Adolescent pediatric pain tool for multidimensional measurement of pain in children and adolescents.

Very few multidimensional tools are available for measurement of pain in children and adolescents. We critically reviewed the scientific literature to examine the psychometrics and utility of the Adolescent Pediatric Pain Tool (APPT), a multidimensional self-report tool that evaluates the intensity, location, and quality (including affective, evaluative, sensory, and temporal) dimensions of pain. The APPT is available in English and Spanish for children and adolescents, and was modeled after the McGill Pain Questionnaire in adults. We found good evidence for construct validity, reliability, and sensitivity of the APPT for the measurement of pediatric pain. The APPT was used to measure pain in children with different conditions, such as cancer, sickle cell disease, orthopedic, traumatic injuries, and allergy testing. Although the APPT was designed to assess the multiple dimensions of pain, the majority of the reports included results only for the intensity ratings. Unlike the numerical and pediatric faces rating scales, which are widely used in clinical practice and research, the APPT is not limited to the single dimension of pain intensity. It measures multiple dimensions, and may be able to discriminate between nociceptive and neuropathic pain. The APPT is one of a few multidimensional pain measures that can help to advance the science of pediatric pain and its management. When the APPT is used in practice or research, the multiple dimensions of pain may be characterized and compared in different painful conditions. It may guide the use of multimodal interventions in children and adolescents with a variety of pain conditions.

A descriptive feasibility study to evaluate scheduled oral analgesic dosing at home for the management of postoperative pain in preschool children following tonsillectomy.

OBJECTIVES: The purpose of this study, in a sample of preschool children (ages 3-5 years; N = 47), was to evaluate the feasibility of scheduled analgesic dosing following outpatient tonsillectomy in order to optimize pain management. METHODS: Parents were instructed to give their child acetaminophen with hydrocodone (167 mg/5 mL) every 4 hours around the clock for the first 3 days following surgery. Parents recorded ratings of their child's pain with/without swallowing using the Faces, Legs, Activity, Cry, and Consolability (FLACC) behavioral pain scale, pain relief ratings, and severity of analgesic side effects in a home diary. Audiotaped interviews were conducted with parents to document descriptions of their experiences in managing their child's pain at home. RESULTS: Mean FLACC scores with/without swallowing were less than two at each measurement time and pain relief scores increased over time. Total analgesic dose decreased, and the number of missed doses increased over the first 3 days after surgery. Moderate-to-severe daytime sedation, nausea, vomiting, and constipation were reported by parents. DISCUSSION: Study results suggest that acetaminophen with hydrocodone is effective in relieving preschool children's pain following tonsillectomy and that parental adherence to a scheduled analgesic regimen decreases over time. Time-contingent dosing was associated with moderate to severe side effects and should be addressed in discharge teaching with parents. Findings provide insight into parents' perspective of pain management at home following tonsillectomy and methods for relieving their child's pain.

Children's pre-operative tonsillectomy pain education: clinical outcomes.

OBJECTIVE: To examine the effects of pre-operative tonsillectomy pain education on children's (7-13 years) self-reported pre-operative anxiety and post-operative clinical outcomes (i.e., anxiety, pain intensity, quality of pain and sleep, oral intake, perceptions of pre-operative education, and pain expectation). METHOD: A prospective, repeated measures, quasi-experimental design using an age appropriate pain education booklet (n = 30) and a standard care comparison group (n = 30) was employed to investigate children's pre- and post-education anxiety and post-operative tonsillectomy with or without adenoidectomy subjective experiences in the hospital and home settings. Group comparisons were performed using the Wilcoxon test, Fisher's exact test, repeated measures analysis of variance, and mixed model regression. RESULTS: There were no significant differences between groups for measures of anxiety, pain intensity, quality of pain and sleep, oral intake, or expected pain. There was no change in anxiety before or after pre-operative education (P = 0.85). Ninety-six percent (n = 25) of the children in the intervention group reported that pre-operative pain education helped with their post-operative pain and 72% (n = 16) in the control group stated that it would be helpful to learn about pain before surgery. The majority of children in both the intervention and control groups (96%, 91%, respectively) stated learning about the 0-10 numeric pain intensity scale helped or would be helpful to learn pre-operatively. CONCLUSION: Pre-operative pain education did not affect anxiety. Children valued pre-operative pain education. Pre-operative pain education may influence children's perceptions of medical care.

Quantification of analgesic use in children with sickle cell disease.

OBJECTIVES: The purposes of this study were: (1) to quantify analgesic use in children with sickle cell disease who were hospitalized for a vaso-occlusive episode, using the Medication Quantification Scale (MQS) and (2) to examine the relationships between pain intensity scores, number of painful areas marked on a body outline diagram, number of word descriptors of pain quality, and amount of analgesic medications administered. METHODS: Children (5 to 19 y) were asked daily to provide pain intensity ratings and describe the location and quality of their pain. The nursing flowsheets were also reviewed to determine the dose, routes, and the number of times analgesic medications were administered in the previous 24 hours. RESULTS: Mean worst pain intensity score on the day of admission was 84.0+/-9.9 (range 63.8 to 100) on the 0 to 100 Oucher numeric rating scale. The mean MQS score administered on the day of admission was 15.7+/-4.9 (range 6 to 24). This score decreased significantly by 1.2+/-0.5 (P<0.0001; range 0.9 to 2.5) each day of hospitalization. Significant correlations were found between various pain characteristics and total MQS scores prescribed at time of admission. DISCUSSION: The MQS was a useful and sensitive measure to quantify analgesic use in patients with sickle cell disease who were hospitalized for an acute painful episode. The MQS score accounted for variations in the types of analgesic medications, routes of administration, dosing schedules, and opioid dosing requirements.

Initial validation of a numeric zero to ten scale to measure children's state anxiety.

BACKGROUND: Although children experience physical and behavioral consequences from anxiety in many health care settings, anxiety assessment and subsequent management is not often performed because of the lack of clinically useful subjective scales. Current state anxiety scales are either observational or multidimensional self-report measures requiring significant clinician and patient time. Because anxiety is subjective, in this pilot study, we evaluated the validity of a self-report numeric 0-10 anxiety scale that is easy to administer to children in the clinical setting. METHODS: A descriptive correlation research design was used to determine the concurrent validity for a numeric 0-10 anxiety scale with the state portion of the State-Trait Anxiety Inventory for Children (STAIC). During clinic preoperative visits, 60 children, 7-13 yr, provided anxiety scores for the 0-10 scale and the STAIC pre- and posteducation. Simple linear regression and Pearson correlation were performed to determine the strength of the relationship. RESULTS: STAIC was associated with the anxiety scale both preeducation (beta = 1.20, SE[beta] = 0.34, F[1,58] = 12.74, P = 0.0007) and posteducation (beta = 1.97, SE[beta]) = 0.31, F[1,58] = 40.11, P < 0.0001). Correlations were moderate for pre-education (r = 0.424) and posteducation (r = 0.639). CONCLUSIONS: This initial study supports the validity of the numeric 0-10 anxiety self-report scale to assess state anxiety in children as young as 7 yr.

Adolescents' pain experiences following acute blunt traumatic injury: struggle for internal control.

ISSUES AND PURPOSE: Although blunt trauma injury is a common cause for adolescent pain, little is known about the experience of pain as perceived by adolescents. DESIGN AND METHOD: Semistructured interviews were conducted with 13 adolescents following blunt trauma injury. Two age-appropriate valid measures (i.e., Adolescent Pediatric Pain Tool and Temporal Dot Matrix) were incorporated into the interviews to elaborate their pain experiences. Grounded theory method was used to analyze data and build substantive theory. RESULTS: Adolescents' behavioral and cognitive actions (i.e., "internal control") to manage and endure pain were influenced by their pain perceptions, physical losses, and clinicians' actions. PRACTICE IMPLICATIONS: Nurses, family members, and peers have a crucial role in alleviating adolescents' distress and pain.

Children's expectations of pain, perceptions of analgesic efficacy, and experiences with nonpharmacologic pain management strategies at home following tonsillectomy.

PURPOSE: To document children's (ages 6-15 years) descriptions of their pain management at home following tonsillectomy. DESIGN AND METHODS: Audio-taped interviews of 80 children were transcribed and coded. Data for each response category were tabulated. RESULTS: Children reported they had more pain after surgery than expected, the pain medicine helped to take their pain away, taking the pain medicine was associated with a negative response by some children, and cold liquids/food by mouth provided pain relief. PRACTICE IMPLICATIONS: Findings provide insight into children's perspective of pain management at home following tonsillectomy and methods for relieving their pain.

Are there phases to the vaso-occlusive painful episode in sickle cell disease?

The purpose of this study was to describe the pain experience of children with sickle cell disease who were hospitalized for vaso-occlusive painful episodes. The pain experience, and signs and symptoms prior to admission and during hospitalization, are presented in the context of whether there is evidence to support the existence of phases to a vaso-occlusive painful episode. Children were interviewed about the onset of the painful episode and were asked to describe their pain from the day of admission to the day of discharge from the hospital. They were also observed for the absence or presence of signs and symptoms associated with the painful vaso-occlusive episode. Findings from this study provide some evidence to support previous observations related to changes during the evolution of painful episodes that may be occurring in phases (e.g., evolving, inflammatory, resolving), as previously described in adults and children. These phases had different names, although the concepts were similar.

Multidimensional assessment using the adolescent pediatric pain tool: a case report.

PURPOSE: Children's and adolescents' pain experiences are complex and multidimensional. Therefore, assessing a single dimension of pain intensity is in many instances inadequate. The purpose of this case report is to illustrate the benefits of using a multidimensional pain tool to assess vaso-occlusive pain in children and adolescents with sickle cell disease. CONCLUSIONS: The adolescent pediatric pain tool (APPT) provides a valid multidimensional pain assessment that facilitates individual pain assessments that optimize children's and adolescents' pain relief interventions and outcomes. PRACTICE IMPLICATIONS: The APPT is particularly valuable when clinicians encounter children and adolescents experiencing complex, difficult to manage pain.

How do children describe pain? A tentative assessment.

In a study to determine how children describe the experience of pain, we queried a convenience sample of 100 children in hospitals and 114 children in church and private schools who were between 9 and 12 years old. The questions were designed to seek correlations by age among boys and girls, and between hospitalized and non-hospitalized children that would aid health professionals in strategies that will identify and assist the child who is in pain. The preliminary results show that children clearly describe pain, that there are no appreciable differences by age groups, but that children who are hospitalized describe pain differently from children who are not.

Changes in intensity, location, and quality of vaso-occlusive pain in children with sickle cell disease.

A descriptive, longitudinal design was used to examine changes in current, worst, and least pain intensity during hospitalization for a vaso-occlusive episode in children with sickle cell disease. Other dimensions of the pain experience including location and quality were also evaluated. Children reported severe pain on the day of admission with 50% of the episodes showing a current pain intensity score of >70 and a worst pain intensity score of >80. Although both pain intensity scores demonstrated statistically significant decreases by approximately 5% over the course of the hospitalization, these decreases were not clinically significant based on the recommendations made in the American Pain Society's Guideline for the management of acute and chronic pain in sickle cell disease. In contrast to the pain intensity ratings, which did not decrease in 25% of the episodes, pain location surface area decreased in 100% of the episodes. Children described the quality of vaso-occlusive pain using all categories of word descriptors from the adolescent pediatric pain tool. These findings suggest that pain associated with a vaso-occlusive episode is inadequately assessed and managed during hospitalization.

Analgesic efficacy and safety of single-dose intramuscular ketorolac for postoperative pain management in children following tonsillectomy.

The efficacy of ketorolac, a non-steroidal anti-inflammatory drug, in the management of moderate to severe pain in adults, has led us to conduct a trial of this analgesic in children following tonsillectomy. Children were randomized to receive intramuscular (i.m.) ketorolac (1 mg/kg, EXP group, n = 45) or saline (CTL group, n = 42) at the completion of surgery. Intravenous (i.v.) fentanyl (0.5 micrograms/kg/dose) was administered in repeated doses postoperatively. Pain intensity was measured using both the Oucher and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS) to allow for comparison between self-report and behavioral measures of pain intensity. Severity of postoperative bleeding was measured using a 4-point rating scale. The EXP group had a significant reduction in total fentanyl dose (mean: 35.9 micrograms) compared to the CTL group (mean: 48.3 micrograms, t = -2.21, P < 0.03). There was a statistically significant decrease in pre-fentanyl CHEOPS scores in the Post-Anesthesia Care Unit (PACU) in the ketorolac group (F (2, 30) = 5.34, P < 0.01), but not in the saline group (F (2.24) = 2.46, P > 0.05). In the first hour postoperatively, the CHEOPS demonstrated significant decreases in pain intensity scores in response to opioids, in both groups. In the PACU, children were unable to provide a self-report of pain intensity potentially due to a variety of factors (e.g., emergence delirium, agitation, excitement, sedation, and/or pain). However, during the remainder of the postoperative stay, the photographic scale of the Oucher was a more valid measure of pain intensity than the CHEOPS.(ABSTRACT TRUNCATED AT 250 WORDS)

Measuring pain quality: validity and reliability of children's and adolescents' pain language.

Although considerable research has been conducted to identify children's and adolescents' language of pain, research is lacking regarding a method to quantify the pain quality described by this language. Three descriptive studies involving 1223 children, aged 8-17 years, were conducted in school and hospital settings. The aims were to develop and examine the validity and reliability of a word list for measuring pain quality that was free of age, gender, and ethnic biases. A word list with 43 words was developed and resulted in sensory, affective, evaluative, and total scores that correlated with pain location and pain intensity scores (r = 0.19-0.44; P less than or equal to 0.01). Pain quality scores decreased over time in a postoperative pain model. Test-retest reliability of the word list scores was high (r = 0.78-0.95; P less than 0.001). This word list was revised and resulted in a word list with 56 words relatively free of gender, ethnic, and developmental biases. Additional research is needed to assess the psychometric properties of this word list in pediatric populations experiencing different pain syndromes.

A randomized clinical trial of the effectiveness of a scheduled oral analgesic dosing regimen for the management of postoperative pain in children following tonsillectomy.

The purpose of this study was to determine whether around-the-clock (i.e. ATC) dosing of acetaminophen with codeine, with or without nurse coaching, compared to standard care with as needed (i.e. PRN) dosing: reduced children's reports of pain intensity with and without swallowing; increased pain relief, and increased analgesic consumption. Eighty children, 6-15 years, undergoing tonsillectomy were randomized to one of three treatment groups to receive acetaminophen with codeine (120 mg/12 mg/5 ml) for 3 days after surgery: PRN group (N = 28)-every 4 h PRN, with standard postoperative instructions, without nurse coaching; ATC group (N = 26)-every 4 h ATC, with standard postoperative instructions, without nurse coaching; and ATC+coaching group (N = 26)-every 4 h ATC, with standard postoperative instructions and nurse coaching. In all three groups, significant decreases were found over time in pain intensity scores at rest (P < 0.001) and with swallowing (P < 0.001). However, mean pain scores at rest and with swallowing were >3/10 until the fourth evening after tonsillectomy. Children in both ATC dosing groups received significantly greater amounts of acetaminophen and codeine than children in the PRN group (P < 0.003). No significant differences were found in the amount of analgesic administered between the ATC dosing groups with and without nurse coaching. No significant differences were found in the amount of nausea and vomiting among the three groups. Scheduled dosing of acetaminophen with codeine did not provide adequate pain relief for children following tonsillectomy. Nurse coaching does not increase parent's adherence with an ATC dosing schedule.

Pain experience in children with advanced cancer.

BACKGROUND: It is important for health care professionals to understand the pain experience in children with advanced cancer. There has been increased attention to this topic, but systematic studies are limited. OBJECTIVE: To examine pain symptoms and management in children with advanced cancer using child self-report and nurse documentation. METHODS: A prospective, longitudinal method was used to collect data from 62 children over a 5-month period. Children were English and Spanish speaking, ages 6 to 17 years, with advanced cancer. Nurses also provided data. RESULTS: Across all interviews, pain was reported 56% of the time by all children. Nurses documented pain only 23% of the time. Children most frequently reported head pain (31%), followed by abdomen, lower back, leg, and feet pain (20% to 30%). Children consistently reported more intense pain compared with nurses. Nonopioids were used more frequently (45%) than opioids (32%), and nurses' perception of pain intensity was more highly correlated with administration of opioids (r = .72, P < .001). Children who died during their participation in this study received more opioids over time. Pain intensity was relatively stable over time. Nurses noted ethnicity related differences with higher pain levels for Caucasian children, who received analgesics more frequently. DISCUSSION: The children consistently reported pain. Child self-report and nurse documentation of pain differed, as did pain management among children who died compared with those who did not. Ethnicity differences in the identification and management of pain by nurses begs further study. Overall, nurses were aware of and responsive to pain and pain management.

Symptoms in children with advanced cancer: child and nurse reports.

BACKGROUND: Systematic studies on the specific symptom experience in children with advanced cancer are limited. OBJECTIVE: The objective of the study was to examine the common symptoms and to explore commonly occurring symptoms over time. METHODS: A prospective and longitudinal study design was used. Data were collected at 10 data points from 60 children over a 5-month period. Children ranged from 6 to 17 years old, spoke English or Spanish, were diagnosed with advanced cancer, and were receiving healthcare in 1 of 4 Southern California hospitals. Nurses' documentations of symptoms were examined. RESULTS: The study sample was composed of children 6 to 12 years old (52%) and 13 to 17 years old (48%); 42% were female, and 58% were male. Fifty-five percent were Latino, and 30% were Caucasian. Pain, nausea, drowsiness, and energy loss were reported by children in more than 50% of the interviews. Children's and nurses' reports of symptoms were similar except children reported significantly more frequency and intensity of pain. CONCLUSION: Children with advanced cancer were able to report and describe their symptoms. There were few differences by gender, age, and ethnicity. IMPLICATIONS FOR PRACTICE: It is important that children's symptoms are clearly communicated to nurses, and these study findings may be used to anticipate and manage the symptoms experienced by children with advanced cancer.

The pediatric PRO-SELF©: pain control program: an effective educational program for parents caring for children at home following tonsillectomy.

PURPOSE: The purpose of this paper was to provide a description of the components of the PEDIATRIC PRO-SELF©: Pain Control Program. DESIGN AND METHODS: The Program, adapted from studies of this intervention in adults with cancer pain, was tested in two randomized clinical trials of acute pain management in pediatrics. RESULTS: Key strategies most effective for parents in the pediatric ambulatory surgery setting included use of an educational booklet and timer to facilitate adherence to the prescribed analgesic regimen, as well as interactive nursing support. PRACTICE IMPLICATIONS: The PEDIATRIC PRO-SELF©: Pain Control Program can be used with parents caring for children at home following tonsillectomy.

Children with advanced cancer: responses to a spiritual quality of life interview.

PURPOSE: The purpose of this study was to describe the responses of children with advanced cancer to a spiritual quality of life (SQL) interview. DESIGN AND METHODS: Sixty children, ages 6-17, responded to an SQL interview every 2 weeks, for 5 months. The questionnaires were analyzed using content analysis. RESULTS: Children's responses were primarily relational in nature, particularly to their parents. Seventy-eight percent of the interviewees reported they did something to "feel close to God." Children prayed for a "sense of normalcy" (59%) and relational concerns (31%). PRACTICE IMPLICATIONS: Children's care will be enhanced when given the opportunity to express their spiritual and relational concerns.

A randomized clinical trial of the efficacy of scheduled dosing of acetaminophen and hydrocodone for the management of postoperative pain in children after tonsillectomy.

OBJECTIVES: To determine the effectiveness of around-the-clock (ATC) analgesic administration, with or without nurse coaching, compared with standard care with as needed (PRN) dosing in children undergoing outpatient tonsillectomy. METHODS: Children 6 to 15 years of age were randomized to receive acetaminophen and hydrocodone (167 mg/2.5 mg/5 mL) for 3 days after surgery: Group A (N=39)-every 4 hours PRN, with standard postoperative instructions; Group B (N=34)-every 4 hours ATC, with standard postoperative instructions, without nurse coaching; and Group C (N=40)-every 4 hours ATC, with standard postoperative instructions, with coaching. Parents completed a medication log, and recorded the presence and severity of opioid-related adverse effects and children's reports of pain intensity using a 0 to 10 numeric rating scale. RESULTS: No differences were found in analgesic administration or pain intensity scores between the 2 ATC groups. Therefore, they were combined for comparison with the PRN group. Children in the ATC group received more analgesic than those in the PRN group (P<0.0001). Children in the PRN group had higher pain intensity scores compared to children in the ATC group, both at rest (P=0.017) and with swallowing (P=0.017). Pain intensity scores for both groups were higher in the morning compared with the evening (P<0.0001). With the exception of constipation, scheduled analgesic dosing did not increase the frequency or severity of opioid-related adverse effects. DISCUSSION: Scheduled dosing of acetaminophen and hydrocodone is more effective than PRN dosing in reducing pain intensity in children after tonsillectomy. Nurse coaching does not impact parent's adherence to ATC dosing.