Systematic Review of Self-Report Measures of Pain Intensity in 3- and 4-Year-Old Children: Bridging a Period of Rapid Cognitive Development

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

A systematic review of self and observer assessment of pain and related functioning in youth with brain-based developmental disabilities

ABSTRACT

Pain experiences of youth with brain-based developmental disabilities are often overlooked and/or misinterpreted, increasing the risk for poor or inadequate pain assessment and management. Ample measures exist to assess acute and chronic pain, yet their utility and frequency of use in youth with brain-based developmental disabilities is unclear and available measures do not have strong measurement properties for this diverse group. This systematic review identified the scope of self-reported and observer-reported pain assessment in studies of youth (aged 3-24 years) with brain-based developmental disabilities (phase 1) and summarized other measures of pain-related functioning for acute and chronic pain (ie, physical, emotional, social, sleep, and quality of life, within the subset of quantitative studies focused primarily on pain, phase 2). A comprehensive search for English-language studies was conducted in August 2022 in Web of Science, CINAHL, MEDLINE, Cochrane CENTRAL, EMBASE, and APA PsychINFO (PROSPERO registration: CRD42021237444). A total of 17,029 unique records were screened. Of the 707 articles included in phase 1, most assessed chronic pain (n = 314; 62.0%) and primarily used observer-report (n = 155; 31%) over self-report (n = 67; 13%). Of the 137 articles included in phase 2, other outcomes assessed alongside pain intensity included motor ability (16.8%), adaptive functioning (11%), quality of life (8%), pain interference (6.6%), mental health (5.8%), and communication ability (2.9%). Cerebral palsy was the most common population in both phase 1 (n = 343; 48.5%) and phase 2 (n = 83; 59.7%). This review provides a foundational understanding of pain assessment in brain-based developmental disabilities and highlights continued inequities in holistic pain assessment for this population.

Effectiveness of a Regenerative Epithelial Suspension (RES), on the pigmentation of split-thickness skin graft donor sites in children: the dRESsing pilot randomised controlled trial protocol

BACKGROUND

Paediatric donor site wounds are often complicated by dyspigmentation following a split-thickness skin graft. These easily identifiable scars can potentially never return to normal pigmentation. A Regenerative Epidermal Suspension (RES) has been shown to improve pigmentation in patients with vitiligo, and in adult patients following a burn injury. Very little is known regarding the efficacy of RES for the management of donor site scars in children.

METHODS AND ANALYSIS

A pilot randomised controlled trial of 40 children allocated to two groups (RES or no RES) standard dressing applied to donor site wounds will be conducted. All children aged 16 years or younger requiring a split thickness skin graft will be screened for eligibility. The primary outcome is donor site scar pigmentation 12 months after skin grafting. Secondary outcomes include re-epithelialisation time, pain, itch, dressing application ease, treatment satisfaction, scar thickness and health-related quality of life. Commencing 7 days after the skin graft, the dressing will be changed every 3-5 days until the donor site is ≥ 95% re-epithelialised. Data will be collected at each dressing change and 3, 6 and 12 months post skin graft.

ETHICS AND DISSEMINATION

Ethics approval was confirmed on 11 February 2019 by the study site Human Research Ethics Committee (HREC) (HREC/18/QCHQ/45807). Study findings will be published in peer-reviewed journals and presented at national and international conferences. This study was prospectively registered on the Australian New Zealand Clinical Trials Registry (available at https://anzctr.org.au/ACTRN12620000227998.aspx).

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry [Available at https://anzctr.org.au/ACTRN12620000227998.aspx].

Does Education Improve Nurses' Knowledge, Attitudes, Skills, and Practice in Relation to Pain Management? An Integrative Review

BACKGROUND

Pain is undertreated in both adults and children and a major factor linked to this is nurses' lack of knowledge as evidenced by studies undertaken globally.

OBJECTIVE

This review sought to explore the effects educational interventions can have on nurses' knowledge, attitudes, skills, and practice regarding pain management.

DESIGN

An integrative review DATA SOURCES: Systematic search of CINAHL, MEDLINE, AMED, EMBASE, and Psych INFO.

REVIEW/ANALYSIS METHODS

Five major databases were systematically searched from the year 2000-December 2019 with a total of 33 studies included in the final review.

RESULTS

The literature revealed that many nurses had inadequate knowledge and a poor attitude towards pain at baseline, which may be improved through educational intervention. However, misconceptions remained at post-intervention, particularly regarding pharmacological pain management.

CONCLUSIONS

Education is a possible means to enhance nurses' knowledge and improve attitudes and practices in pain management. However, there was some evidence that this may decline over time, and continuous professional updates are likely required.

Exploring Parental Responses to Pre-schoolers' "Everyday" Pain Experiences Through Electronic Diary and Ecological Momentary Assessment Methodologies

Objective: Parental influence during children's "everyday" pain events is under-explored, compared to clinical or experimental pains. We trialed two digital reporting methods for parents to record the real-world context surrounding their child's everyday pain events within the family home. Methods: Parents (N = 21) completed a structured e-diary for 14 days, reporting on one pain event experienced by their child (aged 2.5-6 years) each day, and describing child pain responses, parental supervision, parental estimates of pain severity and intensity, and parental catastrophizing, distress, and behavioral responses. During the same 2-week period, a subsample of parent-child pairs (N = 9) completed digital ecological momentary assessments (EMA), immediately after any chosen pain event. Children reported their current pain while parents estimated the child's pain and indicated their own distress. Results: "Everyday" pain events frequently featured minor injuries to the child's head, hands or knees, and child responses included crying and non-verbal comments (e.g., "Ouch!"). Pain events occurred less frequently when parents had been supervising their child, and supervising parents reported lower levels of worry and anxiety than non-supervising parents. Child sex was significantly associated with parental estimates of pain intensity, with parents of girls giving higher estimates than parents of boys. Child age was significantly associated with both the number of pain events and with parental estimates of pain intensity and child distress: the youngest children (2-3 years) experienced the fewest pain events but received higher pain and distress estimates from parents than older children. Hierarchal Linear Modeling revealed that parental estimates of pain severity were significant positive predictors of parental distress and catastrophizing in response to a specific pain event. Furthermore, higher levels of parental catastrophic thinking in response to a specific pain event resulted in increased distress, solicitousness, and coping-promoting behaviors in parents. The EMA data revealed that children reported significantly higher pain intensity than their parents. Conclusion: The electronic pain diary provided a key insight into the nature of "everyday" pain experiences around the family home. Digital daily reporting of how the family copes with "everyday" events represents a viable means to explore a child's everyday pains without disrupting their home environment.

Interoception in preschoolers: New insights into its assessment and relations to emotion regulation and stress

Interoception may play an important role for emotion regulation and stress, thereby affecting mental health in children and adults. Yet, little is known on interoception in preschool children. Therefore, we investigated interoceptive accuracy using the adapted Jumping Jack Paradigm (JJP) and its relationship with emotion regulation and stress. In Study I, 40 preschoolers completed the JJP and an emotion regulation task, demonstrating a positive relationship between interoceptive accuracy and emotion regulation at trend level (R² = 0.231, p = .023; β = .278, p = .073). In Study II, 31 preschoolers completed the adapted JJP before and after an acute laboratory stress test. Higher total cortisol output following acute stress induction was associated with reduced interoceptive accuracy (r = -0.670, p = .017). Extending earlier findings in adults and school-children, the relationship of interoceptive accuracy with emotion regulation and stress highlights the importance to investigate interoception in early childhood.

Ability of 3- to 5-year-old children to use simplified self-report measures of pain intensity

Little is known about self-report pain intensity scales best suited for young children. We tested the ability of preschool children to use two simplified scales (concrete ordinal and faces). Three- to 5-year-olds (n = 123) were asked to make binary discriminations ('less' vs 'more' pain) between response options using the Simplified Faces Pain Scale and Simplified Concrete Ordinal Scale and to complete a seriation task. Eighty participants were also asked to use the Simplified Concrete Ordinal Scale, with modified verbal anchors, to rate the loudness of tones and to assess practice effects. Binary discrimination accuracy and seriation ability improved with age. When using the Simplified Concrete Ordinal Scale to rate the loudness of tones, even the 3-year-olds performed significantly better than chance, and performance was better in 4- and 5-year-olds. Little evidence supported the ability of 3-year-olds to use either of the simplified tools in the pain context. The 4-year-olds demonstrated greater accuracy in using the Simplified Concrete Ordinal Scale than the Simplified Faces Pain Scale, suggesting that the Simplified Concrete Ordinal Scale may be more appropriate for this age group.

Pain assessment from Swedish nurses' perspective

METHODS

This study is a qualitative interview study. The authors used the stimulated recall interview (SRI) with nurses working at a children's hospital in southern Sweden for the data collection. In total twelve nurses were interviewed and qualitative content analysis was used for the data analysis.

RESULTS

The results are presented as one theme: Need for higher competencies and evidence, and three categories: Routines can enable pain assessment, Trusting one's own assessment of the whole picture, and Pain assessment scales as an extra workload. The interviewed nurses acknowledged that pain assessment tools are a vital part of the field of pain treatment. They also had trust issues with measuring and estimating pain by means of a tool such as pain scale. Furthermore, their opinion was that too many different tools and methods add up towards a more blurry and stress-related environment and due to a lack of consistent routines, pain assessment is seen as a work-related burden in the daily routines.

CONCLUSION

Results from the present study indicated that nurses need clear routines in combination with continued education regarding pain assessment with pain scales, which might be the key to successful pediatric pain assessment and thus to better pain management within pediatrics.

Single dose of intraoperative intravenous morphine for analgesia in children undergoing tonsillectomy: Randomized, double-blind clinical trial

INTRODUCTION

Children undergoing tonsillectomy have severe pain in the postoperative period. One of the pharmacological options for analgesia is opioids, such as morphine. However, the risks of adverse effects, such as increased recovery time from anesthesia and respiratory depression, can limit its use.

OBJECTIVES

To evaluate the use of intraoperative intravenous morphine to reduce immediate postoperative pain in children undergoing tonsillectomy.

METHODS

In this double-blind randomized study, children aged 3-10 years were submitted to tonsillectomy, with or without adenoidectomy, and divided into two groups. Children in group M received 0.1 mg/kg of intravenous morphine during anesthetic induction, while those in the control group received conventional anesthesia without morphine. Postoperative pain perceptions were assessed at 30, 60, 120, 180 and 240 min after recovery from anesthesia, by the children themselves and also by their parents or guardians, using a facial pain scale.

RESULTS

A total of 57 children were included, 30 in the group with morphine and 27 in the group without morphine. According to the children themselves, the postoperative pain was less at the evaluations performed at 30 min after awakening from anesthesia (p =  0.023), while according to their parents/guardians, the pain was less intense in the evaluations performed at 30 (p =  0.002), 60 (p =  0.006) and 180 min (p =  0.007) after awakening. Moreover, postoperative analgesics were less requested by children in the morphine group. No observed side effects were associated with the use of morphine.

CONCLUSION

A single dose of intravenous morphine during anesthetic induction reduced the intensity of immediate postoperative pain in children undergoing tonsillectomy, without increasing the time of awakening from anesthesia and with lower consumption of rescue analgesics.

Quantifying postoperative sleep loss associated with increased pain in children undergoing a modified Nuss operation

PURPOSE

The presence of pain may interrupt sleep and impede normal postoperative recovery; however, no prior studies have quantified sleep loss due to pain in children undergoing inpatient surgery. Wearable accelerometers objectively measure sleep patterns in children. We aimed to quantify sleep loss associated with patient reported pain scores after a Modified Nuss operation.

METHODS

Ten patients undergoing Modified Nuss operations were recruited during their inpatient stay. Children wore an Actigraph GT3X-BT accelerometer postoperatively during their hospital stay. Hourly sleep minutes were recorded using the Actigraph between 10 pm and 6 am. Patient reported pain scores were abstracted from patient charts. Mixed linear regression models, adjusting for within-subject random effects, were estimated to quantify the association between hourly sleep minutes and patient reported pain scores.

RESULTS

Patients were 30% female, with an average age of 15.7 years (range 13-22). The majority (70%) of patients were white non-Hispanic. All patients received a patient controlled analgesic pump. Average postoperative length of stay was 4.8 days (range 4.0-6.0; SD = 0.8). A total of 240 sleep hours and associated pain scores were analyzed. Patients slept on average 48 min per hour. Mixed model analysis predicted that a 1-point increase in pain score was associated with 2.5 min per hour less sleep time.

CONCLUSION

Increases in patient-reported pain scores are associated with sleep loss after a Modified Nuss operation. Objectively quantifying sleep loss associated with postoperative pain using accelerometer data may help clinicians better understand their patient's level of pain control. Our findings provide the basis for future studies aimed at more accurately titrating pain medication to optimize sleep and speed up recovery.

LEVEL OF EVIDENCE

Case Series Without Comparison Group, Level IV.

Behavioral Adjustment of Preschool Children With and Without Craniofacial Microsomia

OBJECTIVE

The study aim was to assess behavioral adjustment in preschool children with and without craniofacial microsomia (CFM).

DESIGN

Multisite cohort study of preschoolers with CFM ("cases") or without CFM ("controls").

PARTICIPANTS

Mothers (89%), fathers (9%), and other caregivers (2%) of 161 preschoolers.

OUTCOME MEASURE

Child Behavior Check List (CBCL 1.5-5); linear regressions with standardized effect sizes (ES) adjusted for sociodemographic confounds.

RESULTS

Child Behavior Check Lists for 89 cases and 72 controls (average age 38.3 ± 1.9 months). Children were male (54%), white (69%), and of Latino ethnicity (47%). Cases had microtia with mandibular hypoplasia (52%), microtia only (30%), or other CFM-associated features (18%). Nearly 20% of cases had extracranial anomalies. Composite CBCL scores were in the average range compared to test norms and similar for cases and controls. On the subscales, cases' parents reported higher Anxious/Depressed scores (ES = 0.35, P = .04), Stress Problems (ES = 0.40, P = .04), Anxiety Problems (ES = 0.34, P = .04), and Autism Spectrum Problems (ES = 0.41, P = .02); however, the autism subscale primarily reflected speech concerns. Among cases, more problems were reported for children with extracranial anomalies and certain phenotypic categories with small ES.

CONCLUSIONS

Behavioral adjustment of preschoolers with CFM was comparable to peers. However, parental reports reflected greater concern for internalizing behaviors; thus, anxiety screening and interventions may benefit children with CFM. Among cases, more problems were reported for those with more complex presentations of CFM. Craniofacial microsomia-related speech problems should be distinguished from associated psychosocial symptoms during developmental evaluations.

The validity of simplified self-report pain intensity assessment tools in preschool-age children undergoing adenotonsillectomy

PURPOSE

To assess the validity of simplified pain scales, including the Simplified Faces Pain Scale (S-FPS) and Simplified Concrete Ordinal Scale (S-COS) in preschool-age children who underwent adenotonsillectomy (T&A) by comparing the values of simplified pain scales with the Faces Pain Scale-Revised (FPS-R) and the Faces, Legs, Activity, Cry, Consolability (FLACC) observational pain scale.

METHODS

The present study consisted of 100 pediatric patients between the ages of 3 and 6 years old who had T&A. A two-step pain assessment approach with S-FPS and S-COS and FPS-R and FLACC pain scales was performed with children with the help of their parents or caregivers at the 1st, 6th and 12th hours, and over the 7 days after surgery.

RESULTS

The mean scores of S-FPS and S-COS were higher than the mean FPS-R scores for each time point for all age groups. The total number of children reporting no pain was higher for FPS-R than S-FPS and S-COS for each age group and the difference was significant for 3-, 4- and 5- year olds. S-FPS, S-COS and FPS-R showed a moderate correlation with FLACC in all age groups, whereas the correlation values were not significantly different between the tests.

CONCLUSION

In the present study, we found that S-FPS and S-COS were valid options for estimating pain in preschool children including 3- and 4-year-olds who underwent T&A.

Examining a New Scale for Evaluating Taste in Children (TASTY)

OBJECTIVES

Pediatric medication taste impacts adherence, and current recommendations advocate for direct input from pediatric patients on medication taste during drug development. However, the lack of a widely used, validated measurement tool limits taste assessments. This protocol examines the validity of, and preferences for, a newly created self-report taste rating scale designed with images centered on taste (TASTY), compared with 2 existing hedonic taste scales.

METHODS

This study was a prospective, single-center, randomized survey of child-parent dyads recruited from pediatric ambulatory care clinics and ancillary service waiting rooms. Parents facilitated the survey by identifying foods that they perceived their child would recall as pleasant, neutral, and unpleasant. Children were asked to rate each of the 3 food items on each of 3 different faces scales presented in random order. Parents and children were also asked which scale they preferred and why.

RESULTS

Ninety child-parent dyads completed this study (mean child age was 6.7 ± 2.9 years, 58% female). All 3 scales performed comparably with no significant differences (p > 0.05). However, concordance between parental assignment and child rankings was markedly lower in 3-year-olds (r < 0.4) and 4-year-olds (r < 0.6) than for children 5 years and older (r > 0.9). TASTY was preferred by both parents and children when compared with the other scales.

CONCLUSIONS

This novel hedonic taste scale for pediatric use is equally valid and preferred to comparable faces scales. The TASTY scale may be beneficial in developing standardized methodology for evaluating drug palatability.

Am I being watched? The role of researcher presence on toddlers' behaviour during 'everyday' pain experiences: a pilot study

Objective: Paediatric research on 'everyday' pain experiences is sparse, stemming from a lack of appropriate methodologies. We explored the feasibility of two methodologies for conducting naturalistic observations of 'everyday' pains within family's homes, against an established methodology for day-care observations. Design: Within family homes, video-cameras recorded a typical morning or afternoon (maximum three hours), either with, or without researcher presence. To compare feasibility, children in day-care were observed by researchers for three hours without video-recording. Outcome measures: logistics of observation, child pain behaviours, caregiver responses to child pain. Results: Thirteen children (M_age = 45.4 months) were recorded at home, experiencing 14 pain events. Researcher presence increased child distress intensity, but reduced the number of pain events compared to sessions without a researcher. Thirty-two children (M_age = 48.4 months) were observed in day-care, experiencing 44 pain events. Children experiencing pain events in day-care exhibited decreased distress and lower personal control than those observed at home. Across all conditions, caregivers engaged mostly in physical comfort. Researcher estimates of child pain were highest if scored while present in the home. Conclusions: Observing everyday pain events within the child's natural environment is feasible and may provide insight into the social context of childhood pain experiences.

End points for sickle cell disease clinical trials: patient-reported outcomes, pain, and the brain

To address the global burden of sickle cell disease (SCD) and the need for novel therapies, the American Society of Hematology partnered with the US Food and Drug Administration to engage the work of 7 panels of clinicians, investigators, and patients to develop consensus recommendations for clinical trial end points. The panels conducted their work through literature reviews, assessment of available evidence, and expert judgment focusing on end points related to: patient-reported outcomes (PROs), pain (non-PROs), the brain, end-organ considerations, biomarkers, measurement of cure, and low-resource settings. This article presents the findings and recommendations of the PROs, pain, and brain panels, as well as relevant findings and recommendations from the biomarkers panel. The panels identify end points, where there were supporting data, to use in clinical trials of SCD. In addition, the panels discuss where further research is needed to support the development and validation of additional clinical trial end points.

Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer

Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.

The Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ): Development and Initial Psychometric Evaluation of a Brief and Comprehensive Measure of Pain and Pain Outcomes in Hospitalized Youth

Pediatric pain assessment in the hospital traditionally involves the patient's self-report of pain intensity using a numeric rating scale, which does not capture the complexity of the pain experience. No valid, comprehensive measure of pain in hospitalized youth exists. This study was designed to develop and conduct initial psychometric testing of the Pediatric American Pain Society Patient Outcomes Questionnaire (Pediatric APS-POQ), a comprehensive patient-reported measure of pain and pain outcomes in hospitalized youth. A multidisciplinary group of pediatric pain researchers and clinicians collaborated to adapt the adult APS-POQ Revised to pediatrics, including a patient-report and parent proxy version. The adapted measures were administered to 218 pediatric inpatients (age M = 13.4 years, 56% female) and 214 of their parents (80% mothers) at 4 US children's hospitals. The measure was feasible to administer within the inpatient setting and was acceptable and understandable to pediatric patients and their parents. Internal consistency was adequate for both patient-report and parent proxy (α = 0.77). Confirmatory factor analysis supported the following 6 domains, consistent with the adult measure: pain intensity, functional interference, emotional response, side effects, perceptions of care, and usual pain. Additional research is needed to further support the reliability and validity of this measure in diverse clinical populations. PERSPECTIVE: To reduce the impact of pain on hospitalized youth, pediatric pain assessment must move beyond ratings of pain intensity. The Pediatric APS-POQ provides a brief but comprehensive assessment of pain and pain outcomes in hospitalized children and adolescents, which will allow for greater individualization in hospital-based pain management and quality improvement purposes.

Children Listening to Music or Watching Cartoons During ER Procedures: A RCT

OBJECTIVE

This study aims to determine if listening to music and watching cartoons are effective to distract children from pain and distress during procedures in the emergency room (ER).

METHODS

This study is a single-center, 3-armed, superiority randomized controlled trial comparing listening to music, watching cartoons, and standard care during ER procedures in children aged 3-13 years. The primary outcome was pain measured from video footage with the Alder Hey Triage Pain Score (AHTPS). Children older than 4 years self-reported pain with the Faces Pain Scale-Revised (FPS-R). The secondary outcome was distress measured with the Observational Scale of Behavioral Distress-revised (OSBD-r). Another indicator of distress was heart rate.

RESULTS

Data of 191 participants were analyzed for the 3 groups: music (n = 75), cartoon (n = 62), and control (n = 54). The median age was 7.3 years (4.9-9.7). In multivariable analysis, pain assessed with the AHTPS was significantly lower (B = -1.173, 95% confidence interval -1.953, -0.394, p = .003) in the music group than in the control groups. Across the 3 groups, 108 children self-reported pain with the FPS-R after the procedure. The scores were lowest in the music group, but the differences between groups were not significant (p = .077). OSBD-r distress scores assigned during the procedures were not significantly different between the 3 groups (p = .55). Heart rate directly after the procedure was not statistically significantly different between the 3 groups (p = .83).

CONCLUSIONS

Listening to recorded music is a beneficial distraction for children experiencing pain during ER procedures, whereas watching cartoons did not seem to reduce pain or distress.

Pain Assessment in the Patient Unable to Self-Report: Clinical Practice Recommendations in Support of the ASPMN 2019 Position Statement

Pain is a subjective experience, unfortunately, some patients cannot provide a self-report of pain verbally, in writing, or by other means. In patients who are unable to self-report pain, other strategies must be used to infer pain and evaluate interventions. In support of the ASPMN position statement "Pain Assessment in the Patient Unable to Self-Report", this paper provides clinical practice recommendations for five populations in which difficulty communicating pain often exists: neonates, toddlers and young children, persons with intellectual disabilities, critically ill/unconscious patients, older adults with advanced dementia, and patients at the end of life. Nurses are integral to ensuring assessment and treatment of these vulnerable populations.

The impact of medical clowns exposure over postoperative pain and anxiety in children and caregivers: An Israeli experience

While postoperative pain management was shown to reduce unwanted physiological and emotional outcomes, pediatric postoperative pain management remains suboptimal. Medical-clowns were shown to be beneficial in many medical contexts including reduction of stress, anxiety and pain. This study was set to assess the effectiveness of medical-clowns on pediatric postoperative pain reduction. Children age 4 or above, planned for elective hernia repair surgery were recruited. Children were randomly divided to a control or medicalclown escorted groups. Demographical and clinical data were collected using questionnaires and electronic sheets. Children escorted by clowns reported lower levels of pain upon admittance, discharge and 12- hours post-surgery. Statistically significant reduction of parental distress and significantly higher serum cortisol levels were observed in the clown-therapy group. Although small, our study supports the possibility that preoperative medical-clown therapy might be a cheap, safe and yet beneficial method for postoperative pain reduction.

The role of parental acute psychological distress in paediatric burn re-epithelialization

OBJECTIVES

Following a paediatric burn, parents commonly experience high levels of acute psychological distress, which has been shown to increase child psychological distress as well as child procedural distress. The influence of psychological stress and perceived pain on wound healing has been demonstrated in several laboratory and medical populations. This paper investigates the influence of parental acute psychological distress and procedural behaviour on the child's rate of re-epithelialization, after controlling for child procedural distress.

DESIGN

A prospective observational study with longitudinal outcome.

METHODS

Eighty-three parents of children 1-6 years old reported acute psychological distress (post-traumatic stress symptoms [PTSS], guilt, pre-procedural fear, general anxiety/depression symptoms) in relation to their child's burn. A researcher observed parent-child behaviour at the first dressing change, and parents and nurses reported child procedural distress (pre-, peak-, and post-procedural pain and fear). These variables, along with demographic and injury information, were tested for predicting time to re-epithelialization. Date of re-epithelialization was determined by the treating consultant.

RESULTS

Days to re-epithelialization ranged from 3 to 35 days post-injury. A hierarchical multiple regression analysis found wound depth and size significantly accounted for 28% of the variance in time to re-epithelialization. In Block 2, child peak-procedural pain significantly accounted for 6% additional variance. In Block 3, parental PTSS significantly accounted for 5% additional variance.

CONCLUSIONS

Parental PTSS appears to be an important but under-recognized factor that may influence their child's burn re-epithelialization. Further investigation is required to understand the mechanisms contributing to this association. Statement of contribution What is already known on this subject? Psychological stress delays wound healing, and this relationship has been found in paediatric burn populations with procedural pain. Parental psychological stress is often present after a child's burn and is related to the child's procedural coping and distress. What does this study add? Parental post-traumatic stress is related to delayed child burn re-epithelialization. This association is in addition to procedural pain delaying re-epithelialization.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

METHODS

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

RESULTS

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

Children's Perceptions of Pictures Intended to Measure Anxiety During Hospitalization

Many children experience anxiety during a hospital stay, which can have an adverse impact on their recovery and response to future hospital care. To facilitate assessment of anxiety in young children and children with communicative disabilities, the short S-STAI (short version of the State scale of the State-Trait Anxiety Inventory), has previously been adapted to a visual format. The aims of the present study were (a) to validate the pictures used to represent emotions and the steps of a quantitative scale ('a lot' - 'some' - 'a little'), including to determine whether any of them should be replaced, and (b) to assess different pictures to be used for a qualitative scale ('good/like' - 'in between/so-so' -'bad/dislike') in the same instrument. A total of 103 children aged 5-8 years were asked to choose verbal labels for pictures of facial expressions intended to represent emotions, match those pictures with the emotional categories used in the short S-STAI (Tense/Nervous, Worried/Afraid, Calm/Relaxed, and Happy/Content) and indicate their preferences for pictures intended to represent the steps of a quantitative scale and a qualitative one. The children understood both scales and the differences between positive and negative emotions in the short S-STAI. The older children (aged 7 and 8) significantly more often chose a picture for each step of the scales that was intended to represent that particular step. The article discusses implications for the choice of pictures representing emotional states in the short S-STAI and presents recommended pictures.

A parent-science partnership to improve postsurgical pain management in young children: Co-development and usability testing of the Achy Penguin smartphone-based app

BACKGROUND

Young children are at risk for poorly managed pain after surgery, with significant negative consequence to their quality of life and health outcomes. Mobile applications offer a highly accessible, engaging, and interactive medium to improve pain assessment and management; however, they generally lack scientific foundation or support.

AIMS

The aims of this study were to describe a successful parent-science partnership in the development and testing of Achy Penguin, a parent-developed iOS app to help assess and manage acute pain in young children, and to evaluate and refine the usability of Achy Penguin in young children with acute postoperative pain.

METHODS

Three cycles of iterative usability testing were conducted with 20 4- to 7-year-old children (M = 5.8 years) in hospital who had recently undergone surgery (n = 6-7 children/cycle). Semistructured qualitative interviews were analyzed using simple content analysis.

RESULTS

Feedback from children and further integration of evidence-based pediatric pain knowledge led to refinements in app pain assessment and management content, as well as app flow and functionality. Changes improved children's ease of use and understanding and satisfaction by simplifying language in app instructions and content, adding audio and pictorial instructions, and increasing the engagement, interactiveness, immersiveness, and general appeal of pain management strategies.

CONCLUSIONS

This article showcases the value of collaborative partnerships between various stakeholders (parents, app developers, and researcher/health care providers) to address gaps in pediatric pain care. The Achy Penguin app shows promise for improving pain assessment and management in young children, although further evaluation of app effectiveness and implementation is warranted.

Psychological interventions for needle-related procedural pain and distress in children and adolescents

BACKGROUND

This is the second update of a Cochrane Review (Issue 4, 2006). Pain and distress from needle-related procedures are common during childhood and can be reduced through use of psychological interventions (cognitive or behavioral strategies, or both). Our first review update (Issue 10, 2013) showed efficacy of distraction and hypnosis for needle-related pain and distress in children and adolescents.

OBJECTIVES

To assess the efficacy of psychological interventions for needle-related procedural pain and distress in children and adolescents.

SEARCH METHODS

We searched six electronic databases for relevant trials: Cochrane Central Register of Controlled Trials (CENTRAL); MEDLINE; PsycINFO; Embase; Web of Science (ISI Web of Knowledge); and Cumulative Index to Nursing and Allied Health Literature (CINAHL). We sent requests for additional studies to pediatric pain and child health electronic listservs. We also searched registries for relevant completed trials: clinicaltrials.gov; and World Health Organization International Clinical Trials Registry Platform (www.who.int.trialsearch). We conducted searches up to September 2017 to identify records published since the last review update in 2013.

SELECTION CRITERIA

We included peer-reviewed published randomized controlled trials (RCTs) with at least five participants per study arm, comparing a psychological intervention with a control or comparison group. Trials involved children aged two to 19 years undergoing any needle-related medical procedure.

DATA COLLECTION AND ANALYSIS

Two review authors extracted data and assessed risks of bias using the Cochrane 'Risk of bias' tool. We examined pain and distress assessed by child self-report, observer global report, and behavioral measurement (primary outcomes). We also examined any reported physiological outcomes and adverse events (secondary outcomes). We used meta-analysis to assess the efficacy of identified psychological interventions relative to a comparator (i.e. no treatment, other active treatment, treatment as usual, or waitlist) for each outcome separately. We used Review Manager 5 software to compute standardized mean differences (SMDs) with 95% confidence intervals (CIs), and GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 59 trials (20 new for this update) with 5550 participants. Needle procedures primarily included venipuncture, intravenous insertion, and vaccine injections. Studies included children aged two to 19 years, with few trials focused on adolescents. The most common psychological interventions were distraction (n = 32), combined cognitive behavioral therapy (CBT; n = 18), and hypnosis (n = 8). Preparation/information (n = 4), breathing (n = 4), suggestion (n = 3), and memory alteration (n = 1) were also included. Control groups were often 'standard care', which varied across studies. Across all studies, 'Risk of bias' scores indicated several domains at high or unclear risk, most notably allocation concealment, blinding of participants and outcome assessment, and selective reporting. We downgraded the quality of evidence largely due to serious study limitations, inconsistency, and imprecision.Very low- to low-quality evidence supported the efficacy of distraction for self-reported pain (n = 30, 2802 participants; SMD -0.56, 95% CI -0.78 to -0.33) and distress (n = 4, 426 participants; SMD -0.82, 95% CI -1.45 to -0.18), observer-reported pain (n = 11, 1512 participants; SMD -0.62, 95% CI -1.00 to -0.23) and distress (n = 5, 1067 participants; SMD -0.72, 95% CI -1.41 to -0.03), and behavioral distress (n = 7, 500 participants; SMD -0.44, 95% CI -0.84 to -0.04). Distraction was not efficacious for behavioral pain (n = 4, 309 participants; SMD -0.33, 95% CI -0.69 to 0.03). Very low-quality evidence indicated hypnosis was efficacious for reducing self-reported pain (n = 5, 176 participants; SMD -1.40, 95% CI -2.32 to -0.48) and distress (n = 5, 176 participants; SMD -2.53, 95% CI -3.93 to -1.12), and behavioral distress (n = 6, 193 participants; SMD -1.15, 95% CI -1.76 to -0.53), but not behavioral pain (n = 2, 69 participants; SMD -0.38, 95% CI -1.57 to 0.81). No studies assessed hypnosis for observer-reported pain and only one study assessed observer-reported distress. Very low- to low-quality evidence supported the efficacy of combined CBT for observer-reported pain (n = 4, 385 participants; SMD -0.52, 95% CI -0.73 to -0.30) and behavioral distress (n = 11, 1105 participants; SMD -0.40, 95% CI -0.67 to -0.14), but not self-reported pain (n = 14, 1359 participants; SMD -0.27, 95% CI -0.58 to 0.03), self-reported distress (n = 6, 234 participants; SMD -0.26, 95% CI -0.56 to 0.04), observer-reported distress (n = 6, 765 participants; SMD 0.08, 95% CI -0.34 to 0.50), or behavioral pain (n = 2, 95 participants; SMD -0.65, 95% CI -2.36 to 1.06). Very low-quality evidence showed efficacy of breathing interventions for self-reported pain (n = 4, 298 participants; SMD -1.04, 95% CI -1.86 to -0.22), but there were too few studies for meta-analysis of other outcomes. Very low-quality evidence revealed no effect for preparation/information (n = 4, 313 participants) or suggestion (n = 3, 218 participants) for any pain or distress outcome. Given only a single trial, we could draw no conclusions about memory alteration. Adverse events of respiratory difficulties were only reported in one breathing intervention.

AUTHORS' CONCLUSIONS

We identified evidence supporting the efficacy of distraction, hypnosis, combined CBT, and breathing interventions for reducing children's needle-related pain or distress, or both. Support for the efficacy of combined CBT and breathing interventions is new from our last review update due to the availability of new evidence. The quality of trials and overall evidence remains low to very low, underscoring the need for improved methodological rigor and trial reporting. Despite low-quality evidence, the potential benefits of reduced pain or distress or both support the evidence in favor of using these interventions in clinical practice.

Pain Experience in a US Children's Hospital: A Point Prevalence Survey Undertaken After the Implementation of a System-Wide Protocol to Eliminate or Decrease Pain Caused by Needles

OBJECTIVES

Pain in hospitalized children remains under-assessed and undertreated. With this study, we aim to describe results from a repeat single-day, hospital-wide survey of children's pain and its treatment after the initiation of a hospital-wide quality improvement initiative used to reduce or eliminate pain caused by needle procedures.

METHODS

All patients and parents listed on the inpatient morning census, in emergency department and outpatient surgery registration lists, were invited to participate in a brief single-day point prevalence survey of their experience with pain and its management in the hospital setting. Results were compared with a survey conducted 2 years earlier, before implementation of a system-wide Children's Comfort Promise needle pain treatment and prevention protocol.

RESULTS

A total of 194 children and their parents participated in the current survey. A higher percentage of children reported having no pain compared with the previous survey (33% vs 24%; P = .07; not significant) and fewer experienced severe pain (score ≥7 out of 10). Fewer children identified pain caused by needles as the cause of the worst pain (21% vs 30%), although it remained the highest reported cause of the most painful experience overall. The number of pain management strategies administered and offered to children with needle pain (distraction, positioning, numbing cream, and sucrose and/or breastfeeding for infants) increased.

CONCLUSIONS

The implementation of a mandatory Comfort Promise protocol used to minimize or prevent pain caused by elective needle procedures was associated with a significant reduction in overall pain prevalence and improved use of evidence-based practices for needle pain management.

Split laminotomy versus conventional laminotomy: postoperative outcomes in pediatric patients

OBJECTIVE Split laminotomy is a technique for accessing the spinal canal from the posterior midline that minimizes muscle dissection and bone removal. Benefits of this approach in minimizing postoperative pain and muscle atrophy in the adult population have been reported, but pediatric data are limited. Herein, the authors evaluate the benefits of the split laminotomy technique in pediatric patients. METHODS Data obtained in patients who underwent posterior spine surgery at Children's Hospital of Wisconsin for an intradural midline pathology between April 2008 and June 2015 were reviewed retrospectively. Each patient was assigned to one of two groups, the split-laminotomy or conventional-laminotomy group. The primary outcomes assessed were mean daily pain score, total opioid use over a period of 72 hours after surgery, and the degree of paraspinal muscle atrophy and fat infiltration found on short-term (1-4 months) and long-term (1-4 years) follow-up spine MRI studies. RESULTS A total of 117 patients underwent lumbar-level surgery (83 conventional laminotomy, 34 split laminotomy), and 8 patients underwent thoracic-level surgery (4 in each group). No significant difference in the mean daily pain scores between groups was found. The daily opioid use was significantly lower in the split-laminotomy group on postoperative day 0 (POD0) and POD1 but not on POD2 (p = 0.01, 0.01, and 0.10, respectively). The total opioid use over the 72-hour postoperative period was significantly lower in the split-laminotomy group (p = 0.0008). The fat/muscle ratio was significantly higher in both the short-term and long-term follow-up periods in the conventional-laminotomy group (p = 0.01 and 0.0002, respectively). The rate of change of paraspinal muscle fat infiltration was significantly lower in the split-laminotomy group than in the conventional-laminotomy group (p = 0.007). The incidence of complications was not significantly different between groups (p = 0.08). CONCLUSIONS This study was of the largest series reported thus far of pediatric patients who underwent split laminotomy and the only controlled study that has involved children. The authors' results reinforce the short-term benefit of split laminotomy in minimizing acute postoperative pain and long-term benefits of decreasing muscle atrophy and fatty degeneration, which are known to be associated with the development of chronic pain and spinal instability. Additional efforts for assessing long-term effects in the development of chronic pain, spinal instability, and spinal deformity are still necessary.

Qualitative Assessment of Face Validity and Cross-Cultural Acceptability of the Faces Pain Scale: "Revised" in Cameroon

The Faces Pain Scale-Revised (FPS-R) is a self-report pain scale validated in numerous countries, but not in Cameroon. We postulated that while cultural factors influence pain perception and expression, the FPS-R should remain culturally acceptable for pediatric use. A convenience sample of 36 pediatric patients, aged 4 to 16 years, representing three primary language groups, was enrolled at Mbingo Baptist Hospital (MBH). Pre- and postanalgesia FPS-R scores and vital signs were obtained. Audio-recorded cognitive interviews were performed with each participant. Written questionnaires were also provided to physicians, nurses, and caretakers to further explore cultural perceptions of pain. Four independent reviewers analyzed interview transcripts and questionnaires using inductive reasoning and identified common themes pertaining to gender differences, societal roles, and pain perception. Basic comprehension of the FPS-R was present across language groups, vital sign changes corresponded with FPS-R alterations, and the FPS-R appears intuitive for pediatric use.

A Scoping Review of Pain in Children after Traumatic Brain Injury: Is There More Than Headache?

Headache is a common source of pain in children after traumatic brain injury (TBI); however, relatively little is known about nonheadache pain in this pediatric population. The present review seeks to map the extant literature to determine the prevalence, characteristics, and impact of nonheadache pain in children post-TBI of all severities. We found that of 109 studies published on pain in children after a TBI, 95 (87%) were focused exclusively on headache pain and only 14 (13%) reported on nonheadache pain or overall pain, with half (n = 7) in the form of case studies. Overall, the level of evidence was low, with only three level 1 high-quality prospective studies. In one study, over half (57.1%) of adolescents who experienced persistent pain post-TBI reported pain in multiple body sites (e.g., back, lower limb, and neck).¹ For each additional noncephalic pain site, the risk for developing chronic migraine is also increased. Nevertheless, pain in body regions other than the head is often not assessed systematically in pediatric TBI research. Findings of the current review suggest that pain assessment in children post-TBI needs improvement, given that pain is linked to worse recovery, poorer quality of life, and can be long-lasting. More rigorous examination of nonheadache pain and its role in impeding recovery in children post-TBI is imperative and has the potential to improve the care and management of children with TBI. We conclude with recommendations for pain assessment, discuss gaps in the literature, and highlight directions for future research.