Wiley

Paediatric and Neonatal Pain

Published by Wiley

Online ISSN: 2637-3807

Disciplines: Pediatrics

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Participants' preferences (N = 30) for the individual pain words. PCS is a trademark of Tobii Dynavox LLC. All rights reserved. Used with permission.
Exploring children's preferences for graphic symbols to represent pain‐related words

October 2024

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49 Reads

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Nina Swanepoel

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Aims and scope


Paediatric and Neonatal Pain is a multidisciplinary, open access journal with a span across medicine and nursing, serving healthcare workers and the paediatric care research community. The journal has a focus on cutting-edge research into paediatric and neonatal pain management, clinical practice, and analgesia.
As part of Wiley’s Forward Series, this journal offers a streamlined, faster publication experience with a strong emphasis on integrity. Authors receive practical support to maximize the reach and discoverability of their work.

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Participants' preferences (N = 30) for the individual pain words. PCS is a trademark of Tobii Dynavox LLC. All rights reserved. Used with permission.
Exploring children's preferences for graphic symbols to represent pain‐related words
  • Article
  • Full-text available

October 2024

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49 Reads

Children who are hospitalized may sometimes not be able to communicate verbally to self‐report their pain or other symptoms due to medical conditions, medical interventions, or communication difficulties. As such, these children may need other means, such as augmentative and alternative communication (AAC) strategies, in this case, graphic symbols, to express their pain‐related experiences and receive applicable treatment. Choosing suitable graphic symbols to represent pain‐related words contributes to the effective use and implementation of visual support. This study explored the preferences of 6.0–9.11‐year‐old (years; months) children with typical development regarding graphic symbols to represent pain‐related words. These symbols were selected from two commonly used and widespread symbol resources: Picture Communication Symbols (PCS®) and Aragonese Portal of Augmentative and Alternative Communication (ARASAAC) symbols. A descriptive, quantitative study design was employed, including a total of 30 typically developed South African children. Data were collected by means of an electronic questionnaire and analyzed using descriptive and inferential statistics. Probability values were determined and predictions, as well as inferences, were implemented. The results showed that the children preferred ARASAAC symbols to represent most pain‐related words (p < 0.001). It is important to consider stakeholders' (in this case, children's) input on their preferences in designing communication support to enable participation during the clinical decision‐making process.


Patient flow summary. Enrollment numbers and infusion dosing changes by patient in operating room and PICU postoperative Days 0–2. LT, liver transplantation; Mg, magnesium; MgSO4, magnesium sulfate; OR, operating room; POD, postoperative day; TP, total pancreatectomy & islet cell autotransplantion.
Vasoactive‐inotropic scores. Average peak vasopressor infusion dose displayed in operating room and PICU postoperative Days 0–2. LT, liver transplantation; Mg, magnesium; POD, postoperative day; TP, total pancreatectomy & islet cell autotransplantation.
Intravenous fluid boluses. Average intravenous fluid bolus requirements for PICU postoperative Days 0–3 during or proximal to magnesium sulfate infusion. Co, control; LT, liver transplantation; Mg, magnesium; POD, postoperative day; TP, total pancreatectomy & islet cell autotransplantation.
Pain Scores. Average verbal pain score by postoperative day in PICU. Co, control; LT, liver transplantation; Mg, magnesium; POD, postoperative day; TP, total pancreatectomy & islet cell autotransplantation.
Prolonged magnesium sulfate infusion as adjuvant analgesia in postoperative transplant patients in the pediatric ICU: Preliminary results of a feasibility study

August 2024

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11 Reads

The opioid crisis has emphasized identification of opioid‐sparing analgesics. This study was designed as a prospective trial with retrospective control group to determine feasibility for implementing a high‐dose prolonged magnesium sulfate infusion for adjuvant analgesia in the pediatric intensive care unit. Approval was granted for study of children receiving total pancreatectomy with islet cell autotransplantation and liver transplantation ages 3–18 years. Study exclusions were pregnancy, neuromuscular disease, hypersensitivity, preoperative creatinine >1.5 times upper limit normal, arrhythmia or pacemaker presence, and clinician concern. Eleven patients were enrolled between January 2020 and December 2022. Magnesium sulfate bolus (50 mg/kg) followed by intravenous infusion (15 mg/kg/h) was initiated in the operating room and extended postoperatively (maximum 48 h). Serum magnesium levels were monitored serially. To prioritize safety, infusion dose was decreased by 5 mg/kg/h for levels greater than 3.5 mg/dL. Clinical team otherwise followed standard multimodal pain practice. Primary outcome was oral morphine equivalent per kg per day during intensive care course (maximum 7 days). Secondary outcomes focused primarily on magnesium safety, including hemodynamic variables, electrolyte variables, respiratory support, and opioid‐related side effects. There were no serious adverse events. Treatment group trended toward slightly higher intravenous fluid requirement (~1 bolus), however no increase in blood product. Treatment and control groups were otherwise comparable in targeted outcomes and overall adverse event profile. Use of a high‐dose magnesium sulfate infusion protocol for analgesic postoperative use in select transplant recipients appears feasible for continued optimization of study in the PICU.


Population flow chart.
Mean maintenance doses of morphine, midazolam and dexmedetomidine over time. Day 0 corresponds to dexmedetomidine introduction.
Use of dexmedetomidine during mechanical ventilation in extremely preterm and extremely low birth weight neonates receiving morphine: A single‐center retrospective study

July 2024

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39 Reads

Analgesia and sedation are often provided during mechanical ventilation in extremely preterm neonates. Opioids and benzodiazepines are the most frequently used agents but can have adverse effects. Dexmedetomidine, an alpha‐2 agonist, might be interesting to spare opioid and benzodiazepine use. The objective of this study was to describe a cohort of mechanically ventilated extremely, preterm infants treated with morphine with or without dexmedetomidine. This was a retrospective, observational, single‐center study in the neonatal intensive care unit of Creteil. We included preterm neonates born before 28 weeks of gestation and/or weighting less than 1000 g hospitalized between July 2017 and June 2020, on mechanical ventilation for at least 72 h and who received morphine with or without dexmedetomidine as a second‐ or third‐line treatment. We described morphine and midazolam exposure, respiratory, and digestive outcomes for patients who received dexmedetomidine and those who did not. Twenty nine preterm infants received morphine and dexmedetomidine, and 44 received morphine without dexmedetomidine. Dexmedetomidine was used in patients of 25.7 [25.1–26.7] weeks, 680 [600–750] g and significantly more often in patients with vascular complications during pregnancy (p = 0.008), intrauterine growth restriction (p = 0.01) and in patients who received higher cumulative doses of morphine (p = 0.01). Morphine and midazolam doses tended to decrease after the introduction of dexmedetomidine. Dexmedetomidine was never discontinued because of side effects. In this study, dexmedetomidine, used as a second or third‐line treatment during mechanical ventilation, was associated with a decrease in morphine and midazolam doses after introduction. Dexmedetomidine was used in a specific population of extremely preterm infants, with severe respiratory disease, who required prolonged mechanical ventilation and high morphine doses. This study highlights the need for pharmacokinetic/pharmacodynamic studies in this population, followed by randomized controlled trials and studies on the long‐term effects of dexmedetomidine to determine its place in analgosedation of ventilated preterm infants.



Study flow chart.
Cold and vibration for children undergoing needle‐related procedures: A non‐inferiority randomized clinical trial

June 2024

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49 Reads

The use of a rapid, easy‐to‐use intervention could improve needle‐related procedural pain management practices in the context of the Emergency Department (ED). As such, the Buzzy device seems to be a promising alternative to topical anesthetics. The aim of this study was to determine if a cold vibrating device was non‐inferior to a topical anesthetic cream for pain management in children undergoing needle‐related procedures in the ED. In this randomized controlled non‐inferiority trial, we enrolled children between 4 and 17 years presenting to the ED and requiring a needle‐related procedure. Participants were randomly assigned to either the cold vibrating device or topical anesthetic (4% liposomal lidocaine; standard of care). The primary outcome was the mean difference (MD) in adjusted procedural pain intensity on the 0–10 Color Analogue Scale (CAS), using a non‐inferiority margin of 0.70. A total of 352 participants were randomized (cold vibration device n = 176, topical anesthetic cream n = 176). Adjusted procedural pain scores' MD between groups was 0.56 (95% CI:−0.08–1.20) on the CAS, showing that the cold vibrating device was not considered non‐inferior to topical anesthetic. The cold vibrating device was not considered non‐inferior to the topical anesthetic cream for pain management in children during a needle‐related procedure in the ED. As topical anesthetic creams require an application time of 30 min, cost approximately CAD $40.00 per tube, are underused in the ED setting, the cold vibrating device remains a promising alternative as it is a rapid, easy‐to‐use, and reusable device.


Search strategy, presented in a flow diagram according to the PRISMA guidelines. RCT, randomized controlled trial.
The efficacy of wound catheter infusion with local anesthetics for the treatment of postoperative pain in children: A systematic review

June 2024

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67 Reads

Wound catheter infusion (WCI) with local anesthetics (LA) is a regional anesthesia technique, which has shown to produce effective postoperative analgesia in adults, without any adverse effects on wound healing. To investigate the efficacy and safety of WCI with LA for the treatment of postoperative pain in children, we conducted a systematic review of literature published until 2020. The literature search included articles concerning subcutaneous WCI with LA, in the surgical wound, as treatment of postoperative pain, in children <18 years of age. Exclusion criteria were studies describing peripheral nerve blocks, intercostal, abdominal or thoracic wall blocks and single local anesthetic infiltration of the surgical wound. The articles were appraised for quality and only randomized controlled trials with a Jadad score ≥3 were included for evaluation of results concerning postoperative pain scores and opioid use. All relevant original studies, including observational studies and case reports, were assessed for adverse events and measurements of LA plasma concentrations during WCI. A total of 1907 articles were found, leading to 92 relevant abstracts selected for further review. After exclusion of articles of which full texts could not be retrieved or because of exclusion criteria, 28 articles remained. Thirteen articles described randomized controlled trials, of which 10 were assessed as good or excellent in quality. Due to the small number and heterogeneity of the studies, the data could not be pooled. Instead, results were described per type of procedure: abdominal surgery, extremity surgery, thoracic surgery and iliac crest bone harvesting. Reduced pain scores and opioid needs were demonstrated after abdominal and extremity surgery. In five studies, plasma levels of LA were measured, which all remained below toxic thresholds. In all relevant studies, no serious adverse events concerning the use of WCI were reported.



PRISMA flow diagram.
Risk of bias of included studies. Low risk Some concerns High risk
A systematic review of in‐person versus remotely delivered interventions for youth with chronic pain

The COVID‐19 pandemic prompted a rapid shift from in‐person to virtually‐delivered care. Many youth with chronic pain have the ability to access care virtually; however, little is known about the efficacy of pain care for youth with chronic pain delivered virtually when compared to in‐person. Such evidence is essential to guide youth in making decisions about their care, but also to inform what options health professionals present to youth. The purpose of this systematic review and meta‐analysis was to examine the efficacy of interventions that are delivered in‐person versus virtually for youth with chronic pain. Five databases (i.e., CINAHL, EMBASE, MEDLINE, APA PsycINFO, and Web of Science) were searched in October 2022 to identify randomized controlled trials that compare single/multimodal interventions for pediatric chronic pain delivered in‐person versus virtually. A total 3638 unique studies were identified through database and other searching, two of which satisfied established criteria for inclusion in this review. Both studies compared psychological interventions delivered virtually versus in‐person for youth with chronic pain and showed comparable efficacy across modalities. The planned meta‐analyses could not be conducted due to different outcomes within each study that could not be combined. This systematic review highlights a critical gap in the evidence regarding the efficacy of virtually delivered interventions for youth with chronic pain. This evidence is necessary to inform treatment decisions for youth, and further research is required to develop the evidence to inform clinical interventions, especially as virtual treatments continue to be offered.


Percentage of physicians (n = 57) who considered treatments for neuropathic and bone pain appropriate/very appropriate to use.
Prevalence of side effects of cancer treatment that are seen often or very often according to nurses and physicians (n = 132).
Prevalence of nurses and physicians that expressed a high or very high need for training in different areas.
Pain in pediatric oncology—A Swedish nationwide follow‐up study among nurses and physicians

December 2023

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35 Reads

To examine nurses' and physicians' assessments of pain in children with cancer, and to identify the methods in use to diagnose, evaluate, and treat pain. In addition, to examine whether/how the healthcare professionals' assessment and management of pain has changed compared to 1995 and identify the needs for training. The study has a descriptive and comparative design. 363 nurses and physicians working with children with cancer in Sweden were invited to participate in April 2017. Participants answered an updated version of a questionnaire used in 1995 by Ljungman et al. focusing on the healthcare professionals’ experience of pain among their patients, their pain treatment strategies, and need for training. 120 nurses and 65 physicians participated. Fifty percent of nurses and 55% of physicians answered that moderate‐to‐severe pain was experienced often or very often by children with cancer. Methods recommended in international guidelines to diagnose, evaluate, and treat pain were generally followed. Compared with findings from 1995 by Ljungman et al., nurses, and physicians assessed that moderate‐to‐severe pain was seen more often. The greatest need for training was reported for pharmacology, different routes for administration of opioids, treatment with nitrous oxide, and nonpharmacological interventions. Nurses and physicians assessed that moderate‐to‐severe pain is often present in children with cancer. More time to treat pain in the department and training in certain areas seem to be needed to improve pain management.


Median oral morphine milligram equivalents. EPI, epidural group; LB, liposomal bupivacaine group; LB + D, liposomal bupivacaine + dexamethasone. Comparison of oral morphine milligram consumption between the three study groups at time points 0–24 h postoperatively, 24–48 h postoperatively, and 48–72 h postoperatively.
Posterior spinal fusion for adolescent idiopathic scoliosis and the impact of postoperative intravenous dexamethasone supplementation

November 2023

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40 Reads

Postoperative care pathways for adolescent idiopathic scoliosis patients undergoing posterior spinal fusion have demonstrated decreases in postoperative opioid consumption, improved pain control, and lead to decreased lengths of stay. Our objective was to implement postoperative steroids to reduce acute postoperative opioid consumption, pain scores, and length of stay. Dosing consisted of intravenous dexamethasone 0.1 mg/kg up to 4 mg per dose for a total of three doses at 8, 16, and 24 h postoperatively. As part of a quality initiative, we compared three cohorts of patients. The initial retrospective epidural cohort (EPI) (n = 59) had surgeon placed epidural catheters with infusion of ropivacaine 0.1% postoperatively for 18–24 h. Following an institutional change in postoperative care, epidural use was discontinued. A second cohort (n = 149), with prospectively collected data, received a surgeon placed erector spinae plane block and wound infiltration with a combination of liposomal and plain bupivacaine (LB). A third cohort (n = 168) was evaluated prospectively. This cohort received a surgeon placed erector spinae plane block and wound infiltration with liposomal and plain bupivacaine and additionally received postoperative dexamethasone for three doses (LB + D). Compared to the LB cohort, the LB + D cohort demonstrated statistically significant decreases in oral milligram morphine equivalents per kilogram at 0–24, 24–48, and 48–72 h. There was a statistically significant difference in median pain scores at 24–48 and 48–72 h in LB + D versus LB. The LB + D cohort's median length of stay in hours was significantly less compared to the LB cohort (52 h vs. 70 h, p < 0.0001). Postoperative intravenous dexamethasone was added to an established postoperative care pathway for patients undergoing posterior spinal fusion for idiopathic scoliosis resulting in decreased VAS pain scores, opioid consumption, and shorter length of stay.



Pain communication in children with autism spectrum disorder: A scoping review

October 2023

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130 Reads

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3 Citations

Children with autism spectrum disorder (ASD) experience social interaction and communication challenges and often display repetitive, restricted patterns of behavior, activities, and interests. The concept of pain is regarded as one of the most complex human stressors due to its subjective and personal nature and the influences of multiple internal and external factors. Due to the complexity of this disorder, it remains concerning how children with ASD communicate their pain and how observers (i.e., parents, carers, and health care practitioners) respond to these children's pain communication. This scoping review aimed to identify how children with ASD communicate or express their pain. Ten studies met the inclusion criteria for further data extraction. Through reflexive thematic analysis, two main themes were identified: verbal and nonverbal responses used by children with ASD to communicate their pain that could influence pain assessment and management strategies. This review highlighted that children with ASD utilized various verbal and nonverbal methods to communicate their pain experiences and that these methods differed compared to children without disabilities. Furthermore, this review emphasizes the importance of holistic pain assessment strategies as well as additional pictorial support for children with ASD. This review recommends that future research should focus on understanding how the inclusion of different stakeholders in pain assessment for children with ASD, can contribute to holistic pain assessment.


A longitudinal observational study on the epidemiology of painful procedures and sucrose administration in hospitalized preterm neonates

August 2023

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131 Reads

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5 Citations

Although sucrose is widely administered to hospitalized infants for single painful procedures, total sucrose volume during the entire neonatal intensive care unit (NICU) stay and associated adverse events are unknown. In a longitudinal observation study, we aimed to quantify and contextualize sucrose administration during the NICU stay. Specifically, we investigated the frequency, nature, and severity of painful procedures; proportion of procedures where neonates received sucrose; total volume of sucrose administered for painful procedures; and incidence and type of adverse events. Neonates <32 weeks gestational age at birth and <10 days of life were recruited from four Canadian tertiary NICUs. Daily chart reviews of documented painful procedures, sucrose administration, and any associated adverse events were undertaken. One hundred sixty‐eight neonates underwent a total of 9093 skin‐breaking procedures (mean 54.1 [±65.2] procedures/neonate or 1.1 [±0.9] procedures/day/neonate) during an average NICU stay of 45.9 (±31.4) days. Pain severity was recorded for 5399/9093 (59.4%) of the painful procedures; the majority (5051 [93.5%]) were heel lances of moderate pain intensity. Sucrose was administered for 7839/9093 (86.2%) of painful procedures. The total average sucrose volume was 5.5 (±5.4) mL/neonate or 0.11 (±0.08) mL/neonate/day. Infants experienced an average of 7.9 (±12.7) minor adverse events associated with pain and/or sucrose administration that resolved without intervention. The total number of painful procedures, sucrose volume, and incidence of adverse events throughout the NICU stay were described addressing an important knowledge gap in neonatal pain. These data provide a baseline for examining the association between total sucrose volume during NICU stay and research on longer‐term behavioral and neurodevelopmental outcomes.


Adolescents' experiences of Help Overcoming Pain Early—A school based person‐centred intervention for adolescents with chronic pain

July 2023

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58 Reads

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3 Citations

To illuminate adolescents' experiences of Help Overcoming Pain Early (HOPE), a person‐centred intervention delivered in a school setting by school nurses. Twenty‐one adolescents with chronic pain recruited from secondary school, who had completed the HOPE intervention, were included in the interview study. The HOPE intervention was built on person‐centred ethics and consisted of four meetings between school nurses and adolescents on the subject of stress and pain management. A qualitative method using content analysis with an inductive approach was employed. In the interviews, the adolescents describe how they reclaim their lives with the help of HOPE. They use different strategies and parts of the intervention to move on with their lives. A trustful relationship, as that with the school nurse, was essential to dare to change. The overarching theme summarizes in Becoming myself again and is built up by three sub‐themes: Trust a pillar for growth , Making sense of my life with pain , and Putting myself into the world again . A person‐centred intervention such as HOPE applied in a school context is promising for promoting confidence in adolescents with chronic pain. A trust‐building process emerged, in terms of both the adolescents' trust in the healthcare staff they meet and their confidence in their own ability to handle and influence their situation, which in the long term can promote trust in themselves as a person.


Cortisol levels are related to neonatal pain exposure in children born very preterm at age 18 months in two independent cohorts

May 2023

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59 Reads

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5 Citations

Exposure to pain‐related stress from frequent invasive procedures in the neonatal intensive care unit (NICU) has been associated with altered physiological stress regulation, neurodevelopment, and behavior in children born very preterm (≤32 weeks gestation). Previously, in a cohort born 2003–2006 (Cohort 1), we found that, at 18 months corrected age (CA), children born extremely low gestational age (ELGA; 24–28 weeks) and very low gestational age (VLGA; 29–32 weeks), had higher pre‐test cortisol levels and a different pattern of cortisol output across a developmental assessment involving cognitive challenge compared to children born full‐term (FT; 39–41 weeks). Also, greater neonatal pain‐related stress exposure among the preterm children was related to higher pre‐test cortisol levels. Given the adverse long‐term effects of neonatal pain in preterm infants and the ensuing rise in clinical concerns to appropriately manage pain in the NICU in recent years, we aimed to examine whether our findings from Cohort 1 would still be evident in an independent cohort (Cohort 2) born 2006–2011 and recruited from the same tertiary NICU in Vancouver, Canada. We also compared the cortisol patterns, clinical and socio‐demographic factors, and their interrelationships between the two cohorts. In Cohort 2, our findings using multi‐level modeling support and extend our earlier findings in Cohort 1, demonstrating that children born ELGA display higher pre‐test cortisol levels than FT. As well, greater cortisol output across assessment was related to more anxiety/depressive behaviors in children born VLGA. Importantly, children born ELGA were exposed to less neonatal pain/stress, mechanical ventilation, and morphine in Cohort 2 than Cohort 1. In both cohorts, however, cortisol levels and patterns were related to neonatal pain/stress and clinical factors (days on mechanical ventilation, overall morphine exposure). Despite less exposure to pain/stress and adverse clinical factors in Cohort 2 compared to Cohort 1, cortisol levels and patterns across cognitive challenge in preterm children at 18‐month CA were consistent across the two independent cohorts. These findings highlight that, despite improvements to neonatal care, children born extremely preterm continue to display altered HPA axis activity, which is associated with their poorer neurodevelopmental and behavioral outcomes.


Co‐occurring chronic pain and primary psychological disorders in adolescents: A scoping review

May 2023

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56 Reads

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3 Citations

Long‐term health conditions, whether mental or physical, often co‐occur in adolescents. For instance, adolescents with chronic pain may experience co‐occurring primary psychological disorders. In this scoping review, we determine the influence of co‐occurring chronic pain and primary psychological disorders on adolescents' functioning. A systematic search of six databases was conducted to identify articles if they were: (1) peer‐reviewed; (2) reported original findings; (3) included participants aged 11–19 years, who experienced chronic pain (i.e., pain lasting 3 months or more) and had a co‐occurring diagnosis of a primary psychological disorder; and (4) assessed functioning. Searches returned 9864 articles after the removal of duplicates. A two‐phase abstract and full‐text screening process identified two eligible articles which compared emotional functioning ( n = 1) and social functioning ( n = 2) between groups of adolescents with co‐occurring chronic pain and primary psychological disorders with adolescents only reporting chronic pain. Overall findings revealed no differences in social functioning, but adolescents with co‐occurring chronic pain and a primary psychological disorder (depression and anxiety) reported worse emotional functioning compared with adolescents with chronic pain alone. This review confirms the limited research on the co‐occurrence of primary psychological disorders and chronic pain in adolescents by only identifying two eligible articles exploring the co‐occurrence of chronic pain with depression, anxiety, and/or attentional disorders.


Co‐designing clinical trials alongside youth with chronic pain

May 2023

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55 Reads

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2 Citations

Youth have a right to participate in research that will inform the care that they receive. Engagement with children and young people has been shown to improve rates of enrollment and retention in clinical trials as well as reduce research waste. The aim of the study is to gain practical insight on the design of trials specifically on (1) recruitment and retention preferences, (2) potential barriers to research, and (3) study design optimization. Based on this youth engagement, we will co‐design two clinical trials in headaches with youth. Two recruitment strategies were used to recruit 16 youth from across Canada (aged 15–18 years) from an existing youth group, the KidsCan Young Persons' Research Advisory Group (YPRAG) and a new youth group in collaboration with Solutions for Kids in Pain (SKIP). Four virtual, semi‐structured discussion groups were held between April and December 2020, which included pre‐circulated materials and utilized two distinct upcoming planned trials as examples for specific methods feedback. Individual engagement evaluations were completed following the final group session using the Public and Patient Engagement Evaluation Tool. Descriptive results were shared with participants prior to publication to ensure appropriate interpretation. The discussion was centred around three themes: recruitment and retention preferences, potential barriers to participation, and study design optimization. Youth indicated that they would prefer to be contacted for a potential study directly by their physician (not over social media), that they would like to develop rapport with study staff, and that one of the barriers to participation is the time commitment. The youth also provided feedback on the design of the clinical trial including outcome measurement tools, data collection, and engagement methods. Feedback on the virtual format of the engagement events indicated that participants appreciated the ease of the online discussion and that the open‐ended discussion allowed for easy exchange of ideas. They felt that despite a gender imbalance (towards females) it was an overall inclusive environment. All participants reported believing that their engagement will make a difference to the work of the research team in designing the clinical trials. Perspectives from a diverse group of youth meaningfully improved the design and conduct of two clinical trials for headaches in children. This study provides a framework for future researchers to engage youth in the co‐design of clinical trials using online engagement sessions.


PRISMA 2009 flow diagram.
Digital tools for assessing chronic pain in children (5–11 years): Systematic review

April 2023

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44 Reads

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2 Citations

Pediatric chronic pain places a significant burden on children, their families, and healthcare services. Effective pain measurement is needed for both clinical management and research. Digital pain measurement tools have been developed for adult and adolescent populations however less is known about measurement in younger children. In this systematic review, we aimed to identify, describe, and evaluate (in terms of acceptability) digital tools for the assessment of chronic pain in children (5–11 years). We searched five databases (Cochrane Library, EMBASE, MEDLINE, PsycINFO, and CINAHL), between January 2014 and January 2022. We included empirical studies which included digital tool/s to assess pain in children aged between 5–11 years with chronic pain conditions. We independently double‐screened the papers to determine eligibility. We followed PRISMA guidelines for reporting. A total of five papers, covering four digital tools, were included. The digital tools used ranged from a static online survey to a highly interactive, personalized tablet application. Two studies were cross‐sectional and two collected longitudinal pain data via electronic devices outside the clinical setting. Digital features of the tools included: dynamic testing (n = 2), notifications/prompts (n = 1), data transmission (n = 1), remote monitoring (n = 1), accessibility (n = 1), data visualization/feedback (n = 1), personalization/customization (n = 1), gamification (n = 1) and data labeling (n = 1). Qualitative usability data was only available for one of the tools, which indicated its acceptability and highlighted preferred features/functions by child users (creative and personalizable features, gamification features), and parental users (symptom tracking). This review has highlighted the limited number of digital assessment tools available for children with chronic pain aged 5–11. This review identified some examples of technology enabling the capture of longitudinal, repeated measurement of multiple dimensions of pain (intensity, location, quality). We suggest directions for future research.


Pediatric pain knowledge and attitudes among health care professionals—A National Danish Survey

April 2023

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77 Reads

Aim To explore and compare Danish health‐care professionals’ attitudes and knowledge towards pain management of children. Methods The cross‐sectional study was carried out using the Pediatric Pain Knowledge and Attitudes Questionnaire. The questionnaire was distributed to all health care professionals caring for children in three hospital settings, including nurses and physicians in departments of pediatric, emergency, and anesthesia and medical laboratory technologists. Results The study was conducted in 2020 and 765 health care professionals participated. Within the six main categories included in the questionnaire, there were significant differences between nurses and physicians in three subcategories: view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Comparing nurses with medical laboratory technicians, there were significant differences in the subcategory "view on the care of children in pain." Comparing types of clinical departments, there were significant differences in the subcategories’ view on the care of children in pain, using drugs to relieve pain, and the four mandatories. Overall, we found that the participating health professionals did not have a uniform understanding of pain management and therefore might treat children differently. Conclusion The present study highlights the need to align health care professionals’ knowledge regarding pain assessment and management of children, as well as the need to develop and test interventions that support the use of knowledge in practice.


Specialist Immunization Clinic pathway for “Difficult to vaccinate children”.
Process Map from Intake to Appointment.
The development and evaluation of a vaccination pathway for children with intellectual and developmental disability and needle fear

March 2023

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104 Reads

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3 Citations

This qualitative study describes the development and evaluation of a clinical pathway to facilitate the implementation of catch‐up vaccinations for children with significant needle fear, particularly in children with developmental disabilities. The Specialist Immunization Team, based at a tertiary level teaching children's hospital, participated in process mapping activities using Motivational Interviewing (MI) techniques and reflective discussions. Team members developed a clinical pathway by incorporating parental feedback from semistructured interviews and clinical expertise from within the team, facilitated by colleagues from the Child Development Unit. A process map was developed that included process strengths and touch points with an action plan that was discussed and agreed upon. A repeat process mapping activity was conducted 16 months later. Reports from parental feedback included: positive, efficient, and successful experiences of having their child undergo catch‐up vaccinations. The experience empowered families for further procedures. Team members reported improvements in triaging appropriate children for the pathway, and an increase in confidence to interact and manage behaviors of children with significant anxiety and challenging behaviors. They also reported an increase in successful vaccinations with improved clinical judgment of facilitating the sedation pathway. This study demonstrates that using group facilitation using motivational interviewing in reflective discussions and process mapping utilizing parent and staff feedback in service improvement activities results in efficient and successful service delivery with improved patient outcomes.


Pictorial support in person‐centered care for children with options for the child to create an avatar (a), create a name and choose a pet (b), choose between symptoms (c), assess and report level of symptoms by the use of the electronic Faces Thermometer Scale (d), an open‐ended symptom‐related question (e), use a body map (f), respond to choose pictures of symptoms (g), get an overview of assessment scores (h) and receive suggestions for self‐support (i).
Two examples of the Charleston Pediatric Pain Pictures illustrating a painful situation and its corresponding vignettes.²⁰
Tools used for validation (a) the faces pain Scale‐Revised²⁵ and (b) the Coloured Analogue Scale²⁶
Data collection procedure in the: (a) post‐surgery pain setting and (b) dental pain setting
Psychometric evaluation of the electronic faces thermometer scale for pain assessment in children 8–17 years old: A study protocol

March 2023

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109 Reads

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2 Citations

It is often a challenge for a child to communicate their pain, and their possibilities to do so should be strengthened in healthcare settings. Digital self-assessment provides a potential solution for person-centered care in pain management and promotes child participation when a child is ill. A child's perception of pain assessment differs when it is assessed using digital or analog formats. As we move into the digital era, there is an urgent need to validate digital pain assessment tools, including the newly developed electronic Faces Thermometer Scale (eFTS). This study protocol describes three studies with the overall aim to evaluate psychometric properties of the eFTS for assessing pain in children 8–17 years of age. A multi-site project design combining quantitative and qualitative methods will be used for three observational studies. Study 1: 100 Swedish-speaking children will report the level of anticipated pain from vignettes describing painful situations in four levels of pain and a think-aloud method will be used for data collection. Data will be analyzed with phenomenography as well as descriptive and comparative statistics. Study 2: 600 children aged 8–17 years at pediatric and dental settings in Sweden, Denmark, Iceland, and USA will be included. Children will assess their pain intensity due to medical or dental procedures, surgery, or acute pain using three different pain Scales for each time point; the eFTS, the Faces Pain Scale Revised, and the Coloured Analogue Scale. Descriptive and comparative statistics will be used, with subanalysis taking cultural context into consideration. Study 3: A subgroup of 20 children out of these 600 children will be purposely included in an interview to describe experiences of grading their own pain using the eFTS. Qualitative data will be analyzed with content analysis. Our pilot studies showed high level of adherence to the study procedure and rendered only a small revision of background questionnaires. Preliminary analysis indicated that the instruments are adequate to be used by children and that the analysis plan is feasible. A digital pain assessment tool contributes to an increase in pain assessment in pediatric care. The Medical Research Council framework for complex interventions in healthcare supports a thorough development of a new scale. By evaluating psychometric properties in several settings by both qualitative and quantitative methods, the eFTS will become a well-validated tool to strengthen the child's voice within healthcare.


of the theme “perfect storm.”
of the theme “fighting in the dark.”
of the theme “drawing a line under it.”
“You just want someone to help”: Outcomes that matter to parents when their child is treated for chronic pain

March 2023

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85 Reads

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7 Citations

In children's chronic pain services, healthcare decisions involve a three‐way interaction between the child, their parent or guardian, and the health professional. Parents have unique needs, and it is unknown how they visualize their child's recovery and which outcomes they perceive to be an indication of their child's progress. This qualitative study explored the outcomes parents considered important, when their child was undergoing treatment for chronic pain. A purposive sample of twenty‐one parents of children receiving treatment for chronic musculoskeletal pain, completed a one‐off semi‐structured interview that involved drawing a timeline of their child's treatment. The interview and timeline content were analyzed using thematic analysis. Four themes are evident at different points of the child's treatment course. The “perfect storm” that described their child's pain starting, “fighting in the dark” was a stage when parents focused on finding a service or health professional that could solve their child's pain. The third stage, “drawing a line under it,” changed the outcomes parents considered important, parents changed how they approached their child's pain and worked alongside professionals, focusing on their child's happiness and engagement with life. They watched their child make positive change and moved toward the final theme “free.” The outcomes parents considered important changed over their child's treatment course. The shift described by parents during treatment appeared pivotal to the recovery of young people, demonstrating the importance of the role of parents within chronic pain treatment.


Proportion of patients who received psychosocial interventions by (a) number and (b) type.
Distribution of primary outcomes, all ages combined and by age group.
The certified child life specialist: A novel resource in the pediatric primary care clinic for managing children's pain during routine immunizations

March 2023

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36 Reads

This study evaluated the effect of the Certified Child Life Specialist (CCLS) on pediatric pain and pain management during routine immunization administration in the pediatric primary care clinic. Children 4–12 years of age (n = 125) presenting for a well child physical examination at a rural primary care clinic were selected to receive standard nursing care or standard nursing care plus CCLS support during routine immunization administration. Patient reported pain was measured using the Faces Pain Scale‐Revised (FPS‐R), and patient behavioral responses were measured during immunization administration using the Children's Emotional Manifestation Scale (CEMS). The performance of psychosocial interventions and administration of topical pain‐relieving interventions were measured between both groups. CCLS support was associated with fewer negative emotional behaviors during immunization administration among 7‐ to 12‐year‐old children and a significantly higher provision of psychosocial interventions and topical pain‐relieving interventions among all ages. This study demonstrates that the presence of a CCLS can increase the provision of psychosocial and pain‐relieving interventions and reduce distress during immunization administration in a busy pediatric primary care clinic.


Pain prevalence in the clinical sample.
Prevalence of headaches and abdominal pain (at least once a week) in the clinical sample and the general population sample based on Brun et al.¹⁰
Prevalence of pain in the ESSENCE⁹ and Depression and/or Anxiety Groups.
Prevalence of chronic pain in children and adolescents with psychiatric conditions

February 2023

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116 Reads

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3 Citations

The prevalence of pain in children and adolescents with psychiatric conditions is rarely investigated. The aims of the current study were to (a) describe the prevalence of headaches and abdominal pain in children and adolescents with psychiatric conditions, (b) compare the prevalence of pain in children and adolescents with psychiatric conditions with that in the general population, and (c) investigate the associations between pain experience and different types of psychiatric diagnoses. Families with a child aged 6–15 years who had been referred to a child and adolescent psychiatry (CAP) clinic completed the Chronic Pain in Psychiatric Conditions questionnaire. Information about the child/adolescent's psychiatric diagnosis(es) was extracted from the CAP clinic's medical records. The children and adolescents included in the study were divided into diagnostic groups and compared. Their data were also compared with data of control subjects collected during a previous study of the general population. Abdominal pain was more common among girls with a psychiatric diagnosis (85%) than in the matched control population (62%, p = 0.031). Children and adolescents with neurodevelopmental diagnoses had a higher prevalence of abdominal pain than children and adolescents with other psychiatric diagnoses. Pain conditions in children and adolescents with a psychiatric diagnosis are common and must be addressed.


Parenting Pain Away logo.
Evolution of the homepage design.
Prompt for the quick summary page.
Example of dropdown revision (post Cycle 2).
Parenting Pain Away: Development and usability testing of an educational website about infant procedural pain management

February 2023

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45 Reads

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1 Citation

All newborns undergo minor painful procedures (e.g., injections). Despite strong evidence supporting parents' efficacy to reduce procedural pain (e.g., breastfeeding), parents remain an underutilized resource. Limited evidence‐based resources about infant procedural pain management targeting parents in the perinatal period exist. We co‐created Parenting Pain Away, a website to enhance parents' access to information and participation in procedural pain management following birth. This study aimed to conduct iterative usability testing with the perinatal population to refine Parenting Pain Away based on target users' identified needs and satisfaction. In 2020, parents of healthy newborns or expectant parents from an Atlantic Canadian province, participated in two iterative cycles of usability testing of Parenting Pain Away. Through recorded interviews, participants were directed to use the “Think Aloud” approach (e.g., verbalize what they see, think, feel) as they navigated through the website. Participants completed online questionnaires related to demographics and user satisfaction, measured by the Post Study System Usability Questionnaire (PSSUQ). Descriptive statistics and content analysis were conducted to analyze the data. In total, there were 10 participants with an average age of 29.9 years (SD = 3.9). Participants identified as mothers (n = 7) or fathers (n = 3) and were expecting (n = 6) or had a newborn (n = 4). The PSSUQ overall scores were 1.84 (SD = 0.55) and 1.34 (SD = 0.49) in Cycles 1 and 2, respectively, indicating high user satisfaction on the 7‐point scale. When comparing between the two cycles, the average overall score was lower in Cycle 2, suggesting improved satisfaction. Participants provided positive feedback about the website and suggested major refinements to simplify content and site navigation. Findings from usability testing cycles were used to inform refinements of the Parenting Pain Away in response to participant satisfaction and feedback. Engaging target users in the development process enhanced this website in preparation for further effectiveness testing.


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117 days

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