Cognitive developmental influences on the ability of preschool-aged children to self-report their pain intensity

Pain Assessment in the Patient Unable to Self- Report: Clinical Practice Recommendations in Support of the ASPMN 2024 Position Statement

Recognizing and managing pain is especially challenging for vulnerable populations who cannot communicate their discomfort. Because there is no valid and reliable objective measure of pain, the American Society for Pain Management Nursing advocates for comprehensive assessment practices articulated in a Hierarchy of Pain Assessment. These practices must gather relevant information to infer the presence of pain and evaluate a patient's response to treatment. Nurses and other healthcare providers must be advocates for those who cannot communicate their pain experience.

Harnessing technology to measure individual differences in spatial thinking in early childhood from a relational developmental systems perspective

According to the Relational Developmental Systems perspective, the development of individual differences in spatial thinking (e.g., mental rotation, spatial reorientation, and spatial language) are attributed to various psychological (e.g., children's cognitive strategies), biological (e.g., structure and function of hippocampus), and cultural systems (e.g., caregiver spatial language input). Yet, measuring the development of individual differences in spatial thinking in young children, as well as the psychological, biological, and cultural systems that influence the development of these abilities, presents unique challenges. The current paper outlines ways to harness available technology including eye-tracking, eye-blink conditioning, MRI, Zoom, and LENA technology, to study the development of individual differences in young children's spatial thinking. The technologies discussed offer ways to examine children's spatial thinking development from different levels of analyses (i.e., psychological, biological, cultural), thereby allowing us to advance the study of developmental theory. We conclude with a discussion of the use of artificial intelligence.

Pain monitoring app leads to less pain in children with cancer at home: Results of a randomized controlled trial

BACKGROUND

The authors developed a pain monitoring app offering educational information, and real-time health care professional feedback on clinically significant pain (>4 numeric rating scale [NRS]-11) for children with cancer to reduce pain at home.

METHODS

This monocenter, nonblinded randomized controlled trial enrolled Dutch children (0-18 years old) receiving cancer treatment (≥3 months after diagnosis, ≥2 months treatment remaining). Children were randomly assigned to use the app or receive usual care (two parallel groups). We assessed whether use of the app yielded less clinically significant pain (aim 1) and whether it affected pain severity, duration, interference, pain management strategies, and parental emotional well-being (aim 2). The app was also evaluated by families (aim 3).

RESULTS

A total of 94 children were randomized to use the app (15 drop-outs), and 90 were to receive care as usual (11 drop-outs). The app group (n = 79, mean age: 7.5 [5.1] years, 48% girls, 63% hemato-oncology diagnosis) reported significantly less clinically significant pain compared to usual care (n = 79, mean age: 7.5 [5.4] years, 52% girls, 65% hemato-oncology diagnosis) (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.198-0.734]) (aim 1), as well as significantly lower pain severity (β = -0.27; 95% CI, -0.407 to -0.142). No differences were found for duration, interference, or management strategies. Parents in the app group reported significantly less distress compared to usual care (β = -0.84; 95% CI, -1.61 to -0.03]) (aim 2). Families generally evaluated the app positively (aim 3).

CONCLUSIONS

Use of the app resulted in less clinically significant pain at home. The exact working mechanisms of the app should be further elucidated.

Comparison of symptoms, signs and magnetic resonance imaging in children aged 5-18 years with temporomandibular joint disease

BACKGROUND

Temporomandibular joint diseases (TMD) are an important clinical condition in childhood as in adults. There is variation in the frequency and distribution of complaints in children about this disorder.

MATERIALS AND METHODS

This study was conducted on 407 children aged 5-18 years. Patients with dentofacial function problems, trauma, history of surgery, and malignancy were excluded from the study. Patients with temporomandibular magnetic resonance imaging in their records were classified as normal, reduction disc displacement and non-reduction disc displacement.

RESULTS

Patients symptoms were click (77.2%), pain (71.5%), headache (61.2%), bruxism (31.9%), locking (28%), difficulty in mouth opening (24.3%). The most common clinical findings are normal mouth opening (62.2%) and deviation (44.9%). When the MR results were examined, 55.1% of female and 66.6% of male were observed to be normal, and this statistically shows that males have more normal MR findings.

CONCLUSION

TMD are also observed in children. Clinical history and findings are helpful in diagnosis, but the contribution of imaging methods may be limited. If head and neck pain is detected in children, TMD should be kept in mind.

Correlation between FLACC scale score and analgesic requirement in children undergoing Minimally Invasive Surgery

Postoperative pain presents several challenges in pediatric Minimally Invasive Surgery. The Faces, Legs, Activity, Cry, and Consolability (FLACC) scale is a valid scale for pediatric postoperative pain. The aim of our study was to assess postoperative pain using FLACC scale and to analyze the correlation between FLACC scale score and analgesic requirement in children underwent Minimally Invasive Surgery. We retrospectively analyzed data of 153 children aged 2 months-3 years who underwent Minimally Invasive Surgery in our unit from January 2019 and December 2019. Postoperative pain assessment was established using FLACC scale. In each patient were analyzed the correlation between FLACC score and analgesic requirement. Pain evaluation was assigned immediately after surgery and at 15 and 60 minutes. 36.6% of patients (56 children) were asleep so considered pain free; 21.6% of patients (33 children) had a FLACC score more than 7 so they required analgesics and the pain assessment 15 and 60 minutes after was significantly lower. 41.8% of patients (64 children) had a postoperative FLACC score less than 3, so they didn't require any analgesic treatment. On the basis of our results, we recommend FLACC scale for postoperative pain assessment in children underwent MIS aged 2 months-3 years. FLACC scale is an effective and precise scale in detection of postoperative analgesic requirement in children and it could be extended in different age groups with further research.

'That's what makes me better': Investigating children and adolescents' experiences of pain communication with healthcare professionals in paediatric rheumatology

BACKGROUND

Pain communication should be an integral part of clinical consultations, particularly in paediatric rheumatology where children and adolescents frequently present with chronic musculoskeletal pain. To date, literature exploring the nature of and extent to which pain communication occurs has focused on healthcare professionals as respondents, yielding inconsistent and incomplete findings. The aim of this study was to explore children and adolescents' experiences of pain communication in the context of paediatric rheumatology consultations.

METHODS

Data were collected using semi-structured telephone interviews with children and adolescents recruited from three tertiary paediatric rheumatology centres in the United Kingdom. A framework analysis approach was used to explore the similarities and divergences in participant accounts.

RESULTS

Twenty-six children and adolescents (aged 6-18 years, median = 14, 58% female) participated. Diagnoses included: juvenile idiopathic arthritis, Chronic Idiopathic Pain Syndromes, Ehlers Danlos Syndrome/Hypermobility. Four themes were identified: (1) Co-ordination of pain communication; (2) Barriers to pain communication; (3) Facilitators of pain communication; (4) Dissatisfaction with pain communication. These themes particularly encompassed the process of communication, disclosure of effective and ineffective approaches and the impact of communication. Participants expected questions about pain, felt cared about and found talking about pain natural. Challenges included augmenting the feeling of being different to peers and concerns about management plans changing as a result of pain conversations.

CONCLUSIONS

Children and adolescents recalled a range of effective and ineffective pain communication approaches. Our study informs recommendations which highlight how healthcare professionals can improve their communication about pain with children and adolescents in the future.

SIGNIFICANCE

Our findings demonstrate that children and adolescents attending paediatric rheumatology expect to be and value being asked about their pain during consultations with healthcare professionals. Children and adolescents remember many of the processes involved, experiences of and the outcomes of pain communication. The current study reveals insights which can improve healthcare professional pain communication with children and adolescents. Our study introduces key recommendations for healthcare professionals to have more effective pain conversations in future.

Psychometric properties of a self-assessment fear scale in children aged 4 to 12 years. Scary Scale

BACKGROUND

Caregivers encounter difficulties differentiating fear and pain experienced by children and tend to interpret what children may feel, often resulting in inadequate pain management. While many pain self-assessment scales are available, there is no validated self-assessment fear scale for children.

METHODS

The aim of this prospective study was to validate, in children aged 4 to 12 years, the psychometric properties of our scale. In a first part, in a school setting, five exercises were given to 484 children in order to validate the expression of fear, grade the intensity of the faces, the ability to discriminate the faces and the equality of the intervals. The scale's reproducibility was studied by assessing the children's fear in everyday situations at two different time points. In a second part, in a hospital setting, the aim was to test the scale's feasibility. Sixty children admitted to one emergency care department self-assessed their fear with the Scary Scale.

FINDINGS

The expression of fear was validated by 57.64% (p < 0.0001) of the children in comparison with three other emotions (pain, surprise, sadness).The 7-9 year-olds validated the other properties (gradation, discrimination, equality, reproducibility). The 4-6 year-olds failed to validate the gradation exercise, but succeeded with the others. In the hospital, 95% of children self-assessed their fear using the scale.

DISCUSSION

Our self-assessment fear scale was validated in children aged 7-12 years specifically and was readily feasible in the hospital. We recommend its use in that age group in every care situation triggering fear.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT02675504.

Clinical Interpretation of Self-Reported Pain Scores in Children with Acute Pain

OBJECTIVE

To identify self-reported pain scores that best represent categories of no pain, mild, moderate, and severe pain in children, and a pain score that accurately represents a child's perceived need for medication, that is, a minimum pain score at which a child would want an analgesic.

STUDY DESIGN

Prospective cross-sectional cohort study of children aged 6-17 years presenting to a pediatric emergency department with painful and nonpainful conditions. Pain was measured using the 10-point Verbal Numerical Rating Scale. Receiver operating characteristic -based methodology was used to determine pain scores that best differentiated no pain from mild pain, mild pain from moderate pain, and moderate pain from severe pain. Descriptive statistics were used to determine the perceived need for medication.

RESULTS

We analyzed data from 548 children (51.3% female, 61.9% with a painful condition). The scores that best represent categories of pain intensity are as follows: 0-1 for no pain; 2-5 for mild pain; 6-7 for moderate pain; and 8-10 for severe pain. The area under the curve for the cut points differentiating each category ranged from 0.76 to 0.88. The median pain score representing the perceived need for medication was 6 (IQR, 4-7; range, 0-10).

CONCLUSIONS

We identified population-level self-reported pain scores in children associated with categories of pain intensity that differ from scores conventionally used. Implementing our findings may provide a more accurate representation of the clinical meaning of pain scores and reduce selection bias in research. Our findings do not support the use of pain scores in isolation for clinical decision making or the use of a pain score threshold to represent a child's perceived need for medication.

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.

Automated Pain Assessment in Children using Electrodermal Activity and Video Data Fusion via Machine Learning

Pain assessment in children continues to challenge clinicians and researchers, as subjective experiences of pain require inference through observable behaviors, both involuntary and deliberate. The presented approach supplements the subjective self-report-based method by fusing electrodermal activity (EDA) recordings with video facial expressions to develop an objective pain assessment metric. Such an approach is specifically important for assessing pain in children who are not capable of providing accurate self-pain reports, requiring nonverbal pain assessment. We demonstrate the performance of our approach using data recorded from children in post-operative recovery following laparoscopic appendectomy. We examined separately and combined the usefulness of EDA and video facial expression data as predictors of childrens self-reports of pain following surgery through recovery. Findings indicate that EDA and facial expression data independently provide above chance sensitivities and specificities, but their fusion for classifying clinically significant pain vs. clinically nonsignificant pain achieved substantial improvement, yielding 90.91% accuracy, with 100% sensitivity and 81.82% specificity. The multimodal measures capitalize upon different features of the complex pain response. Thus, this paper presents both evidence for the utility of a weighted maximum likelihood algorithm as a novel feature selection method for EDA and video facial expression data and an accurate and objective automated classification algorithm capable of discriminating clinically significant pain from clinically nonsignificant pain in children.

A Pilot Comparison of High- Versus Low-Tech Palatability Assessment Tools in Young Children

BACKGROUND

Medication refusal in children is largely driven by aversive taste profiles, which in turn influence adherence and therapeutic outcomes. However, there are no standardized methods for evaluating taste in young children. This study compares facial recognition technology with three hedonic visual scales in this population.

METHODS

Children, 3-7 years of age, were enrolled with informed parental permission into an institutional review board-approved, double-blind, randomized investigation. Each child received three test articles: prednisone (bitter), simple syrup (sweet), and filtered water (neutral), with an appropriate washout. Facial recognition software (Noldus FaceReader 7) recorded facial expression and intensity for 30-60 s after administration. Participants subsequently rated taste using three hedonic scales (5-point Sjövall and 5- and 3-point TASTY) and responded to simple questions on their perception of the test article. Repeated measures analysis of variance and multiple regression analysis were used to explore associations between palatability measures.

RESULTS

Twelve children (seven males: ten white and two black) completed the study without adverse effects. There were no significant differences in participant characteristics by randomization sequence. The three hedonic scales tracked similarly for each test substance, with correlations between the 5-point scales (r = 0.899) comparable to those between the 3- and 5-point scales (r = 0.860-0.903). Hedonic scales appeared more reliable in assessing taste response than facial recognition, which did not effectively discriminate positive and negative responses.

CONCLUSIONS

Our experience suggests that the TASTY scales appear to offer the greatest promise for assessing palatability in future clinical use.

Effects of Pain-Reporting Education Program on Children's Pain Reports-Results From a Randomized Controlled Post-operative Pediatric Pain Trial

Objective: Accurate assessment of patients' pain is an essential part of adequate analgesic treatment. Although reporting pain is a complex task, limited-to-no instructions are provided to pediatric patients regarding this process. Our goal in this randomized parallel-group clinical trial (Clinicaltrial.gov study protocol number NCT04306679) was to evaluate if a training program designed to improve children's ability to understand and use pain scales in a post-surgical setting would affect their pain scores. Methods: Eligible children (aged 8-17), hospitalized for elective surgery and their parents were randomized into two groups. Pre-surgery the intervention group underwent a multi-media program aimed to teach and train how to report pain. The control group received standard pre-surgical instructions. Post-surgery, the children reported their pain on 4 pain scales. The primary outcome was the concordance between children's pain intensity scores reported on four pain scales, both in terms of within-child standard deviation and absolute difference. Results: Ninety-six children met inclusion criteria and completed the study. The trained subjects' pain reports had significantly (p = 0.002) lower within-subject standard deviation (0.41 ± 0.31) than the control group (0.67 ± 0.46). In line, regarding absolute difference, the concordance of children's pain reports was twice better in the trained group (mean difference of 0.43 ± 0.40) than in the control group (0.88 ± 0.70) (p < 0.001). Discussion: Our results suggests that children's ability to report pain is a skill that can be improved. Future studies should test the potential clinical impacts of educational interventions aimed to improve pain assessment in children and adults.

Diagnostic accuracy of the Diagnostic Criteria for Temporomandibular Disorders for children aged 8-12 years

BACKGROUND AND OBJECTIVE

Objective of this study was to determine whether the diagnostic accuracy of the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) is sufficient for use among schoolchildren aged 8-12 years.

METHODS

This prospective cohort study on diagnostic accuracy with calibrated examiners was conducted among 533 children of both sexes aged 8-12 years, with and without TMD symptoms, selected randomly from the Rhein-Neckar district. Self-reporting of non-dental facial pain was used as the reference standard, against which we calculated the following for the pain-related items of the DC/TMD (index test): sensitivity, specificity, positive and negative likelihood ratios, diagnostic odds ratio, accuracy and 95% Wilson Score confidence intervals. We also calculated the area under the receiver-operating characteristic (AUROC) curve displaying sensitivity and specificity.

RESULTS

Our final sample consisted of 282 children, half of whom reported having facial pain and 3.2% reported sounds from the temporomandibular joints (TMJs). Despite high specificity (90.78%; 95% confidence interval (CI): [84.86%; 94.53%]), sensitivity of the adapted DC/TMD for pain on maximum jaw opening was poor (37.59%; 95% CI: [30.02%; 45.81%]). For pain on palpation, more similar values were recorded for sensitivity (74.47%; 95% CI: [66.69%; 80.95%]) and specificity (70.21%; 95% CI: [62.21%; 77.14%]). The diagnostic odds ratio was >1 for both examinations. The AUROC for pain on opening was 68.39% (95% CI: [62.62%; 74.16%]), and for pain on palpation, it was 74.63% (95% CI: [69.45%; 79.81%]), whereas the combination of both resulted to an AUROC of 74.09% (95% CI: [68.96%; 79.21%]). It was not possible to measure the diagnostic accuracy of the DC/TMD regarding TMJ sounds or jaw-opening limitations, as they occurred too rarely in our sample.

CONCLUSION

In this study, the diagnostic accuracy of the DC/TMD for TMD-related pain in children was lower than that recorded for adults in previous studies.

Observation of Emergency Room Nurses Managing Pediatric Pain: Care to Be Given… Care Given…

BACKGROUND

Although pain undeniably has negative consequences, pain management often remains suboptimal, particularly in the pediatric population in the emergency room (ER).

AIM

In this observational study using qualitative and quantitative methods, we investigated everyday adherence to current nursing best-practice pediatric guidelines in the ER paying particular attention to the interaction between children, parents, and nurses.

METHODS

An adapted version of the nursing observation tool for pain management was used to describe pediatric pain management provided by nurses caring for children (0-14 years old) admitted to the ER. We also assessed child-parent-nurse interactions. (The aim of the study was presented to the nurses as part of the survey on interactions without specifying the focus on pain management.) RESULTS: Forty-seven children were included (91 painful episodes) during the observation period (112 hours). There was a screening for pain in 55% of cases, and pain scales were used in 10% of cases. Analgesic treatments were administered in 75% of cases (procedural or disease-related pain). Follow-up evaluations were performed in 19% of cases. Nonpharmacologic approaches were scarcely used. The use of both helpful and nonhelpful languages were noted during interactions with children and parents. Parents' collaboration was rarely requested to help relieve their child's pain.

CONCLUSIONS

Our results show that pediatric pain management in the ER could be optimized. Parents are still not considerably involved in their child's pain management. Parents' involvement could contribute to improving pediatric pain management.

Parent-Child Agreement on Postconcussion Symptoms in the Acute Postinjury Period

OBJECTIVES

To evaluate parent-child agreement on postconcussion symptom severity within 48 hours of injury and examine the comparative predictive power of a clinical prediction rule when using parent or child symptom reporting.

METHODS

Both patients and parents quantified preinjury and current symptoms using the Postconcussion Symptom Inventory (PCSI) in the pediatric emergency department. Two-way mixed, absolute measure intraclass correlation coefficients were calculated to evaluate the agreement between patient and parent reports. A multiple logistic regression was run with 9 items to determine the predictive power of the Predicting and Preventing Postconcussive Problems in Pediatrics clinical prediction rule when using the child-reported PCSI. Delong's receiver operating characteristic curve analysis was used to compare the area under the curve (AUC) for the child-report models versus previously published parent-report models.

RESULTS

Overall parent-child agreement for the total PCSI score was fair (intraclass correlation coefficient = 0.66). Parent-child agreement was greater for (1) postinjury (versus preinjury) ratings, (2) physical (versus emotional) symptoms, and (3) older (versus younger) children. Applying the clinical prediction rule by using the child-reported PCSI maintained similar predictive power to parent-reported PCSI (child AUC = 0.70 [95% confidence interval: 0.67-0.72]; parent AUC = 0.71 [95% confidence interval: 0.68-0.74]; P = .23).

CONCLUSIONS

Overall parent-child agreement on postconcussion symptoms is fair but varies according to several factors. The findings for physical symptoms and the clinical prediction rule have high agreement; information in these domains are likely to be similar regardless of whether they are provided by either the parent or child. Younger children and emotional symptoms show poorer agreement; interviewing both the child and the parent would provide more comprehensive information in these instances.

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.

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.

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.

"Seeing Pain Differently": A Qualitative Investigation Into the Differences and Similarities of Pain and Rheumatology Specialists' Interpretation of Multidimensional Mobile Health Pain Data From Children and Young People With Juvenile Idiopathic Arthritis

Background

In contrast to the use of traditional unidimensional paper-based scales, a mobile health (mHealth) assessment of pain in children and young people (CYP) with juvenile idiopathic arthritis (JIA) enables comprehensive and complex multidimensional pain data to be captured remotely by individuals. However, how professionals use multidimensional pain data to interpret and synthesize pain reports gathered using mHealth tools is not yet known.

Objective

The aim of this study was to explore the salience and prioritization of different mHealth pain features as interpreted by key stakeholders involved in research and management of pain in CYP with JIA.

Methods

Pain and rheumatology specialists were purposively recruited via professional organizations. Face-to-face focus groups were conducted for each specialist group. Participants were asked to rank order 9 static vignette scenarios created from real patient mHealth multidimensional pain data. These data had been collected by a researcher in a separate study using My Pain Tracker, a valid and acceptable mHealth iPad pain communication tool that collects information about intensity, severity, location, emotion, and pictorial pain qualities. In the focus groups, specialists discussed their decision-making processes behind each rank order in the focus groups. The total group rank ordering of vignette scenarios was calculated. Qualitative data from discussions were analyzed using latent thematic analysis.

Results

A total of 9 pain specialists took part in 1 focus group and 10 rheumatology specialists in another. In pain specialists, the consensus for the highest pain experience (44%) was poorer than their ranking of the lowest pain experiences (55%). Conversely, in rheumatology specialists, the consensus for the highest pain experience (70%) was stronger than their ranking of the lowest pain experience (50%). Pain intensity was a high priority for pain specialists, but rheumatology specialists gave high priority to intensity and severity taken together. Pain spread was highly prioritized, with the number of pain locations (particular areas or joints) being a high priority for both groups; radiating pain was a high priority for pain specialists only. Pain emotion was challenging for both groups and was only perceived to be a high priority when specialists had additional confirmatory evidence (such as information about pain interference or clinical observations) to validate the pain emotion report. Pain qualities such as particular word descriptors, use of the color red, and fire symbols were seen to be high priority by both groups in interpretation of CYP pain reports.

Conclusions

Pain interpretation is complex. Findings from this study of specialists’ decision-making processes indicate which aspects of pain are prioritized and weighted more heavily than others by those interpreting mHealth data. Findings are useful for developing electronic graphical summaries which assist specialists in interpreting patient-reported mHealth pain data more efficiently in clinical and research settings.

The Complexities of Nurses' Pain Assessment in Hospitalized Preverbal Children

BACKGROUND

Preverbal children are at increased risk for underassessment of pain. Pain is a social transaction involving the child in pain and the nurse assessor. However, our understanding of the nurse's part in this transaction is limited.

AIMS

The aim of this study was to explore nurses' assessment of pain in hospitalized preverbal children based on self-selected clinical examples.

DESIGN

Qualitative, descriptive design.

SETTINGS

Five different hospital units in Canada and Norway. All units had an observational pain scale for preverbal children available for use.

PARTICIPANTS/SUBJECTS

Nurses (N = 22) with ≥1 year experience caring for preverbal children.

METHODS

Individual, semistructured interviews. Data were analyzed using inductive thematic analysis.

RESULTS

Nurses' assessment of pain in hospitalized preverbal children emerged as a nonlinear complex process incorporating different actions and reflections in response to the child's situation and expression of distress. Information from parents was routinely included in the assessment, although further parental involvement varied considerably. Although each assessment was personalized to the individual child, the nurse used previous experiences to interpret observations of and information from the child and the parents. Few nurses described using structured pain scales, but when used, these scales were included as only one aspect of their overall assessment.

CONCLUSIONS

Nurses preferred pain assessment based on clinical judgment and tailored to the individual child. Implementation strategies that aim to integrate structured pain scales with clinical judgment to assess pain may be more likely to succed. Further examination of this approach is warranted.

The juvenile fibromyalgia syndrome (JFMS): a poorly defined disorder

Juvenile fibromyalgia syndrome (JFMS) is a chronic condition characterized by symptoms of chronic diffuse musculoskeletal pain and multiple painful tender points on palpation. It is often accompanied by fatigue, disorders of sleep, chronic headaches, irritable bowel syndrome, and subjective soft tissue swelling. The complexity of the presenting clinical picture in JPFS has not been sufficiently defined in the literature. Similarities to adult fibromyalgia syndrome in JFMS are often difficult to compare, because many of the symptoms are "medically unexplained" and often overlap frequently with other medical conditions. However, a valid diagnosis of JFMS often decreases parents' anxiety, reduces unnecessary further investigations, and provides a rational framework for a management plan. The diagnostic criteria proposed by Yunus and Masi in 1985 to define JFMS were never validated or critically analyzed. In most cases, the clinical diagnosis is based on the history, the physical examination that demonstrates general tenderness (muscle, joints, tendons), the absence of other pathological conditions that could explain pain and fatigue, and the normal basic laboratory tests. Research and clinical observations defined that JFMS may have a chronic course that impacts the functional status and the psychosocial development of children and adolescents. This paper briefly reviews the existing knowledge on JFMS focusing on the diagnosis, clinical and the epidemiological characteristics in children and adolescents for better understanding of this disorder.

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.

Validation of the "Pain Block" concrete ordinal scale for children aged 4 to 7 years

Pain scales using faces are commonly used tools for assessing pain in children capable of communicating. However, some children require other types of pain scales because they have difficulties in understanding faces pain scales. The goal of this study was to develop and validate the "Pain Block" concrete ordinal scale for 4- to 7-year-old children. This was a multicenter prospective observational study in the emergency department. Psychometric properties (convergent validity, discriminative validity, responsivity, and reliability) were compared between the "Pain Block" pain scale and the Faces Pain Scale-Revised (FPS-R) to assess the validity of the "Pain Block" scale. A total of 163 children (mean age, 5.5 years) were included in this study. The correlation coefficient between the FPS-R and the Pain Block scale was 0.82 for all participants which increased with age. Agreement between the 2 pain scales was acceptable, with 95.0% of the values within the predetermined limit. The differences in mean scores between the painful group and nonpainful group were 3.3 (95% confidence interval, 2.6-4.1) and 3.8 (95% confidence interval, 3.1-4.6) for FPR-S and Pain Block, respectively. The pain scores for both pain scales were significantly decreased when analgesics or pain-relieving procedures were administered (difference in Pain Block, 2.4 [1.4-3.3]; and difference in FPS-R, 2.3 [1.3-3.3]). The Pain Block pain scale could be used to assess pain in 4- to 7-year-old children capable of understanding and counting up to the number 5, even if they do not understand the FPS-R pain scale.

Validity and Reliability of the Verbal Numerical Rating Scale for Children Aged 4 to 17 Years With Acute Pain

STUDY OBJECTIVE

The Verbal Numerical Rating Scale is the most commonly used self-report measure of pain intensity. It is unclear how the validity and reliability of the scale scores vary across children's ages. We aimed to determine the validity and reliability of the scale for children presenting to the emergency department across a comprehensive spectrum of age.

METHODS

This was a cross-sectional study of children aged 4 to 17 years. Children self-reported their pain intensity, using the Verbal Numerical Rating Scale and Faces Pain Scale-Revised at 2 serial assessments. We evaluated convergent validity (strong validity defined as correlation coefficient ≥0.60), agreement (difference between concurrent Verbal Numerical Rating Scale and Faces Pain Scale-Revised scores), known-groups validity (difference in score between children with painful versus nonpainful conditions), responsivity (decrease in score after analgesic administration), and reliability (test-retest at 2 serial assessments) in the total sample and subgroups based on age.

RESULTS

We enrolled 760 children; 27 did not understand the Verbal Numerical Rating Scale and were removed. Of the remainder, Pearson correlations were strong to very strong (0.62 to 0.96) in all years of age except 4 and 5 years, and agreement was strong for children aged 8 and older. Known-groups validity and responsivity were strong in all years of age. Reliability was strong in all age subgroups, including each year of age from 4 to 7 years.

CONCLUSION

Convergent validity, known-groups validity, responsivity, and reliability of the Verbal Numerical Rating Scale were strong for children aged 6 to 17 years. Convergent validity was not strong for children aged 4 and 5 years. Our findings support the use of the Verbal Numerical Rating Scale for most children aged 6 years and older, but not for those aged 4 and 5 years.

Measuring Musculoskeletal Pain in Infants, Children, and Adolescents

Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.

Procedural Pain Scale Evaluation (PROPoSE) study: protocol for an evaluation of the psychometric properties of behavioural pain scales for the assessment of procedural pain in infants and children aged 6-42 months

INTRODUCTION

Infants and children are frequently exposed to painful medical procedures such as immunisation, blood sampling and intravenous access. Over 40 scales for pain assessment are available, many designed for neonatal or postoperative pain. What is not well understood is how well these scales perform when used to assess procedural pain in infants and children.

AIM

The aim of this study was to test the psychometric and practical properties of the Face, Legs, Activity, Cry and Consolability (FLACC) scale, the Modified Behavioural Pain Scale (MBPS) and the Visual Analogue Scale (VAS) observer pain scale to quantify procedural pain intensity in infants and children aged from 6-42 months to determine their suitability for clinical and research purposes.

METHODS AND ANALYSIS

A prospective observational non-interventional study conducted at a single centre. The psychometric and practical performance of the FLACC scale, MBPS and the VAS observer pain scale and VAS observer distress scale used to assess children experiencing procedural pain will be assessed. Infants and young children aged 6-42 months undergoing one of four painful and/or distressing procedures were recruited and the procedure digitally video recorded. Clinicians and psychologists will be recruited to independently apply the scales to these video recordings to establish intrarater and inter-rater reliability, convergent validity responsiveness and specificity. Pain score distributions will be presented descriptively; reliability will be assessed using the intraclass correlation coefficient and Bland-Altman plots. Spearman correlations will be used to assess convergence and linear mixed modelling to explore the responsiveness of the scales to pain and their capacity to distinguish between pain and distress.

ETHICS AND DISSEMINATION

Ethical approval was provided by the Royal Children's Hospital Human Research Ethics Committee, approval number 35220B. The findings of this study will be disseminated via peer-reviewed journals and presented at international conferences.

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

Claims are made for the validity of some self-report pain scales for 3- and 4-year-old children, but little is known about their ability to use such tools. This systematic review identified self-report pain intensity measures used with 3- and/or 4- year-old participants (3-4yo) and considered their reliability and validity within this age span. The search protocol identified research articles that included 3-4yo, reported use of any pain scale, and included self-reported pain intensity ratings. A total of 1,590 articles were screened and 617 articles met inclusion criteria. Of the included studies, 98% aggregated self-report data for 3-4yo with data for older children, leading to overestimates of the reliability and validity of self-report in the younger age group. In the 14 studies that provided nonaggregated data for 3-4yo, there was no evidence for 3-year-old and weak evidence for 4-year-old children being able to use published self-report pain intensity tools in a valid or reliable way. Preschool-age children have been reported to do better with fewer than the 6 response options offered on published faces scales. Simplified tools are being developed for young children; however, more research is needed before these are adopted.

PERSPECTIVE

Some self-report pain scales have been promoted for use with 3- and 4-year-old children, but this is on the basis of studies that aggregated data for younger and older children, resulting in overestimates of reliability and validity for the preschool-age children. Scales with fewer response options show promise, at least for 4-year-old children.

Chronic Pain Assessments in Children and Adolescents: A Systematic Literature Review of the Selection, Administration, Interpretation, and Reporting of Unidimensional Pain Intensity Scales

BACKGROUND

Advances in pain assessment approaches now indicate which measures should be used to capture chronic pain experiences in children and adolescents. However, there is little guidance on how these tools should best be administered and reported, such as which time frames to use or how pain scores are categorised as mild, moderate, or severe.

OBJECTIVE

To synthesise current evidence on unidimensional, single-item pain intensity scale selection, administration, interpretation, and reporting.

METHODS

Databases were searched (inception: 18 January 2016) for studies in which unidimensional pain intensity assessments were used with children and adolescents with chronic pain. Ten quality criteria were developed by modifying existing recommendations to evaluate the quality of administration of pain scales most commonly used with children.

RESULTS

Forty-six studies met the inclusion criteria. The highest score achieved was 7 out of a possible 10 (median: 5; IQR: 4-6). Usage of scales varied markedly in administrator/completer, highest anchors, number of successive assessments, and time referent periods used.

CONCLUSIONS

Findings suggest these scales are selected, administered, and interpreted inconsistently, even in studies of the same type. Furthermore, methods of administration are rarely reported or justified making it impossible to compare findings across studies. This article concludes by recommending criteria for the future reporting of paediatric chronic pain assessments in studies.