Karin Plummer

VPNG State Conference 2015

Paediatric Pain Assessment and Management

PhD CandidateMurdoch Childrens Research InstituteThe Children’s Cancer Centre (RCH)The University of Melbourne

The objectives for this presentation are to:• Review the current state of paediatric acute pain assessment.

• Discuss current approaches to assessing pain in children.

• Consider the latest research examining paediatric pain assessment

Limits applied to this presentation:

• Acute pain

• Infants and neonates excluded

Objectives

Challenges of understanding children’s pain

“Competent pain assessment is the first step towardpain management, especially in paediatric settings”

van Dijk, M (2005),pg 33

Why is managing children’s pain still so painful?

Kozlowski, L et al. (2014)• 86% of children reported pain, however, only 48% had a documented pain score.

Harrison, D et al. (2014)• 84% reported that pain was experienced, yet pain scores were documented in only 34 (55%) charts

in the previous 24 hrs

Twycross, A et al (2013)• 10 children observed post-operatively all received at least 2 assessments in the 72 hour review

period.• 75% of these occurred in the first 24 hours

Stevens, B et al (2012)• 68% of 3,822 hospitalised children's charts had a pain assessment documented at least once in the

previous 24 hours, yet only 29% recorded a pain intensity and 5% documented the use of a validated pain tool.

Pain stimulus

and perception

Child’s expression

of pain

Caregiver assessment

and interpretation

of pain

Pain management

The Social Communication Model of Pain

AcuteProceduralPersistent

Fear AnxietyDistress

VerbalNon-verbal

Physiological

Developmental stage

Previous experience of pain

Who is askingConsequences of

telling

KnowledgeAttitudesBeliefs

Knowing the child

Pharmacological

Non-Pharmacological

Craig, K. D. (2009). The social communication model of pain. Canadian Psychology, 50(1), 22-32.

Approaches to paediatric acute pain assessment

1.Self report

3.Knowledge of the context

2.Observation of pain

behaviours

Huguet, A., J. N. Stinson and P. J. McGrath (2010). "Measurement of self-reported pain intensity in children and adolescents." Journal of Psychosomatic Research 68: 329-336.

“Pain intensity cannot be measured in the sense that a thermometer measures temperature; it can only

be estimated from different points of view”

Von Baeyer, 2009 pg 41

Face scales

Numerical rating scales

Visual analogue scales

Categorical responses • “Pieces of hurt”

Self-report of pain

Worst PainImaginableNo PainWorst PainImaginableNo Pain

Huguet, A., J. N. Stinson and P. J. McGrath (2010). "Measurement of self-reported pain intensity in children and adolescents." Journal of Psychosomatic Research 68: 329-336.

Selecting the most appropriate tool

Self-report of pain

Age is the best predictor

1. von Baeyer, C. L. (2009). "Children's self-report of pain intensity: What we know, where we are headed." Pain Research and Management 14(1): 39-45.2. Tomlinson, D., C. L. von Baeyer, J. N. Stinson and L. Sung (2010). "A systematic review of faces scales for the self-report of pain intensity in children."

Pediatrics 126(5): e1168-1198.

Age is the best predictor

1. von Baeyer, C. L. (2009). "Children's self-report of pain intensity: What we know, where we are headed." Pain Research and Management 14(1): 39-45.

2. von Baeyer, C. L. v., S. J. Forsyth, E. A. Stanford, M. Watson and C. T. Chambers (2009). "Response biases in preschool children's ratings of pain in hypothetical situations." European Journal of Pain 13(2): 209-213.

Smiling versus neutral

anchor faces?

Self-report of painChildren’s preferences for Faces Pain Scales

1. von Baeyer, C. L. (2009). "Children's self-report of pain intensity: What we know, where we are headed." Pain Research and Management 14(1): 39-45.

2. von Baeyer, C. L. v., S. J. Forsyth, E. A. Stanford, M. Watson and C. T. Chambers (2009). "Response biases in preschool children's ratings of pain in hypothetical situations." European Journal of Pain 13(2): 209-213.

Self-report of painIs it really the “Gold Standard”

Child 1

• Child groaning, diaphoretic and splinting abdomen

• Pain score 0/10

Child 2

• Child playing, relaxed and smiling

• Pain score 10/10

Children’s self report of pain don’t always make sense!This may be due to challenges of:

ScreeningSeriation Anchoring

Context of pain

Observational pain tool

< 3 years of age Support self-report

Non-communicating

children

World Health Organisati on (2012). Persisti ng pain in children package: WHO guidelines on the pharmacological treatment of persisti ng pain in children with medical il lnesses.

Observation of painMain behavioural

indicators of acute pain are:

Facial expressionBody movement and

postureInability to be consoled

CryingGroaning

1. World Health Organisati on (2012). Persisti ng pain in chi ldren package: WHO guidel ines on the pharmacological treatment of persisti ng pain in chi ldren with medical i l lnesses.

2. Bringuier, S et al (2009). "A prospecti ve comparison of post-surgical behavioural pain scales in pre-schoolers highl ighti ng the r isk of false evaluati ons." Pain 145 (1-2): 60-68.

Observation of painConsiderations for the behavioural

assessment of painThe rated behaviours may not be specific to pain.

Pain vs distressNeed to consider the observation period.

Some children are able to control their behaviour.Expected cues may be hidden or exaggerated based on

the context of pain.Child may be too unwell or withdrawn.

The ability to move.Reliant on caregivers to recognise pain.

Risk of under-assessment of pain

1. Blount, R. L. and K. A. Loiselle (2009). "Behavioural assessment of pediatric pain." Pain Res Manag 14(1): 47-52.2. Cohen, L. L., K. Lemanek, R. L. Blount, L. M. Dahlquist, C. S. Lim, T. M. Palermo, K. D. McKenna and K. E. Weiss (2008). "Evidence-based assessment of pediatric

pain." J Pediatr Psychol 33(9): 939-955; discussion 956-937.3. von Baeyer, C. L. and L. J. Spagrud (2007). "Systematic review of observational (behavioural) measures of pain for children and adolescents aged 3 to 18 years." Pain

127(1-2): 140-150.4. Crosta, Q. R., T. M. Ward, A. J. Walker and L. M. Peters (2014). "A review of pain measures for hospitalized children with cognitive impairment." J Spec Pediatr Nurs

19(2): 109-118.

Context Observational scale

Procedural pain Faces, Legs, Activity, Cry, Consolability

Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)

Post-operative In hospital: Faces, Legs, Activity, Cry, Consolability (FLACC)

Home: Parent Post-operative Pain Measure (PPPM)

Critical Care Comfort scale/ Comfort B

Pain related fear Procedure Behaviour Checklist (PBCL)Procedural Behavioural Rating Scale (PBRS)Child Adult Medical Procedure Interaction Scale (CAMPIS)

Non-verbalising child

Non-Communicating Children’s Pain Checklist-Revised (NCCPC)Pediatric Pain ProfileFLACC-Revised

Infant Premature Infant Pain Profile (PIPP)

http://wps.prenhall.com/wps/media/objects/3103/3178396/tools/fl acc.pdf

FLACC Behavioural Assessment Scale

Comfort Behavioural Scale

von Baeyer, C. L., & Spagrud, L. J. (2007). Systematic review of observational (behavioural) measures of pain for children and adolescents aged 3 to 18 years. Pain, 127(1-2), 140-150.

van Dijk, M. et al (2005). Pain control. The COMFORT Behavior Scale: a tool for assessing pain and sedation in infants. American Journal of Nursing, 105(1), 33.

The COMFORT-B scale is a pain and distress assessment instrument:1. Alertness2. Calmness3. Respiratory response or Crying 4. Body movements5. Facial tension6. Muscle tone

Pain score 6-30

Intervene when COMFORT-B scores of 17 or higher are combined with VAS pain

ratings of 4 or higher

Observation of pain: PPPM-SF

Von Baeyer, C. L., C. T. Chambers and D. M. Eakins (2011). "Development of a 10-Item Short Form of the Parents' Postoperative Pain Measure: The PPPM-SF." Journal of Pain(3): 401.

Knowledge of the context

Take the time to assess previous painful experiences

Some helpful questions to ask

about the child and family

• People in my family • Pets • Favourite activities , heroes and characters • How was the child on the way into the hospital and on

arrival?• How does the parent feel about the procedure today.• What language is used in the family to describe pain?• Self soothing and coping strategies

Some helpful questions to ask

about the procedure

• What procedures has the child previously had – how did this go?

• What has worked well previously and what was unhelpful?• Does the child know that a procedure is being performed

today?• Does the parent understand what the procedure is?• Has the procedure been explained to the child in an

appropriate way?• How would the child like to approach this procedure today?

Final thoughts on pain assessment assessment1. Self-report is the starting point

Obtain where possibleUse established scales consistently

2. Consider possible causes of pain3. Observe patients behavior4. Compare pain intensity scores with the patients goals for comfort and function5. Try relieving pain

assess the effects of pharmacological, physical or psychological.

Von Bayer 2012