Bayesian estimation on diagnostic performance of Face, Legs, Activity, Cry, and Consolability and Neonatal Infant Pain Scale for infant pain assessment in the absence of a gold standard

Clinical rating scales for assessing pain in newborn infants

BACKGROUND

Six to nine per cent of all newborn infants require admission to a neonatal intensive care unit (NICU) due to either illness or prematurity. During their stay, these infants are often subjected to many painful procedures that can cause negative long-term consequences. To reduce the negative effects of pain exposure and ensure optimal and safe pain treatment, accurate assessment of pain is necessary. To achieve this, clinicians are dependent on the use of reliable, objective, and standardised clinical rating scales of pain, henceforth referred to as 'rating scales'. Numerous rating scales have been published; however, discrepancies in validity limit their overall applicability in clinical practice and research. Such limitations may lead to an over- or underestimation of pain, resulting in unnecessary sedation or inadequately treated pain, potentially jeopardising infant safety through treatment side effects, including withdrawal symptoms or prolonged discomfort. To date, the majority of rating scales have been developed to assess procedural pain, whilst fewer scales for prolonged pain are available. Premature infants further complicate matters, as they often have a reduced ability to display robust pain behaviour due to their immaturity. Research has also shown that the use of rating scales in clinical practice is suboptimal, due to both inadequate and infrequent implementation alongside inappropriate choice of scale for the specific pain, population, or setting under evaluation. Despite numerous studies investigating the burden of pain in newborn infants, little work has been done to summarise the current evidence on the appropriateness of rating scales for specific types of pain or infant conditions. This has likely been limited by the subjectivity of pain assessment and further complication of assessing such a non-verbal and immature patient population. The immense burden of neonatal pain worldwide has also led to the development of numerous rating scales in various languages, further hindering evidence summation.

OBJECTIVES

To systematically review the literature to compile and describe the development, content, and measurement properties of clinical rating scales for the assessment of pain in newborn infants.

SEARCH METHODS

An Information Specialist systematically searched CENTRAL, PubMed, Embase, and CINAHL. The latest update search is current to July 2023.

SELECTION CRITERIA

We included all study designs that involved the development or testing of a rating scale for assessing pain in newborn infants. We included preterm (born before week 37) and term (born at week 37 or beyond) infants undergoing pain assessment for any medical indication. We also included studies that included healthcare professionals.

DATA COLLECTION AND ANALYSIS

We evaluated clinical rating scales assessing pain in newborn infants using the Consensus-based Standards for the selection of health Measurement Instruments (COSMIN) methodology evaluating content validity, structural validity, internal consistency, reliability, measurement error, hypothesis testing, and cross-cultural validation. We used a modified GRADE approach to assess risk of bias, inconsistency, imprecision, and indirectness.

MAIN RESULTS

We included 79 studies involving a total of 7197 infants, 326 nurses, and 12 physicians. Twenty-seven clinical rating scales were used in 26 countries, with 14 studies evaluating preterm infants, 11 on term infants, 46 on both preterm and term infants, four solely on medical staff, and four on preterm and/or term infants plus medical staff. Following the COSMIN checklist, we found all rating scales to be of very low-certainty evidence, raising concerns regarding their validity, reliability, and applicability in this vulnerable population across diverse clinical settings.

AUTHORS' CONCLUSIONS

Clinical staff should be vigilant when applying the currently available neonatal rating scales. Further development of rating scale content and testing for structural validity are necessary and should be prioritised. Together, they determine the content and structure of rating scales, underpin further testing, including reliability, and their prioritisation will make the greatest contribution to the evidence base for rating scales to assess neonatal pain. Collaborative efforts between clinicians and methodology experts will prevent methodological pitfalls and contribute to improving the validity and reliability of pain-rating scales in neonatology.

Contextual factors associated with neonatal pain responses: clinical observational study

Objectives

This study aimed to identify the contextual factors of neonatal pain responses and provide clinical medical staff with evidence regarding effective means of evaluating neonatal pain and strengthen clinical pain management.

Methods

Two trained nurses independently used the Neonatal Infant Pain Scale (NIPS) to assess the pain scores of 198 neonates after they underwent painful medical procedures. Univariate linear regression analysis was performed to analyze the correlation between contextual factors and NIPS scores. Variables with statistically significant differences (p < 0.2) after univariate linear regression analysis were selected as independent variables, and the NIPS score was used as the dependent variable. Multiple linear regression was used to determine the salient factors associated with neonatal pain responses. This study was registered at the Chinese Clinical Trial Registry (ChiCTR2300074086).

Results

Univariate linear regression analysis showed that the NIPS scores were associated with days after birth, types of painful procedures, Apgar scores at 1 min after birth, and gestational age (GA) (p < 0.2). Multiple regression analysis showed that Apgar score at 1 min after birth (β = 0.272, p < 0.001) and GA (β = 0.503, p < 0.001) were independent associated factors of neonatal pain responses. Neonates with low Apgar scores at 1 min after birth and younger GA had less pronounced pain responses.

Conclusions

The Apgar score at 1 min after birth and GA affected the neonatal pain responses. In this regard, the current clinical method of pain assessment solely through observation of neonatal pain responses is occasionally inaccurate. The Apgar score at 1 min after birth and GA should be considered in determining the neonatal pain status and hence enhance the quality of neonatal pain management.

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.

Assessment and Treatment of Pain in Hospitalized Children at a Tertiary Children's Hospital: A Cross-Sectional Mixed Methods Survey

(1) Background: Acute pain in hospitalized children remains under-recognized and under-treated. Our objective is to benchmark pain assessment, documentation, treatment, and patient experience in children admitted to a US children's hospital. (2) Methods: A cross-sectional, mixed-method survey of pain for children hospitalized ≥24 h. Charts were reviewed for modalities of pain assessment and treatment for all inpatients. If pain was documented, patients/caregivers were surveyed regarding their experience with pain and its management. (3) Results: Chart review: All 107 patients had ≥1 pain score documented. A total of 47 patients had a pain score ≥0, 35 (74.5%) of whom had ≥1 moderate-severe score. Seventy (65.4%) patients received ≥1 intervention for pain, including medications from ≥1 class (e.g., opioids) (n = 55, 51.4%) and/or integrative/non-pharmacologic intervention(s) (n = 39, 36.4%). There were assessment and documentation gaps. Patient survey: A total of 39 (83.0%) interviews were attempted; 25 (53.2%) were completed. The worst pain was mostly caused by acute illness (n = 13, 52%) and painful procedures (n = 10, 40%). Suggestions for improvement included increasing the use of integrative modalities and optimizing patient-clinician communication. (4) Conclusions: All patients admitted ≥24 h had ≥1 pain score documented; however, gaps in documentation were common. Multimodal treatment and integrative modalities were underutilized. Procedures were a frequent cause of under-treated pain, prompting an institution-wide quality improvement project.

Postoperative Analgesia With Modified Thoracoabdominal Nerve Block Through Perichondrial Approach in Neonatal and Infantile Abdominal Surgery

Modified thoracoabdominal nerve block through the perichondrial approach (M-TAPA) is a novel strategy for peripheral nerve block in the abdomen. Its usefulness has been highlighted in adults, but no literature is currently available regarding its efficacy in infants. This report describes the cases of a one-day-old neonate in open abdominal surgery and a one-month-old infant in laparoscopic surgery who received M-TAPA. The postoperative condition of the infants was assessed through a neonate pain scale and the Face, Legs, Activity, Cry, and Consolability behavioral scale, respectively; both scales remained at 0 until discharge. Despite the need for special attention, M-TAPA may provide effective analgesia in neonatal and infant abdominal surgery in addition to adult cases, and its indications should be considered.

Neonatal epidermolysis bullosa: a clinical practice guideline

DEBRA International is undertaking a long-term initiative to develop clinical practice guidelines (CPGs) for epidermolysis bullosa (EB), to -improve the clinical care of people living with EB. Current neonatal care is based on evidence, clinical expertise and trial and error, with collaboration between the EB specialist team, parent or carer and patient, and is dependent on the neonate's individual presentation and type of EB. Early intervention based on research and clinical practice is needed to establish a foundation of knowledge to guide international practitioners to create and improve standards of care and to be able to work effectively with those newly diagnosed with EB. This CPG was created by an international panel with expertise working with persons with EB. The CPG focuses on neonatal care using a systematic review methodology covering four key areas: (i) diagnosis and parental psychosocial support; (ii) hospital management: medical monitoring, wound care and pain; (iii) feeding and nutrition; and (iv) discharge planning and EB education. These four areas highlight the importance of a multidisciplinary team approach, to provide a patient-specific holistic care model that incorporates the needs and wishes of the parents and carers. The Hospital Implementation Tool included promotes transfer of theory to clinical practice.

Application of laryngeal mask airway anesthesia with preserved spontaneous breathing in children undergoing video-assisted thoracic surgery

Purpose

To investigate the feasibility and safety of non-intubated general anesthesia with spontaneous breathing combined with paravertebral nerve blocks (PVNB) in young children undergoing video-assisted thoracic surgery (VATS) and to determine its significance for rapid recovery after pediatric thoracic surgery.

Methods

The data of 46 children aged 6-36 months with an American Society of Anesthesiologists status of I-II who underwent elective VATS under general anesthesia were retrospectively analyzed. Of these patients, 25 underwent non-intubated general anesthesia with spontaneous breathing combined with PVNB (non-intubation group), and 21 received conventional intubated general anesthesia combined with local infiltration anesthesia (intubation group). The following perioperative parameters were compared between the two groups: heart rate (HR), mean arterial pressure, saturation of pulse oximetry (SpO₂), partial pressure end-tidal carbon dioxide, time from the completion of the operation to extubation or removing laryngeal masks, time to first feeding after the operation, length of postoperative in-hospital stay, incidence of postoperative complications, and hospitalization expenses.

Results

The operations were completed successfully in both groups. When the non-intubation group was compared with the intubation group, the minimal SpO₂ level during the surgery was higher (93% vs. 88%, P < 0.001), which might indicate better oxygenation. There was no significant difference of the duration of surgery and intraoperative blood loss between two groups. Compared to the intubation group, the duration of anesthesia (P = 0.027), time from the completion of the operation to extubation (P < 0.001), time to the first feeding after surgery (P < 0.001), and length of postoperative in-hospital stay (P < 0.001) were significantly reduced in the non-intubation group. The incidence of postoperative complications was not significantly different.

Conclusions

Non-intubated general anesthesia with spontaneous breathing combined with PVNB is safe and feasible in young children undergoing VATS and can promote rapid recovery in young children undergoing thoracoscopic surgery.

Procedural Pain Management During Tenotomy for Congenital Talipes Equinovarus

The majority of infants with congenital talipes equinovarus (CTEV) require tenotomy of the tendoachilles. The pain response of this procedure in the awake infant has not been previously reported. In this observational study, multimodal pain management strategies, including oral sucrose, oral paracetamol, topical anesthetic, local anesthetic, a pacifier (dummy), and swaddling, were used. Physiological responses and pain were recorded. Pain was rated out of 10 at regular intervals, using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. Ninety-one infants (65 men, mean age = 53 days, range = 19-217 days) were observed. At baseline, median FLACC, heart rate (HR), and oxygen saturation (Spo₂) were 1, 159, and 97% respectively. Peak median FLACC and HR were 9 and 200, respectively, and lowest median Spo₂ was 92%. The median (interquartile range) time for FLACC to return to 3 or less was 2 (2-5) minutes. Achilles tenotomy for CTEV in the awake infant is associated with high pain levels despite provision of multimodal pain relief measures.

Agreement of the Neonatal Pain, Agitation, and Sedation Scale (N-PASS) With NICU Nurses' Assessments

BACKGROUND

Objective assessment tools should standardize and reflect nurses' expert assessments. The Neonatal Pain, Agitation, and Sedation Scale (N-PASS) and the Neonatal Infant Pain Scale (NIPS) are valid measures of pain. The N-PASS also provides a sedation subscale.

PURPOSE

The objective of this study was to determine N-PASS clinical validity and utility by evaluating agreement of N-PASS scores with bedside nurses' assessments of pain/agitation and sedation in a 64-bed tertiary neonatal intensive care unit.

METHODS

Fifteen bedside nurses trained to use the N-PASS and the NIPS prospectively completed 202 pain/agitation and sedation assessments from a convenience sample of 88 infants, including chronically ventilated, medically fragile infants. N-PASS and NIPS scores were obtained simultaneously but independently of nurse investigators. Bedside nurses also made recommendations about infants' pain and sedation management.

RESULTS

There was moderate agreement between N-PASS pain scores and nurses' recommendations (κ= 0.52), very strong agreement between N-PASS sedation scores and nurses' recommendations (κ= 0.99), and very strong associations between N-PASS pain and NIPS scores (P< .001). Bedside nurse and independent investigator interrater reliability was good for N-PASS pain and NIPS scores (intraclass correlation coefficient [ICC] = 0.83, ICC = 0.85) and excellent for N-PASS sedation (ICC = 0.94). During 93% of assessments, bedside nurses reported that the N-PASS reflected the level of infant sedation well or very well.

IMPLICATIONS FOR PRACTICE AND RESEARCH

The N-PASS provides an easy-to-use, valid, and reliable objective measure of pain and sedation that reflects nurses' assessments. Additional studies using the N-PASS are needed to verify results and the influence of the N-PASS on pain and sedation management for medically fragile infants with chronic medical conditions.

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

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

Optimal management after paediatric lumbar puncture: a randomized controlled trial

BACKGROUND

To evaluate whether a shorter time of lying supine without a pillow and fasting for solids and liquids (LSFSL) after a lumbar puncture (LP) is associated with a higher risk of post-lumbar puncture headache (PLPH) and post-lumbar puncture lower back pain (PLPBP) in a randomized, assessor-blinded, controlled trial.

METHODS

Paediatric patients who underwent their first LP after hospital admission were randomly allocated to either the group with half an hour of LSFSL (0.5 h LSFSL) or 4 h of LSFSL (4 h LSFSL) immediately after LP. The primary outcome is PLPH after LP. The incidence of PLPH, PLPBP, and vomiting; vital signs (respiratory rate, heart rate, blood pressure); and other post-procedure conditions after LP were measured as the outcomes. The Non-inferiority test and Wilcoxon rank-sum test were used to analyse the outcome data.

RESULTS

In total, 400 patients (201 in the 0.5-h LSFSL group and 199 in the 4-h LSFSL group) were included in this trial. Twelve (5.97%) of 201 patients experienced PLPH in the 0.5 h LSFSL group versus 13 (6.53%) of 199 patients in the 4 h LSFSL group (difference 0.56, 95% CI -4.18 to 5.31; p = 0·0108 for the non-inferiority test). Fourteen (6.97%) of 201 patients experienced PLPBP in the 0.5 h LSFSL group versus 17 (8.54%) of 199 patients in the 4 h LSFSL group (difference 1.57, 95% CI -3.66 to 6.82; p = 0.007 for the non-inferiority test). The changes in heart rate (HR), respiratory rate (RP) and systolic blood pressure (SBP) before and after the LP were not different between the 0.5-h LSFSL group and the 4-h LSFSL group. No other adverse events were reported.

CONCLUSIONS

Compared with 4 h of LSFSL after LP, 0.5 h of LSFSL was not associated with a higher risk of PLPH, PLPBP or other adverse events. In conclusion, 0.5 h of LSFSL is sufficient for children undergoing LP.

TRIAL REGISTRATION

Clinical trial NCT02590718 . The date of registration was 08/25/2015.

Continuous caudal epidural analgesia and early feeding in delayed bladder exstrophy repair: a nine-year experience

BACKGROUND

Children undergoing primary closure of bladder exstrophy experience blood loss and significant fluid shifts and require protracted periods of postoperative immobilization to avoid compromising the repair. Suboptimal anxiolysis and pain management is associated with increased morbidity. There is a lack of consensus on the optimal analgesic technique and studies have not previously described analgesic management in delayed bladder exstrophy closure. In exstrophy management, opioid infusions and benzodiazepine sedation are commonplace but are associated with dose-dependent respiratory and gastrointestinal side-effects. We present nine years of caudal epidural anaesthesia in delayed bladder exstrophy repair and describe its facilitation of early extubation and early feeding (within 12 h) without surgical complication.

METHODS

We retrospectively evaluated consecutive infants with classic bladder exstrophy undergoing delayed primary closure with anterior pelvic osteotomies between November 2007 and January 2016. Outcomes and complications were evaluated in terms of postoperative comfort (using the FLACC score-Face, Legs, Activity, Cry, Consolability), epidural failure rate, re-intubation rate and gastrointestinal complications.

RESULTS

Forty-four infants had average age of 5.8 months (range 1.6-17.1 months) and weight of 7.0 kg (range 3.5-11.8 kg), and their duration of surgery was 9.5 h (range 6.9-14.3 h). Forty-two of 44 (95.5%) patients received caudal epidural catheters. At 24 h, 15 of 42 (35.7%) caudal epidurals required supplementation with intravenous opioids. Fewer patients with optimally functioning epidurals required postoperative ventilation (1/27 [3.7%] compared with 3/15 [20.0%]). None of the patients with caudal epidural catheters required re-intubation. Pain scores were lower in infants with isolated caudal epidurals catheters than those with caudal epidurals supplemented by intravenous opioids (day 1 [18 vs 53; P = 0.008]; day 2 [8 vs 15; P > 0.05] and overall [32 vs 65; P = 0.014]). Infants with intravenous opioids experienced higher complications: pruritus (25% [95% confidence interval {CI}: 5%-57%] vs 0% [95% CI: 0%-13%]; P = 0.026) and nausea and vomiting (25% [95% CI: 5%-57%] vs 8% [95% CI: 1%-25%]; P = 0.30) requiring treatment. Nineteen of 44 (43.1%) infants were fed early (within 12 h of surgery). Infants who were fed early had lower pain scores than infants feeding late (day 1 [17.5 vs 31; P > 0.05]; day 2 [5.5 vs 15; P = 0.045]; overall [26 vs 55.5; P = 0.015]) without increase in complications (nausea and vomiting [6.3% vs 20.0%; P = 0.06]; ileus [0.0% vs 0.0%]; aspiration [0.0% vs 0.0%] and re-intubation aspiration [0.0% vs 0.0%]).

CONCLUSIONS

Caudal epidural analgesia facilitates postoperative extubation in infants undergoing delayed exstrophy repair. Early feeding (within the first 12 h) in delayed bladder exstrophy repair is likely to improve patient comfort and consolability without increasing the incidence of gastrointestinal complications. Intravenous opioid may be associated with increased postoperative complications that may influence peri-operative outcomes.

Estimation of diagnostic performance of dementia screening tests: Mini-Mental State Examination, Mini-Cog, Clock Drawing test and Ascertain Dementia 8 questionnaire

OBJECTIVE

Dementia is one of the leading causes of dependence in the elderly. This study was conducted to estimate diagnostic performance of dementia screening tests including Mini-Mental State Examination (MMSE), Mini-Cog, Clock Drawing Test (CDT) and Ascertain Dementia 8 questionnaire (AD8) by Bayesian models.

METHOD

A total of 2015 participants aged 65 years or more in eastern China were enrolled. The four screening tests were administered and scored by specifically trained psychiatrists. The prior information of sensitivity and specificity of every screening test was updated via Bayes' theorem to a posterior distribution. Then the results were compared with the estimation based on National Institute of Aging-Alzheimer's Association criteria (NIA-AA).

RESULTS

The diagnostic characteristics of Mini-Cog, including sensitivity, specificity, PPV, NPV, especially the Youden index, performed well, even better than the combinations of several screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

CONCLUSION

The Mini-Cog with excellent screening characteristics, spending less time, could be considered to be used as a screening test to help to screen patients with cognitive impairment or dementia early. And Bayesian method was shown to be a suitable tool for evaluating dementia screening tests.

Assessment of paediatric pain: a critical review

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