatory information, as well as more appropriate administration of pain medications.

Exploring perspectives on restraint during medical procedures in paediatric care: a qualitative interview study with nurses and physicians

The aim of this study was to explore nurses’ and physicians’ perspectives on and reasoning about the use of restraint during medical procedures on newly admitted preschoolers in somatic hospital care.

We analysed qualitative data from individual interviews with a video recall session at the end with seven physicians and eight nurses. They had earlier participated in video recorded peripheral vein cannulations on preschool children. The data were collected between May 2012 and May 2013 at a paediatric hospital unit in Norway.

The analysis resulted in three main themes: (1) disparate views on the concept of restraint and restraint use (2), ways to limit the use of physical restraint and its negative consequences, and (3) experience with the role of parents and their influence on restraint. Perspectives from both healthcare professions were represented in all the main themes and had many similarities.

The results of this study may facilitate more informed and reflective discussions of restraint and contribute to higher awareness of restraint in clinical practice. Lack of guidance and scientific attention to restraint combined with conflicting interests and values among healthcare providers may result in insecurity, individual dogmatism, and a lack of shared discussions, language, and terminology.

"But Perhaps they could Reduce the Suffering?" Parents' Ambivalence toward Participating in Forced Peripheral Vein Cannulation Performed on their Preschool-Aged Children

PURPOSE

The purpose of this study was to provide a better understanding of how parents experience the use of restraint during the performance of peripheral vein cannulation (PVC) on their child.

DESIGN/METHODS

Qualitative, semi-structured interviews were performed with seven parents and one close relative who had accompanied their 3-5-year-old child while the child resisted the medical procedure of PVC. The analysis was guided by symbolic interactionism and resulted in two themes.

RESULTS

The first theme that emerged, "Negotiating What Quality of Performance Should be Expected", was based on 1) Parents expected child-friendly encounters, 2) Performance of PVC caused unexpected and unnecessary suffering for the child, and 3) Parents explained and excused the performance of PVC. The second theme: "Negotiating One's Own Role and Participation in a Child's Suffering During the Procedure", was based on 1) Parents desired to be acknowledged and approached for suggestions regarding ways to ease the trauma surrounding the procedure, 2) Parents expressed uncertainty regarding the consequences that the procedure would have for the children, and 3) Parents desired to play a protective role, and they tended to engage in self-criticism.

CONCLUSION

When the PVC was less child-friendly, poorly planned and chaotic or performed with lacking skills, the parents became unwilling partners in the unnecessary suffering of the child. A practical implication is that if pediatric health care providers are aiming for the reduction of restraint, they must better understand parents' expectations and experiences and ensure that the use of restraint is used as the last resort.

Parents' experiences of managing their child's postoperative pain at home: an exploratory qualitative study

AIMS AND OBJECTIVES

To understand parents' experiences of managing their child's postoperative pain at home.

BACKGROUND

Recent changes in children's health care services often shift the responsibility of managing children's postoperative pain to parents. Although pain management is important for good postoperative outcomes, it can be a challenging task for families, and children's pain is often under-managed.

DESIGN

This qualitative study used semi-structured interviews to explore parents' experiences of managing their child's postoperative pain at home.

METHODS

Participants were parents of 10 typically developing 5- and 6-year olds, who underwent (adeno)tonsillectomy, and experienced no complications leading to hospitalisation in the postoperative period. One-on-one interviews were conducted with parents within three months of their child's surgery. Interviews were transcribed verbatim and content analysis was used to identify themes in parents' experiences.

RESULTS

All children experienced some postoperative pain. Parents' experiences of managing their child's pain were impacted by balancing the pros and cons of administering analgesic medications, managing the emotional and psychological effects of their child's pain, as well as parents' information needs.

CONCLUSIONS

Most parents' information needs were met yet they still struggled to manage their child's pain. These findings provide insight into some of the barriers that make this process challenging for many families, and what health care centres can do to help support parents manage their child's postoperative pain at home.

RELEVANCE TO CLINICAL PRACTICE

The results of this study may aid in the design of interventions that will support parents when managing their child's postoperative pain at home and thus improve children's experiences.

Self-reported post-operative recovery in children: development of an instrument

RATIONALE, AIMS AND OBJECTIVES

According to the United Nations (1989), children have the right to be heard and to have their opinions respected. Since post-operative recovery is an individual and subjective experience and patient-reported outcome measures are considered important, our aim was to develop and test an instrument to measure self-reported quality of recovery in children after surgical procedures.

METHODS

Development of the instrument Postoperative Recovery in Children (PRiC) was influenced by the Quality of Recovery-24, for use in adults. Eighteen children and nine professionals validated the items with respect to content and language. A photo questionnaire was developed to determine whether the children's participation would increase compared with the text questionnaire. The final instrument was distributed consecutively to 390 children, ages 4-12 years, who underwent tonsil surgery at four hospitals in Sweden.

RESULTS

A total of 238 children with a mean age of 6.5 years participated. According to the parents, 23% circled the answers themselves and 59% participated to a significant degree. However, there was no significant difference in participation between those who received a photo versus a text questionnaire. Psychometric tests of the instrument showed that Cronbach's alpha for the total instrument was 0.83 and the item-total correlations for 22 of the items were ≥0.20.

CONCLUSION

Our results support use of the PRiC instrument to assess and follow-up on children's self-reported post-operative recovery after tonsil operation, both in clinical praxis as well in research.

Hispanic parents' experiences of the process of caring for a child undergoing routine surgery: a focus on pain and pain management

PURPOSE

The purpose was to understand the processes Hispanic parents undergo in managing postoperative care of children after routine surgical procedures.

DESIGN AND METHODS

Sixty parents of children undergoing outpatient surgery were interviewed. Data were analyzed using grounded theory methodology.

RESULTS

Parents experienced five subprocesses that comprised the overall process of caring for a child after routine surgery: (a) becoming informed; (b) preparing; (c) seeking reassurance; (d) communicating with one's child; and (e) making pain management decisions.

PRACTICE IMPLICATIONS

Addressing cultural factors related to pain management in underserved families may instill greater confidence in managing pain.

Validation study of the strategic and clinical quality indicators in postoperative pain management questionnaire in Turkish surgery patients

Determining patient satisfaction with postoperative pain management is an important intervention to improve strategies for effective pain control. The aim of this study was to validate an English version of the 14-item Strategic and Clinical Quality Indicators in Postoperative Pain Management questionnaire in Turkish language. The study included 113 patients who underwent elective surgeries at a university hospital in Bursa, Turkey. The data were collected after translation procedures and final adjustments were done on the original instrument. For the total scale, Cronbach's coefficient α was 0.81 and the main score obtained from the scale was 45.8 ± 10.8. Included were three subscales: nursing interventions, pain management, and environments. Of the patients, 40.7% reported more pain than expected in the postoperative period and their satisfaction with pain relief was 7.4 ± 2.5. This instrument is a reliable and valid instrument in Turkish language and can be used to evaluate the effectiveness of postoperative pain management.

Experienced nurses' use of non-pharmacological approaches comprise more than relief from pain

This study investigated the use of, and reasoning by, experienced nurses regarding non-pharmacological pain approaches to care for children in hospitals, with the aim of increasing our understanding, and hence optimizing, these approaches. Three focus-group interviews with 14 experienced nurses, were conducted in 2009. Our findings emphasized the role of non-pharmacological methods in building and maintaining cooperation with the child and in caring for the child by individualizing the use of non-pharmacological methods.

Parents' treatment of their children's pain at home: pharmacological and nonpharmacological approaches

INTRODUCTION

During childhood, pain often is experienced on a nearly daily basis. This study focuses on pain alleviation techniques provided by parents, because children's painful experiences are most often treated at home. Hypotheses addressed various factors that can influence use of pain alleviation techniques, including parents' level of catastrophizing about their children's pain, children's age, and conversations with health care professionals.

METHOD

A total of 756 parents of children ages 6 to 17 years completed an online survey regarding pain alleviation including use and effectiveness of pharmacological and nonpharmacological techniques, pain catastrophizing, and questions regarding dialogue with health care professionals.

RESULTS

Parents with increased pain catastrophizing used more pharmacological techniques, and child self-administration of pain alleviation techniques increased with the child's age. Parents were more likely to have spoken with their health care professional about pharmacological techniques.

DISCUSSION

This study provides information that can help health care professionals initiate conversations regarding treatment options and align recommendations with techniques that parents are likely to use, and it can help health care professionals provide supportive alternative recommendations.

Use of complementary and alternative medicine by children in Europe: published data and expert perspectives

INTRODUCTION

Few data document the use of complementary and alternative medicine (CAM) in Europe, with even fewer investigating use by children.

METHODS

A narrative, non-systematic review of CAM use in Europe was performed by combining data from published surveys with expert perspectives. Limitations created by a lack of representative studies, varying definitions of CAM use, and what qualifies as CAM in different countries was partially overcome by integrating local experts to summarise information available only in the national language and provide their perspectives about CAM availability, quality, use and popularity in their countries using a semi-structured questionnaire. Local and international published surveys were summarised, and the prevalence of CAM use was extrapolated.

RESULTS

Data from 20 European countries were available, representing 69% of the European population. Some data about CAM use by the general population were available for 90% of the examined countries, whereas peer-reviewed published surveys were available for only 60%. We extrapolated that 56% (range: 10-90%, adjusted for population size) of the European population in general had used CAM at least once in the past year. Surveys in CAM use by children were available for 55% of the investigated countries. The extrapolated prevalence of CAM use by children in Europe was 52% (range: 5-90%, adjusted for population size). Paediatric CAM experts reported an increasing awareness for and use of CAM in healthcare institutions.

CONCLUSION

This precursor for further surveys indicates that CAM appears to be popular not only among adults in Europe, but also for children. Development of a pan-European definition of CAM use and CAM therapies are required to achieve surveys comparable between European countries. Additionally, more research investigating the efficacy and potential adverse effects of CAM therapies is needed because of increasing CAM use by children in Europe.

Effects of patient- and operation-related factors on postoperative pain after orthognathic surgery

PURPOSE

This study aimed to assess the association between patient- and operation-related factors and postoperative pain in patients undergoing intraoral vertical ramus osteotomy (IVRO) or IVRO + genioplasty (GeP) for the treatment of mandibular prognathism.

MATERIALS AND METHODS

A visual analog scale (VAS) was used to evaluate postoperative pain for 2 days in 63 patients who underwent orthognathic surgery (42 IVRO and 21 IVRO + GeP). Correlations between VAS and patient age, sex, blood loss, operation time, and intraoperative reduction in blood parameters were assessed and compared between IVRO and IVRO + GeP procedures.

RESULTS

Mean operation time and blood loss were 252.02 minutes and 99.64 mL in the IVRO group and 317.62 minutes and 187.86 mL in the IVRO + GeP group, respectively. Operation time, blood loss, and postoperative reduction in blood parameters were significantly greater in the IVRO + GeP group than in the IVRO group. Mean VAS scores on the first and second postoperative days were 3.02 and 1.33 in the IVRO group and 2.95 and 1.14 in the IVRO + GeP group. However, postoperative pain did not differ significantly between the IVRO and IVRO + GeP groups on the first or second postoperative day.

CONCLUSIONS

Postoperative pain associated with orthognathic surgery was acceptable, controllable, and not different between IVRO and IVRO + GeP procedures.

The use of ice-lollies for pain relief post-paediatric tonsillectomy. A single-blinded, randomised, controlled trial

OBJECTIVES

To assess whether the use of ice-lollies after tonsillectomy with or without adenoidectomy in children aged 2-12 reduces pain in the immediate postoperative period.

DESIGN

A prospective, randomised, single-blinded study design consisting of two groups with an intention to treat analysis.

SETTING

Tertiary referral centre.

PARTICIPANTS

Children aged 2-12 undergoing tonsillectomy with or without adenoidectomy.

MAIN OUTCOME MEASURES

Pain assessment by nursing staff in the form of the validated modified Children's Hospital of Eastern Ontario Pain Scale at 15, 30 and 60 min and 4 h.

RESULTS

Ninety-two patients were recruited into the study with 46 allocated to receive an ice-lolly and 41 not to receive an ice-lolly after exclusion of those with incomplete data. The two groups were comparable for number, age, sex and diagnosis. The pain score at every time interval was lower in the group that had received the ice-lolly compared with the group that had not. This was statistically significant at 30 (P = 0.008) and 60 min (P = 0.049).

CONCLUSION

Our data suggest that ice-lollies are a cheap, effective and safe method of reducing postoperative pain up to one hour following paediatric tonsillectomy.

Parental involvement in their school-aged children's post-operative pain management in the hospital setting: a comprehensive systematic review

BACKGROUND

Paediatric pain management remains a challenge in clinical settings. Parents can contribute to the effective and accurate pain assessment and management of their child. No systematic reviews regarding the parental involvement in their child's post-operative pain management have been published.

OBJECTIVE

To determine the best available evidence regarding parental involvement in managing their children's post-operative pain in the hospital setting.

INCLUSION CRITERIA

The review considered studies that included parents of all ethnic groups with children aged between 6 to 12 years old who were hospitalised and undergone surgery of any kind with post-operative surgical or incision site pain where care was provided in acute hospital settings. The phenomena of interest were the experiences of parents in managing their children's post-operative pain.

SEARCH STRATEGY

A three-step search strategy was utilised in each component of this review. Major databases searched included: MEDLINE, CINAHL, Scopus, ScienceDirect, the Cochrane library, PubMed as well as Google Scholar. The search included published studies and papers in English from 1990 to 2009.

METHODOLOGICAL QUALITY

Each included study was assessed by two independent reviewers using the appropriate appraisal checklists developed by the Joanna Briggs Institute (JBI).

DATA COLLECTION

Quantitative and qualitative data were extracted from the included papers using standardised data extraction tools from the JBI, Meta-analysis Statistics Assessment and Review Instrument data extraction tool for descriptive/case series and the JBI-Qualitative Assessment and Review Instrument data extraction tool for interpretive and critical research.

DATA SYNTHESIS

The five quantitative studies included in this review were not suitable for meta-analysis due to clinical and methodological heterogeneity and therefore the findings are presented in a narrative form. The two qualitative studies were from the same study, therefore meta-synthesis was not possible. Hence the results of the studies were presented in a narrative format.

RESULTS

Seven papers were included in this review. The evidence identified topics including: pharmacological and non-pharmacological interventions carried out by parents; the experience of concern, fear, helplessness, anxiety, depression, frustration and lack of support felt by parents during their child's hospitalisation; communication issues and knowledge deficits; need for information by parents to promote effective participation in managing their child's post-operative pain.

CONCLUSION

This review revealed pharmacological and non-pharmacological interventions carried out by parents to alleviate their children's post-operative pain. Obstacles and promoting factors influencing parents' experiences as well as their needs in the process of caring were identified.

IMPLICATIONS FOR PRACTICE

Parents' roles in their child's surgical pain management should be clarified and their efforts acknowledged, which will encourage parents' active participation in their child's caring process. Nurses should provide guidance, education and support to parents.

IMPLICATIONS FOR RESEARCH

More studies are needed to examine parents' experiences in caring for their child, investigate the effectiveness of education and guidance provided to parents by the nurses and explore the influence of parents' cultural values and nurses' perceptions of parental participation in their child's care.

The use of nonpharmacological methods for children's postoperative pain relief: Singapore nurses' perspectives

PURPOSE

The purpose of this study was to examine nurses' use of nonpharmacological methods for school-age children's postoperative pain relief.

DESIGN AND METHODS

A survey was conducted in 2008 with a convenience sample of 134 registered nurses from 7 pediatric wards in Singapore.

RESULTS

Nurses who were younger, had less education, lower designation, less working experience, and no children of their own used nonpharmacological methods less frequently.

PRACTICE IMPLICATIONS

Nurses need training and education on nonpharmacological pain relief methods, particularly on methods that have been shown to be effective in prior research but that were less often used by nurses in this study: massage, thermal regulation, imagery, and positive reinforcement.

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

BACKGROUND

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

OBJECTIVES

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

RESULTS

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

CONCLUSIONS

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

'I've just taken you to see the man with the CD on his head': the experience and management of recurrent sore throat in children

Tonsillectomies for children with recurrent sore throat are common. There is a perception amongst medical professionals that parents are eager for surgical intervention but the parent/child perspective is overlooked in the literature. This study aimed to identify parent/child experience of recurrent sore throat. The study was qualitative, using grounded theory approach to data collection/analysis. Semi-structured, in-depth, interviews were conducted with 12 dyads of children (aged 4-16) and their parents, attending two Ear, Nose and Throat outpatient clinics held at a hospital in North East England, referred by their General Practitioner for recurrent sore throats. Analysis revealed recurrent sore throats significantly affected the families' quality of life. Families felt the need for antibiotics and tonsillectomies although parent and child were not always in agreement over their choice of treatment. Families felt empowered when the health care system showed some flexibility, such as allowing self re-referral, giving families greater choice in the way they managed the condition. Policy makers need to be aware of the consequences of recurrent sore throats in children and the needs of families in managing this chronic condition. More flexible approaches to health care, such as self re-referral and use of waiting list to review symptoms, may be needed if the number of tonsillectomies is to be reduced.

A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy

OBJECTIVES

To determine the effectiveness of around-the-clock (ATC) analgesic administration, with or without nurse coaching, compared with standard care with as needed (PRN) dosing in children undergoing outpatient tonsillectomy.

METHODS

Children 6 to 15 years of age were randomized to receive acetaminophen and hydrocodone (167 mg/2.5 mg/5 mL) for 3 days after surgery: Group A (N=39)-every 4 hours PRN, with standard postoperative instructions; Group B (N=34)-every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C (N=40)-every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log, and recorded the presence and severity of opioid-related adverse effects and children's reports of pain intensity using a 0 to 10 numeric rating scale.

RESULTS

No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups. Therefore, they were combined for comparison with the PRN group. Children in the ATC group received more analgesic than those in the PRN group (P<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (P=0.017) and with swallowing (P=0.017). Pain intensity scores for both groups were higher in the morning compared with the evening (P<0.0001). With the exception of constipation, scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects.

DISCUSSION

Scheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children after tonsillectomy. Nurse coaching does not impact parent's adherence to ATC dosing.

Children's tonsillectomy experiences: influencing factors

The aim of this study was to explore factors influencing children's (7-13 years) tonsillectomy experiences and outcomes. A prospective, repeated measures, design was used to investigate the effect of age, gender, ethnicity, time, and previous pain, hospitalization and surgery on children's (N = 60) perceptions of anxiety, pain intensity, quality of pain and sleep, and oral intake. The relationship between postoperative pain and anxiety was also examined. Using a diary, three days of data were collected. Descriptive statistics, Pearson correlation coefficient, and a mixed linear regression model were used for analysis. Children's tonsillectomy experiences and outcomes were affected by time, previous experience, age, and anxiety. Moderate correlations were found between level of anxiety and pain intensity. These findings provide clinicians with additional knowledge to guide their perioperative practice and care of children.

Pain Management Practices in a Pediatric Emergency Room (PAMPER) Study: interventions with nurses

BACKGROUND AND AIM

Children's pain in emergency departments (EDs) is poorly managed by nurses, despite evidence that pain is one of the most commonly presenting complaints of children attending the ED. Our objectives were 2-fold: to verify if tailored educational interventions with emergency pediatric nurses would improve nurses' knowledge of pain management and nurses' pain management practices (documentation of pain, administration of analgesics, nonpharmacological interventions).

METHODS

This intervention study with a pre-post design (baseline, immediately after the intervention [T-2], and 6 months after intervention [T-3]) used a sample of nurses (N = 50) and retrospective chart reviews of children (N = 450; 150 charts reviewed each at baseline, T-2, and T-3) who presented themselves in the ED with a diagnosis known to generate moderate to severe pain (burns, acute abdominal pain, deep lacerations, fracture, sprain). Principal outcomes: nurses' knowledge of pain management (Pediatric Nurses Knowledge and Attitudes Survey [PNKAS] on pain) and nurses' clinical practices of pain management (Pain Management Experience Evaluation [PMEE]).

RESULTS

Response rate on the PNKAS was 84% (42/50) at baseline and 50% (21/42) at T-2. Mean scores on PNKAS were 28.2 (SD, 4.9; max, 42.0) at baseline and 31.0 (SD, 4.6) at T-2. Results from paired t test showed significant difference between both times (t = -3.129, P = 0.005). Nurses who participated in the capsules improved their documentation of pain from baseline (59.3%) to T-2 (80.8%; chi = 12.993, P < 0.001) as well as from baseline (59.3%) to T-3 (89.1%; chi = 29.436, P < 0.001). In addition, nurses increased their nonpharmacological interventions from baseline (16.7%) to T-3 (31.9%; chi = 8.623, P = 0.003). Finally, we obtained significant differences on pain documentation between the group of nurses who attended at least 1 capsule and the group of nurses who did not attend any capsule at both times (T-2 and T-3; chi = 20.424, P < 0.001; chi = 33.333, P < 0.001, respectively).

CONCLUSIONS

The interventions contributed to the improvement of the nurses' knowledge of pain management and some of the practices over time. We believe that an intervention tailored to nurses' needs and schedule has more impact than just passive diffusion of educational content.

The effect of preoperative fasting on postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy

OBJECTIVE

The aim of this prospective randomized study was to examine whether active counseling and more liberal oral fluid intake decrease postoperative pain, nausea and vomiting in pediatric ambulatory tonsillectomy.

METHODS

Families, whose child was admitted for ambulatory tonsillectomy or adenotonsillectomy, were randomly assigned to the study groups (n=116; 58 families in each group). The intervention group received the fasting instructions with face-to-face counseling for the child's active preoperative nutrition, and the control group the fasting instructions according to the hospital's standard procedure. The level of postoperative pain and nausea was scored in the postanesthesia care unit (PACU) during the first postoperative hour, as well as at 2, 4, 8 and 24h postoperatively. The first scoring in PACU was performed by the attending nurse with a 0-10 scale. The rest of the estimations were made independently and simultaneously by the children using a VAS scale, and by the parents using a 0-10 scale.

RESULTS

The children in the control group were in more pain in the PACU than the children in the intervention group, and the difference between the groups was statistically significant (p=0.0002). All pain scores, according to the children and the parents, increased after the surgery. In both groups the highest score values were found at home 8h after surgery, and no significant difference was found between the study groups. On the first postoperative morning, the children in the control group were in pain (p=0.047). The children did not have significant nausea in the PACU, but the nausea increased postoperatively. Four hours after surgery the children were most nauseous according to all estimations (60%, n=116). More than half of the children vomited and most vomited clotted blood. Nausea and vomiting decreased during the evening of the surgery, but six children vomited the next morning, four of them vomited blood. The incidence and intensity of postoperative nausea and vomiting between the intervention and control groups were not statistically significant. However, preoperative nutritional counseling and more liberal per oral fluid intake appeared to have a positive effect on the children's well-being and helped them to better tolerate postoperative nausea and vomiting.

CONCLUSIONS

The preoperative counseling about active preoperative nutrition significantly reduces the child's pain during the first posttonsillectomy hours and might prepare the child to better tolerate the stress of potential postoperative nausea and vomiting.

Children's pre-operative tonsillectomy pain education: clinical outcomes

OBJECTIVE

To examine the effects of pre-operative tonsillectomy pain education on children's (7-13 years) self-reported pre-operative anxiety and post-operative clinical outcomes (i.e., anxiety, pain intensity, quality of pain and sleep, oral intake, perceptions of pre-operative education, and pain expectation).

METHOD

A prospective, repeated measures, quasi-experimental design using an age appropriate pain education booklet (n = 30) and a standard care comparison group (n = 30) was employed to investigate children's pre- and post-education anxiety and post-operative tonsillectomy with or without adenoidectomy subjective experiences in the hospital and home settings. Group comparisons were performed using the Wilcoxon test, Fisher's exact test, repeated measures analysis of variance, and mixed model regression.

RESULTS

There were no significant differences between groups for measures of anxiety, pain intensity, quality of pain and sleep, oral intake, or expected pain. There was no change in anxiety before or after pre-operative education (P = 0.85). Ninety-six percent (n = 25) of the children in the intervention group reported that pre-operative pain education helped with their post-operative pain and 72% (n = 16) in the control group stated that it would be helpful to learn about pain before surgery. The majority of children in both the intervention and control groups (96%, 91%, respectively) stated learning about the 0-10 numeric pain intensity scale helped or would be helpful to learn pre-operatively.

CONCLUSION

Pre-operative pain education did not affect anxiety. Children valued pre-operative pain education. Pre-operative pain education may influence children's perceptions of medical care.

Adolescents' pain experiences following acute blunt traumatic injury: struggle for internal control

ISSUES AND PURPOSE

Although blunt trauma injury is a common cause for adolescent pain, little is known about the experience of pain as perceived by adolescents.

DESIGN AND METHOD

Semistructured interviews were conducted with 13 adolescents following blunt trauma injury. Two age-appropriate valid measures (i.e., Adolescent Pediatric Pain Tool and Temporal Dot Matrix) were incorporated into the interviews to elaborate their pain experiences. Grounded theory method was used to analyze data and build substantive theory.

RESULTS

Adolescents' behavioral and cognitive actions (i.e., "internal control") to manage and endure pain were influenced by their pain perceptions, physical losses, and clinicians' actions.

PRACTICE IMPLICATIONS

Nurses, family members, and peers have a crucial role in alleviating adolescents' distress and pain.

Children's expectations of pain, perceptions of analgesic efficacy, and experiences with nonpharmacologic pain management strategies at home following tonsillectomy

PURPOSE

To document children's (ages 6-15 years) descriptions of their pain management at home following tonsillectomy.

DESIGN AND METHODS

Audio-taped interviews of 80 children were transcribed and coded. Data for each response category were tabulated.

RESULTS

Children reported they had more pain after surgery than expected, the pain medicine helped to take their pain away, taking the pain medicine was associated with a negative response by some children, and cold liquids/food by mouth provided pain relief.

PRACTICE IMPLICATIONS

Findings provide insight into children's perspective of pain management at home following tonsillectomy and methods for relieving their pain.

A snapshot of children's postoperative tonsillectomy outcomes at home

PURPOSE

To describe home outcomes of pain, medication use, fluid intake, and emesis 24 hr after tonsillectomy and adenoidectomy. The theory of unpleasant symptoms provided a conceptualizing framework.

DESIGN AND METHODS

A secondary analysis was conducted. Outcomes for 76 children were recorded on a home diary that included: self-reported pain, analgesic use, fluids ingested, and emesis. Descriptive and inferential statistics were used.

RESULTS

Children reported moderate pain. Children who received analgesics received less than recommended standards. Only 11% of the children drank the recommended fluids, and 31% of the children vomited at home.

PRACTICE IMPLICATIONS

Parents need to become partners in pain management. Recommend multimodal discharge teaching and follow-up phone call at home to ensure adequate analgesic administration and fluid intake.

Perianesthesia Nurses’ Pain Management After Tonsillectomy and Adenoidectomy: Pediatric Patient Outcomes

Tonsillectomy and adenoidectomy (T and A) is a common, painful surgical procedure. The purpose of this descriptive-comparative study was to evaluate the effects of postanesthesia analgesic treatments on self-reported pain intensity, incidence of nausea and vomiting, and amount of oral fluid intake among pediatric patients after T and A. A total of 92 patients, 3 to 18 years old, received one of five analgesic treatments during their postoperative recovery: (1) intravenous fentanyl alone, (2) intravenous fentanyl in combination with an oral analgesic, (3) intravenous morphine alone, (4) intravenous morphine in combination with an oral analgesic, or (5) oral analgesics alone. Although significant differences were found in mg/kg morphine equivalents among the five analgesic groups (P < .0001), there were no differences in pain scores, incidence of nausea and vomiting, or amount of oral intake among the groups. Overall 29% of patients had nausea and vomiting, but all ingested oral fluids before discharge home. Nurses gave significantly more mg/kg morphine equivalents to patients who reported any pain while in the PACU (Phase I recovery) than patients who reported no pain (P = .046). All patient groups reported low pain scores upon discharge from Phase I and Phase II recovery. Nurses, however, reported difficulty obtaining pain-intensity scores for many patients, especially in Phase I. These findings suggest that despite variations in analgesics and the amount of analgesics administered, patients received adequate pain control. The findings also support the need for pain medication titration and validate that the amount required to relieve pain differs from child to child.