Cumulative effects of multiple pain sites in youth with chronic pain.

BACKGROUND: The experience of persistent pain in multiple locations is common in youth. Based on current literature, youth with multiple pain sites (MPS) are at risk of experiencing poorer emotional outcomes and a spread of symptoms into late adolescence and adulthood. Little is known regarding the association between MPS with physical and school functioning domains, particularly after initiation of multidisciplinary pain treatment. Therefore, the objective of this study was to examine the association of MPS with disability and school functioning among youth with chronic pain. METHODS: A total of 195 patients with chronic pain, aged 8-17, and their parents completed measures assessing patient distress and functioning at a multidisciplinary pain clinic evaluation and at 4-month follow-up. RESULTS: At evaluation, 63% of patients presented with MPS; 25% reporting MPS endorsed pain in five or more locations. When controlling for relevant demographic and emotional distress factors, MPS were associated with lower school functioning at evaluation with a persistent trend at follow-up. Although MPS were not a significant predictor of pain-related disability at evaluation, it emerged as significant at follow-up. CONCLUSIONS: Potentially due to the MPS load and the inverse effects that such a pain state has on function, such patients may be at risk for poorer health and school-related outcomes. The mechanisms influencing these relationships appear to extend beyond psychological/emotional factors and warrant further investigation in order to aid in our understanding of youth with MPS. SIGNIFICANCE: Youth with MPS may be at risk for experiencing poorer physical and school functioning in comparison with single-site peers, despite treatment initiation. Further research is warranted to inform assessment and treatment approaches for this subgroup of patients.

Office-based pain management. The 15-minute consultation.

Pain is a ubiquitous component of pediatric illness and injury. Unfortunately, the treatment of pain has remained secondary to the diagnosis and treatment of the disease state. Clinicians' duty is to relieve suffering, and, as such, the relief of pain should be a primary focus. Presently available modalities, when used appropriately, can significantly reduce the pain associated with medical encounters. Careful attention to such approaches may reduce the anxiety about pain, which is often an undercurrent at most health care visits, and allows clinicians and children to focus on getting well and staying healthy.

A comparison of the Mogen and Gomco clamps in combination with dorsal penile nerve block in minimizing the pain of neonatal circumcision.

OBJECTIVES: 1) To compare the Mogen and Gomco clamps with regard to pain experienced during neonatal circumcision, and 2) to assess neonatal circumcision pain with and without dorsal penile nerve block (DPNB). DESIGN/METHODS: A randomized, controlled, nonblinded clinical trial; 48 healthy, full-term infants were randomized into one of the following four groups: Gomco vs Mogen with (+) or without (-) DPNB. DPNB+ infants were injected with 0.8 mL of 1% lidocaine before circumcision. DPNB- infants received no placebo injection. Heart rate, respiratory rate, and oxygen saturation (SaO2) during the procedure were monitored and data transferred to computer files by using the Datalab software system. Crying was recorded on videotape. Pre- and postcircumcision saliva samples for cortisol analysis were collected. Heart rate, respiratory rate, SaO2, cortisol changes, and duration of crying were evaluated statistically with two-way analyses of variance and t tests. RESULTS: The type of clamp but not the use of anesthesia was significantly associated with the length of the procedure (mean Mogen time, 81 seconds; mean Gomco time, 209 seconds) and percentage of respiratory rate change. The use of anesthesia but not the type of clamp was significantly associated with percentage of crying time and percentage of SaO2 change during the procedure. Heart rate changes and total crying time were significantly associated with both the type of clamp and the use of anesthesia. Neither clamp type nor anesthesia status was significantly associated with salivary cortisol changes, although the mean increase for the DPNB- group was approximately twice that for the DPNB+ group. Fifty-six percent of infants circumcised with the Mogen clamp and DPNB did not cry at all during the procedure. CONCLUSIONS: DPNB is effective in reducing neonatal circumcision pain with either the Mogen or the Gomco clamp. For a given anesthesia condition, the Mogen clamp is associated with a less painful procedure than the Gomco. The Mogen clamp with DPNB causes the least discomfort during neonatal circumcision.

Consequences of inadequate analgesia during painful procedures in children.

OBJECTIVE: To explore the effect of inadequate analgesia for painful procedures (bone marrow aspiration, lumbar puncture, or both) on the pain of subsequent procedures. DESIGN: A cohort of patients with cancer who had participated in a placebo-controlled, randomized study that documented the efficacy of oral transmucosal fentanyl citrate for painful procedures rated the pain associated with subsequent procedures performed with open-label oral transmucosal fentanyl. PARTICIPANTS: Twenty-one children undergoing diagnostic procedures who had been participants in previous study. INTERVENTION: All children were given oral transmucosal fentanyl, 15 to 20 microgram/kg, prior to the procedure; at its conclusion they were asked to rate the associated pain. RESULTS: In children younger than 8 years (n = 13), mean pain ratings during each subsequent procedure were consistently higher for those who had received placebo (n = 8) in the original study compared with those who had received the active drug (n = 5). A repeated-measures analysis of variance suggests that this difference is statistically significant (P = .04). Older children (n = 8) did not show this pattern. CONCLUSION: Inadequate analgesia for initial procedures in young children may diminish the effect of adequate analgesia in subsequent procedures.

The use of oral transmucosal fentanyl citrate for painful procedures in children.

OBJECTIVE: To investigate the efficacy and safety of oral transmucosal fentanyl (OTFC) in providing analgesia and sedation for painful diagnostic procedures in children. DESIGN: Randomized, placebo-controlled clinical trial. METHOD: Forty-eight children referred to the University Connecticut Division of Pediatric Hematology/Oncology for bone marrow aspiration or lumbar puncture were randomized to receive either OTFC (15 to 20 micrograms/kg) or a placebo lollipop. Thirty minutes after administration, the procedure was begun. An anesthesiologist monitored the child's heart rate, blood pressure, and oxygen saturation every 10 minutes. At the conclusion of the procedure, the nurse, the child's parent, and all children over 8 years of age were asked to rate the pain associated with the procedure using a 1 to 10 visual analogue scale. Young children (less than 8) used a modified scale, the Oucher, yielding a 0 to 5 score. RESULTS: Significant differences in pain ratings between the OTFC and placebo groups were noted on the pain scores of the parents (P = .005), nurses (P = .001), younger children (P = .006), and older children (P = .013), and median pain scores in the OTFC group were reduced to tolerable levels. Vomiting (P = .003) and itching (P = .001) were more common in the OTFC group, but no clinically significant vital sign deviations occurred. CONCLUSION: OTFC is safe and effective for use in relieving the pain of pediatric procedures, but frequency of vomiting may restrict its clinical usefulness.

Common pain problems in the general pediatric setting.

Pain problems are a routine part of pediatric practice. Physicians should be aware that many common childhood illnesses are painful and that only by addressing the symptoms and the underlying disease concurrently can the legitimate concerns of many children and parents be addressed adequately. Likewise, although needle sticks are necessary for health maintenance, they, too, impose a significant burden on children. The discomfort and dread that injections cause can be reduced significantly through relatively simple and safe approaches. Compassionate medicine dictates that attention be paid to such concerns.

Pediatric pain: interacting behavioral and physical factors.

Pain in infants, children, and adolescents warrants study from a developmental, behavioral, and physiological perspective because maturation of physical, emotional, and cognitive systems influences the way in which pain is experienced and expressed. Pediatric pain is an underdeveloped area ripe for study within the realm of developmental and behavioral pediatrics, as noted by documentation of its undertreatment in children. The focus of this paper is to present issues relevant to the study of pain in children, using the example of the recurrent abdominal pain syndrome to illustrate points regarding epidemiology, assessment, and intervention. It is the opinion of these authors that pediatric pain must be understood from a developmental perspective in both clinical and nonclinical populations of children. Multidisciplinary approaches to research in pain aids in understanding the development of nociceptive transmission and inhibitory systems, the development of pain expression, and the influence of context on pain experience and behavior. The goal of research in pediatric pain is to understand these systems within a developmental context so that preventive and therapeutic intervention strategies can be developed to reduce children's distress and pain-related disability.

Individual differences in children's response to pain: role of temperament and parental characteristics.

Sixty-five families were enlisted in a study exploring factors associated with distress behavior in 5-year-old children receiving diphtheria-tetanus-pertussis immunizations. At a home visit 1 month before the immunization, the following measures were obtained: (1) the Behavioral Style Questionnaire, a measure of temperament: (2) parental self-reports of medically related attributes (eg. "good patient"); (3) parental attitudes toward pain in children and responsiveness to their child's pain; and (4) parental prediction of distress at upcoming immunization. The child's distress behavior during the immunization was evaluated using a modification of the Procedure Rating Scale-Revised and, after the procedure, the child's assessment of his or her pain was elicited using the Oucher. Children's mean Procedure Rating Scale-Revised score was 2.57 of a possible 11. Thirty-one (48%) had low (less than or equal to 1) and 7 (11%) had high distress scores (greater than or equal to 2 SD above the mean). Factors positively correlated with distressed behavior included more "difficult child" cluster characteristics, the individual temperamental dimension of adaptability, but few parental attitudes and attributes. Parent's predictions of distress were the strongest correlates. These findings document the variation that children demonstrate in response to pain and offer some insight into associated innate and environmental factors. These results imply that treatment strategies derived from parental knowledge and tailored to individual characteristics of the child may be most effective in alleviating pain-related distress in medical settings.

The management of pain in children.

There are now safe and effective techniques which can decrease significantly the amount of pain a child will experience in an acute care setting. For such techniques to work, however, the importance of pain management in children must be recognized. It should be assumed that anything that will hurt an adult will also hurt a child and that children are, in fact, often more sensitive to hospital procedures than are adults. Pain assessment should be a part of the child's care plan, and developmentally appropriate ways of recognizing pain should be in place in all hospitals that care for children. Behavioral and pharmacologic techniques should be tailored to the needs of the individual child. The skill of physicians should be assessed not only by their cure of illnesses, but by the comfort they provide in the process.

The undertreatment of pain in children: an overview.

At the present time, the management of pain in children is not addressed with the same vigor and enthusiasm as is the management of pain in adults. Limited accessible information and limited research have allowed inaccurate and inadequate information to persist, which serves to justify the status quo. The personal nature of pain and the complexity of assessing it have offered further obstacles. Changes are occurring, however, which will dramatically alter present practice. It will soon be unacceptable socially and medically to ignore the suffering of children.