1. Paediatric Pain Assessment and Management
VPNG State Conference 2015
Paediatric Pain Assessment and Management
Karin Plummer
PhD Candidate
Murdoch Childrens Research Institute
The Children’s Cancer Centre (RCH)
The University of Melbourne
Hello everyone, My name is karin and I am here to talk to you today about paediatric pain assessment along with my collegue Rebecca who will be discussing paediatric pain management
I am currently researching the complexities of pain assessment and management in medically unwell children

2. Objectives 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
My coolegue and I, rebecca, are her today to talk to you about evidence based paediatric pain practices. Specifically I will be talking about recommendations for pain assessment and how they apply to the perioperative setting

3. Challenges of understanding children’s pain
“Competent pain assessment is the first step toward
pain management, especially in paediatric settings”
van Dijk, M (2005),pg 33
We also know that pain assessment is an important step towards effective management, especially for children who often have a great deal of fear about pain and limited power in the hospital setting

4. 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.
But these recent articles suggest that children’s pain is not being adequately assessed and being made highly visible.
I don’t think this is a reflection of clinicans not caring about childrens pain rather than a reflection of how challenging it is

5. The Social Communication Model of Pain
Craig, K. D. (2009). The social communication model of pain. Canadian Psychology, 50(1),
Pain stimulus and perception
Child’s expression of pain
Caregiver assessment and interpretation of pain
Pain management
Acute
Procedural
Persistent
Verbal
Non-verbal
Physiological
Knowledge
Attitudes
Beliefs
Pharmacological
When you think about it, its really not that easy………
So it all begins with a pain stimulus and children experience this as sensatons, thoughts and feelings about pain. SO this pain may be physical and coFirstly, we have different types of pain: acute, procedural and persistent and I put childrens memories for pain in with persistent pain.
So that is the physical pain, we also have the emotional pain to assess also.
Children then express their pain through multiple channels or they may deny or exagerate their pain based on the consewuences of telling. They may also not have much previous experience of pain.
The caregiver needs to then interpret these signals and decide to manage pain or not, based on how well they know the childs pain behaviours
Developmental stage
Previous experience of pain
Who is asking
Consequences of telling
Non-Pharmacological
Fear
Anxiety
Distress
Knowing the child

6. Approaches to paediatric acute pain assessment
1.Self report
3.Knowledge of the context
2.Observation of pain behaviours
“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
So whats your best chance at getting it right? Use multiple methods of assessment and validated tools
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:

7. Self-report of pain Face scales Numerical rating scales
Visual analogue scales
Categorical responses
“Pieces of hurt”
A self report of pain is an attempt to quantify pain by having the child report a score of the intensity.
There are many recommended scales that can be used.
They are on the web, easy to find, free, cheap to reproduce, come in lots of languages and most importantly they are easy to use.
But which one should you use
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:

8. Age is the best predictor
Self-report of pain
Selecting the most appropriate tool
Age is the best predictor
Age is the best predictor
Age is the best preidcor
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):
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): e

9. Smiling versus neutral anchor faces?
Self-report of pain
Children’s preferences for Faces Pain Scales
Smiling versus neutral anchor faces?
What do children prefer.So what else do we need to take into account when selecting a tool? The anchoring effect of pain scales
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):
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):

10. Children’s self report of pain don’t always make sense!
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):
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):
Is it really the “Gold Standard”
Children’s self report of pain don’t always make sense!
This may be due to challenges of:
Screening
Seriation
Anchoring
Context of pain
Child 1
Child groaning, diaphoretic and splinting abdomen
Pain score 0/10
Child 2
Child playing, relaxed and smiling
Pain score 10/10
So what else do we need to take into account when selecting a tool? The anchoring effect of pain scales

11. Observational pain tool
Observation of pain
Observational pain tool
< 3 years of age
Support self-report
Non-communicating children
Main behavioural indicators of acute pain are:
Facial expression
Body movement and posture
Inability to be consoled
Crying
Groaning
There are some common signs
World Health Organisation (2012). Persisting pain in children package: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses.

12. Considerations for the behavioural assessment of pain
Observation of pain
Considerations for the behavioural assessment of pain
The rated behaviours may not be specific to pain.
Pain vs distress
Need 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
What I have found in my research that observation of pain is the most used method of assessing pain and that is
World Health Organisation (2012). Persisting pain in children package: WHO guidelines on the pharmacological treatment of persisting pain in children with medical illnesses.
Bringuier, S et al (2009). "A prospective comparison of post-surgical behavioural pain scales in pre-schoolers highlighting the risk of false evaluations." Pain 145(1-2):

13. 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 Profile
FLACC-Revised
Infant
Premature Infant Pain Profile (PIPP)
FLACC scores can be high during nonpainful procedures and the during restraint phase of painful procedures. This indicates that FLACC measures a composite of pain and distress in young children.
Blount, R. L. and K. A. Loiselle (2009). "Behavioural assessment of pediatric pain." Pain Res Manag 14(1):
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): ; discussion
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):
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):

14. FLACC Behavioural Assessment Scale

15. Comfort Behavioural Scale
The COMFORT-B scale is a pain and distress assessment instrument:
Alertness
Calmness
Respiratory response or Crying
Body movements
Facial tension
Muscle tone
Pain score 6-30
as it is the only well-studied
instrument that makes explicit accommodation for con-
straints placed on the behavioral expression of pain by
mechanical ventilation and physical restraint.
Intervene when COMFORT-B scores of 17 or higher are combined with VAS pain ratings of 4 or higher
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),
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.

16. Observation of pain: PPPM-SF
Where health professionals can really improve childs pain management is by educating parents
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.

17. Knowledge of the context

18. 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?

19. Final thoughts on pain assessment assessment
1. Self-report is the starting point
Obtain where possible
Use established scales consistently
2. Consider possible causes of pain
3. Observe patients behavior
4. Compare pain intensity scores with the patients goals for comfort and function
5. Try relieving pain
assess the effects of pharmacological, physical or psychological.
Von Bayer 2012