Fever and Pain Management in Childhood: Healthcare Providers' and Parents' Adherence to Current Recommendations

The information seeking behaviors of caregivers in the management of childhood fever - A systematic literature review

INTRODUCTION

Parents' and caregivers' non-evidence-based childhood fever management 'fever phobic' practices have remained relatively stable over more than 34 years despite successful educational interventions. This systematic review aimed to assess the information seeking behavior of caregivers managing fever in their children, as well as to compile the fever management practices undertaken by caregivers by investigating underlying factors influencing them.

METHODS

The electronic databases Pubmed, CINAHL, Medline, and International Pharmaceutical Abstracts were searched using key terms including, fever, child, caregiver, and management. Studies were included if they were written in English, published between January 1980 and January 2021, explored generalized childhood fever management practices of caregivers, and factors which influence fever management. Data extracted included study year and design, location, dimensions of fever management explored (i.e., knowledge, beliefs, detection, and/or treatment of fever), factors influencing management, and information sources used by caregivers.

RESULTS

In total, 36 studies were eligible for inclusion in the study. Twenty-nine of the studies were designed as a cross-sectional survey, six studies were interviews and the remainder were pre-post studies. The review of studies found that parents and caregivers sourced childhood fever management information most commonly from friends and family or their own personal experiences, however, participants most commonly sourced doctors/general practitioners as their first line of information when required. Over the years, trends showed that doctors as well as the internet were more frequently being used as a first line source of information by caregivers.

CONCLUSIONS

Despite decades of research, education and development of evidence-based guidelines caregivers continue to exhibit 'fever phobia' when caring for febrile children. This is demonstrated by their continued use of non-evidence-based methods and increasing reliance on, and incorrect use of antipyretics, alternating antipyretics if fever is not sufficiently reduced or returns. There is an increasing need for the development of easy to access digital resources for caregiver as internet use is rising which mirrors best practice taught to professionals.

Ibuprofen for acute postoperative pain in children

BACKGROUND

Children often require pain management following surgery to avoid suffering. Effective pain management has consequences for healing time and quality of life. Ibuprofen, a frequently used non-steroidal anti-inflammatory drug (NSAID) administered to children, is used to treat pain and inflammation in the postoperative period.

OBJECTIVES

1) To assess the efficacy and safety of ibuprofen (any dose) for acute postoperative pain management in children compared with placebo or other active comparators. 2) To compare ibuprofen administered at different doses, routes (e.g. oral, intravenous, etc.), or strategies (e.g. as needed versus as scheduled).

SEARCH METHODS

We used standard Cochrane search methods. We searched CENTRAL, MEDLINE, Embase, CINAHL and trials registries in August 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children aged 17 years and younger, treated for acute postoperative or postprocedural pain, that compared ibuprofen to placebo or any active comparator. We included RCTs that compared different administration routes, doses of ibuprofen and schedules.

DATA COLLECTION AND ANALYSIS

We adhered to standard Cochrane methods for data collection and analysis. Our primary outcomes were pain relief reported by the child, pain intensity reported by the child, adverse events, and serious adverse events. We present results using risk ratios (RR) and standardised mean differences (SMD), with the associated confidence intervals (CI). We used GRADE to assess the certainty of the evidence.

MAIN RESULTS

We included 43 RCTs that enroled 4265 children (3935 children included in this review). We rated the overall risk of bias at the study level as high or unclear for 37 studies that had one or several unclear or high risk of bias judgements across the domains. We judged six studies as having a low risk of bias across all domains. Ibuprofen versus placebo (35 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen probably reduces child-reported pain intensity less than two hours postintervention compared to placebo (SMD -1.12, 95% CI -1.39 to -0.86; 3 studies, 259 children; moderate-certainty evidence). Ibuprofen may reduce child-reported pain intensity, two hours to less than 24 hours postintervention (SMD -1.01, 95% CI -1.24 to -0.78; 5 studies, 345 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events compared to placebo (RR 0.79, 95% CI 0.51 to 1.23; 5 studies, 384 children; low-certainty evidence). Ibuprofen versus paracetamol (21 RCTs) No studies reported pain relief reported by the child or a third party, or serious adverse events. Ibuprofen likely reduces child-reported pain intensity less than two hours postintervention compared to paracetamol (SMD -0.42, 95% CI -0.82 to -0.02; 2 studies, 100 children; moderate-certainty evidence). Ibuprofen may slightly reduce child-reported pain intensity two hours to 24 hours postintervention (SMD -0.21, 95% CI -0.40 to -0.02; 6 studies, 422 children; low-certainty evidence). Ibuprofen may result in little to no difference in adverse events (0 events in each group; 1 study, 44 children; low-certainty evidence). Ibuprofen versus morphine (1 RCT) No studies reported pain relief or pain intensity reported by the child or a third party, or serious adverse events. Ibuprofen likely results in a reduction in adverse events compared to morphine (RR 0.58, 95% CI 0.40 to 0.83; risk difference (RD) -0.25, 95% CI -0.40 to -0.09; number needed to treat for an additional beneficial outcome (NNTB) 4; 1 study, 154 children; moderate-certainty evidence). Ibuprofen versus ketorolac (1 RCT) No studies reported pain relief or pain intensity reported by the child, or serious adverse events. Ibuprofen may result in a reduction in adverse events compared to ketorolac (RR 0.51, 95% CI 0.27 to 0.96; RD -0.29, 95% CI -0.53 to -0.04; NNTB 4; 1 study, 59 children; low-certainty evidence).

AUTHORS' CONCLUSIONS

Despite identifying 43 RCTs, we remain uncertain about the effect of ibuprofen compared to placebo or active comparators for some critical outcomes and in the comparisons between different doses, schedules and routes for ibuprofen administration. This is largely due to poor reporting on important outcomes such as serious adverse events, and poor study conduct or reporting that reduced our confidence in the results, along with small underpowered studies. Compared to placebo, ibuprofen likely results in pain reduction less than two hours postintervention, however, the efficacy might be lower at two hours to 24 hours. Compared to paracetamol, ibuprofen likely results in pain reduction up to 24 hours postintervention. We could not explore if there was a different effect in different kinds of surgeries or procedures. Ibuprofen likely results in a reduction in adverse events compared to morphine, and in little to no difference in bleeding when compared to paracetamol. We remain mostly uncertain about the safety of ibuprofen compared to other drugs.

Pain Management in Children Admitted to the Emergency Room: A Narrative Review

Pain is a biopsychosocial experience characterized by sensory, physiological, cognitive, affective, and behavioral components. Both acute and chronic pain can have short and long-term negative effects. Unfortunately, pain treatment is often inadequate. Guidelines and recommendations for a rational approach to pediatric pain frequently differ, and this may be one of the most important reasons for the poor attention frequently paid to pain treatment in children. This narrative review discusses the present knowledge in this regard. A literature review conducted on papers produced over the last 8 years showed that although in recent years, compared to the past, much progress has been made in the treatment of pain in the context of the pediatric emergency room, there is still a lot to do. There is a need to create guidelines that outline standardized and easy-to-follow pathways for pain recognition and management, which are also flexible enough to take into account differences in different contexts both in terms of drug availability and education of staff as well as of the different complexities of patients. It is essential to guarantee an approach to pain that is as uniform as possible among the pediatric population that limits, as much as possible, the inequalities related to ethnicity and language barriers.

Determining the fever-related knowledge and practices of mothers with children aged 1-5 years presenting to a child emergency service with fever complaints in Turkiye

PURPOSE

This study aimed to evaluate and determine the knowledge and practices of mothers with children aged between 1 and 5 years presenting to a pediatric emergency service with fever complaints regarding fever management.

DESIGN AND METHODS

This study was descriptive and correlational study was conducted between March and May 2019 with mothers over the age of 18 who brought their children aged 1-5 years to the XX State Hospital Pediatric Emergency Department with fever complaints. To evaluate the descriptive characteristics of the mothers and their practices when their children had a fever, data were collected with a questionnaire form consisting of 36 open-ended questions and the Parents' Fever Management Scale-Turkish Version (PFMS-TR). The data were analyzed using the SPSS 21 software with frequency, percentage, mean, standard deviation, min-max values, chi-squared, Cronbach's alpha, ANOVA, t-test, Kruskal- Wallis test, post hoc analysis with Bonferroni correction and correlation analysis, where p < 0.05, was considered statistically significant.

RESULTS

Of the mothers included in the study, 36.9% (n = 118) were between the ages of 33 and 39, 33.4% (n = 107) were graduates of higher education and 57.2% (n = 183) were homemakers. The mean number of people living at the homes of the participants was 4.26 ± 1.24 (min = 3, max = 8), the mean number of their children was 2.0 ±,97 (min = 1, max = 6), and the mean age of their children was 2.90 ± 1. 37 (min = 1, max = 5). The most common practices of the mothers when their children had fever were taking off their clothes and giving them antipyretic drugs. Moreover, the inappropriate practices of the mothers included rubbing the child with a vinegar and water mixture (11.9%) and cold application (8%). While 55.9% of the mothers were worried that the child would suffer post-fever convulsions 25.9% of them were worried that the child would suffer brain damage. A significant relationship was found between the mean scores of the mothers on PFMS-TR and their educational and economic statuses (p < 0.05).

CONCLUSIONS

Fears of fever are common in mothers, but their knowledge and practices about fever are inaccurate / incomplete.

PRACTICE IMPLICATIONS

Parents should be informed about fever with up-to-date information by nurses, and the appropriate attitude should be established on this issue. Efficient educational activities can reduce fears of mothers and prevent ill-advised practices.

Paediatric fever management practices and antipyretic use among doctors and nurses in New Zealand emergency departments

OBJECTIVES

To assess (i) paediatric fever management practices among New Zealand ED doctors and nurses, including adherence to best practice guidelines; and (ii) the acceptability of a randomised controlled trial (RCT) of antipyretics for relief of discomfort in young children.

METHODS

A cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The primary outcome of adherence to paediatric fever management best practice guidelines was assessed with clinical vignettes and defined as single antipyretic use for the relief of fever-related discomfort.

RESULTS

Out of 602 participants (243 doctors, 353 nurses and six unknown; response rate 47.5%), only 64 (10.6%, 95% confidence interval [CI] 8.3-13.4%) demonstrated adherence to best practice guidelines. In a febrile settled child with normal fluid intake, the percentage of participants that would use antipyretics doubled with abnormal vital signs (33.7% vs 72.9%, difference -39.2%, 95% CI -44.4% to -34.0%). Most participants would use antipyretics for reduced fluid intake (n = 494, 82.1%, 95% CI 78.8-85.0%) in a febrile settled child. Over half (n = 339, 57.1%, 95% CI 53.0-61.1%) would advise giving antipyretics to prevent febrile convulsions. Most (n = 467, 80.0%, 95% CI 76.5-83.1%) participants agreed that a RCT of antipyretics in febrile children <2 years of age with relief of discomfort as a primary outcome is needed.

CONCLUSIONS

Just over 10% of New Zealand ED doctors and nurses demonstrated adherence to paediatric fever management best practice guidelines. A RCT of antipyretics in febrile children <2 years of age specifically addressing relief of discomfort as a primary outcome is strongly supported.

Use of the Theoretical Domains Framework to explore factors influencing paediatric fever management practices and antipyretic use in New Zealand emergency departments

AIM

To explore factors influencing fever management practices and antipyretic use among New Zealand Emergency Department (ED) doctors and nurses using the Theoretical Domains Framework (TDF).

METHODS

Cross-sectional survey of doctors and nurses across 11 New Zealand EDs. The questionnaire examined eight of 12 TDF domains, based on a generic questionnaire validated to assess TDF-based determinants of health-care professional behaviour. Relevant domains were identified by the frequency of beliefs; the presence of conflicting beliefs within a domain; and the likely strength of impact of a belief on paediatric fever management in the ED.

RESULTS

About 602 participants (243 doctors, 353 nurses and 6 unknown) completed the survey (response rate 47.5%). Over half (351/591, 59.6%, 95% confidence interval (CI) 55.5-63.5%) knew the content of clinical practice guidelines regarding antipyretic use in febrile children (TDF Domain Knowledge), or had been trained to ensure antipyretics are given to febrile children only if they appear distressed (347/592, 58.6%, 95% CI 54.5-62.6%) (Skills). Over 40% (246/590, 95% CI 37.7-45.8%) aim to reduce the fever before discharge (Goals). Most (444/591, 75.1%, 95% CI 71.4-78.6%) participants felt capable of explaining appropriate antipyretic use to parents/care givers (Beliefs about Capabilities). Only a minority (155/584, 26.5%, 95% CI 23.0-30.3%) thought that they can ensure antipyretics are given to febrile children only if they appear distressed when the ED is busy (Environmental Context and Resources).

CONCLUSIONS

Using the TDF, we identified factors influencing fever management practices and antipyretic use in the ED. These factors can guide the design of targeted, theory-informed knowledge translation strategies.

Paracetamol and Ibuprofen in the Treatment of Fever and Acute Mild-Moderate Pain in Children: Italian Experts' Consensus Statements

Fever and pain are challenging symptoms in children and adolescents and are common reasons for consultations in primary care and hospital. Paracetamol and ibuprofen are currently the only recommended drugs for treating fever in Italy, but the therapeutic approaches are discrepant in the different settings. In Italy, paracetamol and ibuprofen are the most prescribed analgesics for acute mild–moderate pain in children; however, their use is often inappropriate in that fever is over-treated and pain is under-treated. An Italian board of experts analyzed the motivations for the misalignment between daily practice and guidelines of fever and acute mild–moderate pain management of the territory and hospitals. The expert opinion consensus process underscored the appropriate use of paracetamol and ibuprofen according to clinical scenarios, patients’ profiles, and the safety features of the drugs. Although patients’ profiles can indicate different benefits from paracetamol or ibuprofen, critical issues of fever and acute mild–moderate pain management persist in primary care and hospitals. These expert opinion consensus statements can be an across-the-board tool to harmonize the routine practice between the territory and hospitals, especially under special conditions (at-risk for dehydration, coagulation disorder patients, etc.). It can also promote educational activity about fever and acute mild–moderate pain management to enhance the milestones already achieved by Italian pediatricians.

Assessment of Saudi Mothers' Attitudes towards Their Children's Pain and Its Management

Background and objective: Pain is a bothersome issue that is common among newborns and children of all ages. Pain can be managed using various pharmacological and/or non-pharmacological strategies, which can be delivered by healthcare providers or parents. The aim of this study is to assess the attitude of mothers toward their children’s pain and its management. Methods and materials: A descriptive cross-sectional web-based study was conducted using a developed self-reported questionnaire, from March 2018 to April 2018. Participants involved were Arabic-speaking mothers of children aged between 0 and 12. The data collected included pharmacological and non-pharmacological treatment methodologies utilized to treat pain and the mothers’ attitude towards pain management. Statistical Package for Social Sciences, version 25 was applied to analyze the data, and descriptive statistics were performed. Results: As per the results of this study, the most common site of children’s pain as reported by the mothers was mouth/throat (211; 52.9%), abdomen (199; 49.9%), followed by head (58; 14.5%), and finally, ears (69; 17.3%). The frequency of children’s pain, as stated by the mothers, was less than once a month (196; 49.1%), once in a month (137; 34.3%), and once in a week (48; 12%). The non-pharmacological methods used by mothers at home for the management of their children’s pain were as follows: letting them take rest or sleep (250; 62.6%), feeding them with fluids (228; 57.1%), applying cold packs (161; 40.4%), providing massage therapy (147; 36.8%), using warm packs (141; 35.3%), and taking them to play (119; 29.8%). Conclusion: The misconceptions about pediatric pain management among Saudi mothers that can affect the children’s quality of life are quite noticeable. Implementing educational and awareness programs about the management of child pain could play a major role in making the parents understand the impacts of their misconceptions.

Acute pain management in children: a survey of Italian pediatricians

BACKGROUND

Current guidelines recommend assessing and relieving pain in all children and in all instances; yet, in clinical practice, management is frequently suboptimal. We investigated the attitude of Italian family pediatricians towards the evaluation and treatment of different types of acute pain in children aged 7-12 years.

METHODS

This is a cross-sectional study based on a 17-question survey accessible online from October 2017 to October 2018. Responders had to describe cases of children suffering from any type of acute pain among headache, sore throat, musculoskeletal/post-traumatic pain, and earache. Children's characteristics, pain assessment modalities and therapeutic approaches were queried. The following tests were used: Z-proportion to evaluate the distribution of categorical data; chi-squared and Kruskall-Wallis to explore data heterogeneity across groups; Mann-Whitney for head-to-head comparisons.

RESULTS

Overall, 929 pediatricians presented 6335 cases uniformly distributed across the types examined. Pain was more frequently of moderate intensity (42.2%, P < 0.001) and short duration (within some days: 98.4%, P < 0.001). Only 50.1% of responders used an algometric scale to measure pain and 60.5% always prescribed a treatment. In children with mild-moderate pain (N = 4438), the most commonly used first-line non-opioids were ibuprofen (53.3%) and acetaminophen (44.4%). Importantly, a non-recommended dosage was prescribed in only 5.3% of acetaminophen-treated cases (overdosing). Among the misconceptions emerged, there were the following: i) ibuprofen and acetaminophen have different efficacy and safety profiles (when choosing the non-opioid, effectiveness weighted more for ibuprofen [79.7% vs 74.3%, P < 0.001] and tolerability for acetaminophen [74.0% vs 55.4%, P < 0.001]); ii) ibuprofen must be taken after meals to prevent gastric toxicities (52.5%); ibuprofen and acetaminophen can be used combined/alternated for persisting mild-moderate pain (16.1%). In case of moderate-severe pain not completely controlled by opioids, ibuprofen and acetaminophen were the most used add-on medications, with ibuprofen being much more prescribed than acetaminophen (65.2% vs 23.7%, respectively) overall and in all pain types.

CONCLUSIONS

Several gaps exist between the current practice of pain assessment and treatment and recommendations. Further efforts are needed to raise awareness and improve education on the possible exposure of the child to short- and long-term consequences in case of suboptimal pain management.

Understanding Discomfort in Order to Appropriately Treat Fever

Although national and international guidelines on the management of childhood and adolescent fever are available, some inadequate practices persist, both from parents and healthcare professionals. The main goal of bringing children’s temperature back to normal can lead to the choice of inappropriate drugs or non-necessary combination/alternation of antipyretic treatments. This behavior has been described in the last 35 years with the concept of fever-phobia, caused also by the dissemination of unscientific information and social media. It is therefore increasingly important that pediatricians continue to provide adequate information to parents in order to assess the onset of signs of a possible condition of the child’s discomfort rather than focusing only on temperature. In fact, there is no clear and unambiguous definition of discomfort in literature. Clarifying the extent of the feverish child’s discomfort and the tools that could be used to evaluate it would therefore help recommend that antipyretic treatment is appropriate only if fever is associated with discomfort.

Educational interventions on fever management in children: A scoping review

BACKGROUND

Numerous studies have been conducted specifically to target "fever phobia" and inappropriate fever management skills. However, despite educational intervention, caregivers continue to adopt inappropriate and non-evidence-based practices.

AIMS

To collect and examine peer-reviewed literature for active educational interventions aimed at improving fever management in children and profile them based on: who provided the training, training location, how the intervention was delivered, outcomes of training, and how it was measured.

DESIGN

Scoping Review.

METHODS

MEDLINE, EMBASE, CINAHL, PubMED, PsycINFO, and IPA were searched from January 1980-December 2016. Study location, type of intervention, intervention target, study aim(s), sample size, instruments, outcome measures, and results were extracted.

RESULTS

Thirty-seven studies met the inclusion criteria. Most targeted parents with the remainder focused on healthcare professionals. The interventions and their outcome measures varied significantly from structured group training sessions to video interventions and many using a combination of methods. Most interventions reported a positive impact in outcomes such as knowledge, health service use, or fever management skills.

CONCLUSION

More standardized educational platforms targeted at both caregivers and healthcare professionals with appropriate evaluation methods should be developed and made widely available.

An investigation of the views and practices of Australian community pharmacists on pain and fever management and clinical guidelines

Background:

Fever and pain are common conditions in the Australian healthcare setting. Whilst clinical guidelines provide important therapeutic recommendations, evidence suggests they are not always followed. Given that community pharmacy is one of the most frequently accessed primary healthcare services, it is important to understand the views and practices of community pharmacists in pain and fever.

Objectives:

To investigate the views and practices of Australian community pharmacists in pain and fever management, and their views on relevant clinical guidelines.

Methods:

A cross-sectional study of community pharmacists in Australia was conducted using a customised, anonymous, self-administered, online questionnaire between March and May 2018. To capture a broad range of demographics, pharmacists were recruited via local industry contacts and the Pharmaceutical Society newsletter, with further recruitment through snowball sampling. The main outcomes measured were pharmacists’ views, practices and treatment recommendation of choice in pain and fever management, as well as views on clinical guidelines and training.

Results:

A total of 113 pharmacists completed the survey. In general, paracetamol (72%) was preferred as a recommendation over ibuprofen, and was the drug of choice for most mild to moderate pain and fever scenarios. Majority of pharmacists reported good knowledge of pain and fever management, however, only approximately half reported recent pain management training. Greater than 87% of pharmacists believe that clinical guidelines are useful in fever management, and 79% of pharmacists believe that following clinical guidelines is important in pain management.

Conclusions:

While most pharmacists recognise the importance of guidelines and demonstrated good pain and fever management, results suggests opportunities to promote additional education, upskilling, and research in this space to further optimise pain and fever management in the community.

Ability of Pharmacy Students, Pharmacists and Pharmacy Support Staff to Manage Childhood Fever via Simulation

Objective. To ascertain how pharmacy students (novices) and pharmacy staff (experts) respond to a childhood fever scenario. Methods. Data were collected from 65 second year students and 51 fourth (final) year students in an over-the-counter fever scenario during assessment tasks. Data from pharmacy staff were collected via mystery shopping conducted over nine weeks between March and October 2015. All encounters were immediately scored by the trained simulated client, and immediate feedback was provided for pharmacy staff and fourth year students. Questioning scores and proportions of competent participants were collected in all groups. Statistical comparative analyses were made between fourth year students and pharmacy staff. Pharmacy staff scores were also tracked over time. Results. Second year students performed well, achieving a median questioning score of 100%. Conversely, pharmacy staff scored 22%. A large proportion of the fourth year students and pharmacy staff achieved appropriate outcomes (92% and 65%, respectively); however, a smaller proportion of second year students performed well (52%). The pharmacy staff achieved statistical improvements over time for median questioning scores. Conclusion. Protocol compliant questioning appears to decline with experience. However, experienced counselors are more likely to provide appropriate patient advice. Further improvements in outcomes can also occur when staff are provided feedback and coaching. Mystery shopping simulations can be used as a valuable educational tool.

Utilization of Antipyretics for Nonurgent Fever in a Pediatric Emergency Department

This retrospective cohort study aimed to describe antipyretic use among healthy patients in a pediatric emergency department (ED) with nonurgent fever defined as: triage level 4 or 5, chief complaint fever or temperature 38°C to 39°C, and otherwise normal vital signs, and determine if antipyretic administration is associated with increased ED length of stay (LOS). We compared continuous variables using Kruskal-Wallis and Wilcoxon rank sum testing. We adjusted confounding variables using logistic regression modeling. A total of 22 169 patients were included. Of these, 52% received antipyretic: acetaminophen (38%), ibuprofen (19%), or both antipyretics (5%). ED LOS (median hours) varied by number of antipyretic types given (none, 2.2; ibuprofen, 2.7; acetaminophen, 2.7; and both 3.4, P < .001) and number of doses (0 doses, 2.2, 1 dose, 2.7; 2 doses, 3.4, P < .001). Patients who received antipyretic were more likely to have ED LOS greater than 2 hours (adjusted odds ratio 1.99, 95% CI 1.88-2.11) compared with those with no antipyretic, controlling for age, imaging studies, laboratory studies, antibiotic administration, and disposition.

Comparison of paracetamol, ibuprofen, and diclofenac potassium for pain relief following dental extractions and deep cavity preparations

Objectives:

To compare the effectiveness of different oral analgesics for relieving pain and distress in adults following the extraction of teeth and deep cavity preparations under local anesthesia.

Methods:

This randomized controlled study was conducted between November 2015 and May 2016. One hundred and twenty patients were randomly allocated to 3 groups. Forty patients were in the paracetamol (1 gram) group, 40 in the ibuprofen (400 mg) group and 40 in the diclofenac potassium (50 mg) group. Evaluation of the post extraction and deep cavity preparations pain was made by patients immediately postoperatively, 2, 4 and 6 hours postoperatively on standard 100 mm visual analogue scales (VAS). Furthermore, each patient was observed preoperatively and immediately postoperatively for signs of distress by using a 5 point face scale.

Results:

There were significant decreases in mean pain VAS scores for diclofenac potassium group compared to paracetamol and ibuprofen groups at 4 hours postoperatively (one-way Analysis of Variance: p=0.0001, p=0.001) and 6 hours postoperatively (p=0.04, p=0.005). Changes in distress scores from the preoperative score to the postoperative score were made using the paired sample t-test. There were significant decreases in distress scores between the preoperative and postoperative scores (p=0.0001).

Conclusions:

Diclofenac potassium was more effective than paracetamol or ibuprofen for reducing postoperative pain associated with tooth extraction and deep cavity preparation. Patients’ distress levels can be alleviated by using preemptive analgesics.

Albizia zygia (DC.) J.F. Macbr. (Leguminosae-Mimosoideae) root extract exhibits anti-nociceptive and antipyretic activities in murine models

ETHNOPHARMACOLOGICAL RELEVANCE

The root extract of Albizia zygia (DC.) J.F. Macbr. (Leguminosae-Mimosoideae) is traditionally used in the management of pain and fever. However, little scientific data exists in literature to support its use.

AIM OF STUDY

The present study evaluated the anti-nociceptive and antipyretic properties of the hydroethanolic extract of the roots of Albizia zygia in animal models.

MATERIALS AND METHODS

The analgesic effects were investigated in chemical (acetic acid-induced abdominal writhing and formalin tests), thermal (tail-immersion test) and mechanical (carrageenan-induced hyperalgesia) pain models. Possible mechanisms of anti-nociception were also assessed with antagonists in the formalin test. The anti-pyretic effect was evaluated using the baker yeast-induced pyrexia model in young rats.

RESULTS

The extract (30-300mg/kg, p.o.) and positive controls, diclofenac (3-30mg/kg, i.p.) and morphine (1-10mg/kg, i.p.), significantly (at least P<0.01) attenuated acetic acid-induced visceral pain, formalin- induced paw pain (both neurogenic and inflammatory), thermal pain as well as carrageenan-induced mechanical hyperalgesia in animals. The anti-nociceptive effect of the extract was reversed (at least P<0.05) by the pre-emptive administration of naloxone and atropine; the administration of theophylline, however, exhibited no significant (P>0.05) inhibition of anti-nociception. The extract (30-300mg/kg, p.o) and paracetamol (15-150mg/kg, p.o.) both reversed yeast-induced pyrexia in rats with ED₅₀ values of 48.59±2.59 and 26.19±1.33mg/kg respectively.

CONCLUSION

The findings indicate that the extract possesses significant anti-nociceptive and antipyretic effects which justify its traditional use in the management of pain and fever. Also, anti-nociceptive effect of the extract involves opioidergic and muscarinic cholinergic mechanisms.

Healthcare Providers' Knowledge and Current Practice of Pain Assessment and Management: How Much Progress Have We Made?

Context. Despite improvement in pain management and availability of clinical treatment guidelines, patients in Jordan are still suffering from pain. Negative consequences of undertreated pain are being recognized as a reason for further illnesses and poor quality of life. Healthcare providers (HCPs) are responsible for relieving pain of their patients. Objective. To evaluate the knowledge and attitudes of HCPs toward pain management in Jordan. Methods. A 16-item questionnaire with agree or disagree options was given to 662 HCPs in seven hospitals in Jordan who volunteered to participate in the study. Following data collection, the responses were coded and entered into SPSS. Results. There was a statistically significant difference (p < 0.004) in percentage scores between physicians (36%) and pharmacists (36%) versus nurses (24%). The level of knowledge was the best among physicians, followed by pharmacists specifically in the area of cancer pain management. Nurses scored the lowest for knowledge of pain assessment and management among HCPs. However, HCPs overall scores indicated insufficient knowledge specifically in relation to pain assessment and management among children.