Joke A. M. Hunfeld

Pain in children and adolescents: a common experience

&NA; Little is known about the epidemiology of pain in children. We studied the prevalence of pain in Dutch children aged from 0 to 18 years in the open population, and the relationship with age, gender and pain parameters. A random sample of 1300 children aged 0–3 years was taken from the register of population in Rotterdam, The Netherlands. In the Rotterdam area, 27 primary schools and 14 secondary schools were selected to obtain a representative sample of 5336 children aged 4–18 years. Depending on the age of the child, a questionnaire was either mailed to the parents (0–3 years) or distributed at school (4–18 years). Of 6636 children surveyed, 5424 (82%) responded; response rates ranged from 64 to 92%, depending on the subject age and who completed the questionnaire. Of the respondents, 54% had experienced pain within the previous 3 months. Overall, a quarter of the respondents reported chronic pain (recurrent or continuous pain for more than 3 months). The prevalence of chronic pain increased with age, and was significantly higher for girls (P<0.001). In girls, a marked increase occurred in reporting chronic pain between 12 and 14 years of age. The most common types of pain in children were limb pain, headache and abdominal pain. Half of the respondents who had experienced pain reported to have multiple pain, and one‐third of the chronic pain sufferers experienced frequent and intense pain. These multiple pains and severe pains were more often reported by girls (P<0.001). The intensity of pain was higher in the case of chronic pain (P<0.001) and multiple pains (P<0.001), and for chronic pain the intensity was higher for girls (P<0.001). These findings indicate that chronic pain is a common complaint in childhood and adolescence. In particular, the high prevalence of severe chronic pain and multiple pain in girls aged 12 years and over calls for follow‐up investigations documenting the various bio‐psycho‐social factors related to this pain.

Psychosocial factors associated with chronic pain in adolescents

&NA; A number of psychosocial factors have been associated with the onset, exacerbation and/or maintenance of chronic pain in adolescents. The present study was conducted to evaluate the relative importance of vulnerability, reinforcement, and modeling. We compared 222 adolescents with chronic pain and no documented physiological etiology (headache, back, limb and abdominal pain) with 148 controls and their (respectively 183 vs. 127) parents. Analyses showed that adolescents with chronic pain are more vulnerable in terms of neuroticism, negative fear of failure, and (less) experienced social acceptance. Contrary to our expectations, the chronic pain group experienced less reinforcement for their pain behavior by both parents and peers than the control group. While the number of pain models was higher in the chronic pain group, no differences were found between their parents and those of the adolescents without chronic pain in pain experience, pain parameters, and pain coping. Regression analyses on the contribution of psychosocial factors to chronic pain and its parameters sustained the positive relation between vulnerability, (less) pain reinforcement, pain models and coping with pain. Furthermore, we also found evidence that gender differences have to be taken into account.

Insights in the use of health care services in chronic benign pain in childhood and adolescence

&NA; The utilization of health care services in children and adolescents with chronic benign pain was studied in a Dutch population sample of 254 chronic pain sufferers aged 0–18 years. Children and adolescents who had reported chronic pain (continuous or recurrent pain >3 months) in our previous prevalence study were asked to keep a 3‐week diary on their pain and to fill out questionnaires on background factors, health care use and the impact of pain. Parent ratings were used for children aged 0–11 years, self‐report was used in adolescents (12–18 years). In a 3‐month period, in 53.4% of the cases medication was used for pain, and general practitioners and specialists were consulted for pain in 31.1% and 13.9% of subjects, respectively. Physiotherapists, psychologists and alternative health providers were visited by 11.5, 2.8, and 4.0%, respectively. In the preceding year, 6.4% had been hospitalized due to pain. The most important factors linked to utilizing medical services were gender, various pain characteristics, school absenteeism and disability. Although consulters reported to be less physically fit and less satisfied with health, their parents were better adapted to the pain, by talking and sharing, mutual support, normalization of the child and heightened self‐esteem, than non‐consulters. Prospective studies are needed to test causality of coping on care‐seeking behavior.

The natural course of chronic benign pain in childhood and adolescence: A two-year population-based follow-up study

Study objective. To assess the course of chronic benign pain in childhood and adolescence longitudinally.

Stability of pain parameters and pain-related quality of life in adolescents with persistent pain: a three-year follow-up.

ObjectiveMany juveniles with chronic pain of no known organic cause recover. Because adolescents whose pain persists may have chronic pain as adults, a subsample of 42 adolescents from a prevalence study in which continuation of their pain was observed throughout the study period was investigated quantitatively and qualitatively. All mothers (n = 42) completed a questionnaire on the impact of the adolescents pain on the family. The authors tested the hypothesis that pain parameters, pain-related quality of life, and impact of pain on the family would deteriorate over time. DesignThree-year follow-up questionnaires, diaries, and interviews were used. SettingThe study was conducted in the general population in the Rotterdam area. ParticipantsAdolescents (aged 12–18 years) who indicated chronic pain in our previous prevalence study and in a diary and questionnaire each year of the 3-year follow-up were included in the study. ResultsThe most prevalent pains were limb pain and headache. The pain intensity was mild (33 mm on a visual analog scale), very frequent (72% of all diary entries), and associated with relatively poor functional status and poor psychological and somatic functioning. The pain parameters, pain-related quality of life, and impact of pain on the family (i.e., restrictions in social life and problems in dealing with the stress of the adolescents pain) remained surprisingly stable across the assessments. The interviews showed that pain had become part of the daily life of several adolescents, who structured their activities and sleeping hours to prevent aggravation of pain. In particular, adolescents with headache reported problems with cognitive activities, whereas those with limb pain and back pain reported problems with physical activities. ConclusionsFor adolescents with persistent pain with no known organic cause, intensity and frequency of pain, quality of life, and impact of pain on the family did not change. Generally, they seemed to cope quite well with their pain. In view of these results, further studies should involve follow-up of adolescents with persistent pain into adulthood to establish the determinants of their pain and to find out whether they maintain their adaptive ways of living with their pain.

Physically unexplained chronic pain and its impact on children and their families: The mother's perception

Because children with physically unexplained chronic pain may become the adult chronic pain patients of the future and because little is known about this pain and its impact on children and their families, a sample of 77 children (aged 5-11 years) with this type of pain was investigated. The hypothesis was tested that a greater intensity and frequency of pain would diminish the childs functional status and increase the impact of pain on the family. All mothers completed questionnaires on their perception of the childs functional status and the impact of pain on the family, and kept a diary on the childs pain for three successive weeks, three times daily, by means of a visual analogue scale (VAS) and a behavioural list. The study was conducted in the general population in the Rotterdam area. Children with physically unexplained chronic pain were sampled from those participating in a prevalence study on chronic pain. The average pain was mild (30 mm on a 0-100 mm VAS), moderately frequent (34% of the diary registration time), increased during the day, and did not result in large school absence or problems with functional status. Pain showed a relatively negative impact on family life, especially restrictions in social life and personal strain were reported, based on behavioural changes. In particular, abdominal pain, headache and limb pain are already present in considerable numbers at a young age. Longitudinal research should determine whether shifts occur in pain experience and locations from childhood and adulthood and in different dimensions of functional status and, more broadly, in quality of life resulting from pain.

Measuring Chronic Pain in Children, an Exploration

The study focused on the feasibility and validity of pain instruments and the optimal period of diary registration for measuring chronic pain intensity of 13 children. Highly positive associations were found between the registration of pain on a Visual Analogue Scale and on the Postoperative Pain Measure for Parents. For children under medical treatment for chronic limb pain a one-week diary registration suffices.

QUALITY OF LIFE AND ANXIETY IN PREGNANCIES AFTER LATE PREGNANCY LOSS: A CASE–CONTROL STUDY

Pregnant women with (n=24) and without (n=26) a previous pregnancy loss (>16 weeks) due to congenital anomalies were compared on quality of life and anxiety. Pregnant women with a previous loss were divided into those with and those without a normal livebirth since the loss [cases+ (n=6) and cases− (n=18), respectively]. Psychological measurements were carried out before and after an ultrasound scan in the second trimester of the pregnancy. Women with a previous loss who had not delivered a healthy infant between the loss and the present pregnancy showed a lower quality of life as revealed by feelings of social isolation, negative emotional reactions, and pain than the other groups. In addition, they showed more pregnancy‐related anxiety. The negative emotions were particularly present just before the anomaly scan. Feelings of social isolation, negative emotional reactions, pain, and pregnancy‐related anxiety were significantly positively related to trait anxiety, irrespective of having experienced late pregnancy loss. The implications of this study are that the referring gynaecologist, physician, or midwife should be aware of the strong emotions and major concerns of women in a pregnancy subsequent to a late pregnancy loss. In addition, they should offer these women the opportunity to express their emotional distress.

Trait Anxiety, Negative Emotions, and the Mothers' Adaptation to an infant born subsequent to late Pregnancy Loss: a Case–Control Study

Women with (n=27) a history of late pregnancy loss (≥20 weeks) due to congenital anomalies who had completed the subsequent pregnancy with a live‐birth were compared with a group of mothers with newborns without such a history (n=29) at 4 and 16 weeks post‐partum. The following aspects were assessed: depression, anxiety, psychological distress, and mother–infant adaptation. The women with a previous pregnancy loss showed significantly more negative emotions than the women without such a history. In addition, they considered that their healthy baby experienced more problems with sleeping, crying, eating, and acquiring a regular pattern of this behaviour than the average baby. They also perceived their baby as being less ideal than the women without a previous pregnancy loss. These problems were particularly present 4 weeks post‐partum and were significantly positively related to trait anxiety. The implications of this study are that in women with a history of late pregnancy loss, family physicians and welfare officers should be made aware of possible problems in the mother and in mother–infant adaptation shortly after a normal live‐birth, particularly in those with high trait anxiety. They will then be able to arrange psychological support at an early stage.

Prenatal consultation after a fetal anomaly scan: videotaped exploration of physician's attitude and patient's satisfaction.

The main aim of the study was to evaluate the relationship between the physicians attitude (using the non‐verbal Global Affective Measure of the Roter Analaysis System and the Counselor Rating Form—short version) and the satisfaction of the pregnant women with the prenatal consultation. A secondary aim was to evaluate the womens recall of essential information (i.e. location, severity, prognosis and cause of the anomaly). To this end, 24 prenatal consultations (pregnant women, partners and physicians) were videotaped following a fetal anomaly scan, and a few days later, the pregnant women completed questionnaires to assess their perception of the physicians attitude and their satisfaction with the consultation and the extent to which they could recall the essentials of the information given about the fetal anomaly.