Chronic Pediatric Pain in Low- and Middle-Income Countries

Nation-wide decrease in the prevalence of pediatric chronic pain during the COVID-19 pandemic

OBJECTIVES

The COVID-19 pandemic was expected to increase prevalence and severity of chronic pain. We compared pandemic-era and pre-pandemic prevalence of chronic pain among children in the US.

METHODS

Data were obtained from the 2019 and 2020 National Survey of Children's Health, a web-or mail-based survey representative of children living in the US (n=20,359 in 2019; 29,159 in 2020). Caregiver-reported prevalence of chronic pain was compared between survey years using bivariate and multivariable methods.

RESULTS

The prevalence of chronic pain among US children decreased from 11 to 8% in the first year of the pandemic. Multivariable analysis adjusting for children's and caregivers' demographics and socioeconomic characteristics confirmed that in 2020, odds of caregiver-reported chronic pain declined by 33% (95% confidence interval: 23%, 42%; p<0.001).

CONCLUSIONS

The encouraging finding of a nationwide decrease in the prevalence of chronic pain calls into question initial predictions anticipating the pandemic to contribute to onset or persistence of chronic pain among children.

Pediatric Project ECHO® for Pain: implementation and mixed methods evaluation of a virtual medical education program to support interprofessional pain management in children and youth

BACKGROUND

Pediatric pain is a complex health challenge requiring a multi-modal management approach. It is critical that healthcare providers (HCPs) have access to ongoing, flexible education and mentorship specific to pediatric pain. However, there are significant gaps in available pain education and a need for more opportunities to support interprofessional training. Project Extension for Community Healthcare Outcomes (Project ECHO®) is a model for delivering online HCP education and cultivating a virtual community of practice. Within the pediatric pain setting, ECHO® has potential to improve local access to specialized pain knowledge, particularly among the physicians, nurses, and allied health providers who primarily manage these cases in community and hospital settings across rural and urban environments. The purpose of this study was three-fold. First, to evaluate the feasibility (participation levels, acceptability) of implementing Project ECHO® in the context of pediatric pain. Second, to measure preliminary program impacts on HCP knowledge, self-efficacy, and clinical practice. Third, to characterize HCP program engagement levels before and after onset of the COVID-19 pandemic.

METHODS

A needs assessment was conducted to identify interprofessional education gaps and inform the program curriculum. The no-cost Pediatric ECHO® for Pain program offered TeleECHO sessions (didactic and case-based learning) as well as foundational education. Surveys were distributed at baseline and 6 months to assess outcomes using 7-point Likert scales. Participant engagement was assessed for periods prior to and during the COVID-19 pandemic. Descriptive and inferential statistical analyses were conducted.

RESULTS

Eighty-five TeleECHO sessions were hosted, with a mean attendance of 34.1 ± 23.4 HCPs. Acceptability scores at 6 months (n = 33) ranged from 5.0 ± 1.4 to 6.5 ± 0.5. Participants reported statistically significant (p < 0.05) improvements in knowledge (7 out of 7 topics) and self-efficacy (8 out of 9 skills). Most participants reported positive practice impacts, including improved satisfaction with managing children with pain. Exploratory analyses showed a trend of greater engagement from ECHO® learners after onset of the COVID-19 pandemic.

CONCLUSIONS

Project ECHO® is a feasible and impactful model for virtual education of interprofessional HCPs in managing pediatric pain.

Paediatric chronic pain prevalence in low- and middle-income countries: A systematic review and meta-analysis

BACKGROUND

Chronic pain is a leading cause of morbidity in children and adolescents globally, with a significant impact on quality of life. This is the first systematic review and meta-analysis on paediatric chronic pain in low- and middle-income countries (LMICs).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched MEDLINE (via PubMed), Embase, CINAHL, PsycINFO, Web of Science, Cochrane Database of Systematic Reviews, and the WHO Global Index Medicus for all studies published prior to January 7, 2022. Articles published in all languages that included populations age 19 years and under living in LMICs were considered. Chronic pain was defined as persistent or recurrent pain that is present for ≥3 months, per the International Classification of Diseases (ICD-11) definition. Summary data were extracted from published reports and evaluated with mixed-effects regression analysis. PROSPERO Record ID: CRD42021227967.

FINDINGS

Of the 2875 studies identified, 70 articles were reviewed, with 27 studies representing 20 LMICs eligible for analysis. The average prevalence for each pain type reported with 95% confidence interval is as follows: general/multi-site/any 20% (16-25), musculoskeletal (MSK) pain 9% (7-13), abdominal pain 7% (5-10), headache 4% (2-10), and fibromyalgia per American College of Rheumatology or Yunus and Masi criteria 3% (1-10). Overall, a pooled mean of 8% chronic pain was estimated across all studies. A significantly high level of heterogeneity was found across all studies (I²  >90%). Chronic headache (OR=1·65, 95% CI 1·39-1·96), abdominal pain (OR=1·36, 95% CI 1·22-1·51), and generalized/multi-site pain (OR=1·54, 95% CI 1·31-1·81) were significantly more prevalent in females than males.

INTERPRETATION

The characterization of paediatric chronic pain in low- and middle-income countries suffers from a paucity of data and significant heterogeneity in the assessment methods. Understanding the global burden of chronic pain in this group should be prioritized.

FUNDING

None.

The Arabic Version of the Faces Pain Scale-Revised: Cultural Adaptation, Validity, and Reliability Properties When Used with Children and Adolescents

The Faces Pain Scale-Revised (FPS-R) is widely used to assess pain intensity in young people. The aims of this research were to study the convergent and discriminant validity and reliability properties of a culturally adapted version of the FPS-R for its use with Arabic-speaking individuals. The sample consisted of 292 students living in Lebanon. They were interviewed online, asked to imagine themselves in one of two given situations based on their age (8-12 and 13-18 years old), and then asked rate the intensity of pain they would experience using the FPS-R-Arabic and a Numerical Rating Scale (NRS-11-Arabic). They were also asked to respond to the Pain Catastrophizing Scale (PCS-C-Arabic). Two weeks later, participants were asked to repeat the same procedure. The data showed strong associations between the scores of the FPS-R-Arabic and NRS-11-Arabic (r = 0.72; p < 0.001), which were higher than the associations of the scores of the FPS-Arabic with the PCS-C-Arabic scores (z = 7.36, p < 0.001). The associations between the FPS-R-Arabic scores on the two measurements were also strong (r = 0.76; p < 0.001). The findings support the convergent and discriminant validity and reliability of the FPS-R-Arabic scores when used to measure pain intensity in young people aged 8 to 18 years old.

Pain Assessment and Management in Pediatric Intensive Care Units Around the World, an International, Multicenter Study

The adequate assessment and management of pain remains a challenging task in the Pediatric Intensive Care Unit (PICU). Our goal is to describe how pain is assessed and managed in PICUs around the world and to examine how human and material resources impact achievement of this goal. An international multicenter cross-sectional observational study was designed with the participation of 34 PICUs located in urban, suburban, and rural areas of 18 countries. We evaluated how PICUs around the world assessed and managed pain according to the Initiative for Pediatric Palliative Care recommendations, and how human and material resources impacted achievement of this goal. Data was collected for this study from 2016 to 2018 using questionnaires completed by medical doctors and nurses. In this paper, we focus on the indicators related to how pain is managed and assessed. The average achievement of the goal of pain relief across all centers was 72.2% (SD: 21.1). We found a statistically significant trend of more effective pain management scores, routine assessment, proper documentation, and involvement of pain management experts by increasing country income. While there are efforts being made worldwide to improve the knowledge in pain assessment and management, there is a lack of resources to do so appropriately in low-middle-income countries. There is a mismatch between the existing guidelines and policies, which are mainly designed in high income countries, and the resources available in lower resourced environments.

Successful Use of Multidisciplinary Palliative Care in the Outpatient Treatment of Disseminated Histoplasmosis in an HIV Positive Child

Histoplasmosis is an uncommon opportunistic infection in human immunodeficiency virus (HIV) positive children. The most common form is primary disseminated histoplasmosis, characterized by persistent fever and failure to thrive. A 10-year-old HIV positive girl presented to the Baylor College of Medicine Children’s Foundation—Tanzania Mbeya Center of Excellence (COE) with ulcerated skin lesions and a violaceous facial rash. She also had persistent fevers, severe acute malnutrition, and severe anemia. At diagnosis, the patient was failing first line antiretroviral therapy (ART) with a cluster of differentiation 4 immune cells (CD4) of 24 cells/µL and an HIV viral load (VL) of 196,658 cp/mL. The patient was changed to a second line ART regimen (abacavir, lamivudine, and ritonavir-boosted lopinavir) and received nutritional support, blood transfusions, multiple antibiotics, and meticulous wound care. She also received comprehensive symptom management, psychosocial support, and emergency housing through the COE’s palliative care program. Biopsy of a lesion showed intracytoplasmic organisms consistent with Histoplasmosis capsulatum var capsulatum. The patient was treated with conventional amphotericin B and oral itraconazole and she achieved wound healing as well as immune reconstitution and HIV viral suppression. Amphotericin infusions were given as an outpatient despite the resource constraints of the setting in southwestern Tanzania. Histoplasmosis should be considered in the differential diagnosis of the immunocompromised host with unusual skin manifestations and persistent fever.

Cross cultural adaptation and psychometric properties of the Bengali version of the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5)

BACKGROUND

The oral health related quality of life (OHRQoL) of children in Bangladesh has not yet been measured, as there is no validated OHRQoL measure for that population. The aim of this study was to cross-culturally adapt the child self-report and parental proxy report versions of the Scale of Oral Health Outcomes for 5-year-old children (SOHO-5) into Bengali and test their psychometric properties: face validity, construct validity (convergent and discriminant validity) and reliability (internal consistency and test-retest reliability), among 5-9-year-old children and their parents in Bangladesh and assess associations between dental caries/sepsis and OHRQoL in this population.

METHODS

The forward-backward translated Bengali SOHO-5 was piloted among 272 children and their parents to test its face validity. The questionnaire was administered to 788 children and their parents to evaluate its psychometric properties. Internal consistency of Bengali SOHO-5 was assessed using Cronbach's alpha, and test-retest reliability was assessed using Kappa. Convergent and discriminant validity were assessed through nonparametric tests. The calculation of effect sizes and standard error of measurement facilitated the assessment of minimally important difference (MID) for SOHO-5. The associations of reporting an oral impact with caries and sepsis were assessed via logistic regression models.

RESULTS

Both child self-report and parental proxy report questionnaires showed good face validity. Cronbach's alpha scores were 0.79 and 0.87 for child and parental questionnaire, respectively. A weighted Kappa score of 0.85 demonstrated test-retest reliability of child questionnaire. SOHO-5 scores were significantly associated with subjective oral health outcomes and discriminated clearly between different caries severity and sepsis groups. These differences were considerably higher than the MID. After adjusting for child's age, sex, setting, maternal education and family income, the odds of reporting an oral impact were 2.25 (95% CI 1.98-2.56) and 4.44 (95% CI 3.14-6.28) times higher for each additional tooth with caries and sepsis, respectively.

CONCLUSION

This study provided strong evidence supporting the validity and reliability of both versions of Bengali SOHO-5 as OHRQoL measures. Dental caries and sepsis were associated with poor OHRQoL in this population. The Bengali SOHO-5 is expected to be a useful outcome measure for research and clinical purposes in Bengali speaking child populations.