Pain in Child Health from 2002 to 2015: The early years of an international research training initiative.

Background: The 2018 Global Year for Excellence in Pain Education, an initiative of the International Association for the Study of Pain, brought worldwide attention to the need for education that crosses narrow disciplinary boundaries, addresses up-to-date research methods and findings, and encourages teamwork among trainees and mentors at different levels of training and with different perspectives. Aims: This commentary describes the development of Pain in Child Health (PICH), an interdisciplinary training program for researchers in pediatric pain at the undergraduate, graduate, and postdoctoral levels of training. Methods: Based on documentation of the structure, training processes, leadership, and membership of PICH, we outline its organization and its challenges and accomplishments over the first 12 years of its growth into a well-known international program. Results and Conclusions: Pain in Child Health began as a Strategic Training Initiative of the Canadian Institutes of Health Research in 2002 and developed into an international research training consortium featuring cross-site and cross-discipline mentorship and collaboration. PICH trainees and alumni have contributed extensively to the current scientific literature on children's pain. PICH could serve as a possible model for training and mentorship in other specialized health research domains within and outside thestudy of pain.

Contexte: En 2018, l'Année internationale pour l'excellence en éducation sur la douleur, une initiative de l'Association internationale pour l'étude de la douleur, a attiré l'attention partout dans le monde sur l'importance d'une éducation qui transcende les frontières étroites entre les disciplines, qui aborde les méthodes et les résultats de la recherche les plus actuels et qui encourage le travail d'équipe parmi les apprenants et les mentors à différents niveaux de formation et à partir de différentes perspectives.But: Ce commentaire décrit l'évolution de Pain in Child Heath (PICH), un programme de formation interdisciplinaire destiné aux chercheurs en douleur pédiatrique à tous les niveaux de formation : premier cycle, cycles supérieurs et postdoctoral.Méthodes: À partir de la documentation portant sur la structure, les processus de formation, le leadership et les caractéristiques des membres du PICH, nous décrivons son organisation, ses difficultés et ses accomplissements au cours de ses premiers douze ans, jusqu'à ce qu'il devienne un programme international de renom.Résultats et conclusions: À ses débuts, Pain in Child Health était une initiative de formation stratégique des Instituts de recherche en santé du Canada en 2002. Il s'est par la suite transformé en consortium international de formation à la recherche axé sur le mentorat et la collaboration entre différents sites et différentes disciplines. Les étudiants et les anciens du PICH ont largement contribué à la littérature scientifique sur la douleur pédiatrique. Le PICH pourrait possiblement servir de modèle en matière de formation et de mentorat dans d'autres domaines de recherche spécialisée en santé, que ce soit dans le contexte de l'étude de la douleur ou dans un autre contexte.

Developmental coordination disorder in extremely low birth weight children at nine years.

Developmental coordination disorder (DCD) is defined as an impairment in the development of motor coordination that interferes with academic achievement or activities of daily living (DSM-IV). DCD has been reported to affect 5% to 9% of children in the normal population. This study describes the prevalence of DCD in a cohort of extremely low birth weight children (ELBW, < or = l800 g) at 8.9 years of age, from which were excluded children with major impairments. Seventy-three children were included in the study group, along with 18 term-born, socially matched controls. Of the 73 ELBW children, 37 (51%) were classified as having DCD. ELBW children with DCD also had significantly lower Performance IQ (PIQ) scores and were more likely (43%) to have a learning difficulty in arithmetic than ELBW children who did not have DCD. This study found that DCD is a common problem in school-aged ELBW children.

Pain sensitivity and temperament in extremely low-birth-weight premature toddlers and preterm and full-term controls.

High-technology medical care of extremely low-birth-weight (ELBW) infants (< 1001 g) involves repeated medical interventions which are potentially painful and may later affect reaction to pain. At 18 months corrected age (CCA), we examined parent ratings of pain sensitivity and how pain sensitivity ratings related to child temperament and parenting style in 2 groups of ELBW children (49 with a birth weight of 480-800 g and 75 with a birth weight of 801-1000 g) and 2 control groups (42 heavier preterm (1500-2499 g) and 29 full-birth-weight (FBW) children (> 2500 g). Both groups of ELBW toddlers were rated by parents as significantly lower in pain sensitivity compared with both control groups. The relationships between child temperament and pain sensitivity rating varied systematically across the groups. Temperament was strongly related to rated pain sensitivity in the FBW group, moderately related in the heavier preterm and ELBW 801-1000 g groups, and not related in the lowest birth-weight group (< 801 g). Parental style did not mediate ratings of pain sensitivity. The results suggest that parents perceive differences in pain behavior of ELBW toddlers compared with heavier preterm and FBW toddlers, especially for those less than 801 g. Longitudinal research into the development of pain behavior for infants who experience lengthy hospitalization is warranted.

Early pain experience, child and family factors, as precursors of somatization: a prospective study of extremely premature and fullterm children.

In a prospective study of 36 children who were extremely low birthweight (ELBW: < 1000 g) preterm infants and 36 matched full-term controls, differences were found in somatization at age 4 1/2 years. Only children who had been extremely premature, and thereby experienced prolonged hospitalization and repeated medical intervention in infancy, had clinically high somatization scores on the Personality Inventory for Children. The combination of family relations at age 4 1/2 years, neonatal intensive care experience, poor maternal sensitivity to child cues in mother-child interaction observed at age 3 years, and child avoidance of touch or holding at age 3, predicted somatization scores, prior to school entry. Due to the known higher incidence of actual medical problems among children with a history of extreme prematurity, the high somatization ELBW children were compared with the normal somatization ELBW children. There were no differences in prevalence of actual medical problems between the 2 ELBW groups, and the importance of maternal factors in relation to somatization was confirmed. Child temperament at age 3, but not personality at 4 1/2, was related to somatization. The etiology of recurrent physical complaints of no known medical cause appears to be a multi-dimensional problem. Non-optimal parenting may contribute to the development of inappropriate strategies for coping with common pains of childhood, or of chronic pain patterns, in some children who have experienced prolonged or repeated pain as neonates.

Pain in the preterm neonate: behavioural and physiological indices.

The impact of invasive procedures on preterm neonates has received little systematic attention. We examined facial activity, body movements, and physiological measures in 56 preterm and full-term newborns in response to heel lancing, along with comparison preparatory and recovery intervals. The measures were recorded in special care and full-term nurseries during routine blood sampling. Data analyses indicated that in all measurement categories reactions of greatest magnitude were to the lancing procedure. Neonates with gestational ages as short as 25-27 weeks displayed physiological responsivity to the heel lance, but only in the heart rate measure did this vary with gestational age. Bodily activity was diminished in preterm neonates in general, relative to full-term newborns. Facial activity increased with the gestational age of the infant. Specificity of the response to the heel lance was greatest on the facial activity measure. Identification of pain requires attention to gestational age in the preterm neonate.

Developmental changes in pain expression in premature, full-term, two- and four-month-old infants.

The purpose of this study was to examine the behavioural responses of infants to pain stimuli across different developmental ages. Eighty infants were included in this cross-sectional design. Four subsamples of 20 infants each included: (1) premature infants between 32 and 34 weeks gestational age undergoing heel-stick procedure; (2) full-term infants receiving intramuscular vitamin K injection; (3) 2-month-old infants receiving subcutaneous injection for immunisation against DPT; and (4) 4-month-old infants receiving subcutaneous injection for immunisation against DPT. Audio and video recordings were made for 15 sec from stimulus. Cry analysis was conducted on the first full expiratory cry by FFT with time and frequency measures. Facial action was coded using the Neonatal Facial Action Coding System (NFCS). Results from multivariate analysis showed that premature infants were different from older infants, that full-term newborns were different from others, but that 2- and 4-month-olds were similar. The specific variables contributing to the significance were higher pitched cries and more horizontal mouth stretch in the premature group and more taut tongue in the full-term newborns. The results imply that the premature infant has the basis for communicating pain via facial actions but that these are not well developed. The full-term newborn is better equipped to interact with his caretakers and express his distress through specific facial actions. The cries of the premature infant, however, have more of the characteristics that are arousing to the listener which serve to alert the caregiver of the state of distress from pain.

Neonatal facial and cry responses to invasive and non-invasive procedures.

Evaluation of pain in neonates is difficult due to their limited means of communication. The aim was to determine whether behavioural reactions of cry and facial activity provoked by an invasive procedure could be discriminated from responses to non-invasive tactile events. Thirty-six healthy full-term infants (mean age 2.2 h) received 3 procedures in counterbalanced order: intramuscular injection, application of triple dye to the umbilical stub, and rubbing thigh with alcohol. Significant effects of procedure were found for total face activity and latency to face movement. A cluster of facial actions comprised of brow bulging, eyes squeezed shut, deepening of the naso-labial furrow and open mouth was associated most frequently with the invasive procedure. Comparisons between the 2 non-invasive procedures showed more facial activity to thigh swabbing and least to application of triple dye to the umbilical cord. Acoustic analysis of cry showed statistically significant differences across procedures only for latency to cry and cry duration for the group as a whole. However, babies who cried to two procedures showed higher pitch and greater intensity to the injection. There were no significant differences in melody, dysphonation, or jitter. Methodological difficulties for investigators in this area were examined, including criteria for the selection of cries for analysis, and the logical and statistical challenges of contrasting cries induced by different conditions when some babies do not always cry. It was concluded that facial expression, in combination with short latency to onset of cry and long duration of first cry cycle typifies reaction to acute invasive procedures.

Pain expression in neonates: facial action and cry.

Pain expression in neonates instigated by heel-lance for blood sampling purposes was systematically described using measures of facial expression and cry and compared across sleep/waking states and sex. From gate-control theory it was hypothesized that pain behavior would vary with the ongoing functional state of the infant, rather than solely reflecting tissue insult. Awake-alert but inactive infants responded with the most facial activity, consistent with current views that infants in this state are most receptive to environmental stimulation. Infants in quiet sleep showed the least facial reaction and the longest latency to cry. Fundamental frequency of cry was not related to sleep/waking state. This suggested that findings from the cry literature on qualities of pain cry as a reflection of nervous system 'stress', in unwell newborns, do not generalize directly to healthy infants as a function of state. Sex differences were apparent in speed of response, with boys showing shorter time to cry and to display facial action following heel-lance. The findings of facial action variation across sleep/waking state were interpreted as indicating that the biological and behavioral context of pain events affects behavioral expression, even at the earliest time developmentally, before the opportunity for learned response patterns occurs. Issues raised by the study include the importance of using measurement techniques which are independent of preconceived categories of affective response.