Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties

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.

A randomized controlled trial of graded exposure treatment (GET living) for adolescents with chronic pain

ABSTRACT

Graded exposure treatment (GET) is a theory-driven pain treatment that aims to improve functioning by exposing patients to activities previously feared and avoided. Combining key elements of GET with acceptance-based exposure, GET Living (GL) was developed for adolescents with chronic pain (GL). Based on robust treatment effects observed in our single-case experimental design pilot trial of GL (NCT01974791), we conducted a 2-arm randomized clinical trial comparing GL with multidisciplinary pain management (MPM) comprised of cognitive behavioral therapy and physical therapy for pain management (NCT03699007). A cohort of 68 youth with chronic musculoskeletal pain (M age 14.2 years; 81% female) were randomized to GL or MPM. Owing to COVID-19 restrictions, 54% of participants received zoom video delivered care. Assessments were collected at baseline, discharge, as well as at 3-month and 6-month follow-up. Primary outcomes were self-reported pain-related fear and avoidance. Secondary outcomes were child functional disability and parent protective responses to child pain. As hypothesized, GL improved in primary and secondary outcomes at 3-month follow-up. Contrary to our superiority hypothesis, there was no significant difference between GL and MPM. Patients reported both GL and MPM (in person and video) as credible and were highly satisfied with the treatment experience. Next steps will involve examining the single-case experimental design data embedded in this trial to facilitate an understanding of individual differences in treatment responses (eg, when effects occurred, what processes changed during treatment within the treatment arm). The current findings support GET Living and MPM for youth with chronic pain.

Predictors of triage pain assessment and subsequent pain management among pediatric patients presenting to the emergency department

BACKGROUND

Pediatric patients with pain of various causes present to the emergency department. Appropriate assessment and management of pain are important aspects of emergency department treatment. However, only a few studies have identified the predictors of both outcomes. This study aimed to evaluate the rate of pain assessment at triage and subsequent management and to identify the predictors of each outcome.

METHODS

This was a multi-center retrospective study based at five community emergency departments. Pediatric patients (< 18 years) with pain or injury who presented to the emergency department between February 2018 and May 2018 were included. In addition to patient demographics, the initial pain assessment at triage, reason for visit, and time to analgesia were determined. Further, the type and route of analgesia were identified in patients who received analgesia. Univariate and multivariable regression models were used to identify predictors of pain assessment and management.

RESULTS

There were 4,128 patients with an average age of 9.6 years, and 49.1% of them were female. Only 74.2% of the patients underwent assessment for pain at triage, and 18.3% received analgesia. The median time to analgesia was 95 (IQR: 49-154) min. Most patients presented with head/neck (36.1%), upper limb (21.6%), and lower limb (19.9%) pain. The oral route was the most common analgesia delivery method (67.4%), and ibuprofen and acetaminophen were the primary agents used. Younger age, higher acuity, and presenting with head or neck pain were independent predictors of pain assessment at triage, while children 3-5 years and those with lower extremity pain were more likely to receive analgesia.

CONCLUSION

Although pain assessment at triage has improved in pediatric patients, there is still a major deficiency in adequate pain management. Our study highlights predictors of pain assessment and management that can be considered for improved pediatric care.

Diclofenac for acute postoperative pain in children

BACKGROUND

Many children undergo various surgeries, which often lead to acute postoperative pain. This pain influences recovery and quality of life. Non-steroidal anti-inflammatory drugs (NSAIDs), specifically cyclo-oxygenase (COX) inhibitors such as diclofenac, can be used to treat pain and reduce inflammation. There is uncertainty regarding diclofenac's benefits and harms compared to placebo or other drugs for postoperative pain.

OBJECTIVES

To assess the efficacy and safety of diclofenac (any dose) for acute postoperative pain management in children compared with placebo, other active comparators, or diclofenac administered by different routes (e.g. oral, rectal, etc.) or strategies (e.g. 'as needed' versus 'as scheduled').

SEARCH METHODS

We used standard, extensive Cochrane search methods. We searched CENTRAL, MEDLINE, and trial registries on 11 April 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) in children under 18 years of age undergoing surgery that compared diclofenac (delivered in any dose and route) to placebo or any active pharmacological intervention. We included RCTs comparing different administration routes of diclofenac and different strategies.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Our primary outcomes were: pain relief (PR) reported by the child, defined as the proportion of children reporting 50% or better postoperative pain relief; pain intensity (PI) reported by the child; adverse events (AEs); and serious adverse events (SAEs). We presented results using risk ratios (RR), mean differences (MD), and standardised mean differences (SMD), with the associated confidence intervals (CI).

MAIN RESULTS

We included 32 RCTs with 2250 children. All surgeries were done using general anaesthesia. Most studies (27) included children above age three. Only two studies had an overall low risk of bias; 30 had an unclear or high risk of bias in one or several domains. Diclofenac versus placebo (three studies) None of the included studies reported on PR or PI. We are very uncertain about the benefits and harms of diclofenac versus placebo on nausea/vomiting (RR 0.83, 95% CI 0.38 to 1.80; 2 studies, 100 children) and any reported bleeding (RR 3.00, 95% CI 0.34 to 26.45; 2 studies, 100 children), both very low-certainty evidence. None of the included studies reported SAEs. Diclofenac versus opioids (seven studies) We are very uncertain if diclofenac reduces PI at 2 to 24 hours postoperatively compared to opioids (median pain intensity 0.3 (interquartile range (IQR) 0.0 to 2.5) for diclofenac versus median 0.7 (IQR 0.1 to 2.4) in the opioid group; 1 study, 50 children; very low-certainty evidence). None of the included studies reported on PR or PI for other time points. Diclofenac probably results in less nausea/vomiting compared to opioids (41.0% in opioids, 31.0% in diclofenac; RR 0.75, 95% CI 0.58 to 0.96; 7 studies, 463 participants), and probably increases any reported bleeding (5.4% in opioids, 16.5% in diclofenac; RR 3.06, 95% CI 1.31 to 7.13; 2 studies, 222 participants), both moderate-certainty evidence. None of the included studies reported SAEs. Diclofenac versus paracetamol (10 studies) None of the included studies assessed child-reported PR. Compared to paracetamol, we are very uncertain if diclofenac: reduces PI at 0 to 2 hours postoperatively (SMD -0.45, 95% CI -0.74 to -0.15; 2 studies, 180 children); reduces PI at 2 to 24 hours postoperatively (SMD -0.64, 95% CI -0.89 to -0.39; 3 studies, 300 children); reduces nausea/vomiting (RR 0.47, 95% CI 0.25 to 0.87; 5 studies, 348 children); reduces bleeding events (RR 0.57, 95% CI 0.12 to 2.62; 5 studies, 332 participants); or reduces SAEs (RR 0.50, 95% CI 0.05 to 5.22; 1 study, 60 children). The evidence certainty was very low for all outcomes. Diclofenac versus bupivacaine (five studies) None of the included studies reported on PR or PI. Compared to bupivacaine, we are very uncertain about the effect of diclofenac on nausea/vomiting (RR 1.28, 95% CI 0.58 to 2.78; 3 studies, 128 children) and SAEs (RR 4.52, 95% CI 0.23 to 88.38; 1 study, 38 children), both very low-certainty evidence. Diclofenac versus active pharmacological comparator (10 studies) We are very uncertain about the benefits and harms of diclofenac versus any other active pharmacological comparator (dexamethasone, pranoprofen, fluorometholone, oxybuprocaine, flurbiprofen, lignocaine), and for different routes and delivery of diclofenac, due to few and small studies, no reporting of key outcomes, and very low-certainty evidence for the reported outcomes. We are unable to draw any meaningful conclusions from the numerical results.

AUTHORS' CONCLUSIONS

We remain uncertain about the efficacy of diclofenac compared to placebo, active comparators, or by different routes of administration, for postoperative pain management in children. This is largely due to authors not reporting on clinically important outcomes; unclear reporting of the trials; or poor trial conduct reducing our confidence in the results. We remain uncertain about diclofenac's safety compared to placebo or active comparators, except for the comparison of diclofenac with opioids: diclofenac probably results in less nausea and vomiting compared with opioids, but more bleeding events. For healthcare providers managing postoperative pain, diclofenac is a COX inhibitor option, along with other pharmacological and non-pharmacological approaches. Healthcare providers should weigh the benefits and risks based on what is known of their respective pharmacological effects, rather than known efficacy. For surgical interventions in which bleeding or nausea and vomiting are a concern postoperatively, the risks of adverse events using opioids or diclofenac for managing pain should be considered.

The Rating of Perceived Exertion-Pediatric (RPE-P) Scale: Preliminary Validation

Physical activity is critical to functional rehabilitation for youth with chronic pain, which may be especially true for those with co-occurring obesity. To facilitate the development of physical activity interventions for youth with chronic pain, the newly developed "Rating of Perceived Exertion-Pediatric" scale was modeled after the widely used pain numeric rating scale-11. This study is an initial evaluation of the scale in a sample of adolescents (n = 157, 13-17 years, 51% female) with four subgroups: (1) healthy controls (healthy weight/no pain); (2) chronic pain/healthy weight; (3) obese (no pain); (4) chronic pain/obese. Participants rated perceived exertion using the new scale and the Borg 6-20 Scale of Perceived Exertion while holding a three-minute yoga pose (Warrior II). In the whole sample, the Perceived Exertion-Pediatric scale showed good concurrent (p < 0.001), convergent (all ps < 0.05), discriminant (p = 0.431), and known-groups validity (all ps < 0.05). The chronic pain subgroup also showed good concurrent (p < 0.001), mixed convergent (ps < 0.001 to 0.315), and good discriminant validity (p = 0.607). Limitations include the restricted age range, lack of diversity, and lack of test-retest reliability. The RPE-P shows promise as an assessment tool for perceived exertion in adolescents with and without chronic pain.

Psychometric evaluation of the electronic faces thermometer scale for pain assessment in children 8-17 years old: A study protocol

It is often a challenge for a child to communicate their pain, and their possibilities to do so should be strengthened in healthcare settings. Digital self-assessment provides a potential solution for person-centered care in pain management and promotes child participation when a child is ill. A child's perception of pain assessment differs when it is assessed using digital or analog formats. As we move into the digital era, there is an urgent need to validate digital pain assessment tools, including the newly developed electronic Faces Thermometer Scale (eFTS). This study protocol describes three studies with the overall aim to evaluate psychometric properties of the eFTS for assessing pain in children 8-17 years of age. A multi-site project design combining quantitative and qualitative methods will be used for three observational studies. Study 1: 100 Swedish-speaking children will report the level of anticipated pain from vignettes describing painful situations in four levels of pain and a think-aloud method will be used for data collection. Data will be analyzed with phenomenography as well as descriptive and comparative statistics. Study 2: 600 children aged 8-17 years at pediatric and dental settings in Sweden, Denmark, Iceland, and USA will be included. Children will assess their pain intensity due to medical or dental procedures, surgery, or acute pain using three different pain Scales for each time point; the eFTS, the Faces Pain Scale Revised, and the Coloured Analogue Scale. Descriptive and comparative statistics will be used, with subanalysis taking cultural context into consideration. Study 3: A subgroup of 20 children out of these 600 children will be purposely included in an interview to describe experiences of grading their own pain using the eFTS. Qualitative data will be analyzed with content analysis. Our pilot studies showed high level of adherence to the study procedure and rendered only a small revision of background questionnaires. Preliminary analysis indicated that the instruments are adequate to be used by children and that the analysis plan is feasible. A digital pain assessment tool contributes to an increase in pain assessment in pediatric care. The Medical Research Council framework for complex interventions in healthcare supports a thorough development of a new scale. By evaluating psychometric properties in several settings by both qualitative and quantitative methods, the eFTS will become a well-validated tool to strengthen the child's voice within healthcare.

Co-designing clinical trials alongside youth with chronic pain

Youth have a right to participate in research that will inform the care that they receive. Engagement with children and young people has been shown to improve rates of enrollment and retention in clinical trials as well as reduce research waste. The aim of the study is to gain practical insight on the design of trials specifically on (1) recruitment and retention preferences, (2) potential barriers to research, and (3) study design optimization. Based on this youth engagement, we will co-design two clinical trials in headaches with youth. Two recruitment strategies were used to recruit 16 youth from across Canada (aged 15-18 years) from an existing youth group, the KidsCan Young Persons' Research Advisory Group (YPRAG) and a new youth group in collaboration with Solutions for Kids in Pain (SKIP). Four virtual, semi-structured discussion groups were held between April and December 2020, which included pre-circulated materials and utilized two distinct upcoming planned trials as examples for specific methods feedback. Individual engagement evaluations were completed following the final group session using the Public and Patient Engagement Evaluation Tool. Descriptive results were shared with participants prior to publication to ensure appropriate interpretation. The discussion was centred around three themes: recruitment and retention preferences, potential barriers to participation, and study design optimization. Youth indicated that they would prefer to be contacted for a potential study directly by their physician (not over social media), that they would like to develop rapport with study staff, and that one of the barriers to participation is the time commitment. The youth also provided feedback on the design of the clinical trial including outcome measurement tools, data collection, and engagement methods. Feedback on the virtual format of the engagement events indicated that participants appreciated the ease of the online discussion and that the open-ended discussion allowed for easy exchange of ideas. They felt that despite a gender imbalance (towards females) it was an overall inclusive environment. All participants reported believing that their engagement will make a difference to the work of the research team in designing the clinical trials. Perspectives from a diverse group of youth meaningfully improved the design and conduct of two clinical trials for headaches in children. This study provides a framework for future researchers to engage youth in the co-design of clinical trials using online engagement sessions.

Therapeutic Relationships in Applied Behavior Analysis: Current Status and Future Directions

For behavior analytic practitioners, skills related to building a therapeutic alliance (e.g., empathic statements, reflective listening, affirmations) may be as important as knowledge of and skills in implementation of the science of behavior analysis. We surveyed 277 board certified behavior analysts (BCBAs) to learn more about their training, use of these skills, and their perceptions of how their skills might have changed over years of practicing. The findings suggest that behavior analysts may benefit from explicit training in skills required to establish and maintain therapeutic relationships with parents of children with autism. In this article we review recent research in this area and suggest directions for training of behavior analysts. Further, motivational interviewing is introduced as an evidence-based clinical approach that encompasses many of the skills required to build a therapeutic alliance.

A systematic review of the biopsychosocial dimensions affected by chronic pain in children and adolescents: identifying reliable and valid pediatric multidimensional chronic pain assessment tools

Pediatric chronic pain is a complex experience that is often challenging to describe and measure. Multidimensional tools that evaluate the biopsychosocial impact of chronic pain in pediatric patients can help clinicians to prioritize and tailor interdisciplinary pain care; yet, the psychometric value and clinical utility of such tools has not yet been systematically studied in the literature. The purpose of this review was to identify multidimensional biopsychosocial tools used in pediatric chronic pain, synthesize their reliability and validity evidence, and draw on this evidence to describe the relationships between chronic pain and biopsychosocial domains. The search involved 2 phases to (1) identify eligible tools and (2) conduct a measured forward citation search of tool development articles. Tool eligibility was guided by the Multidimensional Biobehavioral Model of Pediatric Pain and study eligibility was focused on primary chronic pain diagnoses unrelated to disease. Data extraction was focused on reliability and validity evidence of eligible tools, guided by the Standards for Educational and Psychological Testing. Results yielded 6 tools that included 64 eligible studies, highlighting 84 significant relationships between pain and functional interference across 11 biopsychosocial variables. All tools were shown to have good internal consistency and evidence of validity, primarily through relationships to other variables. Of the 6 tools, the most brief and easy to use were the most under studied. Further psychometric research is warranted for these tools to investigate their clinical utility and psychometric properties in guiding and prioritizing pain care for children and adolescents.

Assessment of comorbid symptoms in pediatric autonomic dysfunction

PURPOSE

Pediatric patients with autonomic dysfunction and orthostatic intolerance (OI) often present with co-existing symptoms and signs that might or might not directly relate to the autonomic nervous system. Our objective was to identify validated screening instruments to characterize these comorbidities and their impact on youth functioning.

METHODS

The Pediatric Assembly of the American Autonomic Society reviewed the current state of practice for identifying symptom comorbidities in youth with OI. The assembly includes physicians, physician-scientists, scientists, advanced practice providers, psychologists, and a statistician with expertise in pediatric disorders of OI. A total of 26 representatives from the various specialties engaged in iterative meetings to: (1) identify and then develop consensus on the symptoms to be assessed, (2) establish committees to review the literature for screening measures by member expertise, and (3) delineate the specific criteria for systematically evaluating the measures and for making measure recommendations by symptom domains.

RESULTS

We review the measures evaluated and recommend one measure per system/concern so that assessment results from unrelated clinical centers are comparable. We have created a repository to apprise investigators of validated, vetted assessment tools to enhance comparisons across cohorts of youth with autonomic dysfunction and OI.

CONCLUSION

This effort can facilitate collaboration among clinical settings to advance the science and clinical treatment of these youth. This effort is essential to improving management of these vulnerable patients as well as to comparing research findings from different centers.

Help overcoming pain early, a brief person-centred intervention for adolescents with chronic pain in a school setting, may improve symptoms of insomnia

Introduction and aims

Chronic pain and symptoms of insomnia affect large numbers of adolescents and early interventions are prioritized. The aim of the current study was to evaluate potential secondary effects of the intervention, Help Overcoming Pain Early (HOPE), on symptoms of insomnia and self-rated health.

Methods

The study included non-randomized aggregated data from the active and control conditions in a previously conducted randomized controlled trial evaluating the efficacy of HOPE, after the participants in the control condition also had received the intervention. Symptoms of insomnia were assessed with the Minimal Insomnia Symptom Scale and self-rated health was assessed with one item, at the start of the intervention, post intervention, and at a six-month follow-up. Baseline variables included age, gender, pain localization, pain impact, school absence and symptoms of depression (assessed with the Center for Epidemiological Studies Depression Scale for Children). Inferential analyzes were performed using Linear Mixed Models (LMM). Effect sizes were evaluated by calculating Cohen's d.

Results

There were statistically significant improvements in symptoms of insomnia at the six-month follow-up, and statistically significant improvements in self-rated health at the end of the intervention and at the six-month follow-up. Effect sizes were small across outcomes and assessments.

Discussion and conclusion

Results illustrated significant but small improvements in symptoms of insomnia and self-rated health in adolescents with chronic pain following the HOPE intervention. Although caution is needed when assessing the findings, results illustrate the potential utility of an accessible brief early intervention in a school context.

Safety and feasibility of sutureless pars-plana vitrectomy in sub-Tenon anesthesia (SAFE-VISA): a prospective study

BACKGROUND

To determine the safety and feasibility of sutureless pars-plana vitrectomy (ppV) in sub-Tenon anesthesia.

METHODS

In this prospective study. Pain and anxiety at various times after ppV using a visual analogue scale (VAS) and Wong-Baker-FACES scale as well as visual sensations during surgery were investigated. The surgeon evaluated motility, chemosis, overall feasibility.

RESULTS

ppV was performed on 67 eyes (33 sub-Tenon anesthesia, 34 general anesthesia). Pain during surgery in sub-Tenon anesthesia was 1.8 ± 2.2 (0.0-8.0), anxiety was 2.3 ± 2.2 (0.0-8.5). There was a moderate correlation between pain and anxiety (R2 = 0.58). Comparing sub-Tenon and general anesthesia no difference in pain perception was found the day after surgery. 27.3% of patients saw details, 21.2% saw colors, 90.1% saw light/motion perception, 3.0% had no light perception. Median chemosis after surgery was 1.0 (IQR = 1.0). Median motility of the eye during surgery was 1.0 (IQR = 1.0), median grade was 1.0 (IQR = 1.0). 24.2% of patients showed subconjunctival hemorrhage during or after surgery.

CONCLUSIONS

Sutureless pars-plana vitrectomy in sub-Tenon anesthesia was performed safely, with pain and anxiety levels tolerable for the patients and without the necessity for presence of an anesthesiologist. With 88.9% of patients willing to undergo vitreoretinal surgery in sub-Tenon anesthesia again, we recommend it as a standard option. Trial registration This study was approved by the Institutional Ethical Review Board of the RWTH Aachen University (EK 111/19). This study is listed on clinicaltrials.gov (ClinicalTrials.gov identifier: NCT04257188, February 5th 2020).

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

Parental Postoperative Pain Management Perceptions, Attitudes, and Practices in Pediatric Limb Fractures

BACKGROUND

Post-surgical pain in children is common, severe, and inadequately controlled. An effective model should involve the participation of parents.

AIMS

To investigate parental perceptions, attitudes, and practices in postoperative pain management in children with limb fractures and analyze the factors affecting parental practices.

DESIGN

This was a descriptive cross-sectional study.

SETTINGS

Research was conducted at a tertiary Children's Hospital Affiliated with Soochow University.

PARTICIPANTS

Parents whose children (age, 6-18 years) underwent orthopedic fracture surgery between January 1, 2020, and August 31, 2020, were recruited using purposive sampling.

METHODS

The parents were asked to complete self-report questionnaires: "Pain Management Knowledge and Attitudes Questionnaire" and "Parents' Use of Pain Relief Strategies Questionnaire." The Wong-Baker Faces Scale was used to measure pain intensity in children. The Mann-Whitney U test, Kruskal-Wallis H test, and correlation and regression analyses were used for statistical analyses.

RESULTS

Data of 180 parents were collected. Of the participants, 80.6%, 78.3%, and 71.7% had low-to-moderate scores for knowledge, general attitudes, and use of pain relief strategies, respectively. Moreover, 93.9% of parents had moderate-to-high scores for negative attitudes toward medication, despite 89.5% of them reporting moderate-to-high pain intensities in their children (median proxy-report of pain intensity, 7.0 [3.00]). Multivariate linear stepwise regression showed that parents' use of pain-relief strategies was related to their general attitudes, knowledge, and sex.

CONCLUSIONS

Most parents had low-to-moderate scores for perceptions and general attitudes toward children's postoperative pain management, and use of pain relief strategies. Moreover, they lacked knowledge of and had negative attitudes toward pain assessment and analgesics, which significantly impacted their practices.

CLINICAL IMPLICATIONS

Clinical pediatric nurses should provide appropriate support for the entire family of the child. Moreover, to enhance parental practices, they should develop targeted parental education programs for pain management, particularly regarding pain assessment tools and pain medications.

Commentary: Pediatric Pain Measurement, Assessment, and Evaluation

PEDIATRIC PAIN MEASUREMENT, ASSESSMENT, AND EVALUATION

Renee C.B. Manworren, Jennifer Stinson Seminars in Pediatric Neurology Volume 23, Issue 3, August 2016, Pages 189-200 Assessment provides the foundation for diagnosis, selection of treatments, and evaluation of treatment effectiveness for pediatric patients with acute, recurrent, and chronic pain. Extensive research has resulted in the availability of a number of valid, reliable, and recommended tools for assessing children's pain. Yet, evidence suggests children's pain is still not optimally measured or treated. In this article, we provide an overview of pain evaluation for premature neonates to adolescents. The difference between pain assessment and measurement is highlighted; and the key steps to follow are identified. Information about self report and behavioral pain assessment tools appropriate for children are provided; and fac tors to be considered when choosing a specific 1 are outlined. Finally, we preview future approaches to personalized pain medicine in pediatrics that include harnessing the use of potential digital health technologies and genomics.

Effect of virtual reality combined with repetitive transcranial magnetic stimulation on musculoskeletal pain and motor development in children with spastic cerebral palsy: a protocol for a randomized controlled clinical trial

PURPOSE

This trial aims to investigate the efficacy and safety of virtual reality (VR) combined with repetitive transcranial magnetic stimulation (rTMS) for improving musculoskeletal pain and motor development in children with unilateral spastic cerebral palsy (CP).

METHODS

This study protocol is for a randomized controlled trial consisting of 2 treatment sessions (3 days/week for 4 weeks in each session, with a 1-week interval between sessions). We will recruit children aged 3-10 years with unilateral spastic CP (Gross Motor Function Classification System level I or II). Participants will be randomly divided into 3 groups: the VR + rTMS group (immersive VR intervention, rTMS and routine rehabilitation therapy), rTMS group (rTMS and routine rehabilitation therapy), and control group (sham rTMS and routine rehabilitation therapy). VR therapy will involve a daily 40-minute movement training session in a fully immersive environment. rTMS will be applied at 1 Hz over the primary motor cortex for 20 min on the contralateral side. The stimulation intensity will be set at 90% of the resting motor threshold, with 1200 pulses applied. A daily 60-minute routine rehabilitation therapy session including motor training and training in activities of daily living will be administered to all participants. The primary outcome will be pain intensity, assessed by the Revised Face, Legs, Activity, Cry, and Consolability Scale (R-FLACC). The secondary outcomes will include motor development, evaluated by the 66-item version of the Gross Motor Function Measure (GMFM-66) and Fine Motor Function Measure (FMFM); balance capacity, measured by the interactive balance system; activities of daily living; and quality of life, measured by the Barthel index and the Chinese version of the Cerebral Palsy Quality of Life scale for Children (C-CP QOL-Child). Safety will be monitored, and adverse events will be recorded during and after treatment.

DISCUSSION

Combined application of VR therapy and rTMS may reveal additive effects on pain management and motor development in children with spastic CP, but further high-quality research is needed. The results of this trial may indicate whether VR therapy combined with rTMS achieves a better analgesic effect and improves the motor development of children with spastic CP.

TRIAL REGISTRATION

Registration number: ChiCTR230069853. Trial registration date: 28 March 2023. Prospectively registered.

Dashboard of Short-Term Postoperative Patient Outcomes for Anesthesiologists: Development and Preliminary Evaluation

BACKGROUND

Anesthesiologists require an understanding of their patients' outcomes to evaluate their performance and improve their practice. Traditionally, anesthesiologists had limited information about their surgical outpatients' outcomes due to minimal contact post discharge. Leveraging digital health innovations for analyzing personal and population outcomes may improve perioperative care. BC Children's Hospital's postoperative follow-up registry for outpatient surgeries collects short-term outcomes such as pain, nausea, and vomiting. Yet, these data were previously not available to anesthesiologists.

OBJECTIVE

This quality improvement study aimed to visualize postoperative outcome data to allow anesthesiologists to reflect on their care and compare their performance with their peers.

METHODS

The postoperative follow-up registry contains nurse-reported postoperative outcomes, including opioid and antiemetic administration in the postanesthetic care unit (PACU), and family-reported outcomes, including pain, nausea, and vomiting, within 24 hours post discharge. Dashboards were iteratively co-designed with 5 anesthesiologists, and a department-wide usability survey gathered anesthesiologists' feedback on the dashboards, allowing further design improvements. A final dashboard version has been deployed, with data updated weekly.

RESULTS

The dashboard contains three sections: (1) 24-hour outcomes, (2) PACU outcomes, and (3) a practice profile containing individual anesthesiologist's case mix, grouped by age groups, sex, and surgical service. At the time of evaluation, the dashboard included 24-hour data from 7877 cases collected from September 2020 to February 2023 and PACU data from 8716 cases collected from April 2021 to February 2023. The co-design process and usability evaluation indicated that anesthesiologists preferred simpler designs for data summaries but also required the ability to explore details of specific outcomes and cases if needed. Anesthesiologists considered security and confidentiality to be key features of the design and most deemed the dashboard information useful and potentially beneficial for their practice.

CONCLUSIONS

We designed and deployed a dynamic, personalized dashboard for anesthesiologists to review their outpatients' short-term postoperative outcomes. This dashboard facilitates personal reflection on individual practice in the context of peer and departmental performance and, hence, the opportunity to evaluate iterative practice changes. Further work is required to establish their effect on improving individual and department performance and patient outcomes.

Back pain in children and adolescents: a cross-sectional study

PURPOSE

Back pain is a growing problem worldwide, not only in adults but also in children. Therefore, it is becoming increasingly important to investigate and understand the factors that influence the early onset of back pain. The aim of this study was to determine the prevalence of back pain in children and adolescents and to identify predisposing risk factors and protective factors.

METHODS

A cross-sectional study was conducted between October and December 2019 in schools from northern Portugal, evaluating 1463 students aged 9 to 19 years, of both genders. The instruments used were the Spinal Mouse® to assess posture, the Inbody 230® to assess body composition, an online questionnaire to characterize the sample and back pain, and the FITescola® battery test to access physical fitness.

RESULTS

Half of the subjects experienced back pain at least once in their lifetime. The most frequently mentioned were lumbar spine and thoracic spine, mostly with mild or moderate pain intensities. Age, female gender, percent body fat, prolonged smartphone and computer use, hyperkyphosis, and the lateral global spine tilt to the left side are all factors with higher relative risk of back pain. Practicing physical activity or sports regularly and video games have a protective effect.

CONCLUSION

The prevalence of back pain in children and adolescents is very high: The study enhances the case for protective factors such as physical activity habits or video games while reinforcing risk factors such as percent body fat, prolonged smartphone or computer use, and posture.

Utilization of individual components of enhanced recovery after surgery (ERAS) protocol improves post-operative outcomes in adolescent idiopathic scoliosis: a blueprint for progressive adoption of ERAS

PURPOSE

Enhanced recovery after surgery [ERAS] is an approach for standardization of perioperative care aimed at improving patient outcomes. The primary aim of this study was to determine if length of stay (LOS) differed by protocol type (ERAS vs. non-ERAS [N-ERAS]) in patients undergoing surgery for adolescent idiopathic scoliosis (AIS).

METHODS

A retrospective cohort study was conducted. Patient characteristics were collected and compared between groups. Differences in LOS were assessed using regression adjusting for age, sex, BMI, pre-surgical Cobb angle, levels fused and year of surgery.

RESULTS

Fifty nine ERAS patients were compared to 81 N-ERAS patients. Patients were comparable in their baseline characteristics. Median LOS was 3 days (IQR = 3-4) for the ERAS group, compared to 5 days (IQR = 4-5) for the N-ERAS group (p < 0.001). The ERAS group had a significantly lower adjusted rate of stay (RR = 0.75; 95% CI = 0.62-0.92). The ERAS group had significantly lower average pain on post-operative days 0 (least-squares-mean [LSM] 2.66 vs. 4.41, p < 0.001), POD1 (LSM 3.12 vs. 4.48, p < 0.001) and POD5 (LSM 2.84 vs. 4.42, p = 0.035). The ERAS group had lower opioid consumption (p < 0.001). LOS was predicted by the number of protocol elements received; those receiving two (RR = 1.54 95% CI = 1.05-2.24), one (RR = 1.49; 95% CI = 1.09-2.03) or none (RR = 1.60, 95% CI = 1.21-2.13) had significantly longer rates of stay than those receiving all four.

CONCLUSION

Adoption of modified ERAS-based protocol for patients undergoing PSF for AIS led to significant reduction in LOS, average pain scores, and opioid consumption.

Deep learning-guided postoperative pain assessment in children

ABSTRACT

Current automated pain assessment methods only focus on infants or youth. They are less practical because the children who suffer from postoperative pain in clinical scenarios are in a wider range of ages. In this article, we present a large-scale Clinical Pain Expression of Children (CPEC) dataset for postoperative pain assessment in children. It contains 4104 preoperative videos and 4865 postoperative videos of 4104 children (from 0 to 14 years of age), which are collected from January 2020 to December 2020 in Anhui Provincial Children's Hospital. Moreover, inspired by the dramatic successful applications of deep learning in medical image analysis and emotion recognition, we develop a novel deep learning-based framework to automatically assess postoperative pain according to the facial expression of children, namely Children Pain Assessment Neural Network (CPANN). We train and evaluate the CPANN with the CPEC dataset. The performance of the framework is measured by accuracy and macro-F1 score metrics. The CPANN achieves 82.1% accuracy and 73.9% macro-F1 score on the testing set of CPEC. The CPANN is faster, more convenient, and more objective compared with using pain scales according to the specific type of pain or children's condition. This study demonstrates the effectiveness of deep learning-based method for automated pain assessment in children.

Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals

Aim

Limb reconstruction with external fixators requires appropriate pain management to promote effective analgesia and healing while minimising adverse events of the analgesic technique used. The objective of this prospective case series was to evaluate a multimodal analgesia regimen designed to reduce opioid requirements and hence reduce the opioid-related side effect profile.

Materials and methods

A prospective cohort of patients undergoing lower limb reconstruction surgery (LRS) were managed through an evidence-informed multimodal analgesia guideline (MMAG), including acetaminophen, pregabalin, dexmedetomidine, IV lidocaine, and opioids. Outcome measures included intraoperative and post-operative opioid administration, post-operative pain scores, time to achieve mobilisation milestones, and post-operative complications. Surveys were conducted to obtain patient reported experiences.

Results

26 patients were included in this prospective case series. 110.59 (84.29, 162.13) (median, interquartile range) µg/kg/hr intraoperative IV morphine equivalent opioids were administered. In the first 48 hours post-operatively, patients received 11.49 (6.41, 19.35) µg/kg/hr of IV morphine equivalent dose. Median level of pain (0-10) in the first 48 post-operative hours was 2 (1, 2). Patients achieved mobilisation. And 19/20 patients surveyed reported 'yes' to having effective pain management; 17/20 patients had no unwanted side effects associated with analgesia medications. There were no cases of compartment syndrome.

Conclusion

This multimodal analgesia regime applied to patients undergoing lower LRS with external fixators demonstrates the feasibility of this analgesic regimen which revealed effective pain control, early mobilisation, with minimal side effects, but warrants further study.

Clinical significance

This study provides valuable evidence that this standardised multimodal anaesthesia and analgesia regimen is feasible, offers adequate post-operative comfort and encourages early mobilization while minimising opioid use and adverse events in a paediatric LRS population at our institution.

How to cite this article

Wang AWT, Chhina H, Cooper A. Multimodal Analgesia for Paediatric Patients Undergoing Lower Limb Reconstruction with External Fixators: A Prospective Case Series of Post-operative Pain and Functional Goals. Strategies Trauma Limb Reconstr 2023;18(3):140-147.

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Facilitating pain assessment and communication in people with deafness: a systematic review

BACKGROUND

Pain is a common reason for seeking out healthcare professionals and support services. However, certain populations, such as people with deafness, may encounter difficulties in effectively communicating their pain; on the other side, health care professionals may also encounter challenges to assess pain in this specific population.

AIMS

To describe (a) the state of the research in the field of pain assessment in individuals with deafness; (b) instruments validated; and (b) strategies facilitating the pain communication or assessment in this population.

METHODS

A systematic review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines were performed, searching Medline, CINAHL, Scopus, Embase and PsycInfo databases, from their initiation to July 2023. Primary and secondary studies, involving adults with deafness and investigating pain assessment and communication difficulties, facilitators, or barriers, were eligible. The included studies were assessed in their methodological quality with the Quality Assessment for Diverse Studies tool; data extraction and the narrative synthesis was provided by two researchers.

RESULTS

Five studies were included. Two were validation studies, while the remaining were a case report, a case study and a qualitative study. The interRAI Community Health Assessment and the Deafblind Supplement scale have been validated among people with deafness by reporting few psychometric properties; in contrast, instruments well established in the general population (e.g. Visual Analogue Scale) have been assessed in their usability and understandability among individuals with deafness, suggesting their limitations. Some strategies have been documented as facilitating pain communication and assessment: (a) ensuring inclusiveness (the presence of family members as mediators); (b) ensuring the preparedness of healthcare professionals (e.g. in sign language); and (c) making the environment friendly to this population (e.g. removing masks).

CONCLUSIONS

The research regarding pain in this population is in its infancy, resulting in limited evidence. In recommending more research capable of establishing the best pain assessment instrument, some strategies emerged for assessing pain in which the minimum standards of care required to offer to this vulnerable population should be considered.

Perioperative gabapentin usage in pediatric patients: A scoping review

BACKGROUND

There has been a recent focus among anesthesiologists on reducing the use of perioperative opioids in favor of multimodal analgesic regimens. Gabapentin has played an integral role in this evolution of practice. This comprehensive review assesses the current clinical evidence on the efficacy of perioperative gabapentin regarding postoperative pain and opioid requirements among the pediatric surgery population.

DATA SOURCES

Pubmed, CINAHL, Embase, Scopus, and Web of Science Review.

METHODS

This scoping review of the above databases includes all studies examining the use of gabapentin perioperatively in pediatric patients and its association with postoperative pain intensity and postoperative opioid consumption through July 2021. The inclusion criteria encompassed all studies evaluating gabapentin in the perioperative pediatric population through randomized controlled trials (RCTs) and retrospective studies. Relevant metadata from each study were abstracted and descriptive statistics were used to summarize the results.

RESULTS

Fifteen papers met the inclusion criteria for this review, including 11 RCTs and 4 retrospective studies. Sample sizes ranged from 20 to 144 patients. Administered doses varied widely, mainly between 5 and 20 mg/kg. The studies included primarily orthopedic (10) and neck surgery cases (3). Seven papers had gabapentin provided preoperatively only, two postoperative only, and six both pre- and postoperatively. Of the studies assessing postoperative pain, 6/11 studies saw a decrease in postoperative pain in at least one period for the gabapentin group. Of the studies considering opioid requirements, 6/10 reported a reduction, 1/10 an increase, and 3/10 no difference in opioid requirements for the gabapentin groups. Yet, most of these pain and opioid requirement findings were only significant at one to two time points in the study follow-up periods, and the actual decreases had minimal clinical significance.

CONCLUSIONS

The current data on perioperative gabapentin in pediatric patients are insufficient to support the routine use of gabapentin in pediatric patients. Additional high-quality RCTs with more standardized protocols for gabapentin administration and outcome measures are necessary to provide more definitive conclusions.

The Effect of Virtual Reality on Pain Experienced by School-Age Children During Venipuncture: A Randomized Controlled Study

Objective: The use of virtual reality (VR) as a non-pharmacologic method may enable children to tolerate invasive procedures in a hospital setting easily and feel less pain. This study aimed at determining the effect of using a VR headset during venipuncture on pain level, heart rate (HR), and oxygen saturation values in children aged 7-12 years old. Materials and Methods: This was a randomized controlled experimental study. This study included 102 children (experimental group: 52; control group: 50) who visited a pediatric outpatient clinic of a university hospital in Turkey between May 2018 and May 2019. Data were collected using the Child and Family Information Form, State Anxiety Inventory for Children, Faces Pain Scale-Revised (FPS-R). Before venipuncture, state anxiety and pain scores of the children were evaluated. The children in the experimental group wore VR headsets during venipuncture. The children in the control group underwent standard venipuncture procedure. Pain scores were evaluated again in both groups after the venipuncture. Before, during, and after the venipuncture, pulse and oxygen saturation values were measured. Results: It was determined that post-procedure pain score was 1.46 ± 1.49 in the experimental group and 4.44 ± 2.26 in the control group. Post-venipuncture pain mean scores were significantly lower in the experimental group than those of the children in the control group (Z = -6.574; P = 0.001). Secondary outcomes: The mean HR during the procedure was significantly lower in the experimental group (99.27 ± 18.34/min) than in the control group (108.20 ± 21.42/min) (P = 0.026; t = -2.265). There was no statistically significant difference between the before and after the procedure difference of oxygen saturation values (Experimental group: -0.15 ± 1.54; Control Group: 0.04 ± 0.93) between groups (Z = -0.023; P = 0.982). Conclusion: It was determined that post-venipuncture pain mean scores were significantly lower in the experimental group than in the control group. VR is effective to reduce the pain of children during venipuncture. VR headsets may be recognized as effective instruments to reduce the pain level of children in hospital settings. (Clinicaltrials.gov: NCT04950478).

Ultrasound-guided PIVC insertion: a randomised controlled trial protocol

Ultrasound-guided insertion of peripheral intravenous catheters (PIVCs) is an alternative to traditional anatomical landmark-based insertion. However, data on its performance in paediatric patients of varying levels of difficult intravenous access are limited. The researchers hypothesise that ultrasound-guided PIVC insertion will increase first-attempt success compared with landmark technique. This randomised, parallel-group, single-centre, superiority trial commenced recruiting in July 2021, including hospitalised children (aged 0 (>37 weeks gestation) to 18 years) requiring a PIVC. It will recruit 180 children, stratified by degree of perceived difficulty, and centrally randomised into two groups (ratio 1:1). The primary outcome is first-attempt PIVC insertion success. Secondary outcomes include total number of PIVC insertion attempts, PIVC insertion failure, post-insertion complications, dwell time, patient/parent satisfaction, and healthcare costs. The current study will inform the superiority of ultrasound-guided PIVC insertion in comparison with landmark technique. Adoption by healthcare facilities might improve patient outcomes and decrease healthcare costs.

Time to complain about pain: Children's self-reported procedural pain in a randomised control trial of Hall and conventional stainless steel crown techniques

BACKGROUND

Children's pain in dentistry has undesirable short- and long-term consequences; therefore, less invasive treatments merit consideration.

AIM

To investigate procedural pain scores for two treatments for carious primary molars in New Zealand primary care.

DESIGN

This study was a split-mouth randomised control trial, with secondary outcome analysis. Children (4-8 years) with proximal carious lesions on matched primary molars had one tooth treated with the Hall technique (HT) and one treated with a conventional stainless steel crown (CT); treatment type and order of treatment were randomly allocated (allocation concealment). The Wong-Baker self-report pain scale measured pretreatment dental pain, procedural pain at each treatment and post-operative pain.

RESULTS

Data were analysed for 103 children: 49 children had the HT first and 54 children had the CT first. Procedural pain scores did not differ by treatment type, with 71.8% and 76.7% of children reporting low pain for the HT and the CT, respectively. Fewer children reported low procedural pain for the second treatment than the first (p = .047). Most children reported low procedural pain for both treatments (58.3%), although 41.7% experienced moderate-high procedural pain with at least one treatment.

CONCLUSIONS

The HT caused pain for as many children as the CT. There is an opportunity for better dental pain management in this setting.

Impact of Electronic Chronic Pain Questions on patient-reported outcomes and healthcare utilization, and attitudes toward eCPQ use among patients and physicians: prospective pragmatic study in a US general practice setting

Objective

The Electronic Chronic Pain Questions (eCPQ) has been developed to help healthcare providers systematically capture chronic pain data. This study evaluated the impact of using the eCPQ on patient-reported outcomes (PROs) and healthcare resource utilization (HCRU) in a primary care setting, and patient and physician perceptions regarding use of, and satisfaction with, the eCPQ.

Methods

This was a prospective pragmatic study conducted at the Internal Medicine clinic within the Henry Ford Health (HFH) Detroit campus between June 2017 and April 2020. Patients (aged ≥18 years) attending the clinic for chronic pain were allocated to an Intervention Group to complete the eCPQ in addition to regular care, or a control group to receive regular care only. The Patient Health Questionnaire-2 and a Patient Global Assessment were assessed at baseline, 6-months, and 12-months study visits. HCRU data were extracted from the HFH database. Telephone qualitative interviews were conducted with randomly selected patients and physicians who used the eCPQ.

Results

Two hundred patients were enrolled, 79 in each treatment group completed all 3 study visits. No significant differences (p > 0.05) were found in PROs and HCRU between the 2 groups. In qualitative interviews, physicians and patients reported the eCPQ as useful, and using the eCPQ improved patient-clinician interactions.

Conclusion

Adding the eCPQ to regular care for patients with chronic pain did not significantly impact the PROs assessed in this study. However, qualitative interviews suggested that the eCPQ was a well-accepted and potentially useful tool from a patient and physician perspective. By using the eCPQ, patients were better prepared when they attended a primary care visit for their chronic pain and the quality of patient-physician communication was increased.

Single-injection serratus anterior plane block for cardiothoracic surgery via thoracotomy in children: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Serratus anterior plane block (SAPB) has gained popularity in cardiothoracic surgery due to its feasibility and simplicity. However, the efficacy of ultrasound-guided single-injection SAPB in the paediatric population has not been well evaluated, as only a few studies with small sample sizes are available.

METHODS

We searched PubMed, Embase (Ovid), Cochrane Central Register of Controlled Trials, Wanfang databases and China National Knowledge Infrastructure from their inception to 31 September 2022 for randomised comparative clinical trials that compared single-injection SAPB with systemic analgesia or different forms of regional analgesia in children. The primary outcomes included postoperative opioid consumption and pain scores within 24 hours. The secondary outcomes included postoperative adverse events, the need for rescue analgesia and the time from the end of surgery to endotracheal tube removal.

RESULTS

Five randomised controlled trials with 418 children meeting the inclusion criteria were included. SAPB markedly reduced postoperative opioid consumption up to 24 hours compared with controls (mean difference (MD): -0.29 mg/kg, 95% CI -0.38 to -0.20, I 2 =67%]. The postoperative pain scores were reduced compared with controls: 1 hour (MD -0.6, 95% CI -1.17 to -0.04, I 2 =92%), 4-6 hours (MD -1.16, 95% CI -1.87 to -0.45, I 2 =90%) and 12 hours (MD -0.71, 95% CI -1.35 to -0.08, I 2 =86%). The incidence of postoperative nausea and vomiting was comparable between SAPB and controls. One trial suggested that the analgesic effect of SAPB was comparable to that of ICNB (intercostal nerve block).

CONCLUSION

Single-injection SAPB is associated with a reduction in opioid consumption and pain intensity after cardiothoracic surgery via thoracotomy in children. Due to the high heterogeneity, the Grading of Recommendations Assessment, Development and Evaluation scores were low. Clinical trials with rigorous methodological approaches as well as safety endpoints are needed to confirm these preliminary findings.

PROSPERO REGISTRATION NUMBER

CRD42021241691.

A new version of a measurement for presence and impact of pain in children and adolescents - Presence and impact of pain in Kids (PIP-KIDS) questionnaire: Translation, cross-cultural adaptation and measurement properties into Brazilian-Portuguese

BACKGROUND

Musculoskeletal pain in children and adolescents is prevalent and responsible for high levels of disability. Instruments to measure the presence and impact of pain in this population are needed.

OBJECTIVE

To translate, cross-culturally adapt, then test the measurement properties (structural validity, reliability and construct validity) of a questionnaire (Presence and Impact of Pain in Kids (PIP-Kids) questionnaire) to measure the presence and impact of pain in children and adolescents.

DESIGN

Measurement properties study.

METHODS

We conducted a measurement properties study. We translated and culturally adapted the PIP-Kids questionnaire into Brazilian Portuguese. The structural validity was measured by Confirmatory Factor Analysis. Reliability was measured by Kappa Coefficient. Measurement error was measured by the percentage of agreement. Construct validity was measured by Spearman Correlation.

RESULTS/FINDINGS

We included 656 children and adolescents from public and private schools. During the translation and cross-cultural adaptation no changes to wording were necessary. Structural validity confirmed two domains. Reliability by Kappa Coefficient ranges from 0.20 to 0.68. Measurement error by the percentage of agreement ranged from 60.2 to 92%. Construct validity was confirmed with 80.5% in accordance with prior hypotheses.

CONCLUSION

The PIP-Kids questionnaire translation and cross-cultural adaptation were adequate. The PIP-Kids questionnaire also has adequate structural validity with two dimensions (presence and impact), fair reliability, good agreement, and adequate construct validity.

Stress Numerical Rating Scale-11: Validation in Pediatric Inpatient and Outpatient Pain Settings

Stress is a commonly reported issue in pediatric populations of chronic and acute pain. Both outpatient and inpatient settings impose time constraints, which decreases opportunities to measure and address patient stress. The aim of these studies was to evaluate the validity of the Stress Numeric Rating Scale-11 (SNRS-11) in both inpatient and outpatient settings. The SNRS-11 is a single item stress measure ranging from 0 to 10 with endpoint anchors: 0 = "No stress" and 10 = "Highest stress possible". Results showed discriminative validity in the inpatient sample and convergent and discriminant validity in both outpatient and inpatient samples. Additionally, approximately 40% to 50% of the sample reported moderate-severe stress on all post-operative days. The SNRS-11 shows promise as a quick, easy, and free stress measure to be used in both inpatient and outpatient settings.

Parents' perceptions of their child's pain assessment in hospital care: A cross-sectional study

PURPOSE

A prerequisite for successful pain management is identifying the pain and assessing its intensity. The aim of this study was to describe parents' perceptions of their child's pain assessment in hospital care.

DESIGN AND METHODS

This study was a descriptive cross-sectional study. A questionnaire was completed by parents (n = 261) whose child was hospitalized in one of the pediatric units (n = 6) of the University Hospital in Finland. Quantitative data were analyzed using statistical methods; open-ended data were analyzed using inductive content analysis.

RESULTS

Parents reported that their children experienced moderate (36%) to severe pain (42%) during hospitalization. The most intense pain experienced by the children was associated with needle-related procedures (41%). A large proportion of parents (83%) were involved in their child's pain assessment. Parents were satisfied with their child's pain assessment but perceived some shortcomings. Parents hoped that a variety of methods would be used to assess their child's pain and that the parents' and child's views on pain would be taken into account.

CONCLUSIONS

Most children experience moderate to severe pain during hospitalization. Parents are often involved in pain assessment but are rarely instructed to use pain scales.

PRACTICE IMPLICATIONS

Child's pain should be assessed regularly and frequently enough. It is important that the child and parents are involved in shared decision-making about pain assessment and treatment, and they have opportunities to ask questions. Guidance should be offered to parents about the use of pain assessment scales.

Comparative study of two different computer-controlled local anesthesia injection systems in children: a randomized clinical trial

PURPOSE

To compare pain perception associated with two computer-controlled local anesthesia devices, the WAND™ STA (Milestone Scientific Inc., Livingston, NJ, USA) and the Calaject (Rønvig dental MFG, Daugaard, Denmark) in young children.

METHODS

A split-mouth randomized clinical trial comprising 30 patients, aged 6-12 years, received randomly, in two separate sessions, a local anesthesia injection in the maxillary using either the wand STA or the Calaject. Pain perception was evaluated using the patient's heart rate, an 11-point numerical scale (NRS), and the Sound, Eye, and Motor (SEM) body movements. Statistical difference was set at p = 0.05. Repeated measures analysis of variance were conducted to compare the mean pulse for Calaject and STA at different times. It was followed by univariate analysis and Bonferroni multiple comparisons tests. Wilcoxon tests were performed to compare NRS, SEM, and injection duration between Calaject and STA.

RESULTS

There was no significant statistical difference between Calaject and STA in pulse rate before injection (p = 0.720), during injection (p = 0.767), and after injection (p = 0.757). The mean NRS score was significantly greater with STA in comparison with Calaject (p = 0.017). The mean SEM score was also significantly greater with STA in comparison with Calaject (p = 0.002). However, the mean duration was significantly longer with Calaject (p = 0.001).

CONCLUSIONS

Calaject was more effective than STA in reducing pain perception associated with periapical injection in young children.

Analgesia and sedation in critically ill pediatric patients: an update from the recent guidelines and point of view

In the last decades, the advancement of knowledge in analgesia and sedation for critically ill pediatric patients has been conspicuous and relevant. Many recommendations have changed to ensure patients' comfort during their intensive care unit (ICU) stay and prevent and treat sedation-related complications, as well as improve functional recovery and clinical outcomes. The key aspects of the analgosedation management in pediatrics have been recently reviewed in two consensus-based documents. However, there remains a lot to be researched and understood. With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field.    Conclusion: With this narrative review and authors' point of view, we aimed to summarize the new insights presented in these two documents to facilitate their interpretation and application in clinical practice, as well as to outline research priorities in the field. What is Known: • Critically ill pediatric patients receiving intensive care required analgesia and sedation to attenuate painful and stressful stimuli. •Optimal management of analgosedation is a challenge often burdened with complications such as tolerance, iatrogenic withdrawal syndrome, delirium, and possible adverse outcomes. What is New: •The new insights on the analgosedation treatment for critically ill pediatric patients delineated in the recent guidelines are summarized to identify strategies for changes in clinical practice. •Research gaps and potential for quality improvement projects are also highlighted.

Trends in pelvic pain symptoms over 2 years of follow-up among adolescents and young adults with and without endometriosis

ABSTRACT

We described trends in pelvic pain characteristics over 2 years of follow-up among adolescents and adults with and without endometriosis participating in the longitudinal observational cohort of the Women's Health Study: From Adolescence to Adulthood, using data reported at baseline and at years 1 and 2 of follow-up. Participants completed a questionnaire at baseline (between November 2012 and May 2019) and annually thereafter that included validated measures of severity, frequency, and life interference of dysmenorrhea, acyclic pelvic pain, and dyspareunia. Our study population included 620 participants with surgically confirmed endometriosis (rASRM stage I/II = 95%) and 671 community-based and hospital-based controls, with median age = 19 and 24 years, respectively. The proportion reporting hormone use varied across the 3 years ranging from 88% to 92% for cases and 56% to 58% for controls. At baseline, endometriosis cases were more likely to report severe, frequent, and life-interfering dysmenorrhea, acyclic pelvic pain, and dyspareunia compared with controls. Among cases, frequency and severity of dysmenorrhea and dyspareunia were relatively static across 2 years. However, acyclic pelvic pain improved. Severe acyclic pain decreased from 69% at baseline to 46% at year 2. Daily pain decreased from 28% to 14%, and life interference from 68% to 38%. Trends among controls remained fairly stable across 2 years. Among endometriosis cases who completed the questionnaire at all 3 time points, 18% reported persistent, severe acyclic pelvic pain at all 3 time points. Over time, different trends were observed by pelvic pain type among endometriosis cases and controls, supporting the importance of assessing multidimensional features of pelvic pain.

Pain assessment tools for use with children in acute pain in the emergency department

There is a lack of timely administration of an appropriate analgesic for children in acute pain in emergency departments in the UK and elsewhere. Unrelieved acute pain may result in deterioration in a child's physical and psychological condition therefore assessment is essential to enable triage nurses to offer an appropriate analgesic. This should be achieved by using a validated pain assessment tool which, where appropriate, enables the child to self-report their pain. This article describes various validated pain assessment tools for use with children with acute pain and considers how triage nurses can determine which is the most appropriate to use. Regardless of which tool is selected, it is important to offer the child an analgesic and to reassess their pain at appropriate intervals.

Pain and discomfort in children with gastrostomy tubes - In the context of hematopoietic stem cell transplantation

BACKGROUND

In children with malignant and severe non-malignant disorders undergoing hematopoietic stem cell transplantation (HSCT), treatment related pain and discomfort are common. Food consumption may become troublesome, making the use of a gastrostomy tube (G-tube) necessary and resulting in complications, why the purpose was to explore pain and discomfort during the transplantation and post-transplantation time.

METHODS

This was a mixed methods study where data were collected along the child's total health-care process between 2018 and 2021. Questions with fixed answer options were used, simultaneously, semi-structured interviews were performed. In total, sixteen families participated. Descriptive statistics and content analysis were used to describe analysed data.

FINDINGS

Intense pain was common during the post-surgery phase, especially in conjunction with G-tube care, which is why the children needed support to manage the situation. After the post-surgery phase when the skin has healed, most of the children experienced minor to no pain or bodily discomfort, why the G-tube became a well-functioning and supportive tool in daily life.

CONCLUSIONS

This study describes variations in and experiences of pain and bodily discomfort in conjunction with G-tube insertion in a unique sample of children who had undergone HSCT. In conclusion, the children's comfort in daily life after the post-surgery phase seemed to be only marginally affected by G-tube insertion. Children with severe non-malignant disorders seemed to experience a higher frequency and intensity of pain and bodily discomfort due to the G-tube than children with malignant disorders.

PRACTICE IMPLICATIONS

The paediatric care team need competence in assessing G-tube related pain and awareness that experiences may differ depending on the child's disorder.

Effect of the Case for Carpule as a Visual Passive Distraction Tool on Dental Fear and Anxiety: A Pilot Study

The present cross-over study aimed to evaluate the effect of a visual passive distraction tool, a case for carpule, in the management of fear and anxiety during invasive dental treatment. Children between the ages of 4 and 8 years that need at least two treatments with inferior alveolar nerve block were selected. All the included children received two treatments at different moments: in one treatment, local anesthesia was performed with a visual passive distraction tool, the crocodile case, for carpule (experimental); in the other treatment, local anesthesia was performed without the device (control). An evaluation of the anxiety levels was performed by measuring the heart rate and salivary cortisol levels. Wilcoxon's nonparametric test was used for a data analysis (p < 0.05). The mean heart rate with the visual passive distraction device fell from 81.8 to 78.1, while the control rose from 91.4 to 100 (p < 0.05). The mean salivary cortisol levels with the visual passive distraction device fell from 2.0 to 1.6, while in the control, they rose from 2.1 to 2.4 (p < 0.05). In conclusion, the crocodile case for carpule as a visual passive distraction device contributed positively to the management of fear and anxiety during inferior alveolar nerve block in children.

Validation of the Critical-Care Pain Observation Tool (CPOT) in pediatric patients undergoing orthopedic surgery

Background

Postoperative pain cannot be measured accurately among many children with intellectual and developmental disabilities, resulting in underrecognition or delay in recognition of pain. The Critical-Care Pain Observation Tool (CPOT) is a pain assessment tool that has been widely validated in critically ill and postoperative adults.

Aims

The objective of this study was to validate the CPOT for use with pediatric patients able to self-report and undergoing posterior spinal fusion surgery.

Methods

Twenty-four patients (10-18 years old) scheduled to undergo surgery were consented to this repeated-measure, within-subject study. To examine discriminative and criterion validation, CPOT scores and patients' self-reports of pain intensity were collected prospectively by a bedside rater before, during, and after a nonnociceptive and nociceptive procedure on the day following surgery. Patients' behavioral reactions were video recorded at the bedside and retrospectively viewed by two independent video raters to examine interrater and intrarater reliability of CPOT scores.

Results

Discriminative validation was supported with higher CPOT scores during the nociceptive procedure than during the nonnociceptive procedure. Criterion validation was supported with a moderate positive correlation between the CPOT scores and the patients' self-reported pain intensity during the nociceptive procedure. A CPOT cutoff score of ≥2 was associated with the maximum sensitivity (61.3%) and specificity (94.1%). Reliability analyses revealed poor to moderate agreement between bedside and video raters and moderate to excellent consistency within video raters.

Conclusions

These findings suggest that the CPOT may be a valid tool to detect pain in pediatric patients in the acute postoperative inpatient care unit after posterior spinal fusion.

Clinical course of pain intensity in individuals with cerebral palsy: A prognostic systematic review

AIM

To describe the clinical course of pain intensity in individuals with cerebral palsy (CP) resulting from usual care or specific interventions.

METHOD

We conducted an exploratory prognostic systematic review searching electronic databases from inception to 31st December 2021. Evidence from low and moderate risk-of-bias studies was synthesized.

RESULTS

We retrieved 2275 citations; 18 studies met the inclusion criteria and 10 were synthesized. The course of pain intensity in children with CP receiving usual care was stable over 15 weeks (χ² _[2]  = 1.8, p = 0.5). Children who received continuous intrathecal baclofen (CITB) reported significant pain intensity reduction (visual analogue scale [VAS] = -4.2 out of 10, 95% confidence interval [CI] = -6.3 to -2.1]) 6 months postinsertion but similar children receiving usual care had no significant change over 6 months (VAS = 1.3 out of 10, 95% CI = -1.3 to 3.6). Children receiving botulinum neurotoxin A (BoNT-A) injections had significant decreases in pain after 1 month (numeric rating scale = -6.5, 95% CI = -8.0 to -5.0). Adults with chronic pain receiving usual care reported stable pain intensity over time; pain intensity improved in ambulatory adults exercising and those treated surgically for cervical myelopathy.

INTERPRETATION

The course of pain intensity in individuals with CP is unclear. Evidence suggests that children and adults receiving usual care had stable pain intensity over the short or long term. Interventions (CITB and BoNT-A in children and exercise and surgical treatment for cervical myelopathy in adults) had pain intensity reduction. Larger study samples are needed to confirm these results.

WHAT THIS PAPER ADDS

Pain intensity was stable in children with cerebral palsy (CP) receiving usual care. Adults with CP and chronic pain receiving usual care had stable, persistent pain intensity. Children receiving continuous intrathecal baclofen via pump and botulinum neurotoxin A reported significantly lower pain intensities. Adults with chronic pain and dyskinetic CP and cervical myelopathy reported significantly lower pain intensity with exercise or cervical decompression. Limited high-quality evidence exists describing non-procedural pain changes in individuals with CP.

FDG PET Imaging of the Pain Matrix in Neuropathic Pain Model Rats

Pain is an unpleasant subjective experience that is usually modified by complex multidimensional neuropsychological processes. Increasing numbers of neuroimaging studies in humans have characterized the hierarchical brain areas forming a pain matrix, which is involved in the different dimensions of pain components. Although mechanistic investigations have been performed extensively in rodents, the homologous brain regions involved in the multidimensional pain components have not been fully understood in the rodent brain. Herein, we successfully identified several brain regions activated in response to mechanical allodynia in neuropathic pain rat models using an alternative neuroimaging method based on 2-deoxy-2-[¹⁸F]fluoro-d-glucose positron emission tomography (FDG PET) scanning. Regions such as the medial prefrontal cortex, primary somatosensory cortex hindlimb region, and the centrolateral thalamic nucleus were identified. Moreover, brain activity in these regions was positively correlated with mechanical allodynia-related behavioral changes. These results suggest that FDG PET imaging in neuropathic pain model rats enables the evaluation of regional brain activity encoding the multidimensional pain aspect. It could thus be a fascinating tool to bridge the gap between preclinical and clinical investigations.

Les pratiques exemplaires pour l’évaluation et le traitement de la douleur chez les enfants

L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.

Best practices in pain assessment and management for children

Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.

The "STOP Pain" Questionnaire: using the Plan-Do-Study-Act model to implement a patient-family preferences-informed questionnaire into a pediatric transitional pain clinic

BACKGROUND

Patient engagement is an important tool for quality improvement (QI) and optimizing the uptake of research findings. The Plan-Do-Study-Act (PDSA) model is a QI tool that encourages ongoing evaluation of clinical care, thus improving various aspects of patient care. Ascertaining pediatric patient priorities for a pain questionnaire in the post-acute, or transitional pain, setting is important to guide clinical care since active engagement with the population of interest can optimize uptake. We used the PDSA model to adapt a chronic pain questionnaire for the pediatric transitional pain setting to reflect pediatric patient and parent/guardian preferences and to form an example of how the PDSA model can be used to improve clinical care through patient engagement.

METHODS

This project employed the PDSA model to adapt the pediatric Ontario Chronic Pain Questionnaire for use in the pediatric Transitional Pain Service (pedTPS) setting. Plan: Following reviewing the Ontario Chronic Pain Questionnaire and literature on pain questionnaire development, goal-based questions, questions on pain location, relevant Patient-Reported Outcomes Measurement Information System (PROMIS^®) measures and the Pain Catastrophizing Scale, child (PCS-C) and parent (PCS-P), informed the questionnaire. Do: The questionnaire and a satisfaction survey were sent to patients and families through Research Electronic Data Capture (REDCap™).

STUDY

Results from the satisfaction survey were analyzed. Act: Using descriptive statistics employing ordinal mixed-models with random effects, ANOVA, and double-blinded qualitative thematic coding, questionnaire preferences were analyzed and the questionnaire was adapted accordingly before implementation into the (pedTPS).

RESULTS

Eighty-eight questionnaires and satisfaction surveys were analyzed from 69 respondents (32 patients; 37 parents/guardians). Sixty-six (75.00%) surveys indicated satisfaction with the questionnaire. A combined 77 (87.50%) "strongly agreed" (25/88) or "agreed" (52/88) that the questionnaire language was clear. The application of suggested changes to the questionnaire resulted in four versions across the project timeline, which reflected patient and parent/guardian preferences for questions that reflect the themes, "Story"; "Time-Optimal"; and "Pertinent" ("STOP"). There were no statistically significant differences in satisfaction across the versions due to sample size.

CONCLUSION

Most respondents were satisfied with the questionnaire and prefer "STOP" questions. Future studies will focus on testing the questionnaire for validity and reliability across pedTPS populations.

Comparison of ultrasound-guided supraclavicular and costoclavicular brachial plexus blocks in pediatric patients: a randomized clinical trial

PURPOSE

Costoclavicular brachial plexus block has been described recently as a new technique in adults and pediatric patients. In this study, we aimed to compare the supraclavicular and costoclavicular approaches, which are claimed to be effective and practical in pediatric patients.

METHODS

Sixty children were randomized to receive supraclavicular (SC group) or costoclavicular (CC group) brachial plexus blocks prior to surgical incision. Block performance times were recorded as the primary outcome. Procedural features (ideal brachial plexus cord visualization/needle pathway planning time, needle tip/shaft visualization difficulty, number of needle maneuvers, requirement of extra needle maneuvers due to insufficient local anesthetic distribution) and postoperative pain-related data (sensorimotor block intensities, Wong-Baker and FLACC pain scores and analgesic requirements) were also evaluated. To observe the tendency toward respiratory complications, ultrasonographic diaphragm movement amplitude (with M-mode) and diaphragm thickness (with B-mode) were measured postoperatively.

RESULTS

A total of 56 patients were included. Block performance times [70(7-97) vs. 115(75-180) s] were significantly lower in the CC group (p < 0.01). The block success rates did not differ (p > 0.05). The incidence of hemidiaphragm paralysis was 44% in the SC group (p < 0.001), and inspiratory diaphragm thickness was significantly lower (p < 0.01). None of CC group patients experienced hemidiaphragm paralysis. All other parameters were comparable (p > 0.05).

CONCLUSIONS

Although costoclavicular block did not show superiority in pain management, the block performance was perceived as more practical than supraclavicular block. We believe that costoclavicular brachial plexus block stands as a good option in upper extremity surgeries with the advantages of shorter block performance time and reduced ipsilateral hemidiaphragm paralysis risk in pediatric patients.

The Effect of Robot-Led Distraction during Needle Procedures on Pain-Related Memory Bias in Children with Chronic Diseases: A Pilot and Feasibility Study

The current study evaluated the feasibility and preliminary clinical impact of robot-led distraction during needle procedures in children with chronic diseases on pain-related memories. Participants were 22 children (8−12 years old) diagnosed with a chronic disease (e.g., chronic immune deficiency) and undergoing a needle procedure as part of their routine treatment. Children were randomized to the experimental group (i.e., robot-led distraction) or control group (i.e., usual care). For feasibility, we evaluated study- and needle-procedure-related characteristics, intervention fidelity and acceptability, and nurse perceptions of the intervention. Primary clinical outcomes included children’s memory bias for pain intensity and pain-related fear (1 week later). Results indicated that intervention components were >90% successful. Overall, the robot-led distraction intervention was perceived highly acceptable by the children, while nurse perceptions were mixed, indicating several challenges regarding the intervention. Preliminary between-group analyses indicated a medium effect size on memory bias for pain intensity (Hedges’ g = 0.70), but only a very small effect size on memory bias for pain-related fear (Hedges’ g = 0.09), in favor of the robot-led distraction intervention. To summarize, while feasible, certain challenges remain to clinically implement robot-led distraction during needle procedures. Further development of the intervention while accounting for individual child preferences is recommended.

Pain trajectories and well-being in children and young people with cerebral palsy: A cohort study

AIM

To identify 5-week pain intensity trajectories and their association with physical and psychological well-being in children/young people with cerebral palsy (CP).

METHOD

A cohort study was conducted with 101 Canadian children/young people with CP, of whom 49 were female, with an overall mean age of 12 years 11 months (SD 3 years 1 month), range of 8 to 18 years, and classified in any Gross Motor Function Classification System level. Self-reported pain intensity (Faces Pain Scale - Revised) was collected weekly for 5 weeks and physical and psychological well-being (KIDSCREEN-27) at baseline and 5 weeks. Statistical analyses included latent class growth and general linear models.

RESULTS

All Gross Motor Function Classification System levels were represented (I = 40.6%; II = 15.8%; III = 20.8%; IV = 13.9%; V = 8.9%). Five pain intensity trajectories were identified. Three trajectories had very low (35.4%), low (32.4%), or high (4.9%) mean stable pain. Two trajectories had moderate changing pain (16.8%) and high pain decreasing to moderate levels (10.5%) respectively. Trajectory participants with stable high pain had the lowest physical well-being (adjusted β = -10.01; 95% confidence interval [CI] = -19.37 to -0.66). Those in the three trajectories with the highest mean baseline pain intensity (>3 out of 10) had the lowest psychological well-being (adjusted β = -8.27, 95% CI = -14.84 to -1.70; β = -6.74, 95% CI = -12.43 to -1.05; β = -5.82, 95% CI = -15.34 to 3.71).

INTERPRETATION

Almost one-third of participants had moderate-to-high pain intensity trajectories. Membership in the higher pain intensity trajectories was associated with lower physical and psychological well-being.

WHAT THIS PAPER ADDS

Five distinct 5-week pain intensity trajectories were identified in children/young people with cerebral palsy. Thirty-two per cent of participants had moderate-to-high pain intensity trajectories. Participants in the trajectories with higher pain intensity reported lower physical and psychological well-being.

Bibliometric and Visual Analysis of the Current Status and Trends of Postoperative Pain in Children from 1950-2021

Background

Postoperative pain in children has been overlooked for a long time. The knowledge structure, research hotspots and trends related to postoperative pain in children are unclear and have not been systematically summarized.

Purpose

We aimed to analyze the current state of research on postoperative pain in children and to conduct in-depth mining of the knowledge structure.

Methods

The PubMed database for publications on postoperative pain in children between 1950 and 2021 was searched. Bibliographic Item Co-Occurrence Matrix Builder (BICOMB) was performed to obtain the co-word matrix and co-occurrence matrix. The H-index method was used to extract high-frequency main Medical Subject Headings (MeSH) terms/subheadings.

Results

The high-frequency MeSH terms were analyzed by biclustering, strategic diagram and social network analyses. Totally, 4022 publications were retrieved. The analysis showed that 60 countries or regions published relevant documents, with the United States publishing the most significant number of papers. Totally, 811 journals published relevant papers, with Pediatric Anesthesia ranking first. Moreover, we extracted 43 high-frequency main MeSH terms/subheadings and clustered them into five categories: overview, aetiology and epidemiology, pharmacotherapy, opioid administration and dosing, and prevention and control of postoperative pain in children.

Conclusion

Pharmacological treatments, pain prevention and control are the focus of research and are becoming increasingly mature. Opioid stewardship and regional anesthesia is the trend and focus of future research. Our study offers a better understanding of the current status and knowledge structure of postoperative pain in children and provides a reference for improving postoperative pain management in children in the future.

Use of rubber dam versus cotton roll isolation on composite resin restorations' survival in primary molars: 2-year results from a non-inferiority clinical trial

BACKGROUND

This non-inferiority randomised clinical trial aimed to evaluate the survival of direct bulk fill composite resin restorations in primary molars using different methods of moisture control: rubber dam isolation (RDI-local anaesthesia and rubber dam) and cotton roll isolation (CRI-cotton roll and saliva ejector). Secondary outcomes included baseline and 2-year incremental cost, self-reported child's pain scores and patient behaviour during the restorative procedure.

METHODS

A total of 174 molars (93 children) with dentine caries lesions were randomly allocated to study groups (RDI or CRI) and restored with bulk fill composite resin by trained operators. Two blinded examiners assessed the restorations for up to 24 months. Wong-baker faces and Frankl's behaviour rating scales were used for accessing the child's pain and behaviour, respectively. The primary outcome (restoration survival) was analysed using the two-sample non-inferiority test for survival data using Cox Regression (non-inferiority/alternative hypothesis HR > 0.85; CI = 90%). Bootstrap Linear regression was used for cost analysis and logistic regression for pain and behaviour analysis (α = 5%).

RESULTS

After 2-years, 157 restorations were evaluated (drop-out = 9.7%). The survival rate was RDI = 60.4% and CRI = 54.3%. The non-inferiority hypothesis was accepted by the Cox Regression analysis (HR = 1.33; 90% CI 0.88-1.99; p = 0.036). RDI was 53% more expensive when compared to the CRI group. No differences were found between the groups regarding pain (p = 0.073) and behaviour (p = 0.788).

CONCLUSION

Cotton roll isolation proved to be non-inferior when compared to rubber dam for composite restorations longevity in primary molars. Furthermore, the latest presented the disadvantage of higher cost and longer procedure time. Clinical Significance The moisture control method does not influence the longevity of composite restorations in primary molars. Cotton roll isolation proved to be non-inferior to rubber dam isolation and is a viable option for restoring primary molars. Clinical trial registration registered NCT03733522 on 07/11/2018. The present trial was nested within another clinical trial, the CARies DEtection in Children (CARDEC-03-NCT03520309).