Pediatric pain after ambulatory surgery: where's the medication?

OBJECTIVE: The purpose of this controlled study was to provide a description of children's postoperative pain, including pain intensity and analgesic consumption. METHODS: Participants included 261 children, 2 to 12 years of age, undergoing routine tonsillectomy and adenoidectomy surgery. Baseline and demographic data were collected before surgery, and a standardized approach to anesthesia and surgical procedures was used. Pain and analgesic consumption were recorded for 2 weeks at home. RESULTS: On the first day at home, although parents rated 86% of children as experiencing significant overall pain, 24% of children received 0 or just 1 medication dose throughout the entire day. On day 3 after surgery, although 67% of children were rated by parents as experiencing significant overall pain, 41% received 0 or 1 medication dose throughout the entire day. CONCLUSIONS: We conclude that a large proportion of children receive little analgesic medication after surgery and research efforts should be directed to the discrepancy between high ratings of postoperative pain provided by parents and the low dosing of analgesics they use for their children.

Preoperative melatonin and its effects on induction and emergence in children undergoing anesthesia and surgery.

BACKGROUND: Studies conducted in adults undergoing surgery reported a beneficial effect of oral melatonin administered before surgery. There is a paucity of such data in children undergoing anesthesia and surgery. METHODS: Children undergoing surgery were randomly assigned to receive preoperatively oral midazolam 0.5 mg/kg or oral melatonin 0.05 mg/kg, 0.2 mg/kg, or 0.4 mg/kg. The primary outcome of the study was preoperative anxiety (Yale Preoperative Anxiety Scale). The secondary outcomes were the children's compliance with induction (Induction Compliance Checklist), emergence behavior (Keegan scale), and parental anxiety (State-Trait Anxiety Inventory). RESULTS: Repeated measures ANOVA showed that children who received melatonin at any of the three doses were more anxious compared with children who received midazolam (P < 0.001). Parental anxiety did not differ on the basis of the experimental condition (P = ns). The melatonin groups showed a dose-response effect on emergence behavior. Children who received melatonin developed less emergence delirium compared with those who received midazolam (P < 0.05), and the effect was dose related; the incidence after 0.05 mg/kg melatonin was 25.0%, incidence after 0.2 mg/kg melatonin was 8.3%, and incidence after 0.4 mg/kg melatonin was 5.4%. CONCLUSIONS: Midazolam is more effective than melatonin in reducing children's anxiety at induction of anesthesia. Melatonin showed a direct dose-dependent effect on emergence delirium.

A randomized controlled trial of vapocoolant for pediatric immunization distress relief.

OBJECTIVES: The purpose of this study was to evaluate the effectiveness of vapocoolant for preschoolers' immunization injection pain relief. METHODS: Fifty-seven 4 to 6-year-old children were randomized into vapocoolant alone or typical care conditions. Pain was measured at the baseline and at injection via self-report, caregiver report, nurse report, and by an observational scale. RESULTS: Self-report of pain suggested that children in the vapocoolant alone condition demonstrated stronger increases in pain from baseline to injection than children in the typical care condition. All other measures showed significant increases in pain from baseline to injection, but no other measures indicated treatment effects. DISCUSSION: This study revealed that vapocoolant is not an effective pain management intervention for children's intramuscular injections.

Prediction of preoperative anxiety in children: who is most accurate?

BACKGROUND: In this investigation, we sought to assess the ability of pediatric attending anesthesiologists, resident anesthesiologists, and mothers to predict anxiety during induction of anesthesia in 2 to 16-yr-old children (n = 125). METHODS: Anesthesiologists and mothers provided predictions using a visual analog scale and children's anxiety was assessed using a valid behavior observation tool the Modified Yale Preoperative Anxiety Scale. All mothers were present during anesthetic induction and no child received sedative premedication. Correlational analyses were conducted. RESULTS: A total of 125 children aged 2-16 yr, their mothers, and their attending pediatric anesthesiologists and resident anesthesiologists were studied. Correlational analyses revealed significant associations between attending predictions and child anxiety at induction (r(s) = 0.38, P < 0.001). Resident anesthesiologist and mother predictions were not significantly related to children's anxiety during induction (r(s) = 0.01 and 0.001, respectively). In terms of accuracy of prediction, 47.2% of predictions made by attending anesthesiologists were within one standard deviation of the observed anxiety exhibited by the child, and 70.4% of predictions were within two standard deviations. CONCLUSIONS: We conclude that attending anesthesiologists who practice in pediatric settings are better than mothers in predicting the anxiety of children during induction of anesthesia. Although this finding has significant clinical implications, it is unclear if it can be extended to attending anesthesiologists whose practice is not mostly pediatric anesthesia.

Healthcare provider-child-parent communication in the preoperative surgical setting.

OBJECTIVES: Although preoperative preparation programs were once common, most children currently undergoing outpatient surgery are first exposed to the hospital on the day of the procedure. It is advocated that these outpatient children undergo the preparation just prior to surgery. AIM: To assess the amount of time that healthcare providers spend with children and families on the day of surgery in the preoperative area. MATERIALS AND METHODS: The study used video infrastructure in the preoperative holding area of Yale New Haven Children's Hospital to record all interactions between children, families, and healthcare providers. Videotapes were coded to characterize and quantify behaviors of healthcare professionals. RESULTS: On the day of surgery, healthcare providers spent medians of 2.75-4.81 min interacting with children and parents in the preoperative area. Families spent a median of 46.5 min in the preoperative area. Healthcare professionals spent the most time in medical talk (averages of 42.5-48.2% of time spent with family) and little time was spent in nonmedical talk (range of 6.2-6.9% of time spent with family). Anesthesiologists and surgeons spent 28% and 18% of the interview in talk to children; admitting nurses spent more of the interview talking to children (43%). CONCLUSIONS: Families interact with healthcare providers for only a small proportion of the time they spent in the preoperative area. This is likely to be a result of increased production pressure in the perioperative settings and has implications for providing preparation for surgery on the morning of the procedure.

Brief report: prediction of children's preoperative anxiety by mothers and fathers.

OBJECTIVE: To assess the ability of mothers and fathers at predicting children's anxiety at anesthesia induction. METHODS: Participants were parents and their children aged 2-12 years (n = 159). Parents predicted child anxiety using a Visual Analog Scale. Observed child anxiety was assessed using the Yale Preoperative Anxiety Scale. RESULTS: Results of linear regressions indicated that fathers' predictions were significantly related to children's anxiety, whereas mothers' predictions were not. Baseline anxiety in mothers and fathers did not contribute to a model predicting children's observed anxiety. Child gender did not moderate the relations between fathers' predictions and children's observed anxiety. CONCLUSIONS: Fathers' predictions of children's anxiety were related to children's observed anxiety at anesthesia induction; mothers' predictions were not. Thus, fathers may be able to more accurately identify a need for intervention. Further research is needed to better explain discrepancies between mothers and fathers.

Training nursing students in evidence-based techniques for cognitive-behavioral pediatric pain management.

This study evaluates the effects of a didactic training program for nursing students involving developmentally appropriate strategies for cognitive-behavioral pain management in children. Junior-level nursing students were assigned to one of two groups: training or control. Pretraining and posttraining knowledge and attitudes toward pain management were assessed. Implementation of cognitive-behavioral strategies was assessed via clinical role-play. Training participants had significantly more knowledge of cognitive-behavioral strategies after the training program versus before it, and they had more knowledge after the training program than did control participants. The training had no effect on attitude. In the role-play, training participants used a higher ratio of cognitive-behavioral strategies and implemented them in a higher quality manner than did control participants. These results suggest that a brief training program in cognitive-behavioral pain management can improve nursing students' knowledge of cognitive-behavioral pain management strategies and ability to implement them.

The squeaky wheel gets the grease: parental pain management of children treated for bone fractures.

OBJECTIVES: The purpose of this study was to examine parental pharmacological and nonpharmacological pain management practices after extremity fractures. METHODS: Parents of children aged 5 to 10 years who were diagnosed with a fractured limb and treated in an emergency department were recruited and completed pain records at home for 2 days. RESULTS: The findings demonstrated that on the day after the fracture, 20% of children received no analgesia and 44% received 1 dose. On day 2, 30% received no analgesia and 37% received 1 dose. The correlation between analgesia and child report of pain increased from day 1 (r = 0.4, P < 0.05) to day 2 (r = 0.52, P < 0.05) as did parental impression that increased from day 1 (r = 0.43, P < 0.05) to day 2 (r = 0.6, P < 0.05). Correlations between pain scores, however, decreased from day 1 (r = 0.6, P < 0.05) to day 2 (r = 0.41, P < 0.05). Although most children received analgesia based on exhibiting active, loud behaviors such as crying (r = 0.63, P < 0.001), children exhibited quiet behaviors more frequently than crying (59.4 % vs. 31.2%, P < 0.001). CONCLUSIONS: Based on these findings, it was concluded that children received few doses of analgesia at home after a fracture. Although quiet, withdrawn behaviors were exhibited more frequently, parents provided more analgesia if children exhibited active, loud behaviors. Future intervention should be developed to assist parents in recognizing the unique pain cues children exhibit and instructions for safe and effective pain management.

Prevalence and predictors of significant sleep disturbances in children undergoing ambulatory tonsillectomy and adenoidectomy.

OBJECTIVE: To evaluate children's sleep patterns before and after ambulatory surgery and to identify predictors of sleep decrements following surgery. METHODS: Participants were 55, 6- to 12-year-old children undergoing tonsillectomy and adenoidectomy. Sleep was assessed using actigraphy for 5 nights prior to and 5 nights following surgery. Parent state and trait anxiety, and child perioperative anxiety and temperament were assessed. Data on postoperative pain and use of analgesics were collected. RESULTS: Children had significantly less efficient sleep following surgery than before surgery. Approximately one-third of children demonstrated clinically significant decrements in sleep efficiency. Discriminant function analysis indicated less sociable and more anxious children were more likely to experience these sleep decrements, as were children who experienced greater pain in the postoperative period. CONCLUSION: Children's sleep is an important consideration in recovery from surgery and this article takes a first step toward identifying predictors of the development of clinically significant sleep disruptions following surgery.

Exploring sociodemographic and personality characteristic predictors of parental pain perceptions.

BACKGROUND: We studied the relationship between children's and parents' sociodemographic and personality characteristics and parents' perceptions of their children's pain. METHODS: One-hundred-ten parents of children undergoing surgery completed measures of pain perception (e.g., Medication Attitude Questionnaire; MAQ) and parent and child personality characteristics (e.g., Neuroticism, Extraversion and Openness to experience Five-Factor Inventory; NEO-FFI). Factor analysis and logistic regression models were developed. RESULTS: In terms of pain medication perceptions (MAQ), descriptive analysis showed that more than 70% of parents feared side effects of analgesia, 43% thought analgesics were addictive, and 37% thought that the less often children receive analgesia, the better it worked. Factor analyses of the MAQ revealed a three factor solution explaining 52% of the variance in parental pain medication perceptions. Conceptually, these factors represented Appropriate Use Attitude of Analgesics, Concerns about Side Effects, and Avoidance of Analgesia. Stepwise regression models were used to identify predictors of parents' scores on each of the three factors. Results indicated that less educated parents and parents of more sociable and more reactive children were more likely to indicate that they would avoid giving analgesia (Avoidance factor; P < 0.001). Parents with higher conscientiousness scores (NEO-FFI) and those with more impulsive children were more likely to perceive that analgesia was appropriate to use for child pain (Appropriate Use Attitude factor; P < 0.001). DISCUSSION: We conclude that many parents have misconceptions of pain and analgesics, and that child and parent personality characteristics can be used to identify parents at risk of these misconceptions.

Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial.

BACKGROUND: Children and parents experience significant anxiety and distress during the preoperative period. Currently available interventions are having limited efficacy. Based on an integration of the literature in both the anesthesia and psychological milieus, the authors developed a behaviorally oriented perioperative preparation program for children undergoing surgery that targets the family as a whole. METHODS: Children and their parents (n = 408) were randomly assigned to one of four groups: (1) control: received standard of care; (2) parental presence: received standard parental presence during induction of anesthesia; (3) ADVANCE: received family-centered behavioral preparation; and (4) oral midazolam. The authors assessed the effect of group assignment on preoperative anxiety levels and postoperative outcomes such as analgesic consumption and emergence delirium. RESULTS: Parents and children in the ADVANCE group exhibited significantly lower anxiety in the holding area as compared with all three other groups (34.4+/-16 vs. 39.7+/-15; P=0.007) and were less anxious during induction of anesthesia as compared with the control and parental presence groups (44.9+/-22 vs. 51.6+/-25 and 53.6+/-25, respectively; P=0.006). Anxiety and compliance during induction of anesthesia was similar for children in both the ADVANCE and midazolam groups (44.9+/-22 vs. 42.9+/-24; P=0.904). Children in the ADVANCE group exhibited a lower incidence of emergence delirium after surgery (P=0.038), required significantly less analgesia in the recovery room (P=0.016), and were discharged from the recovery room earlier (P=0.04) as compared with children in the three other groups. CONCLUSION: The family-centered preoperative ADVANCE preparation program is effective in the reduction of preoperative anxiety and improvement in postoperative outcomes.

Interventions for paediatric procedure-related pain in primary care.

As a part of routine and specialized health care, children are subjected to a number of invasive medical procedures (eg, immunizations, venipunctures). These events are anxiety provoking and painful, and can have detrimental short-term and long-term effects. The present paper provides an overview of pharmacological and nonpharmacological techniques for the management of procedure-related pain in children, with a focus on clinically relevant information. Sufficient detail is provided to facilitate the translation of reviewed strategies into standard practice.

Correlates of pediatric behavior and distress during intramuscular injections for invasive dental procedures.

Relations between general behavior, temperament, and procedure-related behavior and distress were examined in children receiving intramuscular injections before undergoing restorative dental procedures. Younger children are likely to benefit the most from interventions prior to and during dental procedures. Children's anxiety before dental procedures could help identify those at risk of displaying problematic behaviors. General behavior and temperament seem useful at identiying children who may experience greater levels of pain.

Occulocerebrocutaneous syndrome: a case report.

Occulocerebrocutaneous syndrome is a rare condition characterized by orbital cysts and skin tags. The presence of supernumerary teeth has not previously been associated with this syndrome. A primary supernumerary tooth with a permanent supernumerary successor was found in this case. This highlights the importance of very careful examination when assessing children with syndromes.

Randomized clinical trial of distraction for infant immunization pain.

Distraction has been shown to be an effective technique for managing pain in children; however, few investigations have examined the utility of this technique with infants. The goal of the current study was to investigate the effectiveness of movie distraction in reducing infants' immunization distress. Participants were 136 infants (range=1-21 months; M=7.6 months, SD=5.0 months) and their parents, all of whom were recruited when presenting for routine vaccinations. The parent-child dyads were randomly assigned to either a Distraction or Typical Care control condition. Infant and adult behaviors were assessed using a visual analog scale and a behavioral observation rating scale. Results indicated parents in the Distraction group engaged in higher rates of distraction than those in the Typical Care group, whereas there was no difference in the behavior of nurses in the Distraction and Typical Care groups. In addition, infants in the Distraction group displayed fewer distress behaviors than infants in the Typical Care group both prior to and during recovery from the injection. Findings suggest that a simple and practical distraction intervention can provide some distress relief to infants during routine injections.

Impact of opioid use on outcomes of functional restoration.

OBJECTIVES: To examine the effect of opioid use on psychological function, physical functioning, and return-to-work outcomes of a multidisciplinary rehabilitation program (MRP) for chronic pain. METHODS: The participants were 127 patients with on-the-job injuries who had completed an MRP between 2001 and 2003. Opioid use was controlled by the patients' treating physicians (who were not affiliated with the MRP) and was assessed via patient self-report at the time of admission to the program and discharge. Other measures included pretreatment and posttreatment assessments of depression, pain severity, perceived disability, and physical ability (floor-to-waist lifting capacity). Return-to-work outcomes were obtained via follow-up phone calls approximately 6 months posttreatment. RESULTS: Significant improvements from pretreatment to posttreatment were evidenced on all psychological and physical measures for both opioid users and nonusers. Further, there were no significant posttreatment differences between opioid and nonopioid users on psychological, physical, or return-to-work outcomes. DISCUSSION: The role of opioids in the treatment of chronic pain continues to be controversial. Despite a lack of definitive data on their effectiveness, opioids continue to be prescribed, and thus patients using opioids continue to present for multidisciplinary rehabilitation. Although further exploration is warranted, results of the current study suggest that opioid use during rehabilitation does not necessarily preclude treatment success.

Teaching behavioral pain management to healthcare professionals: a systematic review of research in training programs.

UNLABELLED: Pain is a common and potentially debilitating condition. Whereas there is vast literature on developmentally appropriate behavioral techniques for pain management, results of curriculum evaluations and knowledge surveys reveal a dearth of awareness of these strategies in healthcare professionals. As a result, the development and evaluation of pain management training programs are important endeavors. Results of studies evaluating such programs are promising and suggest that training might be an effective means of impacting healthcare professionals' knowledge, attitudes, and even patient care. These results must be interpreted with caution, however, because the literature contains several conceptual and methodologic limitations. These limitations, in combination with the wide diversity in program components, format of delivery, and research methods, preclude definitive conclusions on the most practical and effective means to provide training. To address this question, further systematic work on the development and evaluation of pain management training programs is warranted. PERSPECTIVE: To address the problems of dissemination of behavioral pain management techniques, the development and evaluation of pain management training programs are important endeavors. The current article presents a systematic review of studies evaluating such programs and provides recommendations for future systematic work in this area.

A comparison of distraction strategies for venipuncture distress in children.

OBJECTIVE: To compare the effects of two pediatric venipuncture distress-management distraction strategies that differed in the degree to which they required children's interaction. METHODS: Eighty-eight 1- to 7-year-old children receiving venipuncture were randomly assigned to one of three treatment conditions: interactive toy distraction, passive movie distraction, or standard care. Distress was examined via parent, nurse, self-report (children over 4 years), and observational coding. Engagement in distraction was assessed via observational coding. RESULTS: Children in the passive condition were more distracted and less distressed than children in the interactive condition. Although children in the interactive condition were more distracted than standard care children, there were no differences in distress between these groups. CONCLUSIONS: Despite literature that suggests that interactive distraction should lower distress more than passive distraction, results indicate that a passive strategy might be most effective for children's venipuncture. It is possible that children's distress interfered with their ability to interact with the distractor.

Pediatric procedural approach-avoidance coping and distress: a multitrait-multimethod analysis.

OBJECTIVE: To evaluate the construct validity of children's approach-avoidance coping and distress during immunizations, and to examine the instruments used to assess these domains. METHODS: We used a multitrait-multimethod matrix to examine the validity of the approach-avoidance coping and distress constructs for 62 4- to 6-year-old children receiving immunization injections. Assessment instruments of both constructs consisted of child, parent, and nurse ratings, and three behavior observation scales. RESULTS: Pediatric procedural distress demonstrated adequate convergent and discriminant validity, and it can be assessed in a valid manner. Whereas most approach-avoidance measures demonstrated good convergent validity, several measures did not adequately distinguish between avoidance and distress. CONCLUSIONS: It is possible that children's approach-avoidance coping may be qualitatively different than adult's approach-avoidance. Researchers should be cognizant of these differences when designing treatments for child procedural distress.