Judith E. Beyer

Discordance between self-report and behavioral pain measures in children aged 3–7 years after surgery

This study examined concurrent self-reports of pain intensity and behavioral responses in 25 children aged 3-7 yr. Behavioral (Childrens Hospital of Eastern Ontario Pain Scale, CHEOPS) and self-report (the Oucher and Analogue Chromatic Continuous Scale) measures of pain were obtained following major surgery. The two self-report measures were strongly and significantly correlated, and the pattern of scores over the 36-hr observation period was as expected. There was little relationship between the scores for the self-report and the behavioral measures. Many children who reported severe pain manifested few of the behavioral indicators of distress used in the CHEOPS. This behavioral response pattern may occur commonly in children experiencing pain after surgery and may limit the applicability of current behavioral scales as sole measures of pain intensity in younger children.

The Assessment of Pain in Children

This article focuses on the methods of pain measurement and assessment in children. The concepts of reliability and validity and the available types of physiologic, self-report, and behavioral measures are addressed. Methods of pain assessment in infants and toddlers, preschoolers, school-aged children, and adolescents are detailed. Finally, some practical suggestions for pediatric pain assessment are provided.

Comparison of morphine and methadone for prevention of postoperative pain in 3- to 7-year-old children*

A randomized, double-blind, prospective study was performed to determine the effects of perioperative administration of morphine or methadone on postoperative analgesic requirements and pain scores in 35 children aged 3 to 7 years undergoing major surgery. After a standardized induction of anesthesia, methadone or morphine, 0.2 mg/kg, was blindly administered, and supplemental doses were titrated to achieve comfort in the recovery room. Pain was assessed during the next 36 hours with a combination of validated behavioral and self-report measures. Patients in the methadone group required fewer supplemental opioid analgesic drugs during the next 36 hours, and reported lower pain scores. No patient had prolonged emergence from anesthesia, and no patient required naloxone or postoperative ventilatory assistance. No major adverse events occurred. We conclude that perioperative intravenous administration of methadone is an effective, inexpensive, and technologically simple means for providing prolonged analgesia for children after surgery.

Patterns of pediatric pain intensity: a methodological investigation of a self-report scale

This was one of a series of studies to examine the validity of the Oucher, an instrument designed to measure childrens self-reports of pain in-tensity. Ninety-five 3− to 12-year-old hospitalized children were included in one or more parts of this descriptive methodological study. Findings indicated that pain scores conformed to expected patterns before and after surgery. Moderate, positive relationships were revealed between pain intensity and the number of doses of analgesics given. Relationships between the Oucher and two other pain measures used were found to be strong and positive. Conclusions indicated that the results provided evidence to support the construct validity of this new instrument.

Construct validity estimation for the African-American and Hispanic versions of the Oucher Scale

This study examined the construct validity of the African-American and Hispanic versions of the Oucher Scale as measures of pain in 104 children ages 3 to 12 years old. Scores on the Oucher Scale, Analogue Chromatic Continuous Scale, and Child Medical Fear Scale were obtained after being administered concurrently on one occasion, either before or after surgery. Additionally, Oucher scores were obtained before and after analgesic administration. Significant correlations were found between the two pain intensity measures, while weak, nonsignificant relationships were revealed between the pain and fear measures. Preanalgesic scores were significantly higher than postanalgesic scores. These findings support the construct validity of the two new ethnic versions of the Oucher.

Changes in intensity, location, and quality of vaso-occlusive pain in children with sickle cell disease.

&NA; A descriptive, longitudinal design was used to examine changes in current, worst, and least pain intensity during hospitalization for a vaso‐occlusive episode in children with sickle cell disease. Other dimensions of the pain experience including location and quality were also evaluated. Children reported severe pain on the day of admission with 50% of the episodes showing a current pain intensity score of >70 and a worst pain intensity score of >80. Although both pain intensity scores demonstrated statistically significant decreases by approximately 5% over the course of the hospitalization, these decreases were not clinically significant based on the recommendations made in the American Pain Societys Guideline for the management of acute and chronic pain in sickle cell disease. In contrast to the pain intensity ratings, which did not decrease in 25% of the episodes, pain location surface area decreased in 100% of the episodes. Children described the quality of vaso‐occlusive pain using all categories of word descriptors from the adolescent pediatric pain tool. These findings suggest that pain associated with a vaso‐occlusive episode is inadequately assessed and managed during hospitalization.

Judging the Effectiveness of Analgesia for Children and Adolescents During Vaso-Occlusive Events of Sickle Cell Disease

The effectiveness of analgesia during sickle cell crisis was examined in this descriptive, exploratory study. Pain scores (using the African-American Oucher and the Adolescent Pediatric Pain Tool) and analgesics administered were examined during a 2-hour observation/interview in the hospital while children/adolescents with sickle cell disease (SCD) experienced a vaso-occlusive episode (VOE). A convenience sample of twenty-one 6- to 16-year olds with SCD was included. Evidence indicated that 15 of the 21 children in the sample were in moderate to severe pain during their interviews, indicating that the analgesics did not effectively control their pain. Most participants (17) had received nalbuphine as the primary analgesic by intravenous infusion drip and/or patient-controlled analgesia pump. Many reasons were identified for the inadequate analgesia. The results suggested that the pain of SCD is very complex, requiring continuous adjustment of comfort measures, especially analgesics. More research is needed to examine pain control in children with SCD.

Management of vaso-occlusive pain in children with sickle cell disease.

Purpose A descriptive, longitudinal design was used to evaluate the pain management strategies used in children with sickle cell disease who were experiencing pain during a vaso-occlusive episode. Methods A list of the medications (name, amount, mode of delivery, and frequency) prescribed and administered for pain management for each participant was recorded on the Medication Quantification Scale Worksheet, starting from day 1 of hospitalization to the day of discharge. Children were asked once each evening to provide three separate ratings of how much the pain medication helped them during the day, evening, and night using a 0-to-10 rating scale. Results Using patient-controlled analgesia (PCA), children self-administered only 35% of the analgesic medications that were prescribed and reported little pain relief. No significant relationships were found between changes in pain relief scores and the amount of analgesics administered. Conclusions Clinicians need to monitor the amount of analgesics delivered in relationship to pain relief and assist children to titrate PCA administration of analgesics to achieve optimal pain control, or to advocate for changes in the PCA regimen when children cannot assume control of pain management.

Quantification of analgesic use in children with sickle cell disease.

ObjectivesThe purposes of this study were: (1) to quantify analgesic use in children with sickle cell disease who were hospitalized for a vaso-occlusive episode, using the Medication Quantification Scale (MQS) and (2) to examine the relationships between pain intensity scores, number of painful areas marked on a body outline diagram, number of word descriptors of pain quality, and amount of analgesic medications administered. MethodsChildren (5 to 19 y) were asked daily to provide pain intensity ratings and describe the location and quality of their pain. The nursing flowsheets were also reviewed to determine the dose, routes, and the number of times analgesic medications were administered in the previous 24 hours. ResultsMean worst pain intensity score on the day of admission was 84.0±9.9 (range 63.8 to 100) on the 0 to 100 Oucher numeric rating scale. The mean MQS score administered on the day of admission was 15.7±4.9 (range 6 to 24). This score decreased significantly by 1.2±0.5 (P<0.0001; range 0.9 to 2.5) each day of hospitalization. Significant correlations were found between various pain characteristics and total MQS scores prescribed at time of admission. DiscussionThe MQS was a useful and sensitive measure to quantify analgesic use in patients with sickle cell disease who were hospitalized for an acute painful episode. The MQS score accounted for variations in the types of analgesic medications, routes of administration, dosing schedules, and opioid dosing requirements.

Trends in Complete Blood Count Values During Acute Painful Episodes in Children With Sickle Cell Disease

Complete blood count (CBC) values are monitored as crude indicators of the hemolytic and inflammatory processes that accompany an acute painful episode in children with sickle cell disease. As part of a larger study that examined the pain experience and pain management of hospitalized children during painful vaso-occlusive episodes, the authors examined trends in CBC values and determined whether there were relationships between these values and pain intensity scores. Children, 5 to 19 years of age, with sickle cell disease whose primary reason for admission was vasoocclusive pain were recruited for participation in the study. Once every evening from the day of admission until the day of discharge, they were asked to rate their worst and least pain using the numeric rating scale of the African American Oucher pain scale. Complete blood count values were obtained from the hospital information system on a daily basis. Parallel changes in CBC values and pain intensity scores were evident within the first 48 hours of hospitalization. However, although the inflammatory and hemolytic processes were resolving, pain persisted at moderate levels throughout the course of hospitalization.