Elizabeth A. Stanford

The frequency, trajectories and predictors of adolescent recurrent pain: A population-based approach

&NA; Recurrent pains are a complex set of conditions that cause great discomfort and impairment in children and adults. The objectives of this study were to (a) describe the frequency of headache, stomachache, and backache in a representative Canadian adolescent sample and (b) determine whether a set of psychosocial factors, including background factors (i.e., sex, pubertal status, parent chronic pain), external events (i.e., injury, illness/hospitalization, stressful‐life events), and emotional factors (i.e., anxiety/depression, self‐esteem) were predictive of these types of recurrent pain. Statistics Canada’s National Longitudinal Survey of Children and Youth was used to assess a cohort of 2488 10‐ to 11‐year‐old adolescents up to five times, every 2 years. Results showed that, across 12–19 years of age, weekly or more frequent rates ranged from 26.1%–31.8% for headache, 13.5–22.2% for stomachache, and 17.6–25.8% for backache. Chi‐square tests indicated that girls had higher rates of pain than boys for all types of pain, at all time points. Structural equation modeling using latent growth curves showed that sex and anxiety/depression at age 10–11 years was predictive of the start‐ and end‐point intercepts (i.e., trajectories that indicated high levels of pain across time) and/or slopes (i.e., trajectories of pain that increased over time) for all three types of pain. Although there were also other factors that predicted only certain pain types or certain trajectory types, overall the results of this study suggest that adolescent recurrent pain is very common and that psychosocial factors can predict trajectories of recurrent pain over time across adolescence.

The role of developmental factors in predicting young children's use of a self-report scale for pain

Abstract Accurate pain assessment is the foundation for effective pain management in children. At present, there is no clear consensus regarding the age at which young children are able to appropriately use self‐report scales for pain. This study examined young childrens ability to use the Faces Pain Scale‐Revised; (FPS‐R; [Hicks CL, von Baeyer CL, Spafford PA, van Korlaar I, Goodenough B. The Faces Pain Scale‐Revised: toward a common metric in pediatric pain measurement. Pain 2001; 93: 173–83]) for pain in response to vignettes and investigated the role of developmental factors in predicting their ability to use the scale. One hundred and twelve healthy children (3–6 years old) were assessed for their ability to accurately use a common faces scale to rate pain in hypothetical vignettes depicting pain scenarios common in childhood. Accuracy was determined by considering whether childrens judgements of pain severity matched the pain severity depicted in the various vignettes. Children were also administered measures of numerical reasoning, language, and overall cognitive development. Results indicated that 5‐ and 6‐year‐old children were significantly more accurate in their use of the FPS‐R in response to the vignettes than 4‐year‐old children, who in turn were significantly more accurate than 3‐year‐old children. However, over half of the 6‐year‐olds demonstrated difficulties using the FPS‐R in response to the vignettes. Child age was the only significant predictor of childrens ability to use the scale in response to the vignettes. Thus, a substantial number of young children experienced difficulties using the FPS‐R when rating pain in hypothetical vignettes, although the ability to use the scale did improve with age.

A normative analysis of the development of pain-related vocabulary in children

&NA; Effective verbalization of pain requires progressive cognitive development and acquisition of social communication skills. Use of self‐report in pediatric pain assessment assumes children have acquired a capacity to understand and use common words to describe pain. The current investigation documented the language most commonly used by young children to describe pain and the age of onset of use of these words. Two complementary research methodologies were employed. Study 1 used the CHILDES database, an aggregated transcript database of multiple research studies examining spontaneous speech development across childhood. Transcripts of 14 randomly selected studies, yielding a total of 245 child participants ranging in age from 1 to 9 years, were searched for seven English primary pain word‐stems: ‘ache’, ‘boo–boo’, ‘hurt’, ‘ouch’, ‘ow’, ‘pain’, and ‘sore’. Study 2 surveyed 111 parents of children aged 3 to 6 years old concerning words the children commonly used for pain. Parents rated their childrens frequency and age of first use of the seven pain word‐stems. Both studies indicated that the most frequently used word‐stems were ‘hurt’, ‘ouch’, and ‘ow’. These words first emerged in childrens vocabularies as early as 18 months of age. The word‐stem ‘pain’ was used relatively infrequently and gradually emerged in childrens vocabularies. The findings indicate that young children rely on a select number of words to describe pain, with these words appearing in childrens vocabularies at an early age. These results have implications for developmentally appropriate pain assessment in young children.

Response biases in preschool children's ratings of pain in hypothetical situations

Response biases are systematic biases in responding to test items that are unrelated to the content of the items. Examples often reported in young children include choosing only the lowest or highest anchors of a scale, or choosing a left‐to‐right sequence of responses. We investigated the presence of response biases in young childrens ratings of pain in hypothetical situations, as a way of gauging their developing understanding of a pain scale over the preschool years. Children aged 3–5 years (N=185) rated items from the Charleston Pediatric Pain Pictures (CPPP) using the Faces Pain Scale‐Revised (FPS‐R). Response biases were identified objectively by computer pattern identification. Anchor biases (choosing the lowest and highest pain faces) occurred in 16% of children. Left–right or right–left sequences occurred in 35%. Monte Carlo simulation established that such patterns occur infrequently by chance (<3% for anchor biases; <6% for sequence biases). Response biases were identified more often in younger than older children. These results reveal that response biases are common in children under 5 years. Clinicians should consider self‐report pain ratings from preschoolers with caution, seek complementary observational assessment, and investigate discrepancies between self‐report and observational estimates of pain. Simplified forms, instructions, and methods of administration for self‐report scales should be developed and validated for use with 3‐ and 4‐year‐olds.

Ow!: spontaneous verbal pain expression among young children during immunization.

Objectives:Although self-reports are a commonly used means of assessing pain in clinical settings, little is understood about the nature of childrens spontaneous verbal expressions of pain. The purpose of this study was to describe verbalizations of pain among children receiving a preschool immunization and to examine how pain verbalizations correspond to childrens facial expressions and self-reports of pain intensity. Methods:Fifty-eight children between the ages of 4 years 8 months and 6 years 3 months (67% female) were videotaped while receiving their routine preschool immunization. Global ratings of facial expression and detailed transcription and coding of pain verbalizations were undertaken. Children provided self-reports of pain using a 7-point faces pain scale. Results:Fifty-three percent of children used verbalizations spontaneously to express their pain. The modal verbalization was the interjection “Ow!,” which expressed negative affect and was specific to the experience of pain. Older children were less likely to use verbalizations to express their pain. Children who used verbalizations to express pain displayed greater facial reactions to pain and rated their pain experience as being more intense than children who did not use words to express their pain. Discussion:Results indicate that many young children do not spontaneously use verbalizations to express pain from immunization. When 5-year-olds use verbalizations to express pain, the verbalizations are most often brief statements that express negative affect and directly pertain to pain. Knowledge of how children verbalize pain may lead to an improved ability to assess and manage pediatric pain.

Seven-year results with the St Jude Medical Silzone mechanical prosthesis

OBJECTIVE The Artificial Valve Endocarditis Reduction Trial was stopped on January 21, 2000, due to a higher incidence of paraprosthetic leak in the St Jude Medical Silzone prosthesis compared with the conventional prosthesis. The Artificial Valve Endocarditis Reduction Trial investigators reported the 2-year results in 2002. This retrospective study assessed the influence on thromboembolism and paraprosthetic leak to 7 years. METHODS A total of 253 patients had 254 operations: 80 aortic valve replacements, 139 mitral valve replacements, and 35 multiple replacements with placement of Silzone prostheses. The mean age was 58.6 years (range 21-84 years, median age 59.8 years), and there were 126 women (49.8%) and 74 concomitant procedures (coronary artery bypass 28.9%). RESULTS Major paraprosthetic leak (repair, re-replacement, or mortality) occurred in 10 of the original procedures after 30 days (3 aortic valve replacements, 3 mitral valve replacements, 4 multiple replacements). Nine occurrences in 8 patients-5 early (<or=2 years) and 4 late (>2 years)-were managed. Seven were managed with definitive re-replacement. One was an early nonoperative fatality. There was 1 late fatality after the second late paraprosthetic leak reoperation. One of the 10 procedures occurring after 2 years had mild to moderate aortic valve replacement paraprosthetic leak managed as an incidental re-replacement at the time of correction of supra valvular patch stenosis. One additional occurrence, in addition to the 8 patients (<30 days), was considered a technical error and not related to the Silzone prosthesis and was replaced with a Silzone prosthesis. The linearized rate of paraprosthetic leak within the first 2 years of follow-up was 1.3%/patient-year and after 2 years was 0.4%/patient-year. The linearized occurrence rate for major thromboembolism was 0.42%/patient-year for aortic valve replacement and 1.71%/patient-year for mitral valve replacement. CONCLUSIONS Paraprosthetic leak with the St Jude Medical Silzone prosthesis was managed both during the early (<or=2 years) and late (>2years) intervals with re-replacement. Late managed events may be manifestations of earlier occurring paraprosthetic leak. Follow-up echocardiograms should meet standards of care, 6 to 12 months after surgery and at the slightest suspicion of dysfunction. There is no advanced continuing risk of the St Jude Medical Silzone prosthesis.