Systematic review of childhood and adolescent risk and prognostic factors for persistent abdominal pain.

This review aimed to identify childhood and adolescence risk and prognostic factors associated with onset and persistence of persistent abdominal pain and related disability and assess quality of the evidence. While findings suggest a possible role for negative emotional symptoms and parental mental health as risk and prognostic factors for onset and persistence of persistent abdominal pain, the evidence is of poor quality overall and nonexistent when it comes to prognostic factors associated with disability. CONCLUSION: Further research is needed to increase confidence in existing evidence and to explore new factors. This research will inform prevention.

Sex differences in parent and child pain ratings during an experimental child pain task.

Research in the field of pediatric pain has largely ignored the role of fathers in their children's pain experiences. The first objective of the present study was to examine the effect of the presence of mothers versus fathers on children's subjective ratings, facial expressions and physiological responses to acute pain. The second objective was to examine whether child and parent sex influence parents' proxy ratings of their children's pain. The final objective was to compare levels of agreement between mothers' and fathers' assessments of their children's pain. Participants included 73 children (37 boys, 36 girls), four to 12 years of age, along with 32 fathers and 41 mothers. Children undertook the cold pressor pain task while observed by one of their parents. During the task, the children's heart rates and facial expressions were recorded. Children provided self-reports and parents provided proxy reports of child pain intensity using the seven-point Faces Pain Scale. Neither child nor parent sex had a significant impact on children's subjective reports, facial expressions or heart rates in response to acute pain. Fathers gave their sons higher pain ratings than their daughters, whereas mothers' ratings of their sons' and daughters' pain did not differ. Kappa statistics and t tests revealed that fathers tended to be more accurate judges of their children's pain than mothers. Overall, this research highlights the importance of examining both parent and child sex differences in pediatric pain research.

Psychological interventions for needle-related procedural pain and distress in children and adolescents.

BACKGROUND: Needle-related procedures are a common source of pain and distress for children. Several psychological (cognitive-behavioral) interventions to help manage or reduce pain and distress are available; however, a previous comprehensive systematic review of the efficacy of these interventions has not been conducted. OBJECTIVES: To assess the efficacy of cognitive-behavioral psychological interventions for needle-related procedural pain and distress in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) on The Cochrane Library (Issue 4, 2005), MEDLINE (1966 to 2005), PsycINFO (1887 to 2005), EMBASE (1974 to 2005), the Cumulative Index to Nursing and Allied Health Literature (1982 to 2005), Web of Science (1980 to 2005), and Dissertation-Abstracts International (1980 to 2005). We also searched citation lists and contacted researchers via various electronic list-servers and via email requests. SELECTION CRITERIA: Participants included children and adolescents aged two to 19 years undergoing needle-related procedures. Only randomized controlled trials (RCTs) with at least five participants in each study arm comparing a psychological intervention group with a control or comparison group were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data and assessed trial quality. Included studies were coded for quality using the Oxford Quality Scale devised by Jadad and colleagues. Standardized mean differences with 95% confidence intervals were computed for all analyses using RevMan 4.0 software. MAIN RESULTS: Twenty eight trials with 1951 participants were included. Together, these studies included 1039 participants in treatment conditions and 951 in control conditions. The most commonly studied needle-procedures were immunizations and injections. The largest effect sizes for treatment improvement over control conditions exist for distraction (on self-reported pain, SMD -0.24 (95% CI -0.45 to -0.04), combined cognitive-behavioral interventions--reduced other-reported distress (SMD -0.88, 95% CI -1.65 to -0.12; and behavioral measures of distress (SMD -0.67, 95% CI -0.95 to -0.38) with hypnosis being the most promising--self-reported pain (SMD -1.47, 95% CI -2.67 to -0.27), with promising but limited evidence for the efficacy of numerous other psychological interventions, such as information/preparation, nurse coaching plus distraction, parent positioning plus distraction, and distraction plus suggestion. AUTHORS' CONCLUSIONS: Overall, there is preliminary evidence that a variety of cognitive-behavioral interventions can be used with children and adolescents to successfully manage or reduce pain and distress associated with needle-related procedures. However, many of the included studies received lower quality scores because they failed to describe the randomization procedure and participant withdrawals or drop-outs from the study. Further RCTs need to be conducted, particularly for the many interventions for which we could not locate any trials.

A comparison of faces scales for the measurement of pediatric pain: children's and parents' ratings.

Faces scales have become the most popular approach to eliciting children's self-reports of pain, although different formats are available. The present study examined: (a) the potential for bias in children's self-reported ratings of clinical pain when using scales with smiling rather than neutral 'no pain' faces; (b) levels of agreement between child and parent reports of pain using different faces scales; and (c) preferences for scales by children and parents. Participants were 75 children between the ages of 5 and 12 years undergoing venepuncture, and their parents. Following venepuncture, children and parents independently rated the child's pain using five different randomly presented faces scales and indicated which of the scales they preferred and why. Children's ratings across scales were very highly correlated; however, they rated significantly more pain when using scales with a smiling rather than a neutral 'no pain' face. Girls reported significantly greater levels of pain than boys, regardless of scale type. There were no age differences in children's pain reports. Parents' ratings across scales were also highly correlated; however, parents also had higher pain ratings using scales with smiling 'no pain' faces. The level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used; parents overestimated their children's pain using all five scales. Children and parents preferred scales that they perceived to be happy and cartoon-like. The results of this study indicate that subtle variations in the format of faces scales do influence children's and parents' ratings of pain in clinical settings.

Biobehavioral responses to acute pain in adolescents with a significant neurologic impairment.

OBJECTIVE: To further understand acute pain response in children with a significant neurologic impairment (SNI), we undertook a descriptive hypothesis-generating study of the response to a routine vaccine among adolescents with SNI. DESIGN: Within-subject crossover design. SETTING: Tertiary care facility for children and adolescents with SNI. PATIENTS: Eight adolescents (mean age = 15 years). INTERVENTIONS: Mock and real vaccine injections. OUTCOME MEASURES: Quantitative measures of heart rate, videotaped facial action, Child Facial Coding System (CFCS), and Facial Action Coding System (FACS); observer ratings visual analog scale (VAS) were obtained before, during, and after a mock injection and routine annual influenza vaccine injection presented in a counterbalanced order. RESULTS: VAS scores were significantly higher during the injection phase than during the other time periods; however, there were no significant differences across study time periods when using the other outcome measures. CONCLUSIONS: Although the dampened behavioral and physiologic reactions to an acute noxious stimulus were similar to those of previous work with developmentally delayed children and frail elderly, it remains unclear what underlies the apparent reduced pain response in this setting. These findings have potentially important implications for the daily care of individuals with significant neurologic impairment and illustrate the compelling need tor further study of the unique character of the pain experience in this setting.

Agreement between child and parent reports of pain.

OBJECTIVE: Parents are often the primary source of information regarding their children's pain in both research and clinical practice. However, parent-child agreement on pain ratings has not been well established. The objective of the present study was to examine agreement between child- and parent-rated pain following minor surgery. SETTING: Tertiary care children's hospital. PARTICIPANTS: A total of 110 children (56.4% male) aged 7-12 years undergoing surgery and their parents. OUTCOME MEASURES: Parents and children independently rated pain intensity by using a 7-point Faces Pain Scale on the day of the child's surgery and the following 2 days. RESULTS: Correlations (both Pearson's and intraclass correlation coefficients) indicated a highly significant relationship between child and parent ratings. However, kappa statistics indicated only poor to fair agreement beyond chance. Parents tended to underestimate their children's pain on the day of surgery and the following day, but not on the second day following surgery. When children's and parents' pain ratings for each of the 3 days were collapsed into a no-pain/low-pain group or a clinically significant pain group, kappa statistics indicated fair to good agreement. Parents demonstrated low levels of sensitivity in identifying when their children were experiencing clinically significant pain. CONCLUSIONS: Correlations between parent and child pain reports do not accurately represent the relationship between these ratings and in fact overestimate the strength of the relationship. Parents' underestimation of their child's pain may contribute to inadequate pain control.

Self-administration of over-the-counter medication for pain among adolescents.

OBJECTIVE: To examine over-the-counter (OTC) medication use and self-administration of medication among adolescents. DESIGN: In-person survey. SETTINGS: Three public junior high schools in Halifax, Nova Scotia. PARTICIPANTS: Six hundred fifty-one junior high school students (7th, 8th, and 9th grades). MAIN OUTCOME MEASURES: A questionnaire regarding OTC medication use and self-administration for head: stomach; ear and throat; muscle, joint, and back; and menstrual pains. RESULTS: Of those who reported taking medication, many adolescents (58.7%-95.9%) reported taking OTC medications for each pain. Medications and knowledge about medications were obtained from a variety of sources, primarily parents. Self-administration was widespread; 58.3% to 75.9% of adolescents reported taking an OTC medication for pain without first checking with an adult in the previous 3 months. Self-administration of medication without the knowledge of adults increased significantly from grades 7 to 9 for all types of pain. Girls tended to self-administer medication more than boys. Higher levels of pain frequency and intensity were related to higher levels of self-administration for all pains except muscle, joint, and back pain. Adolescents reported that they began to self-administer medication between the ages of 11 and 12 years. CONCLUSIONS: Although a relatively responsible picture of self-administration of medication emerges, some adolescents engaged in inappropriate OTC medication use (eg, the common use of aspirin), highlighting the importance of providing adolescents with correct information about these medications.

Coping with pain and surgery: children's and parents' perspectives.

This article examines relations between coping with general and postoperative pain. Children's and parent's coping ratings, and the contribution of temperament and coping to postoperative adjustment. Before and after day surgery, 7-to 12-year-olds (n = 124) rated their coping with pain. Parents rated their child's coping and temperament pain and distress were rated on the day of and 2 days following surgery. Coping with general and postoperative pain were moderately correlated (median r = .48). Except for distraction, all types of coping strategies were used more frequently for general than postoperative pain. Correlations between child and parent coping ratings were moderate (median r = .36). After controlling for emotionality and medications, lower levels of emotion-focused avoidance and higher levels of distraction were related to lower pain and distress. After controlling for a priori surgical group (no-low pain; moderate-high pain), emotionality, and medications, lower levels of emotion-focused avoidance were related to lower pain and distress but distraction was no longer significant in a number of the regressions. Coping with pain has trait-like qualities but differences in the nature and context of pain create differences in strategy use. Level of pain appears to influence the type of coping strategies used. Interventions should target children's use of distraction and minimize us of emotion-focused avoidance.

Development and preliminary validation of a postoperative pain measure for parents.

Parents are now primarily responsible for the at home assessment and treatment of their children's pain following minor surgery. Although some research has suggested that parents underestimate their children's pain following surgery, no behavioral measure exists to assist parents in pain assessment. The Postoperative Pain Measure for Parents was developed based on cues parents reported using to assess their children's pain (e.g. changes in appetite, activity level). The purpose of the present study was to develop and validate this measure by examining the relation between parent-report of child behaviors and child-rated pain. Subjects were 110 children (56.4% male) aged 7-12 years undergoing day surgery at a tertiary-care children's hospital and their parents. Parents and children completed a pain diary for the 2 days following surgery. Children rated their pain and emotional distress and parents rated the presence or absence of specific behaviors from a checklist. Correlations were conducted between each of the 29 behavioral items and child-rated pain on Day 1; 14 items with correlations less than 0.30 were dropped. The remaining 15 items were subjected to a principal axis factor analysis. A one-factor solution was the best fit for the data. The items were then summed to yield a total score out of 15. Internal consistency reliabilities for the measure and correlations with child-rated pain were high on both days following surgery. Child-rated pain and emotional distress were moderately correlated. The Postoperative Pain Measure for Parents was also positively correlated with child-rated emotional distress on both days following surgery. As child-rated pain decreased from Day 1 to Day 2, so did scores on the behavioral measure. The Postoperative Pain Measure for Parents was successful in discriminating between children who had undergone no/low pain surgeries and children who had undergone moderate to high pain surgeries. There were no significant differences in scores on the behavioral measure for child age or sex. Using a cut-off score of six out of 15, the measure showed excellent sensitivity (> 80%) and specificity (> 80%) in selecting children who reported clinically significant levels of pain. This study provides preliminary evidence for the use of the Postoperative Pain Measure for Parents as a valid assessment tool with children between the ages of 7-12 years following day surgery. It is internally consistent and strongly related to child-rated pain. Future research should explore the use of this measure with a younger sample and children with developmental delays.