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

Characteristics of Children With Persistent Pain and Their Parents in a Tertiary Interdisciplinary Pain Clinic

Persistent Pain (PP) in children often has a high impact on their functioning. Knowledge about how to meet the needs is insufficient, especially regarding younger children, children with comorbid psychiatric health conditions, and within different national contexts. A specialized pediatric pain clinic for PP in Sweden offers assessment and interdisciplinary pain rehabilitation (IPR) and collects data on referred children and their parents in a registry. The aims of this study are to (i) describe clinically relevant aspects of children and parents at the first team assessment, (ii) investigate associations between symptoms of psychiatric comorbidity and functioning, (iii) investigate associations between symptoms of ADHD or symptoms of ASD and functioning, and (iv) describe the recommendations after the first team assessment and their rationale. A retrospective cohort study with a descriptive and exploratory design focusing on the characteristics of children (n = 510) and their parents at their first visit for specialized assessment at a tertiary pediatric pain clinic in Sweden between 2013 and 2021. Impairments and complexity appeared to increase with age, with high impact on daily and emotional functioning, especially in relation to symptoms of psychiatric comorbidity and ADHD or ASD. A majority of children and parents were uncertain about the cause of the pain. Only half of the children were recommended IPR, and numerous problems in functioning were found, not only related to pain. In agreement with previous studies describing characteristics of children with PP, there were more girls than boys and older than younger children at the first assessment. Both children and parents report several significant problems in physical, psychological, and social functioning, indicating a need for increased knowledge of PP and care in all kinds of pediatric health care and community settings. Tailored treatment interventions are recommended to improve functioning, including pain education, parental aspects, and addressing psychiatric comorbidities, with a special focus on ADHD or ASD symptoms. More thorough information to referring physicians about evaluations needed before referring to tertiary pain clinics could potentially help set the right expectations for further care and reduce the risk of diagnostic uncertainty.

A clinical study on the application of three-dimensionally printed splints combined with finite element analysis in paediatric distal radius fractures

Purpose

This single-centre randomised clinical trial assessed the clinical efficacy and patient satisfaction of 3D-printed splints optimised via finite element analysis (FEA) for pediatric distal radius fractures.

Methods

This retrospective study included 56 children diagnosed with forearm fractures at our hospital between August 2023 and August 2024. Those who underwent traditional U-shaped forearm plaster immobilisation were compared with those who received a customised 3D-printed splint. FEA was conducted based on the biomechanical characteristics of the forearm; the splint structure was optimised based on the analysis results and created via 3D printing. Outcomes were evaluated using the Patient Satisfaction Questionnaire and Wong-Baker Faces Pain Scale-Revised. Forearm function was evaluated using the Mayo Wrist Score and radiological outcomes. A power calculation was not performed due to the exploratory scope and resource limitations of this preliminary study.

Results

The treatment costs significantly differed between the two groups (p = 0.001). In the Patient Satisfaction Questionnaire, the hot and sweaty item showed no significant difference (p = 0.089), whereas the last week's comfort (p = 0.001), first applied comfort (p = 0.004), weight (p = 0.001), itchiness (p = 0.015), smell (p = 0.003), and overall satisfaction items significantly differed between the two groups (p = 0.004). A comparison of the Mayo Wrist Score showed a statistically significant difference between the two groups after external fixation removal (p = 0.044). There were no significant differences between the two groups in terms of the palmar tilt angle (p = 0.196), ulnar deviation angle (p = 0.460), or height of the radial styloid (p = 0.111).

Conclusion

Both 3D-printed splint and plaster cast fixation methods can effectively treat distal radial fractures in children, but the 3D-printed splint showed superior patient acceptance.

Plasma metabolites associated with endometriosis in adolescents and young adults

STUDY QUESTION

What are the plasma metabolomics profiles associated with endometriosis in adolescents and young adults?

SUMMARY ANSWER

Our findings show dysregulation of plasma metabolomic profiles in adolescents and young adults with endometriosis, revealing systemic elevation of fatty acyls and ceramides in endometriosis cases compared to controls.

WHAT IS KNOWN ALREADY

Endometriosis is a gynecologic disease often presenting with severe pelvic pain impacting around 200 million reproductive-aged women worldwide. However, little is known about the pathophysiology and molecular features of endometriosis diagnosed during adolescence and young adulthood.

STUDY DESIGN, SIZE, DURATION

We conducted a cross-sectional analysis including 190 laparoscopically confirmed endometriosis cases and 120 controls who participated in The Women's Health Study: From Adolescence to Adulthood, which enrolled participants from 2012 to 2018. Control participants were females without a diagnosis of endometriosis enrolled from the same clinics as the cases or recruited from the general population. Among the cases, 81 had blood samples collected before and after surgery.

PARTICIPANTS/MATERIALS, SETTING, METHODS

Plasma metabolites were measured in blood collected at enrollment using liquid chromatography-tandem mass spectrometry, and a total of 430 known metabolites were evaluated in our analysis. We used linear regression adjusting for age at blood draw, BMI, hormone use, and fasting status at blood draw. Metabolite set enrichment analysis (MSEA) was used to identify metabolite classes. Number of effective tests (NEF) and false discovery rate (FDR) were used for multiple testing correction.

MAIN RESULTS AND THE ROLE OF CHANCE

The median age was 17 years for endometriosis cases and 22 years for controls. The majority of endometriosis cases had rASRM stage I or II (>95%). We identified 63 plasma metabolites associated with endometriosis (NEF < 0.05). Endometriosis cases had higher levels of plasma metabolites associated with proinflammatory response [e.g. eicosatrienoic acid (β = 0.61, 95% CI = 0.37, 0.86)], increased oxidative stress response [e.g. xanthine (β = 0.64, 95% CI = 0.39, 0.88)], and downregulation of metabolites related to apoptosis [glycocholic acid (β = -0.80, 95% CI = -1.04, -0.56)]. MSEA revealed increased fatty acyls (FDR = 2.3e-4) and ceramides (FDR = 6.0e-3) and decreased steroids and steroid derivatives (FDR = 1.3e-4) in endometriosis cases compared to controls. When we examined the changes in plasma metabolite profiles before and after surgery among endometriosis cases, 55 endometriosis-associated metabolites significantly changed from before to after surgery. MSEA revealed steroids and steroid derivatives (FDR = 8.1e-4) significantly increased after surgery, while fatty acyls (FDR = 1.2e-4) significantly decreased after surgery. Ceramides did not change from pre- to post-surgery and were elevated in post-surgical blood compared to controls (FDR = 3.9e-3).

LIMITATIONS, REASONS FOR CAUTION

Our study population mainly consists of self-reported non-Hispanic, white individuals and endometriosis cases with superficial peritoneal lesions only, so the generalizability may be limited. Furthermore, despite our large study population of adolescents and young adults with endometriosis, sample size was limited to conduct detailed stratified analyses of plasma metabolomic profiles, especially by post-surgical pelvic pain outcomes.

WIDER IMPLICATIONS OF THE FINDINGS

Our study includes the utilization of state-of-the-art metabolomics technology with high reproducibility to comprehensively investigate the metabolites that were associated with endometriosis diagnosed in adolescents and young adults. Our results suggest a positive impact of endometriosis-related surgery for some, but not all, on systemic metabolic dysregulation in young patients with endometriosis. These results warrant further investigation on whether and how persistent systemic changes despite treatment may lead to long-term chronic disease risk among those diagnosed with endometriosis.

STUDY FUNDING/COMPETING INTEREST(S)

Financial support for establishment of and data collection within the A2A cohort was provided by the J. Willard and Alice S. Marriott Foundation, and support for assay costs was in part provided by the Peery family. This project was funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development R21HD107266. S.A.M., A.L.S., and K.L.T. were supported by Eunice Kennedy Shriver National Institute of Child Health and Human Development R01HD094842. S.A.M. received grant funding from AbbVie, National Institutes of Health, Department of Defense, and Marriott Family Foundation; received honoraria from WERF, Huilun Shanghai, and University of Kansas Medical Center; travel support from SRI, ESHRE, FWGBD, University of Michigan, MIT, ASRM, LIDEA Registry, Taiwan Endometriosis Society, SEUD, Japan Endometriosis Society, NASEM, Endometriosis Foundation of America, Gedeon Richter Symposium at ESHRE; Board member receiving financial remuneration from AbbVie, Roche, LIDEA Registry, Editor of Frontiers in Reproductive Health, Roundtable participation for Abbott; Board member without financial remuneration from NextGen Jane and Statistical Advisory Board member of Human Reproduction; leadership role in Society for Women's Health Research, World Endometriosis Society, World Endometriosis Research Foundation, ASRM, ESHRE. N.S. and K.L.T. receive grant funding from Aspira Women's Health unrelated to this project. The remaining authors have no disclosures relevant to this manuscript.

TRIAL REGISTRATION NUMBER

N/A.

The role of fatigue in adolescents' chronic pain: A study on facets of fatigue in young patients with a chronic pain disorder

Fatigue has been proposed as a potential factor influencing the perception of pain, which could be pertinent for enhancing chronic pain treatment. Exploring the relationship between pain and fatigue during a 3-week inpatient interdisciplinary multimodal pain therapy program, we evaluated children and adolescents (11-18 years) who reported significant chronic pain. Assessment tools included the Multidimensional Fatigue Inventory and other clinical questionnaires. The participants had higher fatigue scores than healthy subjects, general fatigue was found to be associated with the perception of pain in a random-effects model. The connection between fatigue and pain in adolescents with chronic pain suggests that the degree of fatigue and the changes in fatigue were associated with the intensity of their pain. The participants' (N = 94) dimensions of fatigue and the intensity of their pain were reduced. We discuss implications for fatigue-reducing treatments in chronic pain management to reduce pain and augment pain management skills.

Virtual Reality as Active Distraction in Laceration Repair: A Game Changer?

OBJECTIVES

We conducted an unblinded, randomized control trial to determine if immersive virtual reality (VR) goggles decrease pain and fear scores in children undergoing laceration repair in the pediatric emergency department (PED) compared to the standard of care. Secondary outcomes included duration of procedure, physical holding, anxiolytic usage, and desire to use VR goggles again.

METHODS

Ninety-one patients aged 6-17 years in a PED with simple lacerations sutured by PED staff completed surveys. Eligible patients were randomized to receive either VR or standard of care. Guardians and providers also completed surveys. Self-reported pain scores were assessed by the Wong-Baker Faces Pain Scale and fear scores by Children's Fear Scale.

RESULTS

There were significant reductions in pain and fear scores for VR goggles compared to standard of care. Patients rated their mean pain score as 3.7 in controls and 2.3 in the VR group, and mean fear score of 3.0 and 2.2. The likelihood of physical holding was significantly lower among those who used VR goggles (adjusted odds ratio = 0.34, 95% confidence interval [0.13-0.92], P  = 0.033). The likelihood of receiving anxiolytics was lower among the 12- to 17-year-olds (adjusted odds ratio = 0.27, 95% confidence interval [0.11-0.69], P  = 0.006). There was no significant difference in the procedure duration ( P  = 0.06). A total of 97.9% of parents, 93.6% of patients, and 95.7% of providers would use VR again.

CONCLUSION

Virtual reality goggles are an effective tool for distraction for simple laceration repairs. Their use leads to decreased pain and fear. Children who used VR goggles did not require to be held as often for sutures. There was no significant difference in anxiolytics or duration of procedure.

Exploring Pain Adaptation in Youth With Juvenile Idiopathic Arthritis: Identifying Youth and Parent Resilience Resources and Mechanisms

OBJECTIVE

Although juvenile idiopathic arthritis (JIA) is often associated with pain, this experience does not necessitate negative outcomes (eg, depression, functional impairment). Little research has explored youth and parent resilience resources (ie, stable traits) and mechanisms (ie, dynamic processes) in this context, and studies have focused on their contributions independently rather than collectively. This study, informed by the Ecological Resilience-Risk Model in Pediatric Chronic Pain, sought to (1) explore the relationships among youth and parent resilience resources and mechanisms and (2) identify the relative importance (RI; ie, independent contributions when entered simultaneously) of evidence-based youth and parent resources and mechanisms in contributing to youth-reported recovery, sustainability, and growth outcomes.

METHODS

Youth (13-18 years) with JIA and their parents (156 dyads) completed a battery of online questionnaires assessing resilience resources (optimism, resilience), mechanisms (psychological flexibility, pain acceptance, self-efficacy), recovery and sustainability (pain intensity, functional disability, health-related quality of life), and growth (benefit finding) outcomes.

RESULTS

Analyses demonstrated significant positive correlations across within-person resources and mechanisms and weaker correlations across within-dyad resources and mechanisms. Although the RI of predictors varied by outcome, youth pain acceptance was the most robust predictor across models (RI = 0.03-0.15). Some predictors (eg, parent psychological flexibility and pain acceptance) were generally categorized as "Not Important," whereas others (eg, youth resilience) had "Inconclusive" results, suggesting construct overlap.

CONCLUSION

Although additional research is needed to further understand resilience, results highlight the importance of fostering pain acceptance in youth and incorporating parents in psychosocial interventions to optimize living with JIA.

Parental anxiety and catastrophizing in pediatric tonsillectomy pain control: A multivariate analysis

OBJECTIVE

Parental anxiety and/or catastrophizing may bias the interpretation of children's pain and administration of analgesia post-tonsillectomy. We aimed to determine whether high levels of parental anxiety and/or catastrophizing impact child pain intensity interpretation and administration of analgesia.

METHODS

Child-parent dyads were recruited from a tertiary care institution between July 2017-December 2019. Preoperative parental anxiety and catastrophizing were assessed using self-report measures. Postoperative data on child and parent pain intensity, as well as analgesia use, were collected up to 2 weeks post-surgery. Multivariable logistic regression models were created to assess predictors of postoperative child pain intensity and analgesia use.

RESULTS

Our cohort included 234 child-parent dyads. Median child age was 5 years (IQR, 4-6), and 9.0 % of children (n = 21) had a medical comorbidity. Both child- and parent-reported pain intensity were highest on postoperative day 2 (3.65 [SD = 3.08] and 3.67 [SD = 2.51], respectively). Parental catastrophizing did not predict analgesia use at home, although a minimal significant decrease in the odds of analgesia administration was observed on postoperative day 7 (OR 0.932, p = 0.017). Maximal parental anxiety did not predict higher odds of increased child postoperative pain intensity on any postoperative day.

CONCLUSION

Parental catastrophizing prior to tonsillectomy has minimal predictive value for analgesia use postoperatively. Children may be successfully advocating for their own pain control as parental anxiety and catastrophizing do not appear to be unduly influencing analgesia administration. Future studies should explore the impact of parental anxiety on vulnerable pediatric populations who may be unable to self-advocate for pain management.

First-Attempt Success in Ultrasound-Guided vs Standard Peripheral Intravenous Catheter Insertion: The EPIC Superiority Randomized Clinical Trial

Importance

Pediatric peripheral intravenous catheter (PIVC) insertion can be difficult and time-consuming, frequently requiring multiple insertion attempts and often resulting in increased anxiety, distress, and treatment avoidance among children and their families. Ultrasound-guided PIVC insertion is a superior alternative to standard technique (palpation and visualization) in high-risk patients.

Objective

To compare first-time insertion success of PIVCs inserted with ultrasound guidance compared with standard technique (palpation and visualization) across all risk categories in the general pediatric hospital population.

Design, Setting, and Participants

An open-label, pragmatic, superiority, randomized clinical trial was conducted in an Australian quaternary pediatric hospital. Children (ages 0-18 years) requiring PIVC insertion were included between July 2021 and December 2022. One catheter was studied per patient, and analysis was by intention to treat. Data analysis was performed from April to October 2023.

Intervention

Eligible children were randomly assigned (1:1 using computer-generated randomization and concealed allocation) to receive ultrasound-guided or standard PIVC insertion. Randomization was stratified by insertion difficulty (low, medium, or high risk) defined using a standardized tool.

Main Outcomes and Measures

The primary outcome was first-time insertion success. Secondary outcomes included number of insertion attempts, insertion failure, postinsertion complications, dwell time, patient and parent satisfaction, and health care costs.

Results

A total of 164 children were randomly assigned to ultrasound-guided insertion (n = 84) or standard care (n = 80), with 81 (96.4%) and 78 (97.5%) receiving their allocated intervention, respectively. The median (IQR) age was 24 (10-120) months, and 93 children (56.7%) were male. First-time insertion success was higher with ultrasound-guided PIVC insertion (72 children [85.7%]) compared with standard technique (26 children [32.5%]) (risk difference [RD], 53.6%; 95% CI, 41.7%-65.4%; P < .001). Ultrasound-guided insertion led to significantly greater first-time insertion success across all risk categories, with the following RDs: low risk, 30.8% (95% CI, 8.1%-53.5%); medium risk, 56.2% (95% CI, 37.1%-75.3%); and high risk, 69.6% (95% CI, 52.3%-87.0%). Ultrasound-guided PIVC insertion had higher immediate health care costs (between group difference in total mean cost per person, A$9.33; 95% credible interval, A$8.83-A$10.86 [US $5.83; 95% credible interval, $5.52-$6.78]).

Conclusion and Relevance

These findings suggest that ultrasound-guided PIVC insertion improves first-time insertion success across all risk categories in pediatrics, supporting the widespread adoption of ultrasound-guided PIVC insertion in children.

Trial Registration

anzctr.org.au Identifier: ACTRN12621000206820.

SHoes for Adolescent PatEllofemoral pain: study protocol for the SHAPE Australian community-based, randomised clinical trial

INTRODUCTION

Patellofemoral pain affects one-third of adolescents, with most experiencing symptoms into adulthood. Guidelines recommend exercise and foot orthoses based on clinical trials in adults; however, these approaches have been found to be ineffective and have poor adherence in adolescents. 'Minimalist' shoes can reduce patellofemoral joint forces in adults; and may therefore be a promising low burden management approach for patellofemoral pain. This article outlines the protocol for a randomised clinical trial (RCT) that aims to determine if minimalist footwear improves pain, function and other symptoms compared with motion control shoes, in adolescents with patellofemoral pain.

METHODS AND ANALYSIS

This is a 3-month, pragmatic, two-arm parallel group, comparative effectiveness, superiority RCT conducted in Melbourne, Australia. We are recruiting 158 participants aged between 12 and 19 years with patellofemoral pain from the community. Following baseline assessment, participants are randomised to receive either minimalist shoes (intervention group) or motion control shoes (control group, given that clinicians typically advocate motion control shoes for patellofemoral pain). Participants choose one pair of shoes in their allocated group from two colour options. They are advised to wear their study shoes for all planned sports and exercise-based activities over the subsequent 3 months and are also advised that they may wear them as much as desired at other times. The primary outcomes are the 3-month change in (1) severity of the worst knee pain experienced over the past week, measured using a Numerical Rating Scale, and (2) the function in sport and play subscale of the Knee Injury and Osteoarthritis Outcome Score for Children. The secondary outcomes include changes in other parameters of knee pain, symptoms, function in daily activities, health-related and knee-related quality of life, global improvement and fear of movement. Other measures include cointervention use, adherence, adverse events, shoe comfort, descriptive characteristics, physical activity levels, footwear characteristics and objective foot measures.

ETHICS AND DISSEMINATION

This study has been approved by the University of Melbourne Greater than Low Risk Human Research Ethics Committee (reference: 2022-25470-35344-4). Written informed consent is obtained from each participant prior to enrolment. The SHoes for Adolescent PatEllofemoral pain trial will provide the first RCT evidence on the efficacy of minimalist shoes compared with motion control shoes in adolescents with patellofemoral pain. Outcomes will be presented at national and international scientific conferences and published in peer-review journals.

TRIAL REGISTRATION NUMBER

Australian New Zealand Clinical Trials Registry reference: ACTRN12623000042640.

Prognostic factors of chronic postsurgical pain in children and adolescents: a systematic review and meta-analysis

BACKGROUND

Approximately 28% of children and adolescents undergoing major surgery develop chronic postsurgical pain (CPSP; pain persisting>3 months). A previous review attempted to investigate biopsychosocial prognostic factors for pediatric CPSP; however, due to lack of data, no meta-analytic techniques were employed. Since that review, numerous studies have investigated risk/protective factors that fall within an Interpersonal Fear Avoidance Model for CPSP, thus warranting a reinvestigation of prognostic factors.

OBJECTIVE

This systematic review and meta-analysis aimed to examine prognostic factors, measurement tools applied, and their effect on the development of CPSP.

EVIDENCE REVIEW

Prospective, observational studies examining prognostic factors of pediatric CPSP using validated self-report measures were included. 4884 unique publications were screened and 15 met inclusion criteria.

FINDINGS

The pooled effect size for the association between presurgical child pain intensity and the presence of child CPSP was significant, OR=0.540 (95% CI=0.184 to 0.894). Child anxiety, child pain-related anxiety, and parent pain catastrophizing were not significant prognostic factors for child CPSP. Using Grading of Recommendations, Assessment, Development, and Evaluation, the certainty in prognostic estimates was moderate. Risk of bias using Quality in Prognostic Study tool ranged from low to moderate.

CONCLUSIONS

Presurgical pain was the only presurgical risk factor at the meta-analytic level that significantly predicted pediatric CPSP, highlighting the importance of prioritizing pain management throughout the perioperative experience, starting before surgery. Depressive symptoms and sleep disturbance were the two potential risk/protective factors that were unable to be assessed due to insufficient data or use of an unvalidated measure indicating a critical need for future research.

PROSPERO REGISTRATION NUMBER

CRD42022306340.

Prevalence of and recommendation for measuring chronic postsurgical pain in children: an updated systematic review and meta-analysis

BACKGROUND

According to the prior 2017 review (Rabbitts et al), approximately 20% of children and adolescents develop chronic postsurgical pain (CPSP; ie, pain persisting >3 months after surgery) after major surgeries, which is associated with adverse functional and psychological consequences. A major barrier was that definitions of CPSP applied were highly variable. Since that prior review was conducted (n=4 studies in meta-analysis), numerous relevant studies have been published warranting an update.

OBJECTIVE

The aims of this current review were to: (1) provide an updated prevalence estimate for pediatric CPSP and (2) examine definitions of pediatric CPSP applied in current research.

EVIDENCE REVIEW

Prospective, observational studies examining CPSP using a validated self-report pain intensity measure in children were included. 4884 unique publications were screened with 20 articles meeting inclusion criteria. Risk of bias using Quality in Prognostic Study tool ranged from low to high.

FINDINGS

The pooled prevalence of CPSP among mostly major surgeries was 28.2% (95% CI 21.4% to 36.1%). Subgroup analysis of spinal fusion surgeries identified a prevalence of 31% (95% CI 21.4% to 43.5%). Using Grading of Recommendations, Assessment, Development, and Evaluation, the certainty in prevalence estimates was moderate. Studies used a range of valid pain intensity measures to classify CPSP (eg, Numeric Rating Scale), often without pain interference or quality of life measures.

CONCLUSIONS

The overall prevalence of pediatric CPSP is higher than estimated in the prior review, and quality of studies generally improved though with some heterogeneity. Standardizing the measurement of CPSP will facilitate future efforts to combine and compare data across studies.

PROSPERO REGISTRATION NUMBER

CRD42022306340.

Understanding the role of perfectionism in contributing to internalizing symptoms in youth with juvenile idiopathic arthritis

OBJECTIVE

Youth with juvenile idiopathic arthritis (JIA) experience elevated rates of internalizing symptoms, although more research is required to understand this phenomenon. Perfectionism, a multidimensional personality trait that involves dimensions such as striving for flawlessness (self-oriented perfectionism) and feeling that others demand perfection (socially-prescribed perfectionism), is a well-known risk factor for internalizing symptoms that has received minimal attention in pediatric populations. Preregistered hypotheses explored the relationships between youth and parent perfectionism and symptoms of depression and anxiety in youth with JIA, as mediated by (a) youth/parent negative self-evaluations and (b) youth self-concealment.

METHODS

One hundred fifty-six dyads comprised of youth (13-18 years) with JIA and a caregiver completed online questionnaires about trait perfectionism, negative self-evaluations (i.e., pain catastrophizing and fear of pain), self-concealment, and internalizing symptoms.

RESULTS

Positive relationships were observed between parent/youth self-oriented perfectionism and negative self-evaluations, youth self-oriented perfectionism and internalizing symptoms, and youth negative self-evaluations and internalizing symptoms. Parent self-oriented perfectionism was negatively related to youth depression symptoms. Indirect effects were observed for youth self-oriented perfectionism predicting anxiety and depression symptoms through pain catastrophizing (a1b1 = 0.13 and 0.12, 95% CI [.03, .24 and .03, .22], respectively). Exploratory mediations suggested youth socially-prescribed perfectionism might predict internalizing symptoms directly and indirectly through self-concealment.

CONCLUSION

Youth and parent perfectionism are implicated in the internalizing symptoms of youth with JIA and may manifest through youth negative self-evaluations (e.g., catastrophic thoughts) and self-concealment. While future research is needed, screening for perfectionistic tendencies in this population may help guide assessment, prevention, and treatment efforts.

The psychometric assessment of the older adult in pain: A systematic review of assessment instruments

We conducted a systematic review of pain assessment tools suitable for community-dwelling older adults. For this work, we conceptualized existing psychometric tools as falling under the following domains: a) pain intensity/characteristics; b) pain-related interference/disability; c) coping strategies; d) pain beliefs/attitudes/cognitions; e) pain-related fear and anxiety; and f) pain-specific emotional distress. Multi-dimensional and condition-specific tools were also considered. The COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) methodology for systematic reviews of patient-reported outcome measures guided the evaluation of measurement properties, quality of evidence ratings, and recommendations for each measure. A search of Medline, PsycINFO, Web of Science, and the Cumulative Index of Nursing and Allied Health Literature, yielded a total of 21,755 records. Of these, 120 studies, focusing on 57 psychometric tools, were included in this review and categorized into the aforementioned pain assessment domains. The availability of psychometric studies with older adult populations was insufficient for most tools and the quality of evidence ranged from very low to high. Only a small number of tools met the criteria for a strong or tentative recommendation favoring their use. We identified gaps that should be addressed in future research.

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.

The efficacy of wound catheter infusion with local anesthetics for the treatment of postoperative pain in children: A systematic review

Wound catheter infusion (WCI) with local anesthetics (LA) is a regional anesthesia technique, which has shown to produce effective postoperative analgesia in adults, without any adverse effects on wound healing. To investigate the efficacy and safety of WCI with LA for the treatment of postoperative pain in children, we conducted a systematic review of literature published until 2020. The literature search included articles concerning subcutaneous WCI with LA, in the surgical wound, as treatment of postoperative pain, in children <18 years of age. Exclusion criteria were studies describing peripheral nerve blocks, intercostal, abdominal or thoracic wall blocks and single local anesthetic infiltration of the surgical wound. The articles were appraised for quality and only randomized controlled trials with a Jadad score ≥3 were included for evaluation of results concerning postoperative pain scores and opioid use. All relevant original studies, including observational studies and case reports, were assessed for adverse events and measurements of LA plasma concentrations during WCI. A total of 1907 articles were found, leading to 92 relevant abstracts selected for further review. After exclusion of articles of which full texts could not be retrieved or because of exclusion criteria, 28 articles remained. Thirteen articles described randomized controlled trials, of which 10 were assessed as good or excellent in quality. Due to the small number and heterogeneity of the studies, the data could not be pooled. Instead, results were described per type of procedure: abdominal surgery, extremity surgery, thoracic surgery and iliac crest bone harvesting. Reduced pain scores and opioid needs were demonstrated after abdominal and extremity surgery. In five studies, plasma levels of LA were measured, which all remained below toxic thresholds. In all relevant studies, no serious adverse events concerning the use of WCI were reported.

Sensor technology and machine learning to guide clinical decision making in plastic surgery

Subjective clinical evaluations are deeply rooted in medical practice. Recent advances in sensor technology facilitate the acquisition of extensive amounts of objective physiological data that can serve as a surrogate for subjective assessments. Along with sensor technology, a branch of artificial intelligence, known as machine learning, has provided decisive advances in several areas of medicine due to its pattern recognition and outcome prediction abilities. The assimilation of machine learning algorithms into sensor technology can substantially improve our current diagnostic and treatment competencies. This review explores available data on the use of sensor technology and machine learning in areas of interest for plastic surgeons, updates current knowledge on the most recent technological advances, and provides a new perspective on the field.

Anesthetic-sparing effect of dexmedetomidine during total intravenous anesthesia for children undergoing dental surgery: A randomized controlled trial

BACKGROUND

Dexmedetomidine, an α2-adrenergic agonist, reduces propofol and remifentanil requirements when used as an adjunct to total intravenous anesthesia in adults, but studies in a pediatric population are sparse. This study investigates the magnitude of dose-sparing effects of a postinduction dexmedetomidine bolus on propofol and remifentanil requirements during pediatric surgery.

METHODS

In this randomized, double-blind, controlled trial, children aged 2-10 years undergoing elective dental surgery were assigned to one of four groups: placebo, 0.25 mcg/kg dexmedetomidine, 0.5 mcg/kg dexmedetomidine, and 1 mcg/kg dexmedetomidine. Maintenance with fixed-ratio propofol and remifentanil total intravenous anesthesia followed a bispectral index (BIS)-guided algorithm designed to maintain a stable depth of anesthesia. The primary outcomes were time-averaged maintenance infusion rates of propofol and remifentanil. Secondary outcomes in the postanesthetic care unit included sedation scores, pain scores, and time to discharge.

RESULTS

Data from 67 patients were available for analysis. The median [interquartile range] propofol infusion rate was lower in the 1 mcg/kg dexmedetomidine group (180 [164-185] mcg/kg/min) versus placebo (200 [178-220] mcg/kg/min): percent change -10.0%; 95% CI -2.4 to -19.8; p = 0.013. The remifentanil infusion rate was also lower in the 1 mcg/kg dexmedetomidine group (0.089 [0.080, 0.095] mcg/kg/min) versus placebo (0.103 [0.095, 0.106] mcg/kg/min): percent change, -13.7%; 95% CI -5.47 to -21.0; p = .022. However, neither propofol nor remifentanil infusion rates were significantly different in the 0.25 or 0.5 mcg/kg dexmedetomidine groups. In the postanesthesia care unit, there were no differences in pain or sedation scores, and time to discharge was not significantly prolonged in any dexmedetomidine group.

CONCLUSION

Dexmedetomidine 1 mcg/kg reduced the propofol and remifentanil requirements during maintenance of anesthesia in children when administered as a postinduction bolus.

TRIALS REGISTRATION

ClinicalTrials.gov: NCT03422978, date of registration 2018-02-06.

Pain during primary molar local anaesthesia with SleeperOne5 computerized device versus conventional syringe: A randomized, split-mouth, crossover, controlled trial

BACKGROUND

Because of controversial results from clinical studies comparing different dental local anesthesia methods in children, the primary objective of this randomized, split-mouth, crossover, controlled trial was to compare pain intensity during local anaesthesia (LA) performed with a computer-controlled LA delivery system (C-CLADS) versus a conventional syringe (CONV). Secondary objectives included comparisons during dental treatment.

METHODS

Participants (4-8 years) with tooth pair requiring similar treatment were recruited from five French hospitals. The right primary molar, which was treated at the first visit, was randomly allocated to one of the anaesthesia groups (either intraosseous with C-CLADS or infiltration with CONV), whereas the contralateral molar (treated at the second visit) was assigned to the other group. Pain intensity and behaviour outcomes, assessed with the Faces Pain and Venham revised scales, respectively, were compared between groups using Proc mixed. Stratified analyses were performed on dentition and location.

RESULTS

Among 107 participants, the analysis revealed reduced pain perception during LA in the C-CLADS group compared with the CONV group (-0.72, 95% CI: -1.43, -0.006), but not during dental treatment. Stratified analyses showed that this effect was observed only in primary dentition (p = .006) and mandibular molars (p = .005). Behavioural issues were fewer in the C-CLADS group than in the CONV group (p = .05) only during injection.

CONCLUSION

C-CLADS emerged as the preferable system in primary dentition.

Somatosensory profile in individuals with duchenne muscular dystrophy: A quantitative sensory testing (QST) study

OBJECTIVE

This study aimed to quantify somatosensory profiles in individuals with Duchenne muscular dystrophy (DMD).

METHODS

We included 28 participants with genetically confirmed DMD (aged 8-17 years), 14 with chronic pain (DMD-CP), and 14 without pain (DMD-NP), compared to 13 healthy controls (HC) matched for age and sex. Three quantitative sensory testing (QST) modalities were examined: pressure pain threshold (PPT), temporal summation of pain (TSP) and conditioned pain modulation (CPM). Characteristics related to chronic pain, fatigue, psychological distress, and health-related quality of life were assessed using questionnaires.

RESULTS

Decreased PPTs were found in both DMD cohorts across body areas commonly affected by pain (rectus femoris, medial gastrocnemius, paraspinal muscles, upper trapezius), as well as in a less frequently affected remote area (thenar eminence), compared to HCs (p < 0.001). The DMD-CP group exhibited greater TSP compared to HCs (p = 0.025). There were no differences in CPM effects between DMD groups and HCs. No differences were detected in all QST measures between DMD-CP and DMD-NP.

SIGNIFICANCE

This study is the first to explore the somatosensory profile in DMD. Preliminary evidence suggests that generalized hyperalgesia may be a common feature in DMD regardless of pain status. QST measures appear to not distinguish individuals with chronic pain from those without and thus are not recommended for assessing pain in DMD or guiding treatment.

Integrating tailored approaches in perioperative care strategies for neurodivergent individuals

Neurodivergent (ND) individuals exhibit variations in communication, behaviors, and cognition, which present both opportunities and challenges in healthcare settings. Anesthesiologists can offer personalized and compassionate care to ND patients throughout the surgical process. Yet, often, there is limited knowledge of the specific actions that anesthesiologists can take to build a healthcare environment that fully recognizes and meets the unique needs of ND patients. This document highlights the importance of integrating tailored communication and supportive strategies throughout the distinct stages of perioperative and intraoperative care.

A multi-centre, tolerability study of a cannabidiol-enriched Cannabis Herbal Extract for chronic headaches in adolescents: The CAN-CHA protocol

INTRODUCTION

Cannabis products have been used in the management of headaches in adults and may play a role in pediatric chronic pain. Canadian pediatricians report increasing use of cannabis for the management of chronic headaches, despite no well-controlled studies to inform its dosing, safety, and effectiveness. The aim of our clinical trial is to determine the dosing and safety of a Cannabidiol (CBD)-enriched Cannabis Herbal Extract (CHE) for the treatment of chronic headaches in adolescents.

METHODS AND ANALYSIS

Youth, parents, and an expert steering committee co-designed this tolerability study. Twenty adolescents (aged 14 to 17 years), with a chronic migraine diagnosis for more than 6 months that has not responded to other therapies will be enrolled into an open label, dose escalation study across three Canadian sites. Study participants will receive escalating doses of a CBD-enriched CHE (MPL-001 with a THC:CBD of 1:25), starting at 0.2-0.4 mg/kg of CBD per day and escalating monthly up to 0.8-1.0 mg/kg of CBD per day. The primary objective of this study is to determine the safety and tolerability of CBD-enriched CHE in adolescents with chronic migraine. Secondary objectives of this study will inform the development of subsequent randomized controlled trials and include investigating the relationship between the dose escalation and change in the frequency of headache, impact and intensity of pain, changes in sleep, mood, function, and quality of life. Exploratory outcomes include investigating steady-state trough plasma levels of bioactive cannabinoids and investigating how pharmacogenetic profiles affect cannabinoid metabolism among adolescents receiving CBD-enriched CHE.

DISCUSSION

This protocol was co-designed with youth and describes a tolerability clinical trial of CBD-enriched CHE in adolescents with chronic headaches that have not responded to conventional therapies. This study is the first clinical trial on cannabis products in adolescents with chronic headaches and will inform the development of future comparative effectiveness clinical trials.

TRIAL REGISTRATION

CAN-CHA trial is registered with ClinicalTrials.gov with a number of register NCT05337033.

Remote electrical neuromodulation to treat children and adolescents with migraine in the emergency department: A randomized double-dummy pilot trial

OBJECTIVE

Using a double-dummy pilot randomized controlled trial design, we aimed to determine the feasibility and acceptability of comparing remote electrical neuromodulation (REN) to typical care intravenous pharmacologic interventions for the treatment of children and adolescents visiting the emergency department (ED) with migraine, and to compare parallel-group versus crossover trial designs.

BACKGROUND

There are limited data to guide the management of migraine in the ED. Children and adolescents are interested in neuromodulation, and specifically REN, for treatment in this setting, but there are no existing data on this approach.

METHODS

We employed a double-dummy, double-blind, pilot randomized controlled trial that tested two designs in two phases: a parallel-group design and a crossover design (ClinicalTrials.gov identifier: NCT05102591). The intervention arms consisted of: (i) active REN stimulation with matched normal saline placebo intravenously, and (ii) matched sham REN stimulation, intravenous metoclopramide (0.15 mg/kg, maximum 10 mg), and intravenous ketorolac (0.5 mg/kg, maximum 30 mg). Youth aged 8.0-<18.0 years visiting a Canadian tertiary care pediatric ED with migraine attacks as per criteria B-E of the International Classification of Headache Disorders third edition were eligible. Primary outcomes were focused on trial feasibility and acceptability, and preliminary efficacy and safety data were also collected.

RESULTS

A total of 34% (22/65) of those who screened eligible were enrolled. Three participants (14%) withdrew prior to receiving any study interventions. In all, 10 participants were allocated to typical care, and nine to REN. All treated participants (19/19) completed all assessments. Recruitment was higher during the parallel-group phase: 1.1 participants/month versus 0.6 participants/month, and 36% (17/47) versus 28% (five of 18) of screened eligible were enrolled in the parallel-group and crossover phases, respectively. Participants reported positive impressions of REN use in the ED, e.g., higher mean (standard deviation [SD]) levels of interest in using REN only at 3.7 (1.0) versus 2.8 (1.0) in using intravenous interventions only for a future ED visit. Participants and clinical staff reported overall positive impressions regarding the study protocol. Employing an 11-point pain numerical rating scale, the mean (SD) reduction in pain severity score was 2.1 (1.3) and 2.9 (2.9) from baseline to 1 h, and 2.4 (1.6) and 4.0 (3.5) from baseline to 2 h for REN and intravenous interventions, respectively. One participant in the typical care group and none in the REN group experienced adverse events.

CONCLUSION

We demonstrated the feasibility and acceptability of our trial protocol and of using REN to treat youth presenting to the ED with migraine. The parallel-group design generated a higher recruitment rate than the crossover design. Our preliminary efficacy and safety data suggest that REN could be non-inferior to typical care, but we were not powered for these outcomes. Further research on REN's use in the ED setting is warranted.

Postoperative epidural analgesia and outcomes following pediatric bilateral lung and heart-lung transplantation: a retrospective observational study

BACKGROUND

The value of epidural analgesia in pediatric patients having heart and lung transplant surgery is unknown. We aimed to characterize various quality outcomes in patients who did and did not have epidural analgesia.

METHODS

Data were collected retrospectively for 62 patients from 2006 to 2023 at a tertiary care transplant center. Patients were evaluated by epidural status. The primary outcome was a hospital stay in days. Other measures of morbidity and mortality were measured as secondary endpoints.

RESULTS

The mean age was 12.7 (3) years; 54 (87%) received bilateral lung transplantation, and 8 (13%) received en bloc heart-lung transplantation. 41 (66%) were female. Epidural utilization rate was 74 %, n=45. On univariate analysis, epidural analgesia compared with no epidural was associated with a reduction in the median length of hospital stay from 26.5 to 20 days (p=0.02). After adjustment for age, sex and type of operation, there was no significant difference in LOS. Other findings following univariate analysis included reduced time of postoperative ventilation with a median reduction of 7-2 days (p=0.019), and a reduced 5-day postoperative opioid requirement; median of 2.94-1.21 mg/kg/24 hours (p=0.004) with epidural analgesia. Epidural analgesia was not associated with a change in overall survival (p=0.49).

CONCLUSION

Despite a likely improvement in analgesia, we could not demonstrate a definitive impact of epidural analgesia on outcomes in this small cohort of patients. Larger datasets through registries and institutional collaboration will be needed to increase sample size to identify effect sizes and adjust for confounders.

Peer Victimization, Posttraumatic Stress Symptoms, and Chronic Pain: A Longitudinal Examination

Chronic pain and posttraumatic stress disorder symptoms (PTSS) co-occur at high rates in youth and are linked to worse pain outcomes and quality of life. While peer victimization has been posited as a mechanism underlying the PTSS-pain relationship in youth, empirical evidence suggests that it may exacerbate both PTSS and pain. The present study aimed to longitudinally examine PTSS as a mediator in the relationship between peer victimization at baseline and pain-related outcomes at 3 months in youth with chronic pain. Participants included 182 youth aged 10 to 18 years recruited from a tertiary-level children's hospital in Western Canada. At baseline, participants completed measures to assess pain (intensity and interference), peer victimization (relational and overt), and PTSS. The pain was reassessed at a 3-month follow-up. Primary hypotheses were tested utilizing a series of mediation analyses with PTSS as a proposed mediator in the associations between peer victimization and pain outcomes. Youth PTSS mediated the relationship between higher baseline relational victimization and higher 3-month pain interference while controlling for baseline pain interference. Three-month pain intensity was not correlated with peer victimization; thus, pain intensity was not included in the analyses. These findings reveal that PTSS may be an underlying factor in the co-occurrence of peer victimization and chronic pain in youth. Further research is needed to better understand the role of peer victimization in the maintenance of chronic pain to ensure appropriate, effective, and timely interventions that address the social and mental health issues impacting the lives of these youth as well as their pain. PERSPECTIVE: PTSS may be an underlying factor in the co-occurrence between peer victimization and chronic pain in youth, highlighting the need to assess for both peer relationship problems and PTSS in youth with chronic pain.

The relationship between pain, quality of life and physical activity in older community living Australians

The objective of this analysis was to investigate the relationship between pain and quality of life and physical activity as a mediator in the relationship between pain and quality of life. This study utilised a combination of questionnaire data from 503 community-living people aged 70-years and over concerning quality of life, pain, and physical activity. Participants with higher levels of pain intensity experienced lower quality of life and engaged in lessphysical activity (P < 0.05). Physical activity was a mediator in the relationship between pain and quality of life(6.5 %). This study confirms an association between pain and quality of life and highlights physical activ-ity as an essential component of this relationship; further research is needed to understand the mechanism of this relationship.

Chemotherapy-induced neuropathy and pain in pediatric oncology patients: impact of combination therapies

Chemotherapy-induced peripheral neuropathy (CIPN) and associated pain are prevalent adverse effects of pediatric cancer treatment, significantly affecting the patient's quality of life. Their impact and risk factors have yet to be assessed in our country. This study aimed to assess the prevalence and clinical characteristics of CIPN, as well as to explore associations with patient- and treatment-related variables, within a cohort of Argentinean pediatric oncology patients. Sixty-six patients diagnosed with malignant hematopoietic tumors and receiving the neurotoxic agent vincristine were included in this observational study. Variables analyzed included age, gender, anthropometric measurements, tumor type, chemotherapy treatment, development of pain and other symptoms, severity, and analgesic treatment. The study population consisted of 39 boys and 27 girls. Most patients received two or three neurotoxic drugs. Symptoms consistent with CIPN were identified in 15 children, reflecting a prevalence of 23%. The main symptom was pain in the lower limbs, with some patients reporting jaw or generalized body pain. Pain was categorized as moderate or severe in 60% and 27% of cases, respectively. NSAIDs, anticonvulsants, and/or opioids were prescribed. Among the patient- and treatment-related variables analyzed as potential risk factors, the use of vincristine in conjunction with cytarabine and the administration of a higher number of neurotoxic drugs demonstrated significant association with the development of CIPN.

CONCLUSIONS

Combination therapy stands out as a risk factor for clinical CIPN. The high prevalence of moderate/severe pain underscores the importance of close vigilance given its potential to compromise the patient's overall well-being.

WHAT IS KNOWN

• Chemotherapy-induced peripheral neuropathy (CIPN) is a frequent adverse effect and dose-limiting factor in pediatric cancer treatment. • Prevalence varies among regions and risk factors are still under study.

WHAT IS NEW

• Prevalence of symptomatic CIPN is 23% among pediatric patients undergoing treatment for hematopoietic tumors in a referral hospital in Argentina. Most patients report moderate or severe pain. • Combining vincristine with cytarabine and using a higher number of neurotoxic drugs in combination therapies exhibit significant association with the development of CIPN-related symptoms.

Impact of virtual reality on peri-interventional pain, anxiety and distress in a pediatric oncology outpatient clinic: a randomized controlled trial

PURPOSE

Pain and anxiety-inducing interventions have a major impact on pediatric patients. Pain reduction by virtual reality (VR) during port and vein punctures is well studied. This study investigates peri-interventional reduction of pain, anxiety and distress using VR compared to the standard of care (SOC) in a pediatric oncology outpatient clinic.

METHODS

In a randomized, controlled cross-over design, patients aged 6-18 years experience potentially painful interventions accompanied by VR. Observational instruments include NRS, FPS-r, BAADS, mYPAS-SF, PedsQL and SSKJ3-8R. All patients undergo two observations: SOC (A) and VR (B) in a randomized order. In addition, parents and staff are interviewed. Specific conditions for VR in an outpatient clinic setting derived from interprofessional focus group discussion are being explored.

RESULTS

Between July 2021 and December 2022 57 eligible patients were included and randomized to the orders A/B (n = 28) and B/A (n = 29). Thirty-eight patients completed both observations. Characteristics in both groups did not differ significantly. More than half of the patients had no previous experience with VR, 5% decided to discontinue VR prematurely. Peri-interventional pain, anxiety and distress were significantly reduced by VR compared with SOC. 71% of patients and 76% of parents perceived punctures with VR to be more relaxed than previous ones. 95% of patients perceived fun with VR goggles. Detailed questionnaires on individual stress and anxiety were returned from 26 of 38 patients. Focus group discussion with staff yielded evidence for successful implementation of VR in an outpatient clinic.

CONCLUSIONS

The present study shows that VR can be used for peri-interventional reduction of pain, anxiety, and distress in the special environment of a pediatric outpatient clinic. Specific conditions must be met for successful implementation. Further studies are needed to identify particularly susceptible patients and to illuminate alternatives for distraction that are feasible to implement with limited resources.

TRIAL REGISTRATION NUMBER

(ClinicalTrials.gov ID): NCT06235723; 01/02/2024; retrospectively registered. This study adheres to the standard checklist of CONSORT guidelines.

Nurses' Assessment of Pain in Saudi Neonatal Intensive Care Units

BACKGROUND

Research reveals that neonatal pain management in Neonatal Intensive Care Units (NICUs) is suboptimal. There is limited research that assessed NICU nurses' pain assessment practices in Saudi Arabia.

AIM

To assess the nurses' pain assessment practices in the NICU in Saudi Arabia.

DESIGN

This study used a descriptive cross-sectional design.

SETTINGS

Research was conducted using an online survey.

PARTICIPANTS/SUBJECTS

This study was carried out on 65 NICU nurses. The participants were recruited from one governmental and one private hospital in Saudi Arabia.

METHODS

Data on pain assessment practices were collected, including the frequency of pain assessment, pain assessment scales used for preterm and term neonates, and pain assessment documentation. Data were analyzed using frequencies and percentages.

RESULTS

The majority of the participants (94%) routinely assessed pain and documented pain assessment (97%). One-third of the participants assessed pain regularly every hour (32%). The most used pain assessment scales for term neonates were the neonatal infant pain scale (40%) and the cry, required oxygen, increased vital signs, expression, and sleeplessness scale (23%). The most used pain assessment scales for preterm neonates were the neonatal infant pain scale (31%), the cry, required oxygen, increased vital signs, expression, sleeplessness scale (19%), and the premature infant pain profile (17%).

CONCLUSIONS

NICU nurses in Saudi Arabia consistently assessed for and documented pain; however, the tools chosen were sometimes suboptimal. A substantial number of NICU nurses used invalid tools to assess pain in term and preterm neonates. An interventional program is needed to enhance the use of evidence-based practice recommendations regarding neonatal pain assessment by nurses in the Neonatal Intensive Care Units in Saudi Arabia.

Interactive and passive mixed reality distraction: effects on cold pressor pain in adults

While interactive distractors are predicted to be more effective in reducing acute pain than passive distractors, the underlying mechanisms remain poorly understood. Previous work using Virtual-Reality (VR) has suggested that interactive distraction may be enhanced by increasing the person's sense of immersion. Despite the possible utility of immersive VR in reducing pain, some people report being disoriented and motion sick, and it doesn't allow for interactions with environment (e.g., following instructions from medical staff). Here, we explore the role of the immersion in the effectiveness of interactive distraction by employing an alternative technology, a Mixed-Reality (MR) headset that limits disorientation by projecting virtual objects into the real world. Healthy volunteers (18-35 years) participated in two experiments employing either a between (N = 84) or a within-subject (N = 42) design to compare Interactive and Passive distraction tasks presented via MR or a standard computer display. For both experiments, a cold-pressor task was used to elicit pain, with pain tolerance and pain perception being recorded. Analysis revealed that whilst interactive distraction was more effective in reducing pain perception and increasing pain tolerance than passive distraction, the interpretation of results was sensitive to experimental design. Comparison of devices did not reveal significant differences in pain tolerance or pain intensity, while pain unpleasantness was significantly reduced during the MR task using a within-subject design. Our findings add to existing VR studies reporting little additional analgesic benefit of new, immersive technologies compared to traditional computers, but underscores the important impact the choice of experimental design can have on the interpretation of results.

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.

Turkish validity and reliability study of the Alder hey child triage pain scale

AIM

This study was performed to examine the Turkish validity and reliability of the Alder Hey Triage Pain Scale (AHTPS) for children aged 3-15 years who attended the pediatric emergency service with a complaint of pain.

MATERIAL AND METHOD

The sample for the methodological research was composed of 300 children between the ages of 3 and 15 who attended the University Training and Research Hospital Pediatric Emergency Clinic with a complaint of pain. Data were collected by using the Child and Parent Descriptive Information Form, Emergency Service Patient Triage, Treatment and Observation Form, AHTPS, and Wong-Baker Faces Pain Scale (WBFPS).

RESULTS

Of the children participating in the study, 54.3% were female and 30.7% were between the ages of 12-15. The total content validity index score of the AHTPS was determined as 0.99 and the content validity rate score was 0.98. The interobserver concordance of AHTPS was examined and the concordance of two observers was significant and very good (p < 0.001). For the concordance of scale with similar scales, the WBFPS was used and during the 1st and 2nd measurements, intra-observer reliability of AHTPS was statistically significant and very good (p < 0.001). Cronbach alpha values of the scale were in the range of 0.619 and 0.679 and the scale was reliable.

CONCLUSIONS

As a result, the adaptation of the AHTPS to Turkish is a valid and reliable measurement tool.

PRACTICE IMPLICATIONS

Pain assessment for children attending the emergency service should be performed more systematically with scales like the AHTPS.

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.

Age and Sex Differences in Pediatric Neuropathic Pain and Complex Regional Pain Syndrome: A Scoping Review

BACKGROUND

Age and sex differences may exist in the frequency (incidence, prevalence) or symptoms of neuropathic pain (NP) and complex regional pain syndrome (CRPS) due to biopsychosocial factors (eg, neurodevelopment, physiological and hormonal changes, psychosocial differences) that evolve through childhood and adolescence. Age and sex differences may have implications for evaluating screening and diagnostic tools and treatment interventions.

OBJECTIVE

To map the existing literature on pediatric NP and CRPS with respect to age and sex distributions, and age and sex differences in symptomology and frequency.

METHODS

A scoping literature review was conducted. Databases were searched from inception to January 2023. Data were collected on study design, setting, demographics, and age and sex differences in frequency and symptoms.

RESULTS

Eighty-seven studies were included. Distribution of participants with CRPS (n=37 studies) was predominantly early adolescence (10 to 14 y) and female sex, while NP (n=42 studies) was most commonly reported throughout adolescence (10 to 19 y) in both sexes. Forty-one studies examined age and sex differences in frequency; 6 studies reported higher frequency in adolescence. Very few studies (n=11) examined differences in symptomology.

DISCUSSION

Large epidemiological studies are required to further understand age and sex differences in frequency of pediatric NP and CRPS. Age and sex differences must be considered when evaluating screening and diagnostic tools and treatment interventions to ensure relevance and validity to both sexes and across ages. Validated tools will improve understanding of age-dependent and sex-dependent differences in symptoms, pathophysiology, and psychosocial impact of pediatric NP and CRPS.

Prevalence and burden of pain across the entire spectrum of Huntington's disease

BACKGROUND

Pain is an important symptom in Huntington's disease (HD), however, not systematically studied and understood. The objective of the current study is to assess the prevalence of pain, pain interference in daily activities, painful conditions, analgesic use and the severity of the pain burden across different disease stages and 'Age at symptom Onset' groups. Additionally, the association between pain and disease burden was investigated.

METHODS

A cross-sectional analysis was conducted within two large data sets, which included different types of pain scales. Multivariable logistic regression analyses and analyses of variance were performed to compare the pain levels with those in the general population. The analyses were adjusted for sex and age. Locally Estimated Scatterplot Smoothing was used to test the association between pain and the HD pathology score: a measure of disease burden.

RESULTS

The mean prevalence of pain in the HD population was 40% and for pain interference around 35% in both data sets. Patients in the early, middle and late stage of HD experience more pain burden compared with what is reported in patients with chronic pain (p<0.01). A positive and significant association was demonstrated between pain and disease burden. Patients in late stage HD with pain use significantly less analgesics compared with the general population (5% vs 13%, respectively (p<0.01)).

CONCLUSIONS

Pain is a prevalent and important symptom in HD. Severe pain burden in the HD population is present and positively associated with disease burden. Risk for undertreatment with analgesics is nevertheless present. Awareness of pain in HD needs to be increased, both clinically and scientifically.

Clinically significant differences in self-reported pain scores in children with headaches

OBJECTIVES

Changes in pain scores that represent clinically significant differences in children with headaches are necessary for study design and interpretation of findings reported in studies. We aimed to determine changes in pain scores associated with a minimum clinically significant difference (MCSD), ideal clinically significant difference (ICSD), and patient-perceived adequate analgesia (PPAA) in this population.

METHODS

We performed a secondary analysis of two prospective studies of children with headaches presenting to an emergency department. Two serial assessments were performed in children aged 6-17 and 4-17 years who self-reported their pain intensity using the Verbal Numerical Rating Scale (VNRS) and Faces Pain Scale-Revised (FPS-R), respectively. Children qualitatively described any endorsed change in pain score; those who received an analgesic were asked if they wanted additional analgesics to decrease their pain intensity. We used receiver operating characteristic curve-based methodology to identify changes in pain scores associated with "a little less" (MCSD) and "much less" (ICSD) pain and patients declining additional analgesics because they experienced adequate analgesia after treatment (PPAA).

RESULTS

We analyzed 105 children: 63.8% were female and the median (IQR) age was 13 (10-15) years. Ninety-eight children were analyzed for the VNRS and 101 were analyzed for the FPS-R. For the VNRS, raw change and percent reductions in pain scores associated with MCSD, ICSD, and PPAA were 2/10 and 25%, 4/10 and 56%, and 3/10 and 50%, respectively, and for the FPS-R, 2/10 and 25%, 4/10 and 67%, and 4/10 and 60%, respectively. The area under the curve (AUC) associated with a MCSD for both scales ranged from 94% to 98%; the AUC associated with an ICSD or PPAA for both scales ranged from 76% to 83%.

CONCLUSIONS

We identified changes in pain score associated with patient-centered outcomes in children with headaches suitable for designing trials and assigning clinical significance to changes in pain scores reported in studies.

Postsurgical Analgesic Effectiveness of Ultrasound-Guided Parasternal Block After Auricular Reconstruction Using Autologous Costal Cartilage in Pediatric Patients: A Randomized Controlled Trial

OBJECTIVE

To study the efficacy of ultrasound-guided parasternal block (US-PSI) in pediatric patients undergoing auricular reconstruction surgery.

METHODS

For this study, the authors recruited 60 children between the ages of 5 and 12 years who underwent auricular reconstruction with autologous costal cartilage (ACC) to correct microtia. They were randomized to receive either ultrasound-guided modified parasternal block or periprostatic local infiltration anesthesia (PLIA), with 30 cases in each group. Ultrasound-guided parasternal block was administered following anesthesia induction, whereas PLIA was administered after ACC harvest. Lastly, following surgery, all children were provided with patient-controlled intravenous analgesia with sufentanil, and the numeric pain rating scale (NRS) was used to assess the intensity of pain. Our primary outcomes were the resting NRS pain scores and the NRS scores upon coughing at 1, 6, 12, 24, and 48 hours postsurgery. Sufentanil consumption within the first 24 hours of surgery, the mean duration to first ambulation, and the usage of rescue analgesics were our secondary outcomes. The authors also recorded the occurrence of undesirable side effects as well as more serious side effects like pneumothorax.

RESULTS

Pediatric patients who were administered US-PSI showed significantly reduced NRS chest pain scores at 6 and 12 hours postsurgery compared to those who received PLIA (P<0.05). In addition, sufentanil consumption within the first 24 hours postsurgery, duration to first ambulation, and use of rescue analgesics were significantly lower among patients in the US-PSI group when compared to those in the PLIA group (P<0.05).

CONCLUSIONS

This study found that US-PSI was a highly efficacious and safe technique for postsurgical analgesia following auricular reconstruction with ACC in pediatric patients.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Updated recommendations on measures for clinical trials in pediatric chronic pain: a multiphase approach from the Core Outcomes in Pediatric Persistent Pain (Core-OPPP) Workgroup

ABSTRACT

Many gaps remain in finding effective, safe, and equitable treatments for children and adolescents with chronic pain and in accessing treatments in different settings. A major goal of the field is to improve assessment of pain and related experience. Valid and reliable patient-reported outcome measures are critical for advancing knowledge of clinical interventions for pediatric chronic pain. Building on the work of the Ped-IMMPACT group, we previously updated a core outcome set (COS) for pediatric chronic pain clinical trials using stakeholder feedback from providers, youth, and parents. The new COS includes 3 mandatory domains: pain severity, pain-related interference with daily living, and adverse events and 4 optional domains: overall well-being, emotional functioning, physical functioning, and sleep quality. The aim of this study was to use a multiphased approach to recommend specific measures for each of the 7 domains identified in our new COS for pediatric chronic pain. We synthesized evidence through conducting the following: (1) a Delphi study of experts to identify candidate measures for the new COS domains, (2) a review phase to gather evidence for measurement properties for candidate measures, and (3) an expert consensus conference to reach agreement on measurement recommendations. Final recommendations included 9 patient-reported measures. Important contextual considerations are discussed, and guidance is provided regarding strengths and limitations of the recommendations. Implementation of these recommendations may be enhanced by widespread dissemination and ease of access to measurement tools.

Content validity of the electronic faces thermometer scale for pain in children: is a picture worth more than a thousand words?

Introduction

Early recognition of pain in children is crucial, and their self-report is the primary source of information. However, communication about pain in healthcare settings can be challenging. For non-verbal communication regarding different symptoms, children prefer digital tools. The electronic Faces Thermometer Scale (eFTS) utilizes a universal design with colors, face emojis, and numbers on an 11-point scale (0-10) for pain assessment. The aim of this study was to establish content validity of the eFTS for pain assessments in children.

Methods

A mixed methods design was used. The study took place at a university hospital in eastern Sweden, involving 102 children aged 8-17 years who visited outpatient clinics. Participants were presented with 17 pictures representing varying pain levels and asked to assess hypothetical pain using the eFTS. A think-aloud approach was employed, prompting children to verbalize their thoughts about assessments and the eFTS. Quantitative data were analyzed using descriptive and comparative statistics, together with a qualitative approach for analysis of think-aloud conversations.

Results

A total of 1,734 assessments of hypothetical pain using the eFTS were conducted. The eFTS differentiated between no pain (level 0-1) and pain (level 2-10). However, no clear agreement was found in the differentiation between hypothetical pain intensity levels (level 2-10). The analysis revealed that children utilized the entire scale, ranging from no pain to high pain, incorporating numbers, colors, and face emojis in their assessments.

Discussion

The variability in assessments was influenced by prior experiences, which had an impact on the statistical outcome in our study. However, employing the think-aloud method enhances our understanding of how children utilize the scale and perceive its design, including the incorporation of emotion-laden anchors. Children express a preference for using the eFTS to assess their pain during hospital visits.

Perioperative position management of 46 cases with simultaneous bilateral auricle reconstruction: A summary of experience

OBJECTIVES

The primary problem in simultaneous bilateral auricle reconstruction is the fragility of the reconstructed ear structure. Postoperative pressure is strictly prohibited to ensure the operation's effectiveness. The study aimed to summarize the experience of perioperative postural management in simultaneous bilateral auricular reconstruction.

METHOD

This study summarizes the experience of perioperative postural management, providing preoperative sleeping posture adaptability training, neck movement training, standardization of the head position angles and the head suspension time in surgery, using protective headrests, paying attention to the transfer and handover procedures, and using specially designed pillows.

RESULTS

The comprehensive nursing approach in simultaneous bilateral auricular reconstruction significantly reduced complications, improved patient comfort, and optimized postoperative adaptation. Preoperative posture training, standardized intraoperative head positions, and vigilant postoperative care played pivotal roles, demonstrating positive outcomes in 46 cases.

DISCUSSION

Perioperative position management can reduce the risk of complications and pressure injuries, improving patients' postoperative comfort, emotional state, tolerance, and adaptability.

CONCLUSION

All ears were viable and in good shape after long-term follow-up. The experiences discussed in this study can be broadly applied to technically mature ear reconstruction teams.

Measuring moral distress and moral injury: A systematic review and content analysis of existing scales

BACKGROUND

Moral distress (MD) and moral injury (MI) are related constructs describing the negative consequences of morally challenging stressors. Despite growing support for the clinical relevance of these constructs, ongoing challenges regarding measurement quality risk limiting research and clinical advances. This study summarizes the nature, quality, and utility of existing MD and MI scales, and provides recommendations for future use.

METHOD

We identified psychometric studies describing the development or validation of MD or MI scales and extracted information on methodological and psychometric qualities. Content analyses identified specific outcomes measured by each scale.

RESULTS

We reviewed 77 studies representing 42 unique scales. The quality of psychometric approaches varied greatly across studies, and most failed to examine convergent and divergent validity. Content analyses indicated most scales measure exposures to potential moral stressors and outcomes together, with relatively few measuring only exposures (n = 3) or outcomes (n = 7). Scales using the term MD typically assess general distress. Scales using the term MI typically assess several specific outcomes.

CONCLUSIONS

Results show how the terms MD and MI are applied in research. Several scales were identified as appropriate for research and clinical use. Recommendations for the application, development, and validation of MD and MI scales are provided.

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.

Liposomal Bupivacaine Use During Orthognathic Surgery in Cleft Lip and Palate Patients

INTRODUCTION

Effective pain management is crucial in cleft lip and palate (CLP) patients undergoing orthognathic surgery for earlier recovery and decreased opioid reliance. Liposomal bupivacaine (Exparel) is a local anesthetic that provides extended postoperative analgesia in adult patients; however, research on its use in adolescents is limited. This study explores the efficacy of liposomal bupivacaine for postoperative pain management in adolescent CLP patients undergoing orthognathic surgery.

METHODS

The authors performed a retrospective chart review at their institution between July 2020 and December 2022 to identify patients who underwent LeFort I or mandibular osteotomy. Two cohorts were compared: patients who received liposomal bupivacaine and patients who received standard pain medications alone. Outcome measures included intraoperative pain medications, length of stay, breakthrough opioid use, time to first oral intake, volume of oral intake, and opioids prescribed at discharge.

RESULTS

This study included 22 patients who underwent orthognathic surgery. The liposomal bupivacaine group (n=10) demonstrated earlier and greater oral intake during hospitalization compared with controls (n=12). The most significant difference was observed in total breakthrough opioid use, with an average of 8.60 morphine milligram equivalents for liposomal bupivacaine patients compared with 35.1 morphine milligram equivalents for controls ( P =0.037).

CONCLUSIONS

This study provides the first analysis of liposomal bupivacaine use in adolescent CLP patients undergoing orthognathic surgery, demonstrating a significant reduction in postoperative opioid consumption compared with controls. These results may guide future studies of liposomal bupivacaine within CLP patients, potentially as a component of enhanced recovery after surgery guidelines, as well as in cost-analysis studies.

Postoperative accurate pain assessment of children and artificial intelligence: A medical hypothesis and planned study

Although the pediatric perioperative pain management has been improved in recent years, the valid and reliable pain assessment tool in perioperative period of children remains a challenging task. Pediatric perioperative pain management is intractable not only because children cannot express their emotions accurately and objectively due to their inability to describe physiological characteristics of feeling which are different from those of adults, but also because there is a lack of effective and specific assessment tool for children. In addition, exposure to repeated painful stimuli early in life is known to have short and long-term adverse sequelae. The short-term sequelae can induce a series of neurological, endocrine, cardiovascular system stress related to psychological trauma, while long-term sequelae may alter brain maturation process, which can lead to impair neurodevelopmental, behavioral, and cognitive function. Children's facial expressions largely reflect the degree of pain, which has led to the developing of a number of pain scoring tools that will help improve the quality of pain management in children if they are continually studied in depth. The artificial intelligence (AI) technology represented by machine learning has reached an unprecedented level in image processing of deep facial models through deep convolutional neural networks, which can effectively identify and systematically analyze various subtle features of children's facial expressions. Based on the construction of a large database of images of facial expressions in children with perioperative pain, this study proposes to develop and apply automatic facial pain expression recognition software using AI technology. The study aims to improve the postoperative pain management for pediatric population and the short-term and long-term quality of life for pediatric patients after operational event.

Comparison of ultrasonography-guided lateral versus medial costoclavicular brachial plexus block in pediatric patients : A randomized clinical trial

BACKGROUND AND AIMS

Costoclavicular brachial plexus block is gaining popularity due to its ease of application. Lateral and medial costoclavicular approaches have recently been defined. In the current study, we aimed to investigate the procedural execution of these approaches in the pediatric population.

METHODS

In this study 55 children aged between 2 and 10 years were randomized to receive lateral (LC group) or medial (MC group) costoclavicular brachial plexus block after induction of general anesthesia for postoperative analgesia. All patients received bupivacaine (1 mg/kg, 0.25%) within the center of the cord cluster. The number of needle maneuvers was recorded as primary outcome. Block performing features (ideal ultrasound-guided brachial plexus cords visualization, needle pathway planning time, needle tip and shaft visualization difficulty, requirement of extra needle maneuver due to insufficient local anesthetic distribution, block performance time, total procedure difficulty) and postoperative pain-related data (block intensities, pain scores and analgesic requirements) were all compared as secondary outcomes.

RESULTS

The LC group patients required less ultrasound visualization time (median 14 s, range 11-23 s vs. median 42 s, range 15-67 s, p < 0.001) and fewer needle maneuvers (median 1, range 1-2 vs. median 3, range 2-4, p < 0.001) compared to the MC group. Similarly, the median block performance duration was shorter (median 67 s, range 47-94 s vs. median 140s, 90-204 s, p < 0.01) and procedures were perceived as easier (median 4, range 4-5 vs. median 3, range 2-5, p = 0.04) in the LC group. All other parameters were comparable (p > 0.05).

CONCLUSION

The lateral approach required less needle maneuvers than the medial approach. Both techniques represented a good safety profile with favorable analgesic features.

Maximum Pain at Rest in Pediatric Patients Undergoing Elective Thoracic Surgery and the Predictors of Moderate-to-Severe Pain-Secondary Data Analysis

INTRODUCTION

Pain management among children following thoracic surgery is an area of significant practice variability. Understanding the risk factors of moderate-to-severe pain intensity will allow for adequate pain relief. The aim of the study was to assess the maximum intensity of pain at rest in pediatric patients within 24 h of thoracic surgery and to investigate the prevalence and predictors of moderate-to-severe pain.

METHODS AND FINDINGS

This is a prospective cohort study of patients in observational and randomized controlled trials following thoracic surgery. A secondary analysis of data was conducted using data collected from 446 patients aged 7-18 years undergoing thoracic surgery. The primary endpoint was maximum pain intensity (Numerical Rating Scale; NRS; range: 0-10) and the secondary endpoint was the prevalence and predictors of moderate-to-severe pain (NRS > 2/10). The median maximum pain in the cohort was 3 [0; 4]. During the immediate postoperative period, 54% of patients reported a maximum NRS > 2/10. The infusion of morphine by an intravenous route (vs. epidural route) was a protective factor against moderate-to-severe pain. Taking into account the findings related to the type of epidural analgesia (vs. intravenous morphine), it was found that only the administration of 0.25% bupivacaine combined with morphine or fentanyl was a protective factor against moderate-to-severe postoperative pain. Patients aged 14-18 years (vs. aged 7-13 years) had an increased risk of reporting pain as moderate-to-severe.

CONCLUSIONS

The route of analgesic administration, type of multimodal analgesia, and patients' age predict moderate-to-severe pain in pediatric patients after thoracic surgery.

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.

Neonatal Intensive Care Nurses' Knowledge of Neonatal Pain Assessment in Private and Public Hospitals in Jeddah, Saudi Arabia: A Cross-Sectional Study

BACKGROUND

Neonatal Intensive Care Unit (NICU) nurses with adequate neonatal pain assessment knowledge are crucial in effective neonatal pain management. There is limited research that assessed the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

OBJECTIVE

To assess the knowledge of NICU nurses in Saudi Arabia regarding neonatal pain assessment.

DESIGN AND METHODS

 A cross-sectional design using an online survey was conducted to capture information regarding neonatal pain assessment knowledge from 125 NICU nurses in Saudi Arabia. Knowledge of pain assessment was assessed using a modified version of the knowledge, attitudes, and practice scale. Knowledge scores were classified as high, average, and low.

RESULTS

Participants' knowledge regarding neonatal pain assessment was inadequate (Mean = 63/100). The majority of the participants had a low to average level of knowledge (n= 97, 78%).

CONCLUSION

A significant proportion of NICU nurses had inadequate knowledge regarding neonatal pain assessment, which can be improved. Educational interventions are needed to boost these nurses' knowledge regarding neonatal pain assessment.

Cross-informant agreement between caregivers and teachers for prosocial behavior across child welfare settings

Healthy social functioning has been a growing focus for understanding children's positive development and well-being. Despite the flexibility and cost-effectiveness of behavior rating scales, there has been a rising issue of concern in both practice and research applications regarding rating scales and its low cross-informant agreement. The present study aimed to analyze the extent to which caregivers and teachers agree about children's prosocial behaviors, identify whether there were differences in the degree of agreement across child welfare settings, and ultimately offer recommendations for assessing behavior for children involved with child welfare services. To do so, the reports of 1,224 children, caregivers, and teachers from the National Survey of Child and Adolescent Well-Being (NSCAW) I who have been investigated by Child Protective Services (CPS) for abuse and/or neglect have been examined. Intra-class correlation coefficients (ICCs) of caregiver and teacher assessment of children's prosocial functioning were calculated to understand the degree of agreement in their perceptions of children's prosocial behaviors. ICC values presented show that agreement was low but significant across all samples and subscales (ICC range, .11-.22). It is suggested that future researchers pursue examination of the underlying mechanisms or factors that contribute to informant discrepancies.

Recommendations for Patient-Reported Outcomes Measurement Information System pediatric measures in youth with chronic pain: a COnsensus-based Standards for the selection of health Measurement INstruments systematic review of measurement properties

ABSTRACT

The Patient-Reported Outcome Measurement Information System (PROMIS) pediatric measures assess physical, emotional, and social health among children and adolescents. However, their measurement properties have not been systematically examined in youth with chronic pain. A systematic review applying the COnsensus based Standards for the selection of health Measurement INstruments (COSMIN) methodology was conducted to evaluate self-reported PROMIS pediatric measures in youth with chronic pain, assessing 8 measurement properties across all versions (item bank, short form, and computer adaptive testing) from 63 studies covering 25 measures. Moderate or high-quality evidence was most available for content validity, structural validity, internal consistency (measurement precision), and construct validity. Four short-form PROMIS pediatric measures-mobility, anxiety, depressive symptoms, and physical stress experiences-achieved recommendation for the use in chronic pain clinical trials; 7 approached recommendation and 14, including the commonly used PROMIS Pediatric Pain Interference Scale, would be recommended with further evidence. Recommendations were also provided for the use of each measure in observational studies. Overall, based on the existing evidence, a total of 11 self-reported PROMIS pediatric short-form measures, including pain intensity, pain behavior, mobility, sleep disturbance, sleep-related impairment, anxiety, depressive symptoms, psychological stress experiences, physical stress experiences, family relationships, and positive effect, are recommended or approaching recommendation for use in youth ages 8 to 19 years with chronic pain. Research is needed to further establish test-retest reliability, measurement errors, cross-cultural validity, and responsiveness. Future work should expand the evaluation of PROMIS pediatric measures in subpopulations of youth with chronic pain, particularly young children and those with neurodevelopmental disabilities.