The challenges of pain measurement in critically ill young children: A comprehensive review

Evaluation of Pain in the Pediatric Patient Admitted to Sub-Intensive Care: What Is the Evidence? A Scoping Review

BACKGROUND AND OBJECTIVES

Inadequate pain treatment in pediatric patients can cause long-term physical and psychological issues. Accurate detection of pain presence and intensity is crucial, especially in Neonatal and Pediatric Sub-Intensive Care Units. Due to uncertainties about the best pain assessment tool in these settings, it is necessary to review the literature to identify the available evidence.

METHODS

A scoping review was performed to address the question: What tools are available for pain assessment in non-sedated, non-intubated pediatric patients in sub-intensive care? Searches were conducted in databases including PubMed, Scopus, Embase, CINAHL, Cochrane Library, Web of Science, Open Dissertation, as well as CENTRAL and ClinicalTrials.gov registries.

RESULTS

The review included 27 studies, revealing various tools for pain assessment in pediatric sub-intensive settings. All studies favored the use of multidimensional scales, combining physiological and behavioral indicators.

CONCLUSIONS

This review offers a comprehensive overview of the tools for pain assessment in pediatric patients in sub-intensive care settings but does not determine a single best tool. Most studies focused on the validation, translation, and adaptation of these tools. Further research is needed on the practical application of these tools and the perceptions of those administering them.

Use of Biomarkers to Objectively Evaluate Pain in Critically Ill Children: A Scoping Review

BACKGROUND

Many studies have been conducted recently to identify biomarkers that could potentially be used to objectively evaluate pain.

OBJECTIVE

To synthesize and critically analyze primary studies of endogenous biomarkers and their associations with pain to identify suitable biomarkers for the objective evaluation of pain in critically ill children.

METHODS

PubMed, Scopus, and Ovid databases were searched; searches were restricted by publication date, language, species, and participant age. Critical appraisal tools and the Strengthening the Reporting of Observational Studies in Epidemiology checklist were used to evaluate quality of evidence.

RESULTS

All included articles were coded according to methods and findings. Saliva, blood, cerebrospinal fluid, and gingival crevicular fluid were used to detect biomarkers. Enzyme-linked immunosorbent assays were used in most studies (64%). Appropriate statistical analyses were performed at a significance level of P < .05 in included studies. Cytokines, peptides, and hormones were associated with pain, stress, and inflammatory response, suggesting that they can be used to screen for pain in children during painful conditions. Only 1 study in neonates did not show any correlation between saliva biomarkers and pain.

CONCLUSION

According to this literature review, various biomarkers that are easily obtained and measured in a clinical setting are associated with pain in children. Further investigation of these biomarkers through observational studies is suggested to evaluate their suitability for pain assessment in critically ill children.

Efficacy of Distraction for Reducing Pain and Distress Associated With Venipuncture in the Pediatric Posttransplant Population: A Randomized Controlled Trial

OBJECTIVE

Distraction can reduce pain and distress associated with painful procedures but has never been studied in children with solid organ transplants. We aimed to determine whether there is a difference in pain and distress associated with venipuncture in pediatric posttransplant patients who receive distraction compared with those who do not.

METHODS

Randomized controlled trial of children aged 4 to 17 years with solid organ transplants undergoing venipuncture in the outpatient setting. Patients were randomized to receive distraction or no distraction. The primary outcome was the Faces Pain Scale-Revised. Secondary outcomes were the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale. Exploratory outcomes included the number of venipuncture attempts, time to successful venipuncture, and satisfaction of phlebotomists and parents.

RESULTS

Median age of the 40 children enrolled was 11.5 years. Type of transplants included the heart (67.5%), kidney (22.5%), liver (7.5%), and more than 1 organ (2.5%). There was no difference between the Faces Pain Scale-Revised scores in distraction and no distraction groups (1.4; 95% confidence interval, 0.9-1.9; and 1.3, 95% confidence interval, 0.5-2.1, respectively). There was also no difference in the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale scores, number of venipuncture attempts, or time to successful venipuncture. Phlebotomists were more satisfied with the venipuncture when distraction was implemented.

CONCLUSIONS

In children with solid organ transplants, there was no difference in pain and distress associated with venipuncture between those who did and did not receive distraction. There was also no difference in other procedure-related outcomes except for greater phlebotomist satisfaction when distraction was implemented.

Facial expressions of pain in daily clinical practice to assess postoperative pain in children: Reliability and validity of the facial action summary score

BACKGROUND

Behavioural pain scales are recommended to assess postoperative pain for children who are too young to use self-report tools. Their main limitation is underestimation of pain in the days following an intervention. Although relevant, facial expression is not used in daily clinical practice. This prospective study aimed to assess the validity and reliability of the Facial Action Summary Score (FASS), a five-item scale, to assess postoperative pain until hospital discharge in children <7 years.

METHODS

Assessments of pain and anxiety of 123 children using FASS and validated scales were used to study the psychometric validity of the FASS in clinical practice.

RESULTS

The content validity was previously investigated in a development study. The internal validity of the FASS was high with excellent reliability (intraclass coefficient = 0.94) and a high Cronbach α (0.89). Convergent validity with pain scales (FLACC [Face, Legs, Activity, Cry, Consoling] and FPS-R [Faces Pain Scale - Revised]) was high (r > 0.8). Sensitivity to change was verified by a significant decrease in the score after rescue analgesia. For a threshold of 2/5, the FASS shows excellent specificity (97%) and sensitivity (82%). The low number of false negatives is the main strength of this tool.

CONCLUSIONS

This work highlights the interest in using facial expression in daily clinical practice to manage postoperative pain. The FASS is easy to use with excellent psychometric properties and is particularly sensitive to measure pain in the days following surgery.

SIGNIFICANCE

The aim of this study was to prove that facial expression of pain can be used in clinical practice to measure postoperative pain in children. The reduced number of false negatives is the main strength of this tool.

Validation of the Greek Version of Comfort-B, FLACC, and BPS Scales in Critically Ill Children and Their Association with Clinical Severity

BACKGROUND

A variety of valid pediatric pain assessment tools are used in clinical practice globally; however, none have been validated for use in the Pediatric Intensive Care Unit (PICU) in Greece. Furthermore, the association between pain behavioral responses and clinical status is unclear.

AIMS

To assess the reliability and validity of the Greek version of FLACC, Comfort B, and BPS pain scales in critically ill children and to explore their association with clinical severity (Denver MOF, PMODS) and levels of sedation and analgesia.

METHODS

A methodological and descriptive correlational study was performed in a 6-bed PICU. A total of 60 observations in a sample of 30 children (mean age 4.1 years; 63.3% male) were obtained by 2 independent nurses during rest and painful procedures. At the same time, the bedside nurse assessed the child's pain intensity using the VASobs.

RESULTS

High internal consistency and strong interrater reliability were detected (Cronbach's alpha ≥ .85; ICC > .95, p < .001). The agreement between observers was satisfactory (0.71 ≤ Kappa ≤ 0.96, p < .001). Strong correlations were found among the scales (0.65 ≤ rho ≤0 .98, p < .05). Increased pain scores (≥moderate pain) were observed during painful procedures regardless the administration of analgesia. Statistically significant correlations were found between clinical severity and the FLACC and Comfort B scores (-0.577 ≤ rho ≤ -0.384, p < .05).

CONCLUSIONS

These pain tools were found to be suitable for this sample of children in Greece. Wider application of these tools in Greek PICUs and further research regarding their association with the clinical severity and the pain responses is required for the improvement of pain management in critically ill children.

Pain management interventions in the Paediatric Intensive Care Unit: A scoping review

OBJECTIVE

To map research based pain management interventions used in the paediatric intensive care unit.

METHODOLOGY

A scoping review of research literature has been conducted. Five databases were searched from their inception to end 2015 (CINAHL, EMBASE, MEDLINE, PsychINFO, and ProQuest Dissertations & Theses Global). Reference lists from the screened full text articles were reviewed.

RESULTS

7046 articles were identified, 100 underwent full text screening and 27 were included in the scoping review. Seventeen (63%) were non-experimental, and 10 (37%) were experimental, of which 8 (30%) were randomised controlled trials. The majority of the articles focused on pharmacological interventions (n = 21, 78%), one on physical, and one on psychological interventions. Four studies included more than one category of interventions. The majority of the studies focused on post-operative pain management (n = 18, 67%), three (11%) on analgesia and sedation management and six (22%) on other pain management for different conditions.

DISCUSSION

Most studies included in this scoping review focused on medications and post-operative pain management and most were non clinical trials. More research, including clinical trials, is warranted to determine the effectiveness of pharmacological and non-pharmacological interventions for pain management in the paediatric intensive care unit.

Nociception and the neonatal brain

Measuring brain activity in infants provides an objective surrogate approach with which to infer pain perception following noxious events. Here we discuss different approaches which can be used to measure noxious-evoked brain activity, and discuss how these measures can be used to assess the analgesic efficacy of pharmacological and non-pharmacological interventions. We review factors that can modulate noxious-evoked brain activity, which may impact infant pain experience, including gestational age, sex, prior pain, stress, and illness.

Assessment of paediatric pain: a critical review

Pain is a complex experience, and its quantification involves many aspects including physiological, behavioural, and psychological factors. References related to the topic were selected and analysed, along with a PubMed search of the recent and earlier reports. Assessment of pain in infants and children has always been a dilemma for the clinicians. Unlike in adults, it is difficult to assess and effectively treat pain in paediatric age groups, and it often remains untreated or undertreated. Misperceptions are attributed not only to the difficulties in isolating the specific signs of pain but also in recognising and inferring the meaning of the cues available in the complex of individual differences in the reaction pattern of children to pain. In children, several parameters such as age, cognitive level, type of pain, etc. are required to be considered for the selection of appropriate pain assessment tools. Although considerable progress has been made, there is a critical need for a more accurate measurement tool for both research and clinical purposes. This review has critically analysed the various techniques available to assess pain in children with emphasis on current research and present-day status of paediatric pain assessment.

[Pain assessment scales in newborns: integrative review]

OBJECTIVE

To analyze studies on methods used to assess pain in newborns.

DATA SOURCES

Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.

DATA SYNTHESIS

29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.

CONCLUSION

Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

Pharmacokinetic models of morphine and its metabolites in neonates:: Systematic comparisons of models from the literature, and development of a new meta-model

Morphine is commonly used for pain management in preterm neonates. The aims of this study were to compare published models of neonatal pharmacokinetics of morphine and its metabolites with a new dataset, and to combine the characteristics of the best predictive models to design a meta-model for morphine and its metabolites in preterm neonates. Moreover, the concentration-analgesia relationship for morphine in this clinical setting was also investigated. A population of 30 preterm neonates (gestational age: 23-32weeks) received a loading dose of morphine (50-100μg/kg), followed by a continuous infusion (5-10μg/kg/h) until analgesia was no longer required. Pain was assessed using the Premature Infant Pain Profile. Five published population models were compared using numerical and graphical tests of goodness-of-fit and predictive performance. Population modelling was conducted using NONMEM® and the $PRIOR subroutine to describe the time-course of plasma concentrations of morphine, morphine-3-glucuronide, and morphine-6-glucuronide, and the concentration-analgesia relationship for morphine. No published model adequately described morphine concentrations in this new dataset. Previously published population pharmacokinetic models of morphine, morphine-3-glucuronide, and morphine-6-glucuronide were combined into a meta-model. The meta-model provided an adequate description of the time-course of morphine and the concentrations of its metabolites in preterm neonates. Allometric weight scaling was applied to all clearance and volume terms. Maturation of morphine clearance was described as a function of postmenstrual age, while maturation of metabolite elimination was described as a function of postnatal age. A clear relationship between morphine concentrations and pain score was not established.

Current concepts in management of pain in children in the emergency department

Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.

Pain assessment scales in newborns: integrative review

OBJECTIVE: To analyze studies on methods used to assess pain in newborns.DATA SOURCES: Integrative review study of articles published from 2001 to 2012, carried out in the following databases: Scopus, PubMed, CINAHL, LILACS and Cochrane. The sample consisted of 13 articles with level of evidence 5.DATA SYNTHESIS: 29 pain assessment scales in newborns, including 13 one-dimensional and 16 multidimensional, that assess acute and prolonged pain in preterm and full-term infants were available in scientific publications.CONCLUSION: Based on the characteristics of scales, one cannot choose a single one as the most appropriate scale, as this choice will depend on gestational age, type of painful stimulus and the environment in which the infant is inserted. It is suggested the use of multidimensional or one-dimensional scales; however, they must be reliable and validated.

A multidimensional approach to pain assessment in critically ill infants during a painful procedure

OBJECTIVES

Inferring the pain level of a critically ill infant is complex. The ability to accurately extract the appropriate pain cues from observations is often jeopardized when heavy sedation and muscular blocking agents are administered. Near-infrared spectroscopy is a noninvasive method that may provide the bridge between behavioral observational indicators and cortical pain processing. We aimed to describe regional cerebral and systemic hemodynamic changes, as well as behavioral reactions in critically ill infants with congenital heart defects during chest-drain removal after cardiac surgery.

METHODS

Our sample included 20 critically ill infants with congenital heart defects, less than 12 months of age, admitted to the cardiac intensive care unit after surgery.

RESULTS

Cerebral deoxygenated hemoglobin concentrations significantly differed across the epochs (i.e., baseline, tactile stimulus, noxious stimulus) (P=0.01). Physiological systemic responses and Face Leg Activity Cry Consolability (FLACC) pain scores differed significantly across the events (P<0.01). The 3 outcome measures were not found to be associated with each other. Mean FLACC pain scores during the painful procedure was 7/10 despite administration of morphine. Midazolam administration accounted for 36% of the variance in pain scores.

DISCUSSION

We demonstrated with a multidimensional pain assessment approach that significant cerebral, physiological, and behavioral activity was present in response to a noxious procedure in critically ill infants despite the administration of analgesic treatment. Considering that the sedating agent significantly dampened pain behaviors, assessment of cerebral hemodynamic in the context of pain seems to be an important addition.

Maternal touch and talk for invasive procedures in infants and toddlers in the pediatric intensive care unit

The aim of this single-blind, randomized, crossover trial was to test the effect of Touch & Talk (T&T) for infants and toddlers less than 36 months of age (N = 65) in the pediatric intensive care unit on their physiological stability and recovery to an invasive procedure. In the T&T condition, mothers touched, sang, or told stories or rhymes to their child during an invasive procedure. In the control condition, the mothers did not have contact with their child. Physiological measures included heart rate, heart rate variability, and oxygen saturation range during the procedure and change from baseline. Time from the end of the procedure until the heart rate returned to baseline levels gave the recovery time. Analysis was conducted using repeated-measures analysis of covariance. There were no significant differences on any of the physiological parameters by condition during the procedure. However, when controlling for severity of illness, recovery was faster with mothers.

Uncovering pain in critically ill non-verbal children: nurses' clinical experiences in the paediatric intensive care unit

Critically ill paediatric patients are frequently exposed to pain that is required to be assessed and treated effectively. The most reliable resource for assessing pain is the child itself, but children in the paediatric intensive care unit (PICU) are commonly unable to communicate their needs, requiring professional caregivers to uncover and interpret pain. However, nurses and paediatricians do not have sufficient knowledge of how critical illness affects childrens' signs of pain. The aim of this study was to illuminate clinical experiences of pain in the PICU; describing nurses' perceptions of expressions of pain in non-verbal, critically ill 2-6 year old children. The participants were 17 experienced PICU nurses. Data were analysed according to the phenomenographic method and three qualitatively different main categories, gained from clinical experience, emerged: changes in the measurable parameters; perceived muscular tension; and, altered behaviour. Furthermore, contrasting the categories revealed two diverse perspectives to focus pain: measure-oriented and patient-oriented. Subtle expressions of pain were recognised when focus was patient-oriented. These findings support the necessity of actively looking for pain deriving from various perspectives and considering diverse caring needs when doing so. Acknowledging pain makes pain visible.

Evaluation of the methodological quality of systematic reviews of health status measurement instruments

A systematic review of measurement properties of health-status instruments is a tool for evaluating the quality of instruments. Our aim was to appraise the quality of the review process, to describe how authors assess the methodological quality of primary studies of measurement properties, and to describe how authors evaluate results of the studies. Literature searches were performed in three databases. One hundred and forty-eight reviews were included. The purpose of included reviews was to identify health status instruments used in an evaluative application and to report on the measurement properties of these instruments. Two independent reviewers selected the articles and extracted the data. Reviews were often of low quality: 22% of the reviews used one database, the search strategy was often poorly described, and in many cases it was not reported whether article selection (75%) and data extraction (71%) was done by two independent reviewers. In 11 reviews the methodological quality of the primary studies was evaluated for all measurement properties, and of these 11 reviews only 7 evaluated the results. Methods to evaluate the quality of the primary studies and the results differed widely. The poor quality of reviews hampers evidence-based selection of instruments. Guidelines for conducting and reporting systematic reviews of measurement properties should be developed.

Facial expression and pain assessment in the pediatric patient: the primal face of pain

PURPOSE

This paper aims to explore the role of facial expression in pediatric pain assessment. A comparison of tools employing facial expression methodology is presented. The concept of the primal face of pain (PFP) is introduced.

CONCLUSION

The PFP offers an explanation to the utility and deficiency of facial pain scales and facial expression in pain assessment.

PRACTICE IMPLICATIONS

The complexities of pain measurement should preclude the clinical application of untested instruments. For reported tools, a careful evaluation of the psychometric properties and the clinical context must precede application. The concept of the PFP warns against the application of facial pain scales as proxy measures in their intended population. Reliance on facial expression to assess pain in the school-age child is imprecise.

Clinical validation of the Multidimensional Assessment of Pain Scale

BACKGROUND

The Multidimensional Assessment Pain Scale (MAPS), was developed to measure postoperative pain in critically ill preverbal children. Following preliminary psychometric testing, additional validation of this 5-category 10-point scale was required. This article reports the results of a follow-up validation study that aimed to evaluate the clinical validity and utility of the MAPS.

METHODS

The MAPS includes five categories and was tested in response to analgesics in a convenience sample of 19 postoperative critically ill children (94% intubated) aged between 0 and 31 months at a tertiary referral hospital in Western Australia. Convergent and concurrent validity was tested using the MAPS, Faces Legs Activity Cry Consolability (FLACC), and Visual Analog Scale observer (VASobs). Clinical utility of the MAPS was also evaluated.

RESULTS

The Multidimensional Assessment Pain Scale scores decreased significantly by four points (40% of total score) after the administration of a potent dose of morphine (P<0.001). Agreement measurements between MAPS and FLACC and MAPS and VASobs showed that the risk of measurement error was small. Internal consistency of the MAPS would improve if the physiologic item was deleted (Cronbach's alpha 0.79-0.64). However, the actual values of heart rate, systolic, mean, and diastolic arterial pressure were shown to decrease significantly (7-14% decrease) at 15, 30, and 60 min after a potent bolus of morphine (P<0.001). The MAPS also demonstrated clinical feasibility.

CONCLUSIONS

This study showed that 'MAPS like FLACC and VASobs decreases similarly following rescue morphine. MAPS-revised can be recommended for clinical application.

Development and preliminary psychometric testing of the Multidimensional Assessment of Pain Scale: MAPS

BACKGROUND

This study aimed to test the preliminary psychometric properties of the Multidimensional Assessment Pain Scale (MAPS), a clinical instrument developed for assessing postoperative pain in critically ill preverbal children.

METHODS

The MAPS was developed using pain indicators observed in postoperative critically ill infants. Content validity was established by a panel of experts. The scale was tested for validity and reliability in 43 postoperative children aged 0-31 months admitted to the pediatric intensive care units of two tertiary referral hospitals. Pain was measured concurrently by three independent assessors using the MAPS, the Face, Leg, Activity, Cry, and Consolability scale (FLACC) and the Visual Analog Scale (VAS) to assess concurrent and convergent validity.

RESULTS

Internal consistency was moderate (r = 0.68). Interrater reliability of the MAPS was good (kappa: 0.68-0.84) for all categories and moderate for breathing pattern (kappa = 0.54). Excellent interrater reliability was shown for total MAPS (intraclass correlation 0.91). Agreement measurements between MAPS and FLACC, and MAPS and VAS showed that the risk of measurement error was small.

CONCLUSION

Although initial psychometric testing of the MAPS shows promising results, the tool requires further psychometric testing, including responsiveness to analgesic effect (currently in progress).

Pain in children who have life-limiting conditions

Children and adolescents who have life-limiting conditions are vulnerableto acute and chronic pain problems. Many compounding and complicatingfactors often need to be explored in this setting. Barriers to effective painmanagement include poor assessment and measurement of pain anda lack of specialist knowledge. Fears regarding the use of opioids and theirassociation with the end of life must be addressed openly and with clarity.Day-to-day management should include continual appraisal of pain issuesif quality of life is to be maximized. Pain is a complicated phenomenon. The impact of pain and the compli-cated dynamic of suffering in children and young people who have life-lim-iting conditions must not be underestimated. The clinician must be vigilantand take responsibility for all aspects of pain management in these patients.

Pain in elderly people with severe dementia: a systematic review of behavioural pain assessment tools

Background

Pain is a common and major problem among nursing home residents. The prevalence of pain in elderly nursing home people is 40–80%, showing that they are at great risk of experiencing pain. Since assessment of pain is an important step towards the treatment of pain, there is a need for manageable, valid and reliable tools to assess pain in elderly people with dementia.

Methods

This systematic review identifies pain assessment scales for elderly people with severe dementia and evaluates the psychometric properties and clinical utility of these instruments. Relevant publications in English, German, French or Dutch, from 1988 to 2005, were identified by means of an extensive search strategy in Medline, Psychinfo and CINAHL, supplemented by screening citations and references. Quality judgement criteria were formulated and used to evaluate the psychometric aspects of the scales.

Results

Twenty-nine publications reporting on behavioural pain assessment instruments were selected for this review. Twelve observational pain assessment scales (DOLOPLUS2; ECPA; ECS; Observational Pain Behavior Tool; CNPI; PACSLAC; PAINAD; PADE; RaPID; Abbey Pain Scale; NOPPAIN; Pain assessment scale for use with cognitively impaired adults) were identified. Findings indicate that most observational scales are under development and show moderate psychometric qualities.

Conclusion

Based on the psychometric qualities and criteria regarding sensitivity and clinical utility, we conclude that PACSLAC and DOLOPLUS2 are the most appropriate scales currently available. Further research should focus on improving these scales by further testing their validity, reliability and clinical utility.

Capturing postoperative pain responses in critically ill infants aged 0 to 9 months

OBJECTIVES

The purpose of this study was to describe physiologic and behavioral pain behaviors in postoperative critically ill infants. A secondary aim was to identify how these pain responses vary over time.

DESIGN

This observational study was conducted in the pediatric intensive care unit at two tertiary referral hospitals. Using ethological methods of observation, video recordings of postoperative infants were viewed to depict different situations of pain and no pain and were then coded using a reliable checklist.

PATIENTS

A total of 803 recorded segments were generated from recordings of five critically ill infants aged between 0 and 9 months who had undergone major surgery.

MEASUREMENTS AND MAIN RESULTS

There was an 82% agreement between the two coders. Multivariate analyses showed that physiologic responses differed only when adjusted for time. Significant decreases in systolic and diastolic arterial pressure (p < .001 and p = .036, respectively) were associated with postoperative pain exacerbated by painful procedures on day 2. On day 3, however, heart rate, arterial pressure (systolic, diastolic, and mean), and central venous pressure significantly increased (p < .05) in response to postoperative pain. Indicators included vertical stretch of the mouth, hand twitching, and jerky leg movements for postoperative pain and increase in respiratory distress, frown, eyes tightly closed, angular stretch of the mouth, silent or weak cry, jerky head movements, fist, pulling knees up, and spreading feet for postoperative pain exacerbated by painful stimuli.

CONCLUSIONS

Findings support the ability to capture different intensities of postoperative pain in critically ill infants beyond neonatal age. These pain indicators can be used for the development of a pain assessment tool for this group of infants.

Rapid, needle-free delivery of lidocaine for reducing the pain of venipuncture among pediatric subjects

OBJECTIVES

The purpose of this study was to determine the optimal configuration of an investigational, single-use, needle-free, drug system (ALGRX 3268) that delivers powdered lidocaine into the epidermis for the rapid production of local anesthesia among pediatric subjects undergoing venipuncture.

METHODS

Children 3 to 18 years of age were randomly allocated to receive 1 of 3 treatments, ie, (1) placebo, (2) a system configured to deliver 0.25 mg of lidocaine, or (3) a system configured to deliver 0.5 mg of lidocaine, at the antecubital fossa 2 to 3 minutes before venipuncture. Three age groups were included, ie, 3 to 7 years, 8 to 12 years, and 13 to 18 years. Two sets of pain rating scales were used, the Faces Pain Scale-Revised for the youngest age stratum and a visual analog scale for the oldest age stratum. Children in the middle age stratum used both scales.

RESULTS

One-hundred forty-four subjects completed the study. For all ages combined, there was a statistically significant and clinically meaningful reduction in pain scores for subjects who received 0.5 mg of lidocaine, compared with placebo. The reduction in pain after 0.25 mg of lidocaine did not achieve statistical significance.

CONCLUSIONS

Both active configurations were safe and well tolerated by pediatric subjects undergoing venipuncture at the antecubital fossa. ALGRX 3268 at 0.5 mg, administered 2 to 3 minutes before venipuncture, produced significantly lower pain scores, compared with placebo.