Postoperative analgesics for children and adolescents: prescription and administration.

Pain was measured and analgesic treatment examined in 131 children and adolescents, 8-17 years of age, for 5 days after surgery. Analgesic data were converted to 10 mg intramuscular morphine-equivalent doses (IMMSEQ) and were designated appropriate or inappropriate for body weight. Analgesic onset, peak, and duration were calculated in relation to administration routes and the time pain assessments were made. Children reported moderately severe pain in many body locations. Initially, all but two children were prescribed and ultimately all but one received analgesics. Prescribed and administered doses were frequently less than doses recommended for weight. Two-thirds of the children were beyond analgesic action when pain was assessed. Weak to moderately strong associations were noted between IMMSEQ doses and pain intensity scores on each of the 5 postoperative days. Unfortunately, findings indicate that children continue to be undertreated when they experience postoperative pain.

Pain location: validity and reliability of body outline markings by 4 to 7-year-old children who are hospitalized.

This descriptive study addressed the validity and reliability of a body outline for pain location assessment in 4 to 7-year-old children (n = 46) who are hospitalized. The findings support the use of a body outline for pain location in this age group.

Photography. Is it useful in learning how adolescents view hospitalization?

This pilot study explored the use of photography as a media for learning how adolescents view hospitalization. Six adolescents, 13-18 years of age were issued cameras with one roll of film and instructed to take pictures that would document their hospitalization. An interview using the adolescent's pictures was conducted with each subject. The camera was found to be a useful tool and an effective means for helping adolescents share their view of a hospital experience.

Assessing children's and adolescents' pain.

Problems related to the complex task of pain assessment in children and adolescents are identified. Solutions to the problems are presented by describing a variety of tools currently available to assess three distinct dimensions of pain: location, intensity, and quality. Characteristics and strengths of a variety of tools are discussed and examples of each are included. Presented are body outlines to report location, and a variety of tools appropriate for measuring intensity from young preschoolers to adolescents. Worldwide current work describing the development of word lists to describe childhood pain quality is summarized.

Children with cancer: the pain experience away from the health care setting.

Relatively little is known about the nature of pain in children with cancer away from the health care setting. Accordingly, this pilot study focused on the pain experience in this group. A purposive sample of 20 children, ages 4 through 16 years, with any type of cancer, was obtained. A semistructured interview including the Poker Chip Tool and Preschool Body Outline (ages 4 to 7 years) or the Adolescent Pediatric Pain Tool (age 8 to 16 years) was administered to all the children once during a clinic appointment. Supplemental parental input was sought during the interview. Two of the children also were contacted every 2 weeks for 3 months. Content analysis indicated that the children experienced pain in a number of locations, most frequently the "stomach", joints, legs, and back. Pain intensity varied widely. The source of pain identified most often was chemotherapy. The most common pain management strategies mentioned were rest/sleep, analgesics, rubbing, distraction, social support, and heat. Clearly, children with cancer away from the health care setting do have pain. Assessment of pain in children with cancer regardless of setting is a necessity.

Pain behaviors: postsurgical responses of children and adolescents.

There is scant data identifying the range and variety of pain behaviors associated with ongoing, short-term acute pain of older children and adolescents. The purposes of this study were to identify and record pain behaviors manifested by children and adolescents during the first 3 days after surgery and examine the relationship between behaviors and self-report of pain intensity. Data were collected from 37 multi-ethnic children and adolescents using the Word Graphic Rating Scale for self-report of pain intensity and the Pediatric Pain Behavior List to record pain behaviors. The five most frequently observed behaviors were calm, maintaining one position, flexing limbs, eyes shut, and knees drawn up. All children reported pain on the first 2 days postsurgery. Many children who were lying in one position with a calm expression, at the same time, reported moderate to severe pain.

How adolescents describe pain.

This study assesses how adolescents describe the experience of pain. We queried a convenience sample of 156 adolescents, 13-17 years of age, in two schools and four hospitals. Adolescents answered questions on a questionnaire developed by the investigators. Findings suggest that adolescents can clearly describe pain, their feelings when in pain, and the strategies that help when they experience pain. Pain appears to be associated with mental anguish as well as trauma and pathology.

A strategy to assess the temporal dimension of pain in children and adolescents.

Two formats to enable children and adolescents to report the changing intensity, duration, and pattern of their pain were developed and tested: (a) a dot matrix with intensity markers on the y-axis and time markers on the x-axis and (b) a list of words or word phrases describing the temporal dimension of pain. Analyses of the dot matrix markings revealed six patterns of pain: steady decrease, steady increase, ongoing sharp increases and decreases, stair-step increase and decrease, steady increase and decrease, and constant. The 12 words and phrases described how pain began as well as how the pattern of pain changed over time.

Children's and adolescents' pain language in Spanish: translation of a measure.

The decision to include a Spanish-speaking sample in a study of pain in children with leukemia necessitated translation of the data collection tools. Therefore, the Adolescent Pediatric Pain Tool (APPT) was translated by using the standard translation, back-translation procedure. The Spanish word list consists of 66 descriptors in the sensory, affective, evaluative, and temporal domains. After initial pilot work with the translated APPT with well children in the Dominican Republic, additional pilot work was conducted in California. Two of these studies were completed with well children and adolescents, and one study that was part of a clinical research project focused on pain in children and adolescents with leukemia. Although content; construct, concurrent validity; and test-retest reliability were tested, further studies are necessary with larger populations of children and adolescents. This series of pilot studies supports the usefulness of the Spanish translation of the APPT word list, particularly for clinical or research situations in which multiple versions of a tool would counteract ease of use.

Assessment of postoperation pain in children and adolescents using the adolescent pediatric pain tool.

The location, intensity, and quality of pediatric postoperative pain were assessed in a convenience sample of 65 multiethnic children and adolescents, 8 to 17 years old. Pain was measured daily for 5 days during hospitalization using the Adolescent Pediatric Pain Tool (APPT). Mean pain intensity scores and mean number of pain descriptors (quality) decreased over time, but there was no significant change over time for the number of body segments marked (location). The findings provided valid and reliable estimates of adolescents' and children's self-reports of the location, intensity, and quality of postoperative pain.

Use of the McGill Pain Questionnaire to measure pain: a meta-analysis.

A meta-analysis of 51 studies was done to estimate normative mean McGill Pain Questionnaire (MPQ) scores and to assess pain quality and pain intensity as measured by the MPQ in 3,624 subjects with seven painful conditions. Across the painful conditions, all of the estimated normative mean scores were no more than 50% of the maximum score, suggesting that scores may be skewed to the left. Although the estimated normative mean scores were similar among the seven painful conditions, higher affective scores appeared to differentiate chronic painful conditions from acute painful conditions. Of the 78 MPQ words that describe pain quality, only 19 were selected by more than 20% of the subjects. Data reported in the majority of these studies were inadequate to test for differences in scores or word selection pattern by the seven painful conditions.

The word-graphic rating scale as a measure of children's and adolescents' pain intensity.

A program of studies was designed to select and test a pain intensity scale for inclusion in a multidimensional pain assessment tool for children and adolescents. The focus was on determining each scale's validity, reliability, ease of use, preference, and the lack of age, gender, and ethnic biases. Five pain scales were evaluated in four separate studies: a word-graphic rating scale, a visual analogue scale, a graded-graphic rating scale, a magnitude estimation scale (0 to 10), and a color scale. Subjects (N = 1,223) were 8 to 17 years of age and, in three of the studies, were hospitalized and judged to be in pain. In Study 1, well children used the scales to assess pain in an analogue situation selecting the color scale easiest to use and best liked. Convergent validity for the five scales was supported. In Study 2, hospitalized children, who were experiencing pain, overwhelmingly selected the word-graphic rating scale as their choice. A pilot version of a multidimensional pain assessment tool incorporating the word-graphic rating scale was tested in Study 3 using a repeated measures design. The scale demonstrated sensitivity to changes in postoperative pain intensity over time. In Study 4, convergent validity of the five scales and test-retest reliability of the word-graphic rating scale were supported. The series of four studies provides strong evidence to support use of the word-graphic rating scale to measure pain intensity in pediatric populations.

Pain location: validity and reliability of body outline markings by hospitalized children and adolescents.

Although pain location is an important assessment parameter, little research has addressed validity and reliability of a body outline in pediatric populations. In a descriptive study, validity and reliability of markings on a body outline were examined in a convenience sample of 8- to 17-year-old hospitalized children (n = 175). Children marked their pain location on a body outline. Each child then pointed to the pain location on his/her body as a nurse data collector, blind to the child's markings, recorded the location on a second body outline. Data were obtained to substantiate the pain location. Findings provide strong support for the validity and reliability of a body outline and for its inclusion in a multidimensional pediatric pain tool.