Evaluation of the quality of acute pain management in a pediatric surgical setting: Validation of a parent proxy modified version of the revised American Pain Society Patient Outcome Questionnaire

Paediatric Pain Management Experiences of Parents of Children in Botswana Referral Hospitals

AIM

To describe the experience and understanding of paediatric acute pain management practices by parents/guardians' of hospitalised children in Botswana.

DESIGN

Descriptive qualitative study.

METHODS

Face-to-face semistructured interviews were conducted in two public hospitals. Data were transcribed verbatim and analysed using thematic analysis.

RESULTS

A convenience sample of 19 parents/guardians, two fathers, one grandmother and 16 mothers who were recruited in 2019. Six major themes were identified with several subthemes. The themes were as follows: 'soldiering on with hope'-representing the parents/guardians overall general positive outlook; 'facing adversity'-highlighting parents/guardians responses to acute pain management; 'acceptance to nonacceptance of the reality of care'-parents/guardians view on the quality of pain care they received measured against their expectations; 'smiles to unending nightmares'-parents/guardians visualisation of the pain treatment outcomes; 'perceptions of child pain'-parents/guardians' knowledge of pain assessment and treatment strategies that they used or were being used by healthcare providers to their children and 'guarded empathy'-highlighting the intricacies of each child's response to pain. Parents/guardians in Botswana have both positive and negative experiences regarding child pain management in referral hospitals and recognise the need to adequately manage paediatric pain.

PATIENT OR PUBLIC CONTRIBUTION

The results show that parents/guardians in LMIC equally understand the children's pain management and should be involved in decision-making regarding pain management as equal partners. It further highlights the challenges faced by parents due to poorly and inadequately treated acute paediatric pain in hospital units and pushes for hospital policies that ensure that pain is adequately managed for all children.

Efficacy of a Multimodal Surgical Site Injection for Postoperative Pain Control in Pediatric Patients With Cerebral Palsy Undergoing Hip Reconstruction: A Randomized Controlled Trial

BACKGROUND

One in 4 children with cerebral palsy (CP) will undergo orthopaedic surgery during their childhood. Despite its ubiquity, postoperative pain control has been poorly studied in this patient population. Moreover, poor pain management has been associated with adverse surgical outcomes. Multimodal analgesic injections have been well studied in the adult population, demonstrating safety and efficacy in reducing postoperative pain and narcotic consumption, but this modality has not been studied in pediatric patients undergoing similarly complex procedures. The objective of this study was to evaluate the efficacy of a multimodal surgical site injection for postoperative pain control following operative management of hip dysplasia in patients with CP.

METHODS

After obtaining IRB approval, a multicenter, randomized double-blind placebo control trial was completed. Patients below 18 years old with a diagnosis of CP who were scheduled for varus derotation osteotomy (VDRO) of the proximal femur were randomized to receive a surgical-site injection with either a combination of ropivacaine (3 mg/kg), epinephrine (0.5 mg), and ketorolac (0.5 mg/kg) (experimental group) or normal saline (control). All included patients had identical postoperative care, including immobilization, physical therapy, and standardized, multimodal postoperative pain control. Pain scores and narcotic consumption were recorded at regular intervals and compared between groups utilizing two-tailed t test or a nonparametric Mann-Whitney test for quantitative variables and a Fischer exact test for categorical variables.

RESULTS

Thirty-four patients were included, evenly divided between study arms. There were no significant differences in demographic variables, gross motor function classification system (GMFCS), comorbidities, preoperative radiographic parameters, or concomitant surgeries between groups. Patients in the experimental group required significantly lower narcotic medications at all postoperative time points from PACU until hospital discharge compared with controls (0.41 ± 0.42 vs. 1.87 ± 2.05 total morphine mEQ/kg, P =0.01). Similarly, patients in the experimental group were found to have significantly lower pain scores throughout their hospital stays compared with controls (1.0 ± 0.6 vs. 2.4 ± 1.1 mean pain score, P <0.001). There were no significant differences in operative time, OR time, blood transfusion requirements or hospital length of stay between groups. There were no adverse medication reactions or injection site complications in either group.

CONCLUSIONS

In patients with CP undergoing hip reconstruction, surgical-site injection with a multimodal analgesic combination improves pain control and reduces narcotic consumption in the early postoperative period with no observed adverse effects.

SIGNIFICANCE

Local multimodal analgesic injections should be adopted as part of standard multimodal pain control in this patient population for all osseous surgeries.

LEVEL OF EVIDENCE

Level I-therapeutic.

The perceptions and practices of parents and children on acute pain management among hospitalized children in two Botswana referral hospitals

BACKGROUND

Perceptions and practices of parties in pediatric pain are critical in children's access to adequate acute pain management. The personal factors of the child and parents have been shown to be central to pediatric pain management by the Symptom Management Theory.

AIM

To describe children and parents/guardians' perceptions (knowledge, attitudes and beliefs) and practices regarding pediatric acute pain management and explain the influence of socio-cultural and environmental factors on those perceptions and practices.

METHODS

Descriptive cross-sectional survey using modified versions of the American Pain Society Patient Outcome Questionnaire-Revised among parents/guardians and children.

RESULTS

A convenience sample of 275 parents/guardians and 42 children aged 8 to 13 years admitted between date November 2018 and February 2019 to two Botswana tertiary hospitals completed the surveys. Forty-seven percent (n = 129) of parents/guardians reported the child to be in moderate-severe pain, while 38% (n = 16) of children reported pain as moderate-severe at the time of the survey. The children mean scores for cm-APS-POQ-R were 113(33) while parents/guardian's guardians for m-APS-POQ-R were 123(26). The subscales except for the parents/'guardians' pain interference (p = .96) were statistically significant (p = .000), showing adequate knowledge, positive attitudes and high pain intensity for both parents/guardians and children.

CONCLUSION

Parent/guardians and children reported a high incidence of acute pain, were content with pain management services, and showed adequate knowledge of pediatric pain and its management. The incongruence between the intensity of pain, satisfaction on the adequacy of pain management and knowledge and attitudes demonstrated in this study need further inquiry.

Pediatric Postoperative Pain Management in Korea: Parental Attitudes Toward Pain and Analgesics, Self-Efficacy, and Pain Management

PURPOSES

This study aimed to explore parental attitudes toward children's pain and analgesic drugs and parental self-efficacy and use of pain relief strategies in children's postoperative pain management in Korea, and to identify the relationships among these variables.

DESIGN AND METHODS

A cross sectional descriptive study was conducted. Participants were 124 parents of hospitalized children (aged 4-9 years) undergoing tonsillectomy in Korea.

RESULTS

A considerable proportion of parents held misconceptions about how children express pain. For example, 87.9% of parents perceived that children always tell their parents when they are in pain. Moreover, parents reported significant attitudinal barriers to analgesic use with 60.5% of parents believed that side effects are something to worry about when giving children pain medication. Parental attitudes to use analgesics were significantly different by children's gender, family income, and length of hospital stay. Emotional support methods such as touch, parental presence, and comfort/reassurance were the frequently used, whereas cognitive-behavioral approaches such as distraction were less frequently used nonpharmacological pain relief strategies. A parent's self-efficacy in managing children's pain significantly correlated with the appropriate use of analgesics and parental use of pain relief strategies.

CONCLUSIONS

Promoting parental self-efficacy in postoperative pain management is important. Educational interventions focused on behavioral changes of parents, including practical guidance for pharmacological and nonpharmacological pain relief strategies, are needed.

PRACTICE IMPLICATIONS

Providing parents with proper, effective education about children's postoperative pain management should not only provide accurate information but should also enhance parents' self-efficacy in assessing and managing children's pain.

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

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