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Current concepts in management of pain in children in the emergency department
Abstract
Pain is common in children presenting to emergency departments with episodic illnesses, acute injuries, and exacerbation of chronic disorders. We review recognition and assessment of pain in infants and children and discuss the manifestations of pain in children with chronic illness, recurrent pain syndromes, and cognitive impairment, including the difficulties of pain management in these patients. Non-pharmacological interventions, as adjuncts to pharmacological management for acute anxiety and pain, are described by age and development. We discuss the pharmacological management of acute pain and anxiety, reviewing invasive and non-invasive routes of administration, pharmacology, and adverse effects.
Copyright © 2015 Elsevier Ltd. All rights reserved.
... During emergency room stays, invasive procedures are commonly performed for diagnostic and/or therapeutic purposes, which generates an increase in pain and anxiety levels in children [1,2]. Intravenous catheterization, venipuncture or wound sutures are among the most widely used procedures in emergency units globally [3]; at the same time, they are among the most feared by pediatric patients [4] and they increase children's anxiety levels [4][5][6][7]. ...
... On the other hand, the behavior of parents who accompany the child during the procedure and their stay in the emergency department can influence the perception and experience of the situation, which can generate great variability in the perceived intensity of pain and anxiety experienced by children [12][13][14][15]. The emotional response of the parents depends on the experience and the level of anxiety that they themselves feel during the stay in the emergency room and when the procedure is performed, sometimes requiring that health professionals establish strategies to prevent or control negative or blocking situations [1,15]. ...
... They were a total of 3.20 min long and had sequential repetitions [Figs. [1][2][3][4]. ...
Aim: To evaluate the effectiveness of virtual reality to reduce pain and anxiety in pediatric patients during venipuncture procedure in emergency care and the behavioral response of their parents/companions. Background: Virtual reality is being used as a source of distraction in children undergoing invasive procedures. Methods: Quasi-experimental study with 458 children (from 2 to 15 years) who attended a pediatric emergency service from September 2019 to April 2021. An intervention based on virtual reality as a distraction method during venipuncture procedure was applied. The level of pain and anxiety of children and attitude of parents/ companions were assessed. Ordinal and binary logistic regressions were applied. Results: A protective effect of using virtual reality was observed in the intervention group both for the absence of pain (− 4.12; 95 % CI: − 4.85 to − 3.40) and anxiety (− 1.71; 95 % CI: − 2.24 to − 1.17) in children aged between 2 and 15 years. A significant reduction in the blocking response of the accompanying parents (− 2.37; 95 % CI: − 3.017 to − 1.723) was also observed. Conclusions: VR is effective in reducing pain and anxiety in children during venipuncture in emergency care. A positive attitude of the parents during the invasive procedure to their children was found.
... This acute pain related to care can have long-term negative consequences for children, such as phobic behavior towards care and caregivers. Different methods and products are recommended for the prevention and relief of pain associated with care in children [1,2]. Nitrous oxide is the reference product to prevent pain related to painful procedures and care. ...
... However, the small elastic modulus of mucin can be considered negligible when compared to the elastic modulus of polymer [24]. Equation (2) was simplified, and rheological synergism parameters were calculated using the following equation: ...
... This new formulation of (S)-ketamine is a promising alternative to address acute pain. The transmucosal route is interesting (1) to increase the bioavailability of a drug sensitive to first-pass metabolism, (2) to increase the onset of action when compared to per os administration, and (3) to avoid tissue infraction caused by IV or IM injections and thus superimposed pain and distress. ...
(S)-ketamine presents potential for the management of acute pain and, more specifically, for the prevention of pain associated with care. However, the administration route can be a source of pain and distress. In this context, a smart formulation of (S)-ketamine was designed for buccal administration. The combination of poloxamer 407 and sodium alginate enables increased contact with mucosa components (mucins) to improve the absorption of (S)-ketamine. In this study, rheological studies allowed us to define the concentration of P407 to obtain a gelling temperature around 32 °C. Mucoadhesion tests by the synergism method were carried out to determine the most suitable alginate among three grades and its quantity to optimize its mucoadhesive properties. Protanal LF 10/60 was found to be the most effective in achieving interaction with mucins in simulated saliva fluid. P407 and alginate concentrations were set to 16% and 0.1%. Then, the impact of P407 batches was also studied and significant batch-to-batch variability in rheological properties was observed. However, in vitro drug release studies demonstrated that this variability has no significant impact on the drug release profile. This optimized formulation has fast release, which provides potential clinical interest, particularly in emergencies.
... Pain is a common symptom in children receiving hospital care [1]. Optimal pain treatment in children and adolescents is of the utmost importance, as inadequately managed acute pain can lead to chronic pain [2,3] or posttraumatic stress symptoms [4]. ...
... Non-pharmacological methods, such as psychological support and information, distraction, relaxation, massage and heat/cold therapy, are treatments used in children with acute and postoperative pain as well as with persistent disease-related and chronic pain [1,7,8,16,17]. A multimodal analgesic regimen consisting of two or more medications is recommended for children with persistent disease-related pain [17], as well as for those with acute and postoperative pain [1,8,16]. ...
... Non-pharmacological methods, such as psychological support and information, distraction, relaxation, massage and heat/cold therapy, are treatments used in children with acute and postoperative pain as well as with persistent disease-related and chronic pain [1,7,8,16,17]. A multimodal analgesic regimen consisting of two or more medications is recommended for children with persistent disease-related pain [17], as well as for those with acute and postoperative pain [1,8,16]. A variety of analgesic medications and techniques that target different mechanisms in the peripheral and/or central nervous system can provide more effective pain relief compared with single-modality interventions [8]. ...
Background
Pain is a common symptom in children receiving hospital care. Adequate pain management in paediatric patients is of the utmost importance. Few studies have investigated children’s own experiences of pain during hospitalization.
Aim
To describe the prevalence of pain, self-reported pain intensity at rest and during movement, pain management and compliance with pain treatment guidelines in children and adolescents receiving hospital care. Furthermore, to examine self-reported statements about pain relief and how often staff asked about pain.
Methods
A quantitative, cross-sectional study with descriptive statistics as the data analysis method was conducted at a county hospital in western Sweden. Sixty-nine children/adolescents aged 6–18 years who had experienced pain during their hospital stay were included. A structured, verbally administered questionnaire was used to obtain pain reports. The participants were also asked what they considered alleviated pain and how often they told staff about pain. Patient demographics, prescribed analgesics and documentation of pain rating were obtained from medical records.
Results
Fifty children/adolescents (72%) experienced moderate to severe pain in the previous 24 hours. At the time of the interview 36% reported moderate to severe pain at rest and 58% during movement. Seven participants (10%) reported severe pain both at rest and during movement. About one-third were on a regular multimodal analgesic regimen and 28% had used a validated pain rating scale. Thirty children/adolescents (43%) reported that they had experienced procedural pain in addition to their underlying pain condition. Most of the children/adolescents (74%) reported that analgesics provided pain relief. Forty (58%) stated that various non-pharmacological methods were helpful.
Conclusions
Despite evidence-based guidelines, half of the children/adolescents experienced moderate to severe pain, highlighting the need for improvement. Pain levels should be assessed both at rest and during movement. Response to treatment should be evaluated to prevent undertreatment of pain. Compliance with guidelines and professional communication are of the utmost importance for pain management in children/adolescents. Non-pharmacological methods are a valuable part of a pain management strategy. This study shows that it is important to evaluate and improve pain care also outside specialised tertiary clinics.
... According to the literature, the common active distraction techniques include interactive computer or video games, controlled breathing, bubble-blowing, guided imagery, singing, ball squeezing, drawing, coloring, and playing with play dough. The reported passive distraction techniques, in turn, include watching cartoons or animations using a tablet or virtual reality glasses, listening to music, sound, or fairy tales/ stories with headphones, watching puppet plays, smelling lavender essential oil, and watching luminous toys (Alemdar & Aktaş, 2019;Bellieni et al., 2006;Birnie et al., 2018;Bradford et al., 2019;Bukola & Paula, 2017;Koller & Goldman, 2012;Krauss et al., 2016;Lambert et al., 2020;McCarthy & Kleiber, 2006). ...
... Studies in the literature show that active and passive distraction techniques are effective in reducing pain, anxiety, and fear (Birnie et al., 2018;Bradford et al., 2019;Cheraghi et al., 2021;Düzkaya et al., 2021;Erdogan & Ozdemir, 2021;Girgin & Göl, 2020;Hsieh et al., 2017;Krauss et al., 2016). Bubble-blowing, an active distraction technique, provides multisensory stimuli as visual, tactile, and kinesthetic, and cartoon watching, a passive distraction technique, as auditory and visual (Koller & Goldman, 2012;Krauss et al., 2016). ...
... Studies in the literature show that active and passive distraction techniques are effective in reducing pain, anxiety, and fear (Birnie et al., 2018;Bradford et al., 2019;Cheraghi et al., 2021;Düzkaya et al., 2021;Erdogan & Ozdemir, 2021;Girgin & Göl, 2020;Hsieh et al., 2017;Krauss et al., 2016). Bubble-blowing, an active distraction technique, provides multisensory stimuli as visual, tactile, and kinesthetic, and cartoon watching, a passive distraction technique, as auditory and visual (Koller & Goldman, 2012;Krauss et al., 2016). However, there is a lack of evidence in the literature regarding studies comparing the effects of these techniques. ...
Purpose
This study aimed to compare the effects of bubble-blowing (active distraction) and cartoon watching (passive distraction) techniques on pain, anxiety, and fear during venipuncture in children aged 6–8 years.
Design and methods
This experimental study randomly assigned 56 children aged 6–8 years to cartoon watching or bubble-blowing groups. The child, parent, and researcher assessed pain using the Wong-Baker FACES Pain Rating Scale, anxiety using the Children's State Anxiety Scale, and fear using the Children's Fear Scale. The study data were analyzed using the Chi-square tests and independent Sample t-tests.
Results
The groups were similar in clinical and demographic characteristics. The scores on pain, anxiety, and fear during the procedure were lower in the cartoon watching group than in the bubble-blowing group (pain t(47) = 2.638, p = .013; anxiety t(47) = 2.358, p = .023; and fear t(47) = 2.784, p = .008).
Conclusion
This study revealed that cartoon watching as a passive distraction method was more effective in reducing pain, anxiety, and fear during venipuncture in children aged 6–8 years compared to bubble-blowing as an active distraction method.
Practice implications
The cartoon watching technique, which is affordable, easy to access, and effective (in reducing pain, anxiety, and fear), can be safely used during venipuncture in children aged 6–8 years.
... The performance of invasive procedures, both diagnostic and therapeutic in pediatric patients in the hospital environment is very frequent-with venipuncture and intravascular cannulation techniques being predominant (Cardozo Rodrígez and Escobar Valdivia 2020). These techniques cause pain in children (Krauss et al. 2016;Toledo del Castillo et al. 2019) and even generate situations of stress and anxiety, both in the patient and their carers (Ali et al. 2015;Bradford et al. 2019;Eijlers et al. 2019). ...
... Some of these factors are: age (Figueroa Jaramillo 2015;Hedén et al. 2020), gender and the patient's personal circumstances and surroundings (Berke et al. 2017;Filingim 2017;Sorge and Totsch 2017). Other clearly linked factors are the behavior of parents or guardians (Casanovas 2017;Harding et al. 2019;Krauss et al. 2016), and the behavior of the professionals who assist them (Ferraz-Torres et al. 2021;Krauss et al. 2016;Svendsen et al. 2016). Accordingly, the level of anxiety experienced by both children and parents during the procedure can also cause stress and / or anguish in health professionals (Ali et al. 2015), constraining their performance and the development of the technique or procedure (Santos et al. 2020). ...
... Some of these factors are: age (Figueroa Jaramillo 2015;Hedén et al. 2020), gender and the patient's personal circumstances and surroundings (Berke et al. 2017;Filingim 2017;Sorge and Totsch 2017). Other clearly linked factors are the behavior of parents or guardians (Casanovas 2017;Harding et al. 2019;Krauss et al. 2016), and the behavior of the professionals who assist them (Ferraz-Torres et al. 2021;Krauss et al. 2016;Svendsen et al. 2016). Accordingly, the level of anxiety experienced by both children and parents during the procedure can also cause stress and / or anguish in health professionals (Ali et al. 2015), constraining their performance and the development of the technique or procedure (Santos et al. 2020). ...
Invasive techniques such as venipuncture are painful procedures causing stress and anxiety, both in pediatric patients and in their carers. For this reason, efforts are being made to develop mitigating strategies for the patient’s pain and anxiety during the performance. To analyze and evaluate the effectiveness of the use of Virtual Reality distraction techniques as a measure of pain and anxiety reduction in pediatric patients and their parents. In addition, the effects of two modes of Virtual Reality (passive vs. interactive) were compared. A quasi-experimental study was carried out in the pediatric emergency department of a tertiary referral hospital in north Spain. The participants were children who underwent venipuncture for blood extraction and vascular cannulation. From the 124 patients, 51.6% ( n = 64) were girls and 48.4% ( n = 60) were boys ( p = 0.574). The mean age was 8.4 years (SD: 4.1). The mean level of pain experienced was 2.33 (SD: 0.76) in the interactive VR group ( n = 88) versus 2.67 (SD: 1.35) in patients with passive VR ( n = 36) ( p = 0.008); being the presence of anxiety in 27.3% ( n = 24) of the cases treated with interactive Virtual Reality and in 88.9% ( n = 32) of the patients with passive Virtual Reality ( p = 0.000). The virtual reality is an effective method to reduce pain and anxiety levels in pediatric patients, with the effectiveness of interactive virtual reality and its use in the population aged 7–15 years being greater.
... Pain is a common symptom in children presenting to emergency departments [1]. Oligo-analgesia-under treatment of pain-is frequently reported in children, particularly in the younger age group [1]. ...
... Pain is a common symptom in children presenting to emergency departments [1]. Oligo-analgesia-under treatment of pain-is frequently reported in children, particularly in the younger age group [1]. Under treatment of pain has also been shown to exist even in conditions associated with severe pain such as fractures [2,3]. ...
... Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia-an enhancement of the pain response [1]. Policy statements of pain and pediatric and emergency societies endorse the appropriate treatment of children's pain as a key part of emergency department (ED) clinical care [4][5][6][7]. ...
Under treatment of pain is frequently reported in children even in conditions associated with severe pain such as fractures. Recent literature supports adequate and early pain treatment because extreme and uncontrolled pain can lead to hyperalgesia. Since 2017, the treatment of pediatric orthopedic cases in the “Meir” Medical Center was gradually shifted from the orthopedic general emergency department to the pediatric emergency department. The objective was to examine the differences in pain management between the orthopedic and pediatric emergency departments. Upper limb fractures were chosen as a representing case. This retrospective cohort study included children aged 0–18 years that suffered from an upper limb fracture and were admitted to the emergency department in the years 2016 and 2018. In our study, a total of 2520 children suffered from an upper limb fracture and were treated at the Meir Medical Center during the study period. 959 of these children were treated during 2016 in the general emergency department, and 1561 were treated in the pediatric emergency department during 2018. The group characteristics were similar. In the pediatric emergency department compared to general emergency department group, more children received analgesic treatment (47.85% versus 30.4%, p < .001), more opiates were given (13.9% versus 5.3%, p < .001), and the analgesic treatment was more adequate to pain severity. Additionally, sedation was performed more frequently in the pediatric emergency department (21.6% versus 9.5%, p < .001), especially for dislocated fractures (81.5% versus 31.4%, p < .001). Complications: Length of stay, surgery, hospitalization, and recurrent referral rates were similar between the two groups.
Conclusions: The transfer of orthopedic pediatric cases to the pediatric emergency department showed a notable improvement in pain management without an increase in complications or emergency department length of stay.
What is Known:
• Pain management and control is a major issue to address in their treatment.
• Traumatic injuries and especially fractures are common causes for ED admissions.
What is New:
• Comparing pain management and upper limb fractures treatment between general and pediatric ED.
• Pain is better treated in the PED than in the GED, without an increased rate of complications.
... Pain is a common symptom of children who attend emergency departments, which is often under-treated in younger children, those in developing countries and those with cognitive impairment (Krauss et al., 2016). There are several notable differences when comparing pain management in children in emergency departments and ambulance services. ...
... There are typically more staff to share the decision-making load in emergency departments. Emergency departments have a wide variety of analgesics available for administration via different routes including oral, intravenous and nasal (Krauss et al., 2016), whereas relatively few analgesics (four: paracetamol, ibuprofen, Entonox® and morphine) are available for ambulance clinicians in the UK (Joint Royal Colleges Ambulance Liaison Committee. Association of Ambulance Chief Executives, 2019a). ...
... Scott et al. (2013) concluded by stating that pain assessment and management in emergency departments was challenging, in part due to organisational and system requirements that increase time to analgesia. In addition to this, assessing pain for all children aged 0-15 years using a behavioural observational tool might not accurately reflect the patient's true experience of pain, as the use of self-report pain scales where children are old enough to comply effectively are considered the gold standard (Krauss et al., 2016). A similar study was performed recently in the UK, introducing a care bundle to improve pain management in children in emergency departments and minor injury units, however the authors concluded that although small improvements were made, overall the level of pain management still fell below expected standards (Treadgold et al., 2019). ...
Download thesis at: https://eprints.lincoln.ac.uk/id/eprint/45827/
Background
Pain is a highly complex sensory and emotional experience; the biological, psychological and social aspects must each be considered. The intersection between the phenomenon of pain, the unpredictable pre-hospital environment and children is highly convoluted. Studies have shown that pre-hospital pain management in children is poor, despite access to pain management being considered a fundamental human right. Without effective pain treatment, children may suffer long-term psychological changes (e.g. altered pain perception) and are at risk of developing post-traumatic stress disorder. The aim of this thesis was to identify predictors, barriers and facilitators associated with effective pre-hospital pain management in children suffering acute pain and to identify ways to improve the quality of care.
Methods
A postpositivist paradigm was adopted for the study, with a critical realist ontology and a modified objectivist epistemology. A mixed methods sequential explanatory design was adopted, informed by a systematic mixed studies review. The initial quantitative study employed a multivariable logistic regression analysis using routinely collected clinical data to identify predictors of effective pain management. The final qualitative study used face-to-face semi-structured interviews with ambulance clinicians to help explain the identified predictors, identify barriers and facilitators and explore ways to improve the quality of care. Interviews were audio recorded and transcribed verbatim with thematic analysis used to analyse the data.
Results
The systematic mixed studies review included 13 studies (8 quantitative and 5 qualitative) and highlighted the importance of analgesic administration. The initial quantitative study included 2312 clinical records; only 39% of children suffering acute pain achieved effective pain management. Predictors of effective pain management included children who were younger, administered analgesics, attended by a paramedic or living in an area of low or medium deprivation. The final qualitative study included 12 ambulance clinicians (9 paramedics and 3 emergency medical technicians) who provided possible explanations for these disparities. Novel barriers and facilitators were also identified along with ways to improve pain management. Meta-inferences were developed which provided a more comprehensive understanding of this complex phenomenon. To improve pre-hospital pain management in children, the following recommendations were made; 1) explore methods to increase rates of analgesic administration, perhaps by utilising the intranasal and inhaled route; 2) reduce fear and anxiety in children, perhaps by using child friendly uniform, non-pharmacological techniques and more public interaction and 3) reduce fear and anxiety in clinicians, by enhancing training, optimising crew mix and developing a more pragmatic pain assessment tool. A theoretical model of pre-hospital pain management in children was developed as part of this thesis.
Conclusion
Pre-hospital pain management in children may be improved by increasing rates of analgesic administration and reducing the fear and anxiety experienced by children and clinicians. Future research should explore the experience of the child and determine the most important outcome measures. Robust clinical trials are needed to determine the efficacy and safety of intranasal (fentanyl/ketamine) and inhaled (methoxyflurane) analgesics in the pre-hospital setting. Investment in future research and intervention development is imperative; we need to make children’s pain in the pre-hospital setting matter.
... Pain in children is different from that witch experienced in adult [10], variations are also noted in children according age; young children cannot verbalize their pain experience [12]. Besides, parents can be affected by their children pain and increase children's anxiety [13], [14]. ...
... The assessment of pain in children needs use of several behavioral scales [12]. Numerical scales are not suitable for non-verbal infants, the good pain evaluation of pain in young children includes. ...
... The pain can be managed and controlled by different ways. Non-pharmacological approaches can be employed for acute pain [12]. Many interventions are possible depending of age and patient capacity to cooperate, children can benefit from distracting activities, music, plays, interactive games, books, virtual reality, and hypnosis. ...
AIM: The aim of the study was to improve the quality of pain management in Moroccan pediatric oncology units, the Moroccan Society of Paediatric Haematology/Oncology initiated a national quality improvement project in 2014 with the support of the Lalla Salma Foundation for Prevention and Treatment of Cancer. METHODS: To assess the current situation of pain management in Moroccan pediatric oncology patients, two cross-sectional surveys were conducted, involving patient/parental proxies and health-care providers’. RESULTS: The first survey concerned 108 care providers from five institutions. The second survey covered 155 children with cancer from the five Moroccan pediatric oncology units. Among them, 145 reported suffering from pain, which patients/families attributed to the underlying cancer (n = 85), to procedures and treatment (n = 46), or to both the cancer and procedures/treatment (n = 19). Procedural pain was mainly related to lumbar puncture and bone marrow aspirate. The majority of patients/parents reported that pain negatively impacted their emotional, physical, and social functioning. The majority of parents requested further information and communication about pain management. CONCLUSION: Both health-care providers and families of children with cancer in Morocco report need for pain management improvement, including in institutional and educational practices. This current baseline data have informed the development of our ongoing project including continuing education, training, and practice policies development.
... 1 Notwithstanding low child mortality, even in high-income country's quality of care (QOC) for children and adolescents is still a challenge in many settings. [2][3][4][5][6][7][8][9][10][11] Evidence suggest that key gaps in the quality of inpatient child healthcare in highincome and upper middle-income countries include inappropriate hospitalisations, medical errors, drugs over-use, inadequate pain management and unsatisfactory patient Strengths and limitations of this study ► This study describes the development and validation of tools to assess perceived quality of care from the perspective of service providers and users, based on the 'WHO Standards to Improve the Quality of Care for Children and Young Adolescents at Facility Level'. ► The major strength of the tools is the multiphase approach used for their development, which aimed at assessing different properties of the questionnaires, including: content validity-assessed with the contribution of both experts and end users-face validity, acceptability, perceived utility and comprehensiveness, reliability and internal consistency assessed in volunteers. ...
... Open access experience of care. [2][3][4][5][6][7][8][9][10] For example, a recent report from the WHO highlights extreme variations in paediatric hospitalisation rates across Europe, ranging from 150 to 550 per thousand population, suggesting inequity in healthcare. 2 Multicountry surveys and systematic reviews 4 5 report antibiotic prescription rates of up to 60%-75% for common paediatric conditions such as fever, upper respiratory tract infections and diarrhoea, driving high healthcare costs and increasing the risk of antibiotic resistance. 6 7 On the other hand, pain prevention and treatment for children continues to be suboptimal, with a need for wider implementation of both pharmacological and non-pharmacological interventions. ...
Objectives Evidence showed that, even in high-income countries, children and adolescents may not receive high quality of care (QOC). We describe the development and initial validation, in Italy, of two WHO standards-based questionnaires to conduct an assessment of QOC for children and young adolescents at inpatient level, based
on the provider and user perspectives.
Design: Multiphase, mixed-methods study.
Setting: participants and methods The two questionnaires were developed in four phases equally conducted for each tool. Phase 1 which included the prioritisation of the WHO Quality Measures according to predefined criteria and the development of the draft
questionnaires. In phase 2 content face validation of the draft questionnaires was assessed among both experts and end-users. In phase 3 the optimised questionnaires
were field tested to assess acceptability, perceived utility and comprehensiveness (N=163 end-users). In phase 4 intrarater reliability and internal consistency were
evaluated (N=170 and N=301 end-users, respectively).
Results The final questionnaires included 150 WHO Quality Measures. Observed face validity was excellent (kappa value of 1). The field test resulted in response
rates of 98% and 76% for service users and health providers, respectively. Among respondents, 96.9% service users and 90.4% providers rated the questionnaires as
useful, and 86.9% and 93.9%, respectively rated them as comprehensive. Intrarater reliability was good, with Cohen’s kappa values exceeding 0.70. Cronbach alpha
values ranged from 0.83 to 0.95, indicating excellent internal consistency.
Conclusions: Study findings suggest these tools developed have good content and face validity, high acceptability and perceived utility, and good intrarater reliability and internal consistency, and therefore could be used in health facilities in Italy and similar contexts.
Priority areas for future research include how tools measuring paediatric QOC can be more effectively used to help health professionals provide the best possible care.
... Pain is both common and undertreated among children undergoing medical procedures (Birnie et al., 2014(Birnie et al., , 2018. Inadequate pain treatment is frequently reported, particularly for younger children, children with cognitive impairments, and children in developing countries (Krauss et al., 2016). The results of several epidemiological surveys have consistently highlighted that despite improvements in pain management in recent years, a high percentage (up to 86%) of hospitalised children still experience pain and receive inadequate pain management (Friedrichsdorf et al., 2015;Kozlowski et al., 2014;Postier et al., 2018;Twycross & Collis, 2013;Walther-Larsen et al., 2017). ...
... However, because of side effects and postoperative complications, some researchers have recommended reducing the administration of pain medication (Ferland et al., 2018;Pancekauskaitė & Jankauskaitė, 2018). Consequently, several nonpharmacological treatments have attracted wide attention to reduce pain, such as distraction, hypnosis, combinations with cognitive behaviour therapy (CBT) and breathing interventions (Birnie et al., 2018;Chambers et al., 2009;Krauss et al., 2016). Clown intervention, as a form of nonpharmacological therapy that aims to provide humour-based distractions to improve the mood of paediatric patients and reduce their pain, is gaining attention and more widespread use (Dionigi, 2017;Manyande et al., 2015;Pancekauskaitė & Jankauskaitė, 2018). ...
Background
Pain is common in children receiving medical procedures, and there is a lack of adequate awareness and management. In addition, children who undergo medical procedures involving pain may also experience stress, crying and prolonged hospitalisation. Clown intervention is a promising nonpharmacological intervention. However, studies on the effectiveness of clown intervention in pain management have reported conflicting findings.
Objective
To evaluate the effectiveness of clown intervention in relieving pain in children, as well as its effects on cortisol levels, crying duration and length of hospital stay.
Design
Systematic review and meta-analysis of randomised controlled studies.
Data sources
PubMed, Web of Science (SCI), Embase, PsycINFO, the Cochrane Library, Chinese National Knowledge Infrastructure (CNKI), Weipu (VIP), Wanfang Data and SinoMed were systematically searched from inception date to December 31, 2020.
Review methods
Two reviewers independently used the Cochrane risk of bias tool to assess the risk of bias of the included studies. Meta-analysis was conducted when data were available, otherwise, a narrative description was provided. Data were analysed using Review Manager 5.3. The review process is reported according to PRISMA.
Results
Nine studies including 852 children met the inclusion criteria. The results showed that compared with standard care, clown intervention was beneficial for relieving pain. Further subgroup analysis showed that it was more effective with children aged 2–7 years. The duration of crying after the procedure and the length of stay were shortened, but there was no significant difference in cortisol levels.
Conclusion
Clown intervention may be a promising way to relieve acute pain in children, especially those aged 2–7 years. It also seems to shorten the duration of crying and the length of hospital stays, but the effect on cortisol levels is still uncertain. More high-quality randomised controlled trials are needed to confirm these results and take into account different age groups, cultural backgrounds and specific populations.
... [7][8][9][10][11] While significant progress has been achieved in the form of ageappropriate assessment tools and evidence-based effective treatments, children's pain often remains undertreated. 4,[12][13][14][15][16][17] The province of Alberta has a population of 4.1 million individuals. 18 Approximately 55% of the population lives in two large metropolitan areas (Edmonton and Calgary), while the rest of the population is distributed across a broad geographic area. ...
... Techniques and interventions, like family presence during the procedure, positioning, cognitive-behavioral interventions or staff communication skills, can be easily taught and adapted to a variety of ED settings, and therefore it may be wise to strengthen these abilities among ED staff. [13][14][15]17 There is a wide range of medications available at the Alberta EDs, including topical anesthetics. Current evidence already indicates the advantages of topical anesthetics at the ED, including higher success rates for procedures, shorter procedure times and less pain. ...
Purpose:
Many rural and community emergency departments (EDs) experience barriers to providing optimal pain care to children. In preparation for a quality improvement initiative, our team conducted a provincial pediatric pain management practice and needs assessment.
Methods:
An online survey was sent to ED administrators and educators from March to May 2017. Themes included pain assessment, pain and distress management strategies, available resources, education, barriers to care, and opportunities for improvement.
Results:
Forty-five respondents, from 31 EDs representing all five geographic health zones in Alberta, completed the survey. Use of a pain assessment tool was reported at 93.5% (29/31 sites) of the sites. Topical anesthesia was employed "most of the time" before suturing at 67% (18/27) of sites, versus 15% (4/27) before blood work or IV insertion. Eighty-one percent (22/27) of sites reported physically restraining children for procedures "often", while 37% (10/27) reported use of comfort positioning "often". Digital distraction devices were available at 37% (10/27) of sites. Reported challenges included lack of resources (33.3%, 12/36), staff education/knowledge (33.3%, 12/36), and absent policies/poor policy adherence (25.0%, 9/36). Opportunities for improvement included staff member education (73.5%, 25/34) and more resources (58.8%, 20/34). Respondents rated their site's overall ability to manage children's pain as 50/100 [IQR:21,61].
Conclusion:
General EDs report providing suboptimal children's pain care, with use of physical restraint for medical procedures, and under-utilization of evidence-based, inexpensive treatment options. There are many gaps in children's pain care in rural and community EDs which could be addressed through collaborative quality improvement initiatives.
... Massage therapy may reduce pain and anxiety among children with cancer [49,50]. There is also growing evidence regarding skin-to-skin contact especially to reduce procedural pain in neonates and infants [51][52][53][54]. ...
... Especially the answers to the open questions were able to map that the responding experts put a special emphasis on the differences in pain presentation and handling with a pediatric population compared to adults. Pediatric patients should not be treated like small adults, they need a specialized assessment and management [54,58], and an adequate interaction and communication between therapists-child -parents is imperative [59,60]. ...
Specialization training for physiotherapists, occupational therapists, and sports therapists involved in pediatric pain is scarce and curricula are rarely published. The objectives of this study are twofold: firstly, to perform a scoping review to derive important contents for a pediatric pain education curriculum for specialized pain therapists. Secondly, to conduct a survey on specific contents in curricula currently used by pain experts and to obtain their evaluation regarding the importance of such contents for a specialized curriculum. The review substantiated the importance of a specific curriculum in pediatric pain education, but provided little information on adequate contents. In the survey, 45 experts in pediatric pain education confirmed that specific curricula and specialized contents for pediatric pain education are missing. Their answers give a well-defined picture of the specifics needed in the interaction with a pediatric population. The most important items they classified were e.g., the biopsychosocial framework and the impact of pediatric pain on daily life. Those expert ratings were in line with the recommendations of pediatric pain management guidelines. Further curriculum work in an interdisciplinary, international network is highly recommended.
... O tratamento e alívio da dor é direito da criança e deve ser considerada sua faixa etária e seu nível cognitivo, visto que os autorrelatos frente às queixas de dor podem ser um indicativo importante e fidedigno de um episódio de dor. Além disso, a crença de que crianças não respondem e nem possuem lembranças das experiências dolorosas anteriores é falsa 8 . E é fundamental que a dor em crianças seja adequadamente identificada, avaliada e, sobretudo, tratada, o que ainda é uma tarefa complexa para a equipe de saúde 9 . ...
... Quando tratamos de métodos de avaliação da dor podemos citar medições fisiológicas, medições comportamentais, auto relatos e instrumentos multidimensionais apropriados para cada criança, para que possamos melhor avaliar as manifestações de dor 8 . ...
The objective of the study was to understand the criteria used by the nursing team to assess the pain of children hospitalized in a PICU. This is a qualitative study, targeting the Nursing team of a PICU at an inland hospital of the State of São Paulo. Focus groups were held alternating on odd and even days. The data was analyzed using Thematic Analysis proposed by Bardin. The analysis resulted in two categories, the first: "Experiencing the multidimensionality of children's pain: projections and feelings" and the second: "Pediatric pain assessment: care to be improved". Therefore, the interviewees understand the concept of pain in a specific way and do not use standardized criteria for pain assessment, which generates non-systematic assistance in the management of pain in hospitalized children.
... It is a known fact that a proportion of children who access the pediatric ED live a painful and unpleasant experience [1,9,10], not only related to the reason of the medical consultation, but also due to medical procedures performed during the clinical evaluation and treatment. At the same time, pain is one of the most frequent reasons of referral to pediatric EDs, especially in younger children and in those with special needs, a category in which undertreatment of pain (the so-called "oligoanalgesia") is very frequent [1,11,12]. Given that oligoanalgesia is related to long-terms negative behavioral and psychological consequences, [1,13,14] and that the management of pain and anxiety could help the entire medical team in the evaluation and treatment of a child, we identify this gap as a major source of potential improvement, in a continued effort to make pediatric EDs pain-free or at the very least free of iatrogenic traumatic experiences. ...
To date, pain and anxiety are the most common symptoms reported by children who refer to pediatric emergency department. Despite it is well known that the undertreatment of this condition has some negative consequences in a short term and long term of time, gaps in the management of pain in this setting still persist. This subgroup analysis aims to describe the current state of art of pediatric sedation and analgesia in Italian emergency departments and to identify existing gaps to solve. This is a subgroup analysis of a cross-sectional European survey of pediatric emergency departments sedation and analgesia practice undertaken between November 2019 and March 2020. The survey proposed a case vignette and questions addressing several domains, like the management of pain, availability of medications, protocols and safety aspects, staff training and availability of human resources around procedural sedation and analgesia. Italian sites responding to the survey were identified and their data were isolated and checked for completeness. Eighteen Italian sites participated to the study, the 66% of which was represented University Hospitals and/or Tertiary Care Centers. The most concerning results were an inadequate sedation to 27% of patients, lack of availability of certain medications like nitrous oxide, the lack of use of intranasal fentanyl and topical anesthetics at the triage, the rare use of safety protocols and preprocedural checklists, lack of staff training and lack of space. Furthermore, the unavailability of Child Life Specialists and hypnosis emerged. Despite procedural sedation and analgesia in Italian pediatric emergency departments is progressively more used than previously, several aspects still require an implementation. Our subgroup analysis could be a starter point for further studies and to improve and make the current Italian recommendations more homogeneous.
... According to the recommended posology, and following the Italian Drug Agency (AIFA) indications, we decided to give a dose of 10 mg/kg of ibuprofen with a maximum of 600 mg [20] and 0.5 mg/kg of ketorolac with a maximum of 10 mg [6]. We are fully aware that the single dose of ketorolac may be 30 mg, as this was the maximum quantity administered in previous investigations that employed sublingual ketorolac [7,19]. ...
This study is to compare ibuprofen and ketorolac for children with trauma-related acute pain. We conducted a multicentre randomized, double-blind, controlled trial in the Paediatric Emergency Department setting. We enrolled patients aged 8 to 17 who accessed the emergency department for pain related to a limb trauma that occurred in the previous 48 h. At the admission, patients were classified based on numeric rating scale-11 (NRS-11) in moderate (NRS 4–6) and severe (NRS 7–10) pain groups. Each patient was randomized to receive either ibuprofen (10 mg/kg) or ketorolac (0.5 mg/kg) and the placebo of the not given drug in a double dummies design. NRS-11 was asked every 30 min until 2 h after drug and placebo administration. The primary outcome was NRS-11 reduction at 60 min. Among 125 patients with severe pain, NRS-11 reduction after 60 min from drug administration was 2.0 (IQR 1.0–4.0) for ibuprofen and 1.0 (IQR 1.0–3.0) for ketorolac (p = 0.36). Ibuprofen was significantly better, considering secondary outcomes, at 90 min with a lower median of NRS-11 (p 0.008), more patients with NRS-11 less than 4 (p 0.01) and a reduction of pain score of more than 3 NRS-11 points (p 0.01). Among 87 patients with moderate pain, the NRS-11 reduction after 60 min from drug administration was 1.63 (± 1.8) for ibuprofen and 1.8 (± 1.6) for ketorolac, with no statistically significant difference.Conclusions: Oral ibuprofen and ketorolac are similarly effective in children and adolescents with acute traumatic musculoskeletal pain.Trial registration: ClinicalTrial.gov registration number: NCT04133623.
What is Known:
• Limb trauma is one of the most common causes of paediatric emergency department visits. Non-steroidal anti-inflammatory drugs are the most frequently used analgesics in this clinical setting.
In particular ibuprofen is the first over the counter non-steroidal anti-inflammatory drug in terms of use. Ketorolac is considered the most effective non-steroidal anti-inflammatory drug for severe pain.
What is New:
• This study directly compared oral ibuprofen and ketorolac for moderate and severe acute traumatic pain in children and adolescents. Both drugs were similarly effective in children and adolescents with severe pain, and ketorolac was not superior to Ibuprofen for moderate pain.
... Les mesures d'observation de la douleur L'évaluation de signes comportementaux comme l'expression faciale, les pleurs (ou cris), l'irritabilité, l'alimentation insuffisante, les troubles du sommeil et l'inactivité peuvent contribuer à décoder le taux d'inconfort de l'enfant qui est au stade préverbal ou qui est non verbal (21). Des fluctuations des signes vitaux peuvent être corrélées avec la douleur chez le nourrisson, mais ne constituent pas des indicateurs fiables chez les enfants plus âgés (4,21,22). Notamment, l'absence de fluctuations des signes vitaux n'est pas indicatrice de l'absence de douleur chez l'enfant. ...
Résumé
L’évaluation et le traitement de la douleur sont des aspects essentiels des soins pédiatriques. L’évaluation de la douleur adaptée au développement représente une première étape importante pour en optimiser la prise en charge. L’autoévaluation de la douleur est à prioriser. Si c’est impossible, des outils appropriés d’évaluation du comportement, adaptés au développement, doivent être utilisés. Des directives et stratégies de prise en charge et de prévention de la douleur aiguë, qui combinent des approches physiques, psychologiques et pharmacologiques, doivent être accessibles dans tous les milieux de soins. Le meilleur traitement de la douleur chronique fait appel à une combinaison de modalités thérapeutiques et de counseling, dans l’objectif premier d’obtenir une amélioration fonctionnelle. La planification et la mise en œuvre de stratégies de prise en charge de la douleur chez les enfants doivent toujours être personnalisées et axées sur la famille.
... For pre-verbal and non-verbal children, evaluating behavioural signs such as facial expression, cry, irritability, poor feeding, sleep disturbance, and inactivity can help decode a child's discomfort level (21). Changing vital signs may be correlated with pain in infants, but are not reliable indicators in older children (4,21,22). Notably, an absence of change in vital signs does not indicate lack of pain in children. ...
Pain assessment and management are essential components of paediatric care. Developmentally appropriate pain assessment is an important first step in optimizing pain management. Self-reported pain should be prioritized. Alternatively, developmentally appropriate behavioural tools should be used. Acute pain management and prevention guidelines and strategies that combine physical, psychological, and pharmacological approaches should be accessible in all health care settings. Chronic pain is best managed using combined treatment modalities and counselling, with the primary goal of attaining functional improvement. The planning and implementation of pain management strategies for children should always be personalized and family-centred.
... Despite the popularity of opioids in the treatment of acute pain in the pediatric emergency department, NSAIDs should still play a relevant role in treating acute pediatric pain [85]. Ibuprofen, naproxen, diclofenac, and ketorolac are used for mild to moderate pain in pediatric emergency departments, although, in most countries, not all of these medications have marketing authorization for infants [86,87]. ...
Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used in infants, children, and adolescents worldwide; however, despite sufficient evidence of the beneficial effects of NSAIDs in children and adolescents, there is a lack of comprehensive data in infants. The present review summarizes the current knowledge on the safety and efficacy of various NSAIDs used in infants for which data are available, and includes ibuprofen, dexibuprofen, ketoprofen, flurbiprofen, naproxen, diclofenac, ketorolac, indomethacin, niflumic acid, meloxicam, celecoxib, parecoxib, rofecoxib, acetylsalicylic acid, and nimesulide. The efficacy of NSAIDs has been documented for a variety of conditions, such as fever and pain. NSAIDs are also the main pillars of anti-inflammatory treatment, such as in pediatric inflammatory rheumatic diseases. Limited data are available on the safety of most NSAIDs in infants. Adverse drug reactions may be renal, gastrointestinal, hematological, or immunologic. Since NSAIDs are among the most frequently used drugs in the pediatric population, safety and efficacy studies can be performed as part of normal clinical routine, even in young infants. Available data sources, such as (electronic) medical records, should be used for safety and efficacy analyses. On a larger scale, existing data sources, e.g. adverse drug reaction programs/networks, spontaneous national reporting systems, and electronic medical records should be assessed with child-specific methods in order to detect safety signals pertinent to certain pediatric age groups or disease entities. To improve the safety of NSAIDs in infants, treatment needs to be initiated with the lowest age-appropriate or weight-based dose. Duration of treatment and amount of drug used should be regularly evaluated and maximum dose limits and other recommendations by the manufacturer or expert committees should be followed. Treatment for non-chronic conditions such as fever and acute (postoperative) pain should be kept as short as possible. Patients with chronic conditions should be regularly monitored for possible adverse effects of NSAIDs.
... Es más frecuente el dolor actual en aquellos pacientes que ingresaron por trauma y cirugía (p = 0,03), con una prevalencia del 55,6% y 55,3% respectivamente, situación que podría estar relacionada con el tipo de lesión tisular que genera el trauma o la patología quirúrgica asociado a estímulos nocivos, respuesta inflamatoria y mayor nocicepción, respecto a otros motivos de ingreso hospitalario 24,25 . ...
In the hospital setting, pediatric patients can present painful conditions or undergo procedures that generate pain, therefore, recognizing their existence and carrying out a clinical approach to it should be a priority in health care teams.
Objective:
To characterize the pain and its clinical-therapeutic approach in hospitalized patients in the general ward of a tertiary pediatric healthcare institution.
Patients and method:
An observational, cross-sectional, and descriptive study conducted between August and October 2019. 187 patients were included. Study variables were sex, reason for hospita lization, treating specialty, chronic, current, and in the last 24 hours pain, intensity, maximum cause of pain, and analgesic prescription. The FLACC (Face, Legs, Activity, Cry, Consolability) scale was used in children aged between two months and three years, the revised Faces Pain Scale in children between four and eight years of age, and the self-reported Visual Analogue Scale was used in children from nine years of age onwards. After data analysis with descriptive statistics, differences between groups were calculated with the Chi-square test for qualitative variables, and non-parametric tests for comparison of groups with ordinal variables.
Results:
10.7% of the patients had chronic pain, without differences according to sex (p = 0.713). The prevalence of pain at the time of the evaluation was 38.5%, without differences according to sex (p = 0.419). Patients admitted for surgery and trau ma had a higher prevalence of pain (p = 0.034) and 53.5% of the children had an analgesic prescrip tion.
Conclusion:
the prevalence of pain in the hospitalized pediatric patients is high. Additionally, high use of non-opioid analgesia and a low prescription of opioid analgesics in the pediatric sphere is reported for the usual management of moderate and severe intensity pain.
... Moreover, due to the lack of nutrition caused by less eating, the patient's resistance decreases, increases the chance of postoperative infection, and also affects the healing of postoperative wounds. Wellestablished principles for successful management of postoperative pain for children include multimodal analgesia, adequate dosage, administration at regular intervals, and use of appropriate route of administration (Krauss et al., 2016;Makhlouf et al., 2019). A variety of analgesic classes, each present their own risk profiles and unique side effects when used for postoperative analgesia in children undergoing tonsillectomy (Cohen and Sommer, 2016). ...
Tonsillectomy is a frequently performed surgical procedure in children, requiring post-operative analgesia. This study evaluated the efficacy and safety of nalbuphine or sufentanil combined with dexmedetomidine for patient-controlled intravenous analgesia (PCIA) after pediatric tonsillectomy adenoidectomy. A total of 400 patients undergoing tonsillectomy with and without adenoidectomy were included in the study. Patients received a PCIA pump (0.5 mg/kg nalbuphine, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group ND (n = 200). Patients received a PCIA pump (2 μg/kg sufentanil, 2 μg/kg dexmedetomidine and 0.9% sodium chloride to a total volume of 100 ml) for postoperative pain management were classified into Group SD (n = 200). More stable hemodynamic changes were noted in Group ND than Group SD from 1 h to 48 h after operation. At 6, 12, 24, and 48 h after operation, the children in Group ND had higher Ramsay sedation scores than those in Group SD. The times to push the PCIA button in Group ND and Group SD were 2.44 ± 0.74 and 2.62 ± 1.00, showing significant differences ( p = 0.041). The VASR scores of children in Group ND were significantly lower within 6, 12, and 24 h than those in Group SD ( p < 0.05). The VASC scores of children in Group ND were significantly lower within four time points (2, 6, 12, and 24 h) than those in Group SD ( p < 0.05). At 1st day after surgery, the children in Group ND had lower levels of serum ACTH, IL-6, and COR levels than those in Group SD ( p < 0.001). The incidence rates of nausea and vomiting, and pruritus were significantly higher in Group SD than Group ND (5.00% vs. 11.00%, p = 0.028; 1.00% vs. 4.50%, p = 0.032). The total incidence rate of adverse reactions was significantly higher in Group SD than Group ND (15.00% vs. 31.00%, p = 0.0001). The study demonstrated that dexmedetomidine added to nalbuphine PCIA enhanced the analgesic effects, attenuated the postoperative pain, and reduced the stress response after pediatric tonsillectomy adenoidectomy.
... Dealing with procedural pain is an essential part of quality health care [4] and its prevention or reduction also benefits related to anxiety and fear [3]. However, despite the availability of various optimal practice strategies and extensive evidence of their effectiveness, attention to pediatric pain continues to be suboptimal [5,6]; its ineffective management can result in the avoidance or unsatisfactory adherence to treatment [7]. Pediatric acute pain management should always include non-pharmacological interventions as a starting point [8]; these include psychological methods, as the use of distraction techniques [8]. ...
Among the distraction techniques used for the non-pharmacological management of acute pediatric pain, one of the most performed is clown therapy. Despite the presence in the literature of some systematic reviews that evaluate its effectiveness, none of them examines its outcomes on procedural pain which has therefore been investigated in this study. The literature search for randomized controlled trials (RCTs) was performed on the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus over a time frame ranging from each database setup date to 31 July 2021. The primary outcome was the procedural pain of children. We used the Cochrane Risk of Bias tool to assess the risk of bias of the included studies. Six RCTs were selected for this review, which included a total of 517 pediatric subjects. Children undergoing clown therapy during the venipuncture or peripheral vein cannulation procedure reported less pain than those exposed to the standard of care (SMD = −0.55; 95% CI: −1.23, 0.13) but the result was not found to be statistically significant. School-aged children and adolescent reported significantly less pain (SMD = −0.51; 95% CI: −0.92, −0.09). Compared to the standard of care, children’s anxiety was significantly lower with clown therapy (SMD = −0.97; 95% CI: −1.38, −0.56).
Conclusion: Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution.What is Known:
• Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain.
• Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates.
What is New:
• Clown therapy seems effective in reducing procedural pain and anxiety in children.
• The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom.
... Although acetaminophen/paracetamol demonstrates similar inhibitory activity to NSAIDs, it does not have the same anti-inflammatory properties. 22 Both NSAIDs and acetaminophen have been shown to have noninferior analgesic effects when compared to opioids for acute extremity pain. Similar findings have been demonstrated when NSAIDs were compared to opioids for management of post-fracture pain in children. ...
Pediatric pain is challenging to assess and manage. Frequently underestimated in children, untreated pain may have consequences including increased fear, anxiety, and psychological issues. With the current opioid crisis, emergency physicians must be knowledgeable in both pharmacologic and non-pharmacologic approaches to address pain and anxiety in children that lead to enhanced patient cooperation and family satisfaction. This document focuses pain management and distress mitigation strategies for the brief diagnostic and therapeutic procedures commonly performed.
... Es más frecuente el dolor actual en aquellos pacientes que ingresaron por trauma y cirugía (p = 0,03), con una prevalencia del 55,6% y 55,3% respectivamente, situación que podría estar relacionada con el tipo de lesión tisular que genera el trauma o la patología quirúrgica asociado a estímulos nocivos, respuesta inflamatoria y mayor nocicepción, respecto a otros motivos de ingreso hospitalario 24,25 . ...
En el ámbito hospitalario, los pacientes pediátricos pueden presentar cuadros clínicos dolorosos o ser sometidos a procedimientos que generan dolor, por lo tanto, reconocer su existencia y realizar un abordaje clínico de este debe ser una prioridad en los equipos de salud.Objetivo: Caracterizar el dolor y su abordaje clínico-terapéutico en pacientes hospitalizados en la sala general de una institución pediátrica de tercer nivel de atención.Pacientes y Método: Estudio de tipo observacional, transversal, realizado entre agosto y octubre de 2019. Se incluyeron 187 pacientes. Variables de estudio: sexo, motivo de hospitalización, especialidad tratante, dolor crónico, actual y en las 24 horas previas, intensidad, causa máxima de dolor, prescripción analgésica. Se utilizó en niños entre los dos meses y tres años de edad la escala FLACC (Face, Legs, Activity, Cry, Consolability), en niños entre cuatro y ocho años la escala de caras revisada y a partir de los nueve años la escala visual analógica de autoevaluación del dolor. Posterior al análisis de los datos con estadísticos descriptivos, se calcularon las diferencias entre grupos con prueba c2 para variables cualitativas, pruebas no paramétricas para comparación de grupos con variable ordinal.Resultados: el 10,7% de los pacientes presentaban dolor crónico, sin diferencias según el sexo (p = 0,713). La prevalencia de dolor al momento de la evaluación fue del 38,5%, sin diferencias según el sexo (p = 0,419). Pacientes que ingresaron por cirugía y trauma presentaron mayor prevalencia de dolor (p = 0,034) y el 53,5% de los menores tenían prescripción analgésica.Conclusión: La prevalencia del dolor en el paciente pediátrico hospitalizado es alta. Adicionalmente se reporta alto uso de analgesia no opioide y baja prescripción de analgésicos opioides en el entorno pediátrico para el manejo habitual del dolor de intensidad moderada y severa.
... Analgesic dosing for both ibuprofen and acetaminophen were chosen according to institutional guidelines and in line with international recommendations 17 , in order to provide the maximum dose of 30 mg/kg/day of ibuprofen and 80 mg/kg/day of acetaminophen, which are considered safe for children needing consecutive administrations of these drugs for several days. Families were advised to return to the ED in case of untreatable pain or any doubts regarding the cast. ...
Background
Bone fractures are a common reason for children and adolescents to seek evaluation in the ED. Little is known about the pain experienced after cast immobilisation and discharge from the ED and its optimal management. We aimed to investigate the administration of pharmacological analgesia in the first days after cast immobilisation and to identify possible influencing variables.
Methods
A prospective observational cross-sectional study was conducted at the ED of the children’s hospital, Institute for Maternal and Child Health of Trieste, Italy, from October 2019 to June 2020. Patients aged 0–17 years with bone fractures were included. The primary outcome was the administration of analgesia during the 10 days following discharge, while secondary outcomes were the associated variables, including age, gender, fracture type and location, the mean limitation in usual activities and the frequency of re-evaluation at the ED for pain. Data were recorded through a questionnaire, completed by caregivers and collected by the researchers mainly through a telephone interview. The primary endpoint was evaluated as the ratio between the number of children who took at least one analgesic dose and the total enrolled children, while Χ ² or Fisher’s exact tests were used to assess secondary outcomes.
Results
During the study period, 213 patients, mean age 10 years (IQR: 8–13), were enrolled. Among them, 137 (64.3%) did not take any analgesic during follow-up. Among children who were administered analgesia, 22 (28.9%) received it only on the first day, and 47 (61.8%) for less than 5 days. One hundred and sixty one patients (75.6%) did not report any limitation in usual activities because of pain. The administration of analgesia was not related to the child’s age, gender or fracture site. Displaced fractures were associated with significantly more frequent analgesia being taken (OR 5.5, 95% CI 1.4 to 21.0).
Conclusion
Although some studies recommend scheduled analgesic treatment after discharge for bone fractures, this study would suggest analgesia on demand in children with non-displaced fractures, limiting scheduled analgesia to children with displaced fractures.
... Their job has been mostly connected to the development of non-pharmacological interventions and techniques. Such activities have proven to be effective in supporting young patients during hospital routines, promoting compliance and facilitating the work of the medical staff (Vagnoli et al., 2005Caprilli et al., 2007;Viggiano et al., 2015;Antonelli et al., 2019;Dionigi, 2017;Dionigi et al., 2013;Krauss et al., 2016). These promising studies have paved the way for future research to determine how non-pharmacological interventions can enhance physical, mental and emotional wellness as well as happiness, which may also foster patient resilience Wong, , 2016. ...
Humour, a positive psychology (PP1.0) construct (Fischer, Carow, & Eger, 2020) is a central component of resiliency. Having a sense of humour is a sign of human strength, intelligence, and psychological maturity (Abel, 2016; Ghaemi, 2011). Humour allows individuals to emotionally distance themselves from a stressful event in order to cope. Humour is considered as a crucial job resource for individuals across cultures. It has been further credited for several positive outcomes such as resilience and well-being (Billig, 2018). The objective of the chapter is to present a critical review of the moderating role of resilience in adaptive humour styles (self-enhancing and affiliative humour) and well-being at work from a PP1.0 perspective. The findings of the study of Bhattacharyya, Jena, and Pradhan (2019) indicate a significant association between the adaptive humour styles and well-being at work, with resilience as a moderator.
... Acute pain is known to be one of the most frequent reasons for visiting the emergency department (ED). 1 Given that pain is a driving factor for the majority of visits, it is important to understand the epidemiology of the disease. There is little up-to-date information on paediatric ED visits for acute pain, as the majority of acute pain ED epidemiology studies have excluded children, were limited to one institution, or are now outdated. ...
Objective
To describe the epidemiology of paediatric pain-related visits to emergency departments (EDs) across the USA.
Design
Cross-sectional study.
Setting
A representative sample of US ED visits using data from the National Hospital Ambulatory Medical Care Survey (NHAMCS).
Participants
Paediatric (age ≤18 years) ED visits in the 2017 NHAMCS data set.
Data analysis
Each visit was coded as pain-related or non-pain-related using the ‘reason for visit’ variable. Weighted proportions were calculated with 95% CIs. Logistic regression was used to compare odds of pain-related visits.
Outcome measures
Prevalence of pain-related visits among paediatric ED visits.
Results
There were an estimated 35 million paediatric ED visits in the USA in 2017, 55.6% (CI 53.3% to 57.8%) were pain related, which equates to 19.7 million annual visits. The prevalence of pain-related visits reached more than 50% of visits at age 6–7 and plateaued at relatively high proportions. Children of races other than white or black had lower odds of having a pain-related visit (OR 0.48, CI 0.29 to 0.81) than white children, as did children who were black, though the difference was not statistically significant (OR 0.88, CI 0.73 to 1.06). Relative to children covered by private insurance, children with Medicaid or CHIP (Children’s Health Insurance Program) coverage had lower odds of a pain-related visit (OR 0.75, CI 0.60 to 0.93). Injuries represented 46.5% (CI 42.0% to 51.0%) of pain-related visits. Pain scores were reported in less than 50% of pain-related visits.
Conclusion
Pain is the reason for visit in 55.6% of paediatric ED visits across the USA. The prevalence of pain-related visits peak before adolescence and it continues relatively high until the age 18. Injury, racial disparities in pain and poor pain score reporting should remain major topics of study in the paediatric population.
... As a matter of fact, needle phobia has been identified as a relevant cause of vaccination refusal and delayed access to care in adults with measurable health related damages [20]. Clinical guidelines have been developed in order to improve the management of paediatric pain and ensure an appropriate use of pain and distress relief techniques during needle procedures [21,9]. However, most of the available studies focus on patients between 3 and 12 years of age, and few data sources are available regarding pain and distress experienced by adolescents during these procedures. ...
The objective of the study is to investigate pain and distress experienced by a group of adolescents and children during peripheral intravenous cannulation in a paediatric emergency department. This cross-sectional study was performed between November 2019 and June 2020 at the paediatric emergency department of the Institute for Maternal and Child Health of Trieste, Italy. Eligible subjects were patients between 4 and 17 years old undergoing intravenous cannulation, split into three groups based on their age: adolescents (13–17 years), older children (8–12 years), and younger children (4–7 years). Procedural distress and pain scores were recorded through validated scales. Data on the use of topical anaesthesia, distraction techniques, and physical or verbal comfort during procedures were also collected. We recruited 136 patients: 63 adolescents, 48 older children, and 25 younger children. There was no statistically significant difference in the median self-reported procedural pain found in adolescents (4; IQR = 2–6) versus older and younger children (5; IQR = 2–8 and 6; IQR = 2–8, respectively). Furthermore, no significant difference was observed in the rate of distress between adolescents (79.4%), older (89.6%), and younger (92.0%) children. Adolescents received significantly fewer pain relief techniques.
Conclusion: This study shows that adolescents experience similar pain and pre-procedural distress as younger children during peripheral intravenous cannulation.
What is Known:
• Topical and local anaesthesia, physical and verbal comfort, and distraction are useful interventions for pain and anxiety management during intravenous cannulation in paediatric settings.
• No data is available on pain and distress experienced by adolescents in the specific setting of the emergency department.
What is New:
• Adolescents experienced high levels of pre-procedural distress in most cases and similar levels of pain and distress when compared to younger patients
• The number of pain relief techniques employed during procedures was inversely proportional to patient’s age, topical or local anaesthesia were rarely used
... Studies have documented that effective trauma pain management is very important for enhancing patient therapeutic compliance, quality of life, and satisfactory outcomes, which leads to shorter hospital stays [4,5]. Traditional pharmacotherapeutic options for acute pain in trauma settings include different kinds of opioid and non-opioid drugs (e.g., morphine, nitrous oxide, non-steroidal anti-inflammatory drugs) [6][7][8]. However, evidence suggests that these drugs confer an increased likelihood of bleeding, mood disorders, and death in trauma patients [9][10][11]. ...
Introduction:
Evidence on the use of inhaled methoxyflurane in the management of trauma pain is conflicting and obfuscated. This study aimed to determine the efficacy and safety of inhaled methoxyflurane for trauma pain on the basis of published randomized controlled trials (RCTs).
Methods:
RCTs assessing the efficacy of methoxyflurane in adults or adolescents with acute trauma pain published in PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar were searched. The control groups were those that received placebo or standard analgesic treatment (SAT). The primary outcome was the change from baseline in pain scores during the first 30 min of treatment. Secondary outcomes included time to first pain relief, the proportion of patients experiencing pain relief, rescue analgesia rate, the treatment satisfaction of patients and investigators, and the methoxyflurane-related treatment-emergent adverse events (TEAEs).
Results:
A total of nine RCTs (1806 patients) were identified. Results revealed that methoxyflurane provided a clinically unimportant benefit by improving the mean difference of change from baseline in pain intensity (from - 0.44 to - 1.23 cm, p < 0.001) at various time points within the first 20 min compared to control treatment. Besides, methoxyflurane decreased the time of onset of pain relief (mean difference - 5.29 min; 95% CI - 6.97 to - 3.62) and the proportion of patients who needed rescue analgesic medication (risk ratio 1.41; 95% CI 1.17-1.70) despite it increasing the risk of non-severe TEAEs (risk ratio 3.09; 95% CI 1.72-5.57). Notably, the benefit of almost all secondary pain-related outcomes was rendered clinically nonsignificant between methoxyflurane and SAT strata besides the time of onset of pain relief. The quality of evidence was low or very low in all outcomes.
Conclusions:
In emergency situations without effective therapy, this systematic review and meta-analysis provides low-quality evidence that methoxyflurane can be used as a rapid-acting and effective treatment for acute trauma pain, although its utilization is associated a risk of non-severe TEAEs. However, the current evidence does not support the notion that inhaled methoxyflurane offered superior analgesic efficacy to SAT.
Clinical trial number:
PROSPERO registration number CRD42020223000.
... Clinically underestimated and undertreated pain is likely a greater concern for infants and children receiving healthcare than overestimation or overtreatment supporting our concerns about a scale that consistently scores lower than others. 24 In contrast, MBPS scores for eight of the ten phases were higher than the scores allocated using other scales and, in both cases, these were procedural phases (nasogastric tube insertion and oxygen saturation measurement). Very few observations resulted in an MBPS score of "zero" and averaged almost "two" even at baseline. ...
Purpose:
The purpose of this study was to compare the psychometric data and feasibility and clinical utility of the Face Legs, Activity, Cry and Consolability scale (FLACC), the Modified Behavioral Pain Scale (MBPS) and the Visual Analogue Scale for observers (VASobs) used to assess procedural pain in infants and young children.
Patients and methods:
Twenty-six clinicians assessed videorecorded segments of 100 infants and young children who underwent a painful and/or distressing procedure in the emergency department using the FLACC scale, the MBPS and the VASobs pain and VASobs distress.
Results:
VASobs pain scores were lowest across all procedures and phases of procedures (p < 0.001). Inter-rater reliability was lowest for VASobs pain scores (ICC 0.55). Sensitivity and specificity were highest for FLACC scores (94.9% and 72.5%, respectively) at the lowest cut-off score (pain score two). Observers changed their MBPS scores more often than they changed FLACC or VASobs scores, but FLACC scores were more often incomplete. Reviewers did not consider any scale of use for procedural pain measurement.
Conclusion:
The reliability and sensitivity of the FLACC and MBPS were supported by study data but concerns about the capacity of these scales to distinguish between pain- and non-pain-related distress were raised. The VASobs cannot be recommended. Despite its limitations, the FLACC scale may be better suited than other scales for procedural pain measurement.
... Background Managing pain, fear, and anxiety is a key factor in the wellbeing of children presenting for emergency care. These are often underrecognized and undertreated, with inadequately relieved pain and anxiety-producing physiological and psychological stress that have acute and longterm consequences [1][2][3][4][5]. Despite widespread efforts at enhancing pain and anxiety management, multiple barriers continue to exist between children and their comfort in medical settings. ...
Procedural sedation and analgesia outside the operating theater have become standard care in managing pain and anxiety in children undergoing diagnostic and therapeutic procedures. The objectives of this study are to describe the current pediatric procedural sedation and analgesia practice patterns in European emergency departments, to perform a needs assessment-like analysis, and to identify barriers to implementation. A survey study of European emergency departments treating children was conducted. Through a lead research coordinator identified through the Research in European Pediatric Emergency Medicine (REPEM) network for each of the participating countries, a 30-question questionnaire was sent, targeting senior physicians at each site. Descriptive statistics were performed. One hundred and seventy-one sites participated, treating approximately 5 million children/year and representing 19 countries, with a response rate of 89%. Of the procedural sedation and analgesia medications, midazolam (100%) and ketamine (91%) were available to most children, whereas propofol (67%), nitrous oxide (56%), intranasal fentanyl (47%), and chloral hydrate (42%) were less frequent. Children were sedated by general pediatricians in 82% of cases. Safety and monitoring guidelines were common (74%), but pre-procedural checklists (51%) and capnography (46%) less available. In 37% of the sites, the entire staff performing procedural sedation and analgesia were certified in pediatric advanced life support. Pediatric emergency medicine was a board-certified specialty in 3/19 countries. Physician (73%) and nursing (72%) shortages and lack of physical space (69%) were commonly reported as barriers to procedural sedation and analgesia. Nurse-directed triage protocols were in place in 52% of the sites, mostly for paracetamol (99%) and ibuprofen (91%). Tissue adhesive for laceration repair was available to 91% of children, while topical anesthetics for intravenous catheterization was available to 55%. Access to child life specialists (13%) and hypnosis (12%) was rare.
Conclusion : Procedural sedation and analgesia are prevalent in European emergency departments, but some sedation agents and topical anesthetics are not widely available. Guidelines are common but further safety nets, nurse-directed triage analgesia, and nonpharmacologic support to procedural sedation and analgesia are lacking. Barriers to implementation include availability of sedation agents, staff shortage, and lack of space. What is Known: • Effective and prompt analgesia, anxiolysis, and sedation (PSA) outside the operating theatre have become standard in managing pain and anxiety in children undergoing painful or anxiogenic diagnostic and therapeutic procedures. • We searched PubMed up to September 15, 2020, without any date limits or language restrictions, using different combinations of the MeSH terms “pediatrics,” “hypnotics and sedatives,” “conscious sedation,” and “ambulatory surgical procedures” and the non-MeSH term “procedural sedation” and found no reports describing the current practice of pediatric PSA in Europe.
What is New: • This study is, to the best of our knowledge, the first to shed light on the pediatric PSA practice in European EDs and uncovers important gaps in several domains, notably availability of sedation medications and topical anesthetics, safety aspects such as PSA provider training, availability of nonpharmacologic support to PSA, and high impact interventions such as nurse-directed triage analgesia. • Other identified barriers to PSA implementation include staff shortage, control of sedation medications by specialists outside the emergency department, and lack of space.
... Additionally, many physicians do not receive dedicated training in pain management, as the Accreditation Council for Graduate Medical Education (ACGME) has not listed it as a common program requirement [17,18]. Although there have been several studies investigating pain management in the ED, there is a dearth of research investigating cancer pain management in this setting [19][20][21][22]. ...
Purpose
Many patients with cancer seek care for pain in the emergency department (ED). Prospective research on cancer pain in this setting has historically been insufficient. We conducted this study to describe the reported pain among cancer patients presenting to the ED, how pain is managed, and how pain may be associated with clinical outcomes.
Methods
We conducted a multicenter cohort study on adult patients with active cancer presenting to 18 EDs in the USA. We reported pain scores, response to medication, and analgesic utilization. We estimated the associations between pain severity, medication utilization, and the following outcomes: 30-day mortality, 30-day hospital readmission, and ED disposition.
Results
The study population included 1075 participants. Those who received an opioid in the ED were more likely to be admitted to the hospital and were more likely to be readmitted within 30 days (OR 1.4 (95% CI: 1.11, 1.88) and OR 1.56 (95% CI: 1.17, 2.07)), respectively. Severe pain at ED presentation was associated with increased 30-day mortality (OR 2.30, 95% CI: 1.05, 5.02), though this risk was attenuated when adjusting for clinical factors (most notably functional status).
Conclusions
Patients with severe pain had a higher risk of mortality, which was attenuated when correcting for clinical characteristics. Those patients who required opioid analgesics in the ED were more likely to require admission and were more at risk of 30-day hospital readmission. Future efforts should focus on these at-risk groups, who may benefit from additional services including palliative care, hospice, or home-health services.
... 3,4 From both perspectives-causal or predictive-early identification of children with increased susceptibility to chronic pain trajectories is a cornerstone of current pain research. 5 Although most evidence on paediatric pain prognosis has been obtained in clinical settings, 6 a few prospective studies have described the course of pain in cohorts selected independently of initial symptoms. [7][8][9] In the United States, four to six different trajectories were identified including a majority of adolescents without relevant complaints, a considerable proportion with transient pain, and a smaller group with persistent pain. ...
Background
Trajectory studies suggest considerable stability of persistent or recurrent pain in adolescence. This points to the first decade of life as an important aetiologic window for shaping future pain, where the potential for prevention may be optimised.
Objectives
We aimed to quantify changes in mother‐reported pain experience in children between ages 7 and 10 and describe clusters of different pain experiences defined by complementary pain features.
Methods
We conducted a prospective study using data from 4036 Generation XXI birth cohort participants recruited in 2005‐06. Pain history was reported by mothers at ages 7 and 10 using the Luebeck pain screening questionnaire. We tracked changes in six pain features over time using relative risks (RRs) and their 95% confidence intervals (95% CIs). Clusters were obtained using the k‐medoids algorithm.
Results
The risk of severe pain at age 10 increased with increasing severity at age 7, with RRs ranging from 2.18 (95% CI 1.90, 2.50) for multisite to 4.43 (95% CI 3.19, 6.15) for high frequency pain at age 7. A majority of children (59.4%) had transient or no pain but two clusters included children with stable recurrent pain (n = 404, 10.2% of the sample). One of those (n = 177) was characterised by higher probabilities of multisite pain (74.6% and 66.7% at ages 7 and 10, respectively), with psychosocial triggers/contexts (59.3% and 61.0%) and daily‐living restrictions (72.2% and 84.6%). Most children in that cluster (58.3%) also self‐reported recent pain at age 10 and had more frequent family history of chronic pain (60.5%).
Conclusions
All pain features assessed tracked with a positive gradient between ages 7 and 10, arguing for the significance of the first decade of life in the escalation of the pain experience. Multisite pain and psychosocial attributions appeared to be early markers of more adverse pain experiences.
... In the pediatric field, pain is a frequent symptom: it is estimated that 80% of children hospitalized in pediatrics present pain and that 60-70% of visits to the Pediatric Emergency Room (PER) is due to this symptom (3)(4)(5). ...
Background and aim of the work:
Pain is one of the most common symptoms in children who access the Pediatric Emergency Room (PER). However, many studies show that it is poorly evaluated and treated during the triage phase and that in many cases algometric scales aren't used for its evaluation. Faced with this, the Piacenza PER (Italy) implemented the Pain in Pediatric Emergency Room (PIPER) recommendations for the assessment and management of pain from the 1st July 2017. The aim of this study was to detect the possible differences in the trend of the outcomes for the detection and treatment of pain in July-October 2016, 2017, 2018.
Methods:
A retrospective observational study was chosen. 811 discharge letters of extremity traumatized children aged 0-9 years were analyzed, of which 309 referred to the 2016 quarter, 243 to the 2017 quarter and 259 to the 2018 quarter.
Results:
In 2016, the pain of 12 patients was assessed out of a total of 309, in 2017 of 227 out of 243 and in 2018 of 245 out of 259. The Chi Square test about assessed and not assessed pain, gave statistically significant value (p = 1.36E-98), comparing 2016vs2017 and gave not significant value comparing 2017vs2018 (p = 0.58). 4 patients were treated during the triage phase in 2016, 68 in 2017 and 70 in 2018.
Conclusions:
Recommendations introduction has increased the frequency of pain algometric measurements during the triage phase by leading to an improvement in the nursing care outcomes in terms of pediatric pain management.
Objectives:
The aim of this study was to compare the effectiveness of 3 methods (Buzzy, ShotBlocker, and DistrACTION Cards) in reducing pain and anxiety while taking venous blood samples in children.
Methods:
The study population consisted of children aged 9 to 12 years admitted to the Child Health and Diseases Department in a Faculty of Medicine in Turkey. The sample of the study consisted of 242 children (Buzzy = 60, ShotBlocker = 61, DistrACTION Cards = 60, control = 61) who met the patient selection criteria and agreed to participate in the study. The data were obtained using an Information Form, the State-Trait Anxiety Inventory for Children, visual analog scale, and the Faces Pain Scale-Revised.
Design:
This article is an experimental randomized controlled study.
Results:
During venous blood collection, the scores of visual analog scale were significantly lower in ShotBlocker, Buzzy, and DistrACTION Cards groups than the control group. It was also observed that the control group experienced more anxiety than the other groups.
Conclusions:
Methods such as Buzzy, ShotBlocker, and DistrACTION Cards can be used to reduce the anxiety and pain of children during painful procedures such as blood collection and vascular access. Among these methods, "Buzzy" and "DistrACTION Cards" can be preferred as it is equally effective, and then ShotBlocker can be preferred.
Objectives:
To identify the core components of acute pain management in children, re-conceptualise the process and update the existing model to inform nursing research and clinical practice.
Background:
Acute pain in hospitalised children remains suboptimal, despite extensive nursing research and education. Improvements require a patient-centred approach and a conceptual model which includes the role of parents and partnership.
Design:
Using Rodgers' Evolutionary method, a concept analysis was conducted to define the core components for effective acute pain management in children.
Methods:
A scoping review of peer-reviewed literature from 1990 through 2020 was conducted using the terms "pain management," "pain control," "pain treatment," "multi modal," and "concept*". Abstracts from 85 articles were initially reviewed with 30 articles retained for analysis. Core concepts were identified, defined and synthesised. The PRISMA 2020 checklist was used.
Results:
A new model was developed from a synthesis of past work which incorporates the role of parents, the complexity of the process and definitions for shared decision-making. Trust, safety, collaborative communication and genuine partnership were identified as the core components for effective pain management in children, with the triadic relationship of nurses, patients and parents in genuine partnership foundational to the nursing process.
Conclusion:
The new model for acute pain management in children transforms the nurse's role from gatekeeper to facilitator, shifting the process from nurse driven to patient-centred. The new collaborative model will promote shared decision-making for individualised pain assessments, interventions and evaluations.
Relevance to clinical practice:
Establishing the nurse, child, parent partnership as an essential foundation to pain management has the potential to expand pain assessments, optimise treatment selections, advancing clinical practice, patient outcomes and nursing science. No Patient or Public Contributions were included in this paper as this was a concept analysis pulling from past works.
Inflammatory bowel diseases (IBDs) are chronic, immune-mediated disorders that include Crohn's disease and ulcerative colitis. A pediatric onset of disease occurs in about 10% of all cases. Clinical presentation of IBD with rectal bleeding or perianal disease warrants direct referral for endoscopic evaluation. In the absence of red-flag symptoms, a combination of patient history and blood and fecal biomarkers can help to distinguish suspected IBD from other causes of abdominal pain or diarrhea. The therapeutic management of pediatric IBD has evolved by taking into account predictors of poor outcome, which justifies the upfront use of anti-tumor necrosis factor therapy for patients at high risk for complicated disease. In treating patients with IBD, biochemical or endoscopic remission, rather than clinical remission, is the therapeutic goal because intestinal inflammation often persists despite resolution of abdominal symptoms. Pediatric IBD comes with unique additional challenges, such as growth impairment, pubertal delay, the psychology of adolescence, and development of body image. Even after remission has been achieved, many patients with IBD continue to experience nonspecific symptoms like abdominal pain and fatigue. Transfer to adult care is a well-recognized risk for disease relapse, which highlights patient vulnerability and the need for a transition program that is continued by the adult-oriented IBD team. The general pediatrician is an invaluable link in integrating these challenges in the clinical care of patients with IBD and optimizing their outcomes. This state-of-the-art review aims to provide general pediatricians with an update on pediatric IBD to facilitate interactions with pediatric gastrointestinal specialists.
Background
Undertreatment of pain in children is an international problem as many children reports unresolved moderate to severe pain. One key factor which may contribute to under treatment of pain in children by nurses is lack of knowledge. In Ghana opportunities for nurses to learn about pediatric pain have been limited due to gaps in the undergraduate curriculum and inadequate continuing professional education post qualification.
Objective
To assess tutors' knowledge and attitudes to pediatric pain management before and after an educational workshop.
Design
Single group pre-test-post-test design.
Setting
One Ghanaian Nursing Training College.
Participants
All (37) nursing tutors in the college.
Method
Total population sampling was used to access 37 tutors, data were collected using the Knowledge and Attitude Survey Regarding Pain at 3 stages; pre-intervention, immediately after the train-the-trainer based Pediatric Pain Educational Workshop and at 3-months follow-up. Data from the survey were analyzed using descriptive and inferential statistics.
Results
Results at pre-intervention showed low scores in the survey. However, post-intervention results at both the immediate and 3-months follow-up stages revealed a significant increase from pre-intervention: Mean (SD) of 20.35 (4.56), to immediate follow-up Mean (SD) 26.93 (5.02), and 3-months follow-up Mean (SD) 25.19 (5.80) and a p-value of <0.001.
Conclusion
The results suggest tutors' knowledge and attitudes regarding pediatric pain management can be directly improved through a nurse tutor focused educational program. However, knowledge declines with time and as such there is the need for regular update through Continuing Professional Development activities.
Purpose
It was aimed to evaluate the efficacy of Buzzy and cold spray in reducing pain, anxiety, and fear of children during venipuncture in the emergency department (ED).
Methods
This study is an experimental, parallel-group (intervention-control), randomized controlled, single-blind design. The study was conducted with 161 children aged 5–12 years in pediatric ED. Data were collected by the ‘Personal Information Form’, ‘Wong Baker-Facial Expression Rating Scale’, ‘Child Anxiety Statement Scale’, and ‘Child Fear Inventory’. Data were analyzed with descriptive statistics, Mann Whitney U test, Kruskal Wallis H test, and Intraclass Correlation.
Results
Descriptive features of the children were homogeneous. ‘Wong Baker-Facial Expression Rating Scale’, ‘Child Anxiety Statement Scale’, and ‘Child Fear Scale’ score averages of the children in the control group were higher than the children in the Buzzy group and the cold spray group (p < 0.001). The pain scores of the Buzzy group were higher than those in the cold spray group (p < 0.001). The anxiety and fear mean scores of the children in the Buzzy and cold spray groups were similar (p > 0.05).
Conclusion
It was determined that Buzzy and cold spray were more effective than standard care in reducing the level of pain, anxiety, and fear in children ages 5–12 years during venipuncture in the pediatric emergency. The cold spray was more effective in reducing pain than Buzzy.
Practice implications
Nurses can use Buzzy and cold sprays to manage the fear, anxiety, and pain associated with venipuncture.
Opioid abuse and addiction have become a global pandemic, posing tremendous health and social burdens. The rewarding effects and the occurrence of withdrawal symptoms are the two mainstays of opioid addiction. Mu-opioid receptors (MORs), a member of opioid receptors, play important roles in opioid addiction, mediating both the rewarding effects of opioids and opioid withdrawal syndrome (OWS). The underlying mechanism of MOR-mediated opioid rewarding effects and withdrawal syndrome is of vital importance to understand the nature of opioid addiction and also provides theoretical basis for targeting MORs to treat drug addiction. In this review, we first briefly introduce the basic concepts of MORs, including their structure, distribution in the nervous system, endogenous ligands, and functional characteristics. We focused on the brain circuitry and molecular mechanism of MORs-mediated opioid reward and withdrawal. The neuroanatomical and functional elements of the neural circuitry of the reward system underlying opioid addiction were thoroughly discussed, and the roles of MOR within the reward circuitry were also elaborated. Furthermore, we interrogated the roles of MORs in OWS, along with the structural basis and molecular adaptions of MORs-mediated withdrawal syndrome. Finally, current treatment strategies for opioid addiction targeting MORs were also presented.
Objectives
Despite a lack of evidence demonstrating superiority to non-steroidal anti-inflammatory drugs, like ketorolac, that are associated with lower risk of harms, opioids remain the most prescribed analgesic for acute abdominal pain. In this pilot trial, we will assess the feasibility of a definitive trial comparing ketorolac with morphine in children with suspected appendicitis. We hypothesise that our study will be feasible based on a 40% consent rate.
Methods and analysis
A single-centre, non-inferiority, blinded (participant, clinician, investigators and outcome assessors), double-dummy randomised controlled trial of children aged 6–17 years presenting to a paediatric emergency department with ≤5 days of moderate to severe abdominal pain (≥5 on a Verbal Numerical Rating Scale) and are investigated for appendicitis. We will use variable randomised blocks of 4–6 and allocate participants in 1:1 ratio to receive either intravenous (IV) ketorolac 0.5 mg/kg+IV morphine placebo or IV morphine 0.1 mg/kg+IV ketorolac placebo. Analgesic co-intervention will be limited to acetaminophen (commonly used as first-line therapy). Participants in both groups will be allowed rescue therapy (morphine 0.5 mg/kg) within 60 min of our intervention. Our primary feasibility outcome is the proportion of eligible patients approached who provide informed consent and are enrolled in our trial. Our threshold for feasibility will be to achieve a ≥40% consent rate, and we will enrol 100 participants into our pilot trial.
Ethics and dissemination
Our study has received full approval by the Hamilton integrated Research Ethics Board. We will disseminate our study findings at national and international paediatric research conferences to garner interest and engage sites for a future multicentre definitive trial.
Trial registration
NCT04528563 , Pre-results.
Introduction:
There is evidence in the literature for high-fidelity in situ simulation training programs being an effective modality for physicians training. This quality initiative focused on implementation of the procedural sedation and analgesia (PSA) in our pediatric emergency department (PED). The primary outcomes of this study were to evaluate the impact of blended in situ simulation training (BST) program on PSA for closed forearm fracture reduction in the PED and to assess its cost-effectiveness. The secondary outcomes were to estimate this change on PSA's clinical efficacy and safety.
Methods:
Between 2014 and 2018, a single-center, quasi-experimental, uncontrolled before and after study on forearm fracture reduction management was conducted. To assess the impact of our BST-PSA course, both historical control and prospective analyses were performed. Statistical significance was based on Fisher exact test or Pearson χ2 test.
Results:
Eight hundred eighty-five children met inclusion criteria. A significant difference in the number of PSAs performed in the PED, before and after BST, was found (37% vs. 85.3%, P < 0.001). Furthermore, a reduction in the number of hospitalizations for closed fracture reduction was measured (68.2% vs. 31.8%, P < 0.001). The overall cost savings from the BST-enabled increase in PSAs carried out in the PED was €370,714 ($440,838) with a return on investment of 64:1. No significant increase of PSA-related adverse events was found, and no serious adverse events occurred.
Conclusions:
Findings provide evidence of the benefits of implementing BST to enable PSA use in the PED, with an improved patient flow and significant cost savings from avoiding unnecessary hospitalizations.
Forearm fractures are the most common fractures among children and young people aged up to 19 years and these patients frequently present to the emergency department (ED). Many of these fractures can be treated in the ED without the need for inpatient admission. This article examines the assessment, diagnosis and management of forearm fractures. The authors also use a case study format to demonstrate best practice in the treatment of forearm fractures in this age group. The information in this article will enable ED nurses to enhance the experience of children and their families who present with forearm fractures.
Objectives
To identify self-reported pain scores that best represent categories of no pain, mild, moderate, and severe pain in children, and a pain score that accurately represents a child’s perceived need for medication (PNM), i.e. a minimum pain score at which a child would want an analgesic.
Study design
Prospective cross-sectional cohort study of children aged 6-17 years presenting to a pediatric emergency department with painful and non-painful conditions. Pain was measured using the Verbal Numerical Rating Scale. Receiver operating characteristic-based methodology was used to determine pain scores that best differentiated no pain from mild, mild from moderate, and moderate from severe pain. Descriptive statistics were used to determine the PNM.
Results
We analyzed data from 548 children (51.3% female, 61.9% painful conditions). The scores that best represent categories of pain intensity are: 0-1 (no pain), 2-5 (mild), 6-7 (moderate), and 8-10 (severe) out of 10. The area under the curve for the cut points differentiating each category ranged from 0.76 to 0.88. The median pain score representing PNM was 6 (IQR 4, 7; range 0-10) out of 10.
Conclusions
We identified population-level self-reported pain scores in children associated with categories of pain intensity that differ from those conventionally used. Implementing our findings may provide a more accurate representation of the clinical meaning of pain scores and reduce selection bias in research. Our findings do not support the use of pain scores in isolation for clinical decision making or use of a pain score threshold to represent a child’s PNM.
Contexts
: Inadequate pain management in community paediatric palliative care is common. Evidence to inform improved pain management in this population is limited.
Objectives
: To explore the barriers and facilitators to paediatric community-based pain management for infants, children and young people at end-of-life as perceived by healthcare professionals.
Methods
: A qualitative interview study was conducted. Semi-structured interviews were undertaken with 29 healthcare professionals; 12 nurses, five GPs, five consultants and registrar doctors, two pharmacists and five support therapists working in primary, secondary or tertiary care in the United Kingdom and involved in community end-of life care of 0-18-year-olds.
Results
: The data corpus was analysed using an inductive thematic analysis and seven themes emerged: parents’ abilities, beliefs and wellbeing; working relationships between families and healthcare professionals, and between healthcare teams; healthcare professionals’ knowledge, education and experience; health services delivery; nature of pain treatment; and paediatric-specific factors. Across themes, the concepts of partnership working between families and healthcare professionals, and within healthcare teams, and sharing expertise were prevalent.
Conclusion
: Partnership working and trust between healthcare professionals and parents, and within healthcare teams, is needed for effective at-home paediatric palliative pain management. Community healthcare professionals require more education from experienced multidisciplinary teams to effectively manage paediatric pain at end-of-life and prevent emergency hospice or hospital admissions, particularly during the COVID-19 pandemic.
Objectives:
To determine the acute pain level associated with request for analgesia by children and their parents in the pediatric emergency department (ED) when pain was assessed by verbal numeric scale (VNS), visual analog scale (VAS), and verbal rating scale (VRS).
Methods:
A secondary analysis of a prospective cohort study using a sample of children aged 8 to 17 presenting to the ED with acute pain. Patients and their parents were asked to quantify the child's pain on the VNS, VAS, and VRS. Scores for patients and parents who answered "yes" to the request of analgesia were compared with those responding "no."
Results:
A total of 202 patients aged 12.2 ± 2.6 years were enrolled. The median levels of pain associated with a request of analgesia and no request for analgesia by the patient were: 6.0 (4.0-7.4) and 5.0 (3.0-6.0) (Δ 1.0; 95% confidence interval [CI], 0.5-2.0) for the VNS; 5.7 (3.9-7.2) and 4.3 (2.6-5.8) (Δ 1.3; 95% CI, 0.6-1.9) for the VAS; and 2.0 (2.0-2.0) and 2.0 (1.0-2.0) (Δ 0.0; 95% CI, 0.0-0.0) for the VRS.
Conclusions:
Children who requested analgesia had higher pain scores on the VNS and the VAS, than those who did not request analgesia. No difference was demonstrated with the VRS. The pain scores between the analgesia request categories could overlap. This suggests that children seen in the ED should be asked if they want analgesia to decrease their acute pain.
Introduction
Invasive procedures for diagnosis purposes such as venepuncture and peripheral venous catheter insertion are painful procedures that cause great stress for paediatric patients. The objective of this study is to find out the factors that have an impact on the level of anxiety experienced by children undertaken these procedures.
Design and methods
Prospective study, 359 children between 2 and 15 years old were included, treated in a tertiary reference hospital in the region of Navarra (Spain). The impact of the variables recorded was analysed using a regressive analysis, the Wong-Baker and FLACC scales were used to measure the level of pain and the PACBIS scale to measure the level of stress and anxiety.
Results
The average age of the participants was 7.93 years (SD: 4.04), with 51.8% (n = 186) boys and 48.2% (n = 173) girls. The mean value of pain recorded was 4.43 (SD:3.10). 45.7% (n = 123) of the venepuncture techniques was associated with minimum level of anxiety, including 11.1% of intravenous catheterization. Variables determining the anxiety has been detected such as age, sex, level of pain, parental conduct and time spent on the procedure.
Conclusions
Paediatric patients experience high levels of anxiety when undergoing painful procedures which are conditioned by multifactorial reasons. The increase in stress is directly related to the older age (>6 years old) of the patient, and statistically significant by the female gender, the longer duration of the technique and the parental block.
Available evidence from the literature shows that non-pharmacologic strategies should not only be regarded as a possible alternative for procedural sedation, but even more as a crucial adjunct to procedural sedation. Physicians should be well aware that continuous anxiety control is not only essential for effective and safe procedural sedation but also plays a role in allowing an improved quality of the patient’s and parents’ experience. This chapter gives a practical overview of non-pharmacologic strategies, from the perspective of optimal procedural comfort in children and parents. Non-pharmacologic strategies should not be considered as a stand-alone strategy but as part of an integrated perspective of procedural comfort care.
Virtual reality is a relatively new tool for human-computer interaction. A person becomes an active participant in a virtual world. Virtual reality has quickly become the research subject in various medical fields. For example, today many medical procedures are accompanied by severe pain syndrome and require pain relievers. Virtual reality as an effective non-pharmacological means of reducing pain may become a new way of pain management. Currently, there is not enough scientific papers on the efficacy of the method, which has become the reason for this literature review. The goal of the paper is to analyze electronic databases and scientific literature on the topic over the past 5 years (from 2014 to 2019). Virtual reality has been used to reduce pain in children (4 to 17 years old) in the following medical procedures: intravenous injections, care for burn wounds, wound dressing, drug blockade, vaccination, and acute pain syndrome. The results obtained show that virtual reality is an effective non-pharmacological method of pain management. However, there are still some unresolved questions on the interaction between virtual exposure and some pain killers. Moreover, it is also unclear what is more preferable: the initial use of virtual reality therapy followed by a standard therapy, or vice versa. Conclusion. More research is needed to understand the impact of virtual reality in pediatrics on both acute pain and chronic pain. Keywords: virtual reality, pain syndrome, pediatrics. Виртуальная реальность – относительно новый инструмент взаимодействия человека с компьютером, когда человек становится активным участником виртуального мира. Виртуальная реальность быстро стала предметом исследования в разных медицинских областях. Так, например, сегодня многие медицинские процедуры сопровождаются выраженным болевым синдромом и требуют применения обезболивающих препаратов. Новым направлением в обезболивании может стать применение виртуальной реальности как эффективного нефармакологического средства уменьшения болевого синдрома. В настоящее время опубликовано недостаточно научных работ об эффективности этого метода, что стало причиной проведения данного литературного обзора. Цель – анализ электронных баз данных и научной литературы за последние 5 лет (с 2014 по 2019 г.). Виртуальная реальность использовалась для уменьшения болевого синдрома у детей (от 4 до 17 лет) при следующих процедурах: внутривенные инъекции, уход за ожоговыми ранами, перевязка ран, проведение медикаментозных блокад, вакцинация, а также при остром болевом синдроме. Результаты проанализированных исследований показывают, что виртуальная реальность является эффективным нефармакологическим методом уменьшения болевого синдрома. Однако остаются нерешенными вопросы о взаимодействии между виртуальным воздействием и некоторыми обезболивающими препаратами, также неясно, что является более предпочтительным: первоначальное применение терапии с помощью виртуальной реальности, а затем без нее или наоборот. Выводы. Необходимо проведение дополнительных исследований для лучшего понимания влияния виртуальной реальности в педиатрии как на острый болевой синдром, так и на хроническую боль. Ключевые слова: виртуальная реальность, болевой синдром, педиатрия.
To improve the time taken for children arriving to the accident and emergency (A&E) department in pain to receive analgesia. Delivery within 30 minutes of triage was taken as an achievable goal.
262 children who had received analgesia in the "minor injuries" area of West Middlesex University Hospital A&E department were studied over a four month period. Current practice was indicated over the first two months by retrospectively looking at data from 129 children's A&E cards. A Paediatric Pain Protocol was then introduced and another 133 children's cards studied to see if this had made an improvement. The protocol for those children aged over 4 years differed to that for children aged 4 years and under.
For children aged 4 years and over, the introduction of the protocol significantly increased the number that received analgesia within 30 minutes of triage: 55.3% (n=54) post-protocol versus 34.0% (n=33) pre-protocol (p=0.003). However, for children aged 4 years and under there was no change in the proportion that received analgesia within 30 minutes of triage: 56.7% (n=17) postprotocol versus 59.4% (n=19) pre-protocol (p=0.829).
The introduction of a simple Paediatric Pain Protocol has improved the time taken to deliver analgesia to children arriving in this A&E department.
BMC Neurology 2010, 10:20 doi:10.1186/1471-2377-10-20
Published: 31 March 2010
Abstract
Background
Treatment of complex regional pain syndrome type I (CRPS-I) is subject to discussion. The purpose of this study was to develop multidisciplinary guidelines for treatment of CRPS-I.
Method
A multidisciplinary task force graded literature evaluating treatment effects for CRPS-I according to their strength of evidence, published between 1980 to June 2005. Treatment recommendations based on the literature findings were formulated and formally approved by all Dutch professional associations involved in CRPS-I treatment.
Results
For pain treatment, the WHO analgesic ladder is advised with the exception of strong opioids. For neuropathic pain, anticonvulsants and tricyclic antidepressants may be considered. For inflammatory symptoms, free-radical scavengers (dimethylsulphoxide or acetylcysteine) are advised. To promote peripheral blood flow, vasodilatory medication may be considered. Percutaneous sympathetic blockades may be used to increase blood flow in case vasodilatory medication has insufficient effect. To decrease functional limitations, standardised physiotherapy and occupational therapy are advised. To prevent the occurrence of CRPS-I after wrist fractures, vitamin C is recommended. Adequate perioperative analgesia, limitation of operating time, limited use of tourniquet, and use of regional anaesthetic techniques are recommended for secondary prevention of CRPS-I.
Conclusions
Based on the literature identified and the extent of evidence found for therapeutic interventions for CRPS-I, we conclude that further research is needed into each of the therapeutic modalities discussed in the guidelines.
Objective: To examine the effect of psychologic and pharmacologic interventions on children's expectations and 6-month recollections of painful procedures.
Methods: A repeated measures design allowed examination of 22 fourth graders' expectations, experiences, and memories of distress across three conditions (typical care, distraction, topical anesthetic) for a three-injection vaccination series. All participants were African American and from urban, low-income families.
Results: Across conditions, children's expectations of distress were significantly higher than their experience of distress. Distress ratings did not differ among conditions prior to or immediately following the injections; however, children later recalled that the treatment conditions were superior to control for distress relief. Analyses of recall accuracy suggest that the interventions buffered the children from forming negative recollections that occurred with typical care.
Conclusions: Children have negative expectations prior to a procedure despite knowing that a distress management intervention will be employed. However, interventions may thwart the development of negative memories of distress.
Objective
To determine the prevalence and associations of self- and parent-reported pain in young people with cerebral palsy (CP).
Design and setting
Cross-sectional questionnaire survey conducted at home visits in nine regions in seven European countries. Participants were 13 to 17-year-olds (n=667) drawn from population CP registers in eight regions and from multiple sources in one region. 429 could self-report; parent-reports were obtained for 657. Data were collected on: severity, frequency, site and circumstances of pain in previous week; severity of pain associated with therapy in previous year.
Results
The estimated population prevalence of any pain in previous week was 74% (95% CI 69% to 79%) for self-reported pain and 77% (95% CI 73% to 81%) for parent-reported pain. 40% experienced leg pains, 34% reported headaches and 45% of those who received physiotherapy experienced pain during therapy. Girls reported more pain than boys (OR=2.1, 95% CI 1.5 to 3.0) and young people reported more pain if they had emotional difficulties (comparing highest and lowest quartiles: OR=3.1, 95% CI 1.7 to 5.6). Parents reported more pain in children with emotional difficulties (OR=4.2, 95% CI 2.7 to 6.6), or with more impaired walking ability.
Conclusions
Pain in young people with CP is highly prevalent. Because pain causes immediate distress and is associated with lower subjective well-being and reduced participation, clinicians should routinely assess pain. Clinical interventions to reduce pain should be implemented and evaluated. The efficacy of medical and therapeutic interventions causing pain should be re-examined to establish if their benefit justifies the pain and fear of pain that accompany them.
Objective
To evaluate the risk of upper gastrointestinal complications (UGIC) associated with drug use in the paediatric population.
Methods
This study is part of a large Italian prospective multicentre study. The study population included children hospitalised for acute conditions through the emergency departments of eight clinical centres. Patients admitted for UGIC (defined as endoscopically confirmed gastroduodenal lesions or clinically defined haematemesis or melena) comprised the case series; children hospitalised for neurological disorders formed the control group. Information on drug and vaccine exposure was collected through parental interview during the children's hospitalisation. Logistic regression was used to estimate ORs for the occurrence of UGIC associated with drug use adjusted for age, clinical centre and concomitant use of any drug.
Results
486 children hospitalised for UGIC and 1930 for neurological disorders were enrolled between November 1999 and November 2010. Drug use was higher in cases than in controls (73% vs 54%; p<0.001). UGICs were associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) (adjusted OR 2.9, 95% CI 2.1 to 4.0), oral steroids (adjusted OR 2.9, 95% CI 1.7 to 4.8) and antibiotics (adjusted OR 2.3, 95% CI 1.8 to 3.1). The duration of use of these drug categories was short (range 1–8 days). Paracetamol showed a lower risk (adjusted OR 2.0, 95% CI 1.5 to 2.6) compared to ibuprofen (adjusted OR 3.7, 95% CI 2.3 to 5.9), although with partially overlapping CIs.
Conclusions
NSAIDs, oral steroids and antibiotics, even when administered for a short period, were associated with an increased risk of UGIC.
<⁄span> Complex regional pain syndrome (CRPS) is a painful disorder without a known unifying mechanism. There are little data on which to base evaluation and treatment decisions, and what data are available come from studies involving adults; however, even that literature is relatively sparse. Developing robust research for CRPS in children is essential for the progress toward optimal treatment.
<⁄span> To determine potential avenues of research in pediatric CRPS based on a review of the literature. Areas of concern include diagnostic criteria, peripheral mechanisms, central nervous system mechanisms, the role of the autonomic nervous system, possible risk factors, options for prevention and potential avenues of treatment.
<⁄span> A literature review was performed and the results applied to form the hypotheses posited in the form of research questions.
<⁄span> CRPS is a complicated entity that is more than a painful sensory condition. There is evidence for peripheral inflammatory and neurological changes, and reorganization in both sensory and motor cortexes. In addition, a significant motor component is frequently observed and there appear to be tangible risk factors. Many of these pieces of evidence suggest options for prevention, treatment and monitoring progress and outcome. Most of the data are derived from adult studies and need to be replicated in children. Furthermore, there may be factors unique to pediatrics due to developmental changes in neuroplasticity as well as somatic, endocrinological and emotional growth. Some of these developmental factors may shed light on the adult condition.
Administration of oral sucrose or glucose with and without non-nutritive sucking is frequently used as a non-pharmacological intervention for needle-related procedural pain relief in infants.
To determine the effectiveness of sweet-tasting solutions for needle-related procedural pain in infants one month to one year of age compared with no treatment, placebo, other sweet-tasting solutions, or pharmacological or other non-pharmacological pain-relieving methods.
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012); MEDLINE via Ovid (1966 to 2012); CINAHL via OVID (1982 to 2012). The World Health Organization International Clinical Trials Registry Platform was also searched for any ongoing trials. Clinical trial registries, conference proceedings and references for randomised controlled trials (RCTs) were also searched. An updated search was run to capture any new publications before finalising the review in April 2012 and no new included studies were identified. Two review authors (MK & JF) independently abstracted data and assessed quality using a standard form. Authors have been contacted for missing data.
Randomised-controlled trials using a sweet-tasting solution to treat pain in healthy term infants (gestational age 37 weeks and over), between one month and 12 months of age who required needle-related procedures. These procedures included but were not limited to: subcutaneous or intramuscular injections, venepuncture, and heel lance. Studies in which the painful procedure was circumcision, lumbar puncture or supra-pubic bladder aspiration were not included as they are more severe and painful than needle-related procedures. Control conditions included no treatment or placebo (water) or any other identical intervention (same appearance and consistency) without active ingredient, another sweet-tasting solution, a pharmacological pain-relieving method (e.g. paracetamol, topical anaesthetic cream), non-pharmacological pain-relieving method (e.g. distraction method, non-nutritive sucking).
Assessment of trial quality, data extraction and synthesis of data were performed using standard methods of the Cochrane Pain, Palliative and Supportive Care Group. We report mean differences (MD) with 95% confidence intervals (CI) using fixed-effect models as appropriate for continuous outcome measures. We planned to report risk ratio (RR) and risk difference (RD) for dichotomous outcomes. The Chi(2) test and I(2) statistic were used to assess between-study heterogeneity.
Sixty-five (65) studies were identified for possible inclusion in this review. Fourteen published RCTs with a total of 1551 participants met the inclusion criteria. Duration of cry was significantly reduced in infants who were administered a sweet-tasting solution [MD -13.47 (95% CI -16.80 to -10.15)], P < 0.00001 compared with water. However, there was considerable heterogeneity between the studies (I(2) = 94%) that we were unable to explain. Meta-analysis was not able to be undertaken for any of the other outcome measures, except for cry duration, because of differences in study design. However, most of the individual studies that measured pain found sucrose to significantly reduce pain compared with the control group. One study compared sucrose and Lidocaine-prilocaine cream and no significant difference was found between the two treatments for the outcomes pain and cry duration. Due to the differences between the studies, we were unable to identify the optimal concentration, volume or method of administration of sweet-tasting solutions in infants aged one to 12 months. Further large RCTs are needed.
There is insufficient evidence to confidently judge the effectiveness of sweet-tasting solutions in reducing needle-related pain in infants (one month to 12 months of age). The treatments do, however, appear promising. Data from a series of individual trials are promising, as are the results from a subset meta-analysis of studies measuring duration of crying. Further well controlled RCTs are warranted in this population to determine the optimal concentration, volume, method of administration, and possible adverse effects.
Introduction:
After decades of research, the importance of psychological factors in child and adolescent headache is no longer in doubt. However, it is not clearly understood whether different types of headache are comorbid with specific kinds of psychopathology. To address this issue, we set out to establish whether young patients with migraine do or do not show significant levels of psychopathological symptoms compared with age-matched healthy controls and patients with tension-type headache (TTH).
Methods:
Ten studies were selected on the basis of a widely used psychodiagnostic tool (the Child Behavior Checklist (CBCL)) and by applying rigorous criteria: The studies were compared in a meta-analysis in order to evaluate the presence of Internalizing (mainly anxiety and depression) and Externalizing (mainly behavioral problems) symptoms in different types of headache (and versus healthy controls).
Findings:
Patients with migraine showed more psychopathological symptoms than healthy controls. TTH patients also had more psychopathology than controls, although the difference was more marked in the area of Internalizing disorders. Finally, no differences emerged between migraine and TTH.
Discussion and conclusion:
Psychopathological symptoms affect children with migraine, but also children with TTH. Biological, pathophysiological and clinical links need to be established. Effective treatment of affected children and adolescents is imperative in order to prevent chronic evolution. In this context, the CBCL may be a good screening instrument with a view to developing a tailored clinical approach.
This target article presents a theory of human cultural learning. Cultural learning is identified with those instances of social learning in which intersubjectivity or perspective-taking plays a vital role, both in the original learning process and in the resulting cognitive product. Cultural learning manifests itself in three forms during human ontogeny: imitative learning, instructed learning, and collaborative learning – in that order. Evidence is provided that this progression arises from the developmental ordering of the underlying social-cognitive concepts and processes involved. Imitative learning relies on a concept of intentional agent and involves simple perspective-taking. Instructed learning relies on a concept of mental agent and involves alternating/coordinated perspective-taking (intersubjectivity). Collaborative learning relies on a concept of reflective agent and involves integrated perspective-taking (reflective intersubjectivity). A comparison of normal children, autistic children and wild and enculturated chimpanzees provides further evidence for these correlations between social cognition and cultural learning. Cultural learning is a uniquely human form of social learning that allows for a fidelity of transmission of behaviors and information among conspecifics not possible in other forms of social learning, thereby providing the psychological basis for cultural evolution.
The objective of this study was to measure the impact of a structured intervention on pain management in a pediatric emergency department (ED).
Data were prospectively collected from children presenting to an urban tertiary care pediatric ED before and after intervention. Data were collected on the rate and timeliness of analgesic administration, the assessment and reassessment of pain, periprocedural anesthesia, and patient satisfaction. The intervention was developed by a multidisciplinary committee composed of physicians, nurses, and child life specialists and was focused on correcting deficiencies identified before intervention data collection. It consisted of a policy defining pain, pain-appropriate analgesia, age-appropriate pain assessment, and adequate preprocedural and periprocedural analgesia. Implementation occurred through provider education, organizational changes, and patient empowerment.
One hundred two patients were enrolled during the preintervention period, and 109 were enrolled in the postintervention period. The percentage of patients in pain receiving any analgesic increased from 34% to 50%, an increase of 16% (95% confidence interval [CI], 1%-30%). The median time to medication administration decreased from 97 minutes to 57 minutes, a decrease of 40 minutes (95% CI, -84 to 4 minutes). The percentage of children receiving preprocedural analgesia increased from 10% to 62%, an increase of 52% (95% CI, 12%-74%). Reassessment of pain by physicians increased from 6% to 76%, an increase of 70% (95% CI, 59%-78%).
A structured intervention, tailored to pain management shortcomings commonly found in the pediatric ED, can lead to improvements in the treatment and prevention of pain in childhood emergencies.
Extant research comparing laboratory pain responses of children with chronic pain with healthy controls is mixed, with some studies indicating lower pain responsivity for controls and others showing no differences. Few studies have included different pain modalities or assessment protocols.
To compare pain responses among 26 children (18 girls) with chronic pain and matched controls (mean age 14.8 years), to laboratory tasks involving thermal heat, pressure and cold pain. Responses to cold pain were assessed using two different protocols: an initial trial of unspecified duration and a second trial of specified duration.
Four trials of pressure pain and of thermal heat pain stimuli, all of unspecified duration, were administered, as well as the two cold pain trials. Heart rate and blood pressure were assessed at baseline and after completion of the pain tasks.
Pain tolerance and pain intensity did not differ between children with chronic pain and controls for the unspecified trials. For the specified cold pressor trial, 92% of children with chronic pain completed the entire trial compared with only 61.5% of controls. Children with chronic pain exhibited a trend toward higher baseline and postsession heart rate and reported more anxiety and depression symptoms compared with control children.
Contextual factors related to the fixed trial may have exerted a greater influence on pain tolerance in children with chronic pain relative to controls. Children with chronic pain demonstrated a tendency toward increased arousal in anticipation of and following pain induction compared with controls.
As important users of health care, adolescents with chronic conditions deserve to be consulted about their experiences and expectations. This study aimed to explore chronically ill adolescents' preferences regarding providers' qualities, and outpatient and inpatient care. Furthermore, suggestions for improvement of service delivery were collected.
This research was a sequential mixed methods study in adolescents aged 12-19 years with various chronic conditions treated in a university children's hospital. Methods comprised 31 face-to-face interviews at home, a hospital-based peer research project in which nine adolescents interviewed 34 fellow patients, and a web-based questionnaire (n = 990). Emerging qualitative themes were transformed into questionnaire items.
Having "a feeling of trust" and "voice and choice" in the hospital were central to these adolescents. Regarding providers' qualities, "being an expert" and "being trustworthy and honest" were ranked highest, followed by "being caring and understanding", "listening and showing respect", and "being focused on me". Regarding outpatient consultations, preferences were ranked as follows: "answering all questions"; "attending to my and my parents' needs"; and "clear communication", while "limited waiting times" and "attractive outpatient surroundings" scored lowest. Regarding hospitalization, adolescents most preferred to "avoid pain and discomfort", "keep in touch with home", and "be entertained", while "being hospitalized with peers" and "being heard" were least important. Regarding priorities for improvement, 52% of the respondents felt that more attention should be paid to older children, followed by enabling more contact with family and friends (45%), shorter waiting times (43%), and more activities to meet fellow patients (35%).
Adolescents prefer technically competent providers, who are honest and trustworthy, and attend to their needs. As they gradually grow out of the pediatric environment, they desire staff attitudes to become less childish and more age-appropriate, and welcome being treated as an equal partner in care. Health care professionals should inquire into preferences and adjust their communication style accordingly.
Acetaminophen is widely used in children, because its safety and efficacy are well established. Although the risk of developing toxic reactions to acetaminophen appears to be lower in children than in adults, such reactions occur in pediatric patients from intentional overdoses. Less frequently, acetaminophen toxicity is attributable to unintended inappropriate dosing or the failure to recognize children at increased risk in whom standard acetaminophen doses have been administered. Because the symptoms of acetaminophen intoxication are nonspecific, the diagnosis and treatment of acetaminophen intoxication are more likely to be delayed in unintentional cases of toxicity. This statement describes situations and conditions that may contribute to acetaminophen toxicity not associated with suicidal intentions.
OBJECTIVE: To compare the effectiveness of nasal diamorphine spray with intramuscular morphine for analgesia in children and teenagers with acute pain due to a clinical fracture, and to describe the safety profile of the spray. DESIGN: Multicentre randomised controlled trial. SETTING: Emergency departments in eight UK hospitals. PARTICIPANTS: Patients aged between 3 and 16 years presenting with a clinical fracture of an upper or lower limb. MAIN OUTCOME MEASURES: Patients' reported pain using the Wong Baker face pain scale, ratings of reaction to treatment of the patients and acceptability of treatment by staff and parents, and adverse events. RESULTS: 404 eligible patients completed the trial (204 patients given nasal diamorphine spray and 200 given intramuscular morphine). Onset of pain relief was faster in the spray group than in the intramuscular group, with lower pain scores in the spray group at 5, 10, and 20 minutes after treatment but no difference between the groups after 30 minutes. 80% of patients given the spray showed no obvious discomfort compared with 9% given intramuscular morphine (difference 71%, 95% confidence interval 65% to 78%). Treatment administration was judged acceptable by staff and parents, respectively, for 98% (199 of 203) and 97% (186 of 192) of patients in the spray group compared with 32% (64 of 199) and 72% (142 of 197) in the intramuscular group. No serious adverse events occurred in the spray group, and the frequencies of all adverse events were similar in both groups (spray 24.1% v intramuscular morphine 18.5%; difference 5.6%, -2.3% to 13.6%). CONCLUSION: Nasal diamorphine spray should be the preferred method of pain relief in children and teenagers presenting to emergency departments in acute pain with clinical fractures. The diamorphine spray should be used in place of intramuscular morphine.
A Young Mind in a Growing Brain summarizes some initial conclusions that follow simultaneous examination of the psychological milestones of human development during its first decade and what has been learned about brain growth. This volume proposes that development is the process of experience working on a brain that is undergoing significant biological maturation. Experience counts, but only when the brain has developed to the point of being able to process, encode, and interact with these new environmental experiences. This book's aim is to acquaint developmental biologists and neuroscientists with what has been learned about human psychological development and to acquaint developmental psychologists with the biological evidence. The hope is that each group will gain a richer appreciation of both knowledge corpora. The authors hope to appeal to neuroscientists, psychologists, psychiatrists, pediatricians, and their students. The idea for this book was born in 1993 when the authors--a leading developmental psychologist and a pediatrician--met for the first time and recognized the complementarity of their backgrounds and the utility of a collaboration. The reception of their first two papers motivated this attempt to synthesize the available information over a longer developmental era. Learning a great deal over the past decade, the authors hope that their enthusiasm provokes an equally intense curiosity in readers. © 2005 by Lawrence Erlbaum Associates, Inc. All rights reserved.
Background:
Differently from the adult patients, in pediatric age it is more difficult to assess and treat efficaciously the pain and often this symptom is undertreated or not treated. In children, selection of appropriate pain assessment tools should consider age, cognitive level and the presence of eventual disability, type of pain and the situation in which it is occurring. Improved understanding of developmental neurobiology and paediatric analgesic drugs pharmacokinetics should facilitate a better management of childhood pain.
Aim:
The objective of this review is to discuss current practice and recent advances in pediatric pain management.
Methods:
Using PubMed we conducted an extensive literature review on pediatric pain assessment and commonly used analgesic agents from January 2000 to January 2012.
Conclusions:
A multimodal analgesic regimen provides better pain control and functional outcome in children. Cooperation and communication between the anaesthesiologist, surgeon, and paediatrician are essential for successful anaesthesia and pain management.
AimPain is a neglected problem in children with cognitive impairments and few studies compare the clinical use of specific pain scales. We compared the Non-Communicating Children's Pain Checklist Postoperative Version (NCCPC-PV), the Echelle Douleur Enfant San Salvador (DESS) and the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS). The first two were developed for children with cognitive impairment and the third is a more general pain scale.Methods
Two external observers and the child's caregiver assessed 40 children with cognitive impairment for pain levels. We assessed inter-rater agreement, correlation, dependence on knowledge of the child's behaviour, simplicity and adequacy in pain rating according to the caregiver for all three scales.ResultsThe correlation between the NCCPC-PV and the DESS was strong (Spearman correlation coefficient = 0.76) and better than between each scale and the CHEOPS. Although the DESS showed better inter-rater agreement, it was more dependent on familiarity with the child and was judged more difficult to use by all observers. The NCCPC-PV was the easiest use and the most appropriate for rating the child's pain.Conclusion
The NCCPC-PV was the easiest to use for pain assessment in cognitively impaired children and should be adopted in clinical settings.This article is protected by copyright. All rights reserved.
The European Medicine Agency recommendations limiting codeine use in children have created a void in managing moderate pain. We review the evidence on the pharmacokinetic, pharmacodynamic and safety profile of tramadol, a possible substitute for codeine.Conclusion
Tramadol appears to be safe in both pediatric inpatients and outpatients. It may be appropriate to limit the current use of tramadol to monitored settings in children with risk factors for respiratory depression, subject to further safety evidence.This article is protected by copyright. All rights reserved.
Unlabelled:
Paracetamol (acetaminophen) is one of the most popular and widely used drugs for the treatment of pain and fever in children. This drug has multiple mechanisms of action, but its pharmacodynamic is still not well known. The central nervous system is the main site of action and it mirrors the paracetamol effect compartment. The recommended dosages and routes of administration should be different whether paracetamol is used for the treatment of pain or fever. For example, the rectal route, while being efficacious for the treatment of fever, should be avoided in pain management. Paracetamol is a safe drug, but some clinical conditions and concomitant drugs, which are frequent in clinical practice, may increase the risk of paracetamol toxicity. Therefore, it is important to optimize its administration to avoid overdoses and maximize its effect. The principal mediator of the paracetamol toxicity is the N-acetyl-p-benzo-quinone imine (NAPQI), a toxic product of the paracetamol metabolism, which could bind cysteine groups on proteins forming paracetamol-protein adduct in the liver.
Conclusion:
Although frequently prescribed, the concep