COMFORT Behaviour Scale Research Articles

The COMFORT behaviour scale detects clinically meaningful effects of analgesic and sedative treatment.

The COMFORT behaviour scale (COMFORT-B scale) is widely used in paediatric intensive care units to assess young children's pain and distress. It is also used to assess the impact of treatment interventions, but little is known on the scale's sensitivity to detect changes between before and after measurements following an intervention. This study explored the sensitivity to change of the COMFORT-B scale. COMFORT-B scores, originally and prospectively collected as part of standard care, were retrieved from the digital patient data management system. We analysed scores obtained in 747 paired observations, i.e., before and after a pharmacological intervention in 180 paediatric intensive care patients between September 2009 and September 2010. The mean scores before and after an intervention were 20.0 [standard deviation (SD) 3.7] and 14.1 (SD 4.7), respectively. Multilevel regression analysis showed a 6-point mean decline after an intervention (p < 0.0001). The magnitude of this decline was not statistically significantly related to number and type of interventions or time between assessments. In almost three-quarters of cases (74%), the COMFORT-B score dropped to below 17 after a pharmacological intervention, indicating good responsiveness. This is the first study demonstrating that the COMFORT-B scale detects treatment-related changes in pain or distress intensity. This implies that COMFORT-B assessments can effectively guide analgesic and sedation treatment in critically ill children.

Comparison between Comfort-Behavior and Ramsay scales in a pediatric intensive care unit

BACKGROUND AND OBJECTIVES: Studies have tried to compare sedation scales, however time spent with their application has not been studied. This study aimed at checking sedation level of patients admitted to the pediatric intensive care unit according to Comfort-Behavior and Ramsay scales, comparing sedation score and time spent to apply both scales.METHODS: This prospective study has involved patients aged from one day of life until 18 incomplete years, admitted to the pediatric intensive care unit, submitted or not to mechanical ventilation, who needed analgesic and/or sedative therapy and after acceptance of legal representatives. Exclusion criteria were patients under neuromuscular blockers and in process of extubation. A checklist developed by the authors was used to collect dada. Data were collected in four observations per patient (14h, 16h, 18h and 20h), in a total of 48 observations. Sample was made up of six patients.RESULTS: In 22 observations there have been high sedation levels in both scales. Moderate sedation was found in one observation for both scales. No evaluation has shown low sedation levels. Mean time using Comfort-Behavior scale was longer as compared to Ramsay scale (p=0.019). There has been no significant variation among patients and among observers.CONCLUSION: Evaluated scores had similar results; however mean time for Comfort-Behavior scale was longer than for Ramsey scale without variation among patients or among observers.

Cultural adaptation of patient and observational outcome measures: A methodological example using the COMFORT behavioral rating scale

BackgroundThere is little empirical evidence regarding the translation and cultural adaptation of self-report and observational outcome measures. Studies that evaluate and further develop existing practices are needed. ObjectivesThis study explores the use of cognitive interviews in the translation and cultural adaptation of observational measures, using the COMFORT behavioral scale as an example, and demonstrates a structured approach to the analysis of data from cognitive interviews. The COMFORT behavioral scale is developed for assessment of distress and pain in a pediatric intensive care setting. DesignQualitative, descriptive methodological study. SettingOne general public hospital trust in southern Norway. ParticipantsN=12. Eight nurses, three physicians and one nurse assistant, from different wards and with experience caring for children. MethodsWe translated the COMFORT behavior scale into Norwegian before conducting individual cognitive interviews. Participants first read and then used the translated version of the COMFORT behavioral scale to assess pain based on a 3-min film vignette depicting an infant in pain/distress. Two cognitive interview techniques were applied: Thinking Aloud (TA) during the assessment and Verbal Probing (VP) afterwards. In TA the participant verbalized his/her thought process while completing the COMFORT behavioral scale. During VP the participant responded to specific questions related to understanding of the measure, information recall and the decision process. We audio recorded, transcribed and analyzed interviews using a structured qualitative method (cross-case analysis based on predefined categories and development of a results matrix). ResultsOur analysis revealed two categories of problems: (1) Scale problems, warranting a change in the wording of the scale, including (a) translation errors, (b) content not understood as intended, and (c) differences between the original COMFORT scale and the revised COMFORT behavioral scale; and (2) Rater-context problems caused by (a) unfamiliarity with the scale, (b) lack of knowledge and experience, and (c) assessments based on a film vignette. ConclusionsCognitive interviews revealed problems with both the translated and the original versions of the scale and suggested solutions that enhanced the validity of both versions. Cognitive interviews might be seen as a complement to current published best practices for translation and cultural adaptation.

COMFORT behaviour scale and skin conductance activity: what are they really measuring?

To assess how efficiently the COMFORT behaviour scale measures acute pain in neonates, in comparison with skin conductance activity, a validated measure of pain and stress. Images of 36 newborns were analysed before, during and after painful heel pricks to measure glucose levels and compared with skin conductance activity variables. Scale indicators and skin conductance variables were sensitive to changes in the periods 'during-before' and 'during-after' (Wilcoxon's test, p < 0.01). Significant values were found between all scale indicators and number of waves for Kendall's coefficient (p < 0.05), although responses differed when it came to how long they took to increase and correlations varied from fair to moderate (r < 0.6). Facial tension was more closely related to 15 sec after the painful event, while crying and calmness were more closely related to the later intervals (30 and 180 sec). All scale indicators were related to skin conductance activity in all periods, indicating pain perception. Facial tension was the most efficient indicator, while others varied in performance after painful events and possibly indicated stress after trauma. These results are discussed from a phenomenological approach and in an anxiety paradigm.

91 Audit of Pain, Sedation and Withdrawal Practices in the UK, Ireland and the Netherlands

Background and aimsAssessment and management of pain, sedation and drug withdrawal in PICU’s is notoriously difficult. This audit aimed to compare practices across the UK, Ireland (UK&I) and The Netherlands...

Pain status and sedation level in Chinese children after cardiac surgery: an observational study

This study explored current pain status, sedation level and their trajectories in Chinese children after cardiac surgery. Background. Pain and sedation management are fundamental care practices in the critical care setting, yet they both are frequently under-implemented for children after major surgery. Repeated observational design. This study was conducted in a paediatric medical centre in Shanghai, China where 170 children who underwent cardiac surgery were recruited. Pain was measured with the face, legs, activity, cry, consolability scale and sedation levels with the COMFORT Behaviour Scale at 18 fixed time-points for three consecutive postoperative days. Results. The study indicated that 95 children (55·9%) received continuous opioids for pain relief, and 61 children (35·9%) received no analgesics. Multiple sedatives were used for these children, including bolus phenobarbital for 117 children (68·8%), phenergan for 81 children (47·6%) and midazolam for three children (1·8%). The mean pain scores significantly decreased throughout the operation day (POD-0) to the 2nd postoperative day (POD-2) with the lowest score on POD-2. Less than 5% of pain assessments were identified as moderate to severe across all 2815 observations. The sedation scores significantly increased through POD-0 to POD-2 with the highest score on POD-2. The rate of over-sedation was 50·3% with <1% under-sedation occurring among all the observations. Results also suggested that the length of stay in the cardiac intensive care unit was a predictor of increased analgesic usage in the critical care setting (odds ratio: 1·72). Usage of analgesic and sedative agents in cardiac intensive care unit was variable and children experienced low pain scores but a high rate of over-sedation, indicating that healthcare providers should address ways to improve postoperative pain and sedation management in this population. The pain and sedation status for children after cardiac surgery changed across the postoperative days. Healthcare providers should be trained in the use of reliable tools to accurately monitor children's pain and sedation levels.

Construct validity of two pain behaviour observation measurement instruments for young children with burns by Rasch analysis

In this study, construct validity of 2 pain behaviour observation measurement instruments for young children aged 1 to 56months (mean age was 20months) with burns is assessed by using Rasch analysis. The Rasch model, wherein data should meet the model expectations, assumes that an instrument measures one unidimensional construct, and focuses on the items of measurement instruments. The Pain Observation Scale for Young Children (POCIS) and the COMFORT Behaviour Scale (COMFORT-B) measure background and procedural pain as unidimensional. Adequate measurements for scientific research and daily practice can now be obtained.

The COMFORT behavior scale

The COMFORT behavior scale has been validated for postoperative pain in 0- to 3-yr-old children. Scoring is preceded by a 2-min observation period, which nurses may consider too long. The objective of this study was to test the reliability of a 30-sec observation period. Observational study. One Level III intensive care unit at a university children's hospital. Designated pain specialist and all nursing staff. None. The pain specialist and caregiver nurse each conducted a bedside COMFORT behavior scale assessment and assigned an additional pain rating on the 11-point Numerical Rating Scale. Total COMFORT behavior Scale score for the 2-min observation was 17 or higher in 19% of the patients and 11% for the 30-sec observation. The mean COMFORT behavior scale score for the 2-min observation was 13.5 (SD 3.8) and 12.7 (SD 3.7) for the 30-sec observation. The mean difference therefore was 0.8 (confidence interval 0.6-1.1, paired t test, p < .001). Sensitivity and positive predictive value for the 30-sec observation were 0.44 and 0.80, respectively. A 30-sec COMFORT behavior scale observation increases the risk of underscoring pain. Therefore, the 2-min observation period should be adhered to in the interest of the patients.

Discomfort and Pain in Newborns With Myelomeningocele: A Prospective Evaluation

In a worldwide debate on deliberately terminating the lives of newborns, proponents point at newborns with very severe forms of myelomeningocele (MMC) and their assumed suffering, claiming there are no effective means of alleviating their distress. Nevertheless, the degree of discomfort and pain in these newborns has never been assessed in a structured manner. In a prospective cohort study, 28 consecutive newborns with MMC were included over a 5-year period and were followed up throughout their hospital stay for initial treatment. We created 2 disease severity groups on the basis of the Lorber criteria. The primary outcomes were discomfort and pain, assessed by simultaneously scoring 2 validated scales: the visual analog scale for pain and the Comfort Behavioral Scale for discomfort. These scores were coupled to a validated and evidence-based analgesia algorithm. Overall, discomfort related to pain was measured in 3.3% of the scores. This percentage differed little between the preoperative and postoperative periods and did not significantly differ between newborns with less severe MMC and severe MMC (3.9% vs 2.8%; P = .3). The mean dosage of paracetamol was 35 mg/kg per day (95% confidence interval: 32-39); the mean dosage of morphine was 0.9 μg/kg per hour (95% confidence interval: 0.6 -1.2). Over the length of their hospital stays for initial treatment, all newborns with MMC presented with low levels of discomfort and pain independent of disease severity and time frame.

Protocolized post‐operative pain management in infants; do we stick to it?

The American Academy of Pediatrics states that ongoing assessment of pain is essential for adequate pain treatment. Pain assessment by means of the COMFORT behaviour scale and the Numeric Rating Scale is therefore an important component of the post-operative pain treatment protocol for neonates and infants in our intensive care unit (ICU). The study aims to determine degrees of staff compliance with this protocol. This retrospective chart review concerned post-surgical patients under the age of 3 years admitted to our level III ICU over a 1-year period. The degree of compliance to the post-operative pain protocol was measured by the frequency of deviations from protocol-dictated drug treatment and pain assessments. Records of 200 children with a median age at surgery of 98 days (interquartile range 6-320) were analysed. A mean of 11 assessments in the first 72 h post-operatively per patient had been recorded. A total of 2103 pain assessments were retrieved, of which 1675 (79.7%) suggested comfort. Compliance to the protocol (reassessment and correct medication) was provided in 66 (15.4%) of the 428 assessments suggesting pain or distress. The post-operative pain protocol applied in our ICU appears to be effective; however, full compliance to the protocol was marginal, possibly leading to under-treatment of pain.

Evaluation of pain incidence and pain management in a South African paediatric trauma unit.

OBJECTIVES. To evaluate pain incidence and pain management in a South African paediatric trauma unit, and to compare the usefulness of 5 different assessment tools. DESIGN. A prospective observational study, using the Numerical Rating Scale for pain (NRS pain), Numerical Rating Scale for anxiety (NRS anxiety), the Alder Hey Triage Pain Score (AHTPS), the COMFORT behaviour scale and the Touch Visual Pain Scale (TVPS). All patients were assessed at admission; those who were hospitalised were again assessed every 3 hours until discharge. RESULTS. A total of 165 patients, with a mean age of 5.3 years (range 0 - 13), were included. NRS scores were indicative of moderate to severe pain in 13.3% of the patients, and no pain in 24% at admission. Two-thirds of the patients received no analgesics; for them, NRS pain, AHTPS and TVP scores were lower than the scores for the other children. CONCLUSION. Pain and anxiety incidences in this paediatric trauma unit are relatively low. Implementation of a standard pain assessment tool in the emergency department triage system can improve pain management. The AHTPS is the most promising for use in non-Western settings.

The COMFORT-Behavior scale is useful to assess pain and distress in 0- to 3-year-old children with Down syndrome

Many pediatric intensive care units use the COMFORT-Behavior scale (COMFORT-B) to assess pain in 0- to 3-year-old children. The objective of this study was to determine whether this scale is also valid for the assessment of pain in 0- to 3-year-old children with Down syndrome. These children often undergo cardiac or intestinal surgery early in life and therefore admission to a pediatric intensive care unit. Seventy-six patients with Down syndrome were included and 466 without Down syndrome. Pain was regularly assessed with the COMFORT-B scale and the pain Numeric Rating Scale (NRS). For either group, confirmatory factor analyses revealed a 1-factor model. Internal consistency between COMFORT-B items was good (Cronbach’s α = 0.84–0.87). Cutoff values for the COMFORT-B set at 17 or higher discriminated between pain (NRS pain of 4 or higher) and no pain (NRS pain below 4) in both groups. We concluded that the COMFORT-B scale is also valid for 0- to 3-year-old children with Down syndrome. This makes it even more useful in the pediatric intensive care unit setting, doing away with the need to apply another instrument for those children younger than 3.

Validation of the COMFORT Behavior Scale and the FLACC Scale for Pain Assessment in Chinese Children after Cardiac Surgery

Appropriate pain assessment plays a key role in understanding the pain status of critically ill children. However, the utility of the face, legs, activity, cry, consolability (FLACC) scale and the COMFORT Behavior (COMFORT-B) scale have not been extensively explored for children after cardiac surgery in China. A repeated-observation study was conducted to evaluate the concurrent validity and the sensitivity and specificity of the COMFORT-B and FLACC scales for pain assessment after cardiac surgery in 0–7-year-old patients. Patients were assessed with the observational visual analog scale (VASobs), FLACC scale, and COMFORT-B scale simultaneously at 18 fixed time periods for 3 days. Correlations among pain assessments were computed to calculate concurrent validity. Receiver operating characteristic curve analyses identified the FLACC and COMFORT-B scores that could best discriminate pain and no pain based on the VASobs. Multiple regression analyses were performed with FLACC and COMFORT-B pain scores as dependent variables and disease-related treatment characteristics as predictor variables for conducting the analysis. A total of 170 children (98 boys and 72 girls) were included. Significantly positive correlations, ranging from 0.31 to 0.86, were found among the COMFORT-B, FLACC, and VASobs pain assessment instruments. The COMFORT-B and the FLACC scores for children assessed to be in pain (i.e., VASobs ≥4), were significantly higher than scores for children not in pain (VASobs <4). COMFORT-B showed good sensitivity (86%) and specificity (83%) with a cutoff point of 13. FLACC showed excellent sensitivity (98%) and good specificity (88%) for a cutoff point of 2. The COMFORT-B and FLACC scales seem to be useful tools in pain assessment for Chinese children at postcardiac surgery stages, but the study identified that this group of children demonstrated a lower cutoff point for pain than originally set for these two instruments.

Problèmes liés à l’évaluation de la douleur chez le nouveau né en situation de soins palliatifs

Several pain scales are available for newborns, but the assessment of pain in these preverbal beings, who are in continuing neurological development, remains challenging for healthcare teams. Although neonates at the end of life are particularly vulnerable to pain and discomfort, no assessment tool has been validated in this specific population. The difficulties for assessing pain in this context are copies of those potentially encountered in other situations. Questions arise about the limits of the available scales, about possible alterations of responses to a noxious stimulus in particular contexts (extreme immaturity, brain lesions), about possibly painful situations in palliative care, about the nature of scales to choose. Data show a perception of pain at a cortical level by extremely immature infants and the ability for neonates with significant neurological injury to express pain behaviours. For some potentially painful situations (dyspnoea, gasps, hunger) neonatal data are virtually nonexistent. Fundamental scientific data and clinical data from adults and children can give some answers. One will choose scales for which the staff is trained, easily usable (preference for behavioural scales), validated for all gestational ages, reliable in the event of neurological impairment or sedation. An assessment of prolonged pain (EDIN scale or COMFORT Behaviour scale) combined with measures of acute pain (DAN or NFCS scales) is recommended. These scales should be better validated for populations of newborns and situations that are specific to palliative care. A better assessment of the parental perception and of their distress about the discomfort or pain of their child is warranted.

Reliability, validity and clinical utility of three types of pain behavioural observation scales for young children with burns aged 0–5 years

Pain measurement is a prerequisite for individualized pain management and research into pain interventions. There is a need for reliable and valid pain measures for young children with burns. The aim of this study was to investigate whether the pain observation scale for young children (POCIS), the COMFORT behaviour scale (COMFORT-B) and the nurse observational visual analogue scale (VAS obs) are reliable, valid and clinically useful instruments to measure pain in children with burns aged 0–5 years. Participating trained nurses ( N = 102) rated pain of 154 children during hospitalization. Two trained nurses simultaneously assessed pain at fixed intervals by using the previous mentioned measures. Cronbach’s alpha for POCIS was .87 for background and .89 for procedural pain. Intraclass Correlation Coefficients (ICCs) were .75 for background and .81 for procedural pain. COMFORT-B observations yielded Cronbach’s alpha of .77 for background and .86 for procedural pain and ICCs of .83 for background and .82 for procedural pain. The VAS obs resulted in ICCs of .55 for background and .60 for procedural pain. Correlation coefficient between POCIS and COMFORT-B was .79 ( p < .01), Standardized response mean was 1.04 for both POCIS and COMFORT-B. Background pain measured with POCIS and COMFORT-B was lower than procedural pain ( p < .001). Nurses found POCIS easier and quicker to use, but COMFORT-B was found to indicate pain more accurately. Both POCIS and COMFORT-B are reliable, valid and practical scales for pain measurement in young children with burns and can be used in practice and research. The VAS obs was found to be unreliable.

Implementation of standard sedation management in paediatric intensive care: effective and feasible?

To study the effects of the introduction of a sedation treatment protocol for children in intensive care, including nurses' compliance. While several sedation guidelines for adults and children have been developed and implemented, there is little evidence on use of sedation protocols in critically ill infants. Pretest-posttest intervention study. Administered sedatives and analgesics over the first seven days of admission were documented for convenience samples, before (n = 27) and after (n = 29) implementation of standard sedation assessments and a sedation protocol. Sedation was assessed with the COMFORT behaviour scale, Nurse Interpretation of Sedation Score and the Visual Analogue Scale for three-month periods, both pretest and posttest. Starting 21 months after the posttest, nurses' compliance with the sedation protocol, as well as administered sedatives and analgesics were evaluated for 12 months. Infants in the posttest period received significantly more midazolam and morphine. The proportion of patients adequately sedated on the grounds of COMFORT scores had increased from 63% pretest to 72% posttest and to 75% in the long run. Adequate sedation as judged from the sedation protocol cutoffs was found in 71% of the assessments. In 45% of assessments indicating undersedation, the infusion rate had been increased on the guidance of the protocol. A survey among staff revealed that most considered the sedation protocol comprehensible and useful. This study showed that regular sedation assessment in critically ill children was feasible and had become standard practice two years after the first posttest. There is insufficient evidence to conclude whether implementation of a sedation treatment protocol indeed improves sedation treatment. This sedation protocol provides decision trees for increasing or weaning of sedatives in both haemodynamically stable and unstable patients. It standardizes sedation management and allows nurses to adapt medication themselves.

The COMFORT behavioural scale and the modified FLACC scale in paediatric intensive care

To evaluate the concurrent validity and reliability of the behavioural COMFORT and a modified version of the FLACC scale for assessment of pain and sedation in intubated and ventilated children and to evaluate the construct validity of the FLACC scale for assessment of pain. Few instruments are available for assessment of pain/sedation in paediatric intensive care. A prospective observational study was performed postoperatively in 40 children aged 0-10 years. Two trained nurses observed the child simultaneously and assessing COMFORT behavioural (COMFORT-B) and FLACC scores. In comparison, two bedside nurses concurrently scored pain using an observational visual analogue scale (VAS(obs)) and sedation using the Nurse Interpretation of Sedation (NIS) score: oversedated, adequately or insufficient sedated. In 20 additional patients, one nurse assessed FLACC scores before and after analgesics. The majority of patients were <1 year. A moderate but significant correlation was found between each scale and both sedation and VAS(obs). COMFORT-B differentiated better than FLACC between the three sedation levels. For those assessed to be in pain (VAS(obs) > 3), both COMFORT-B and FLACC scores were significantly different compared with VAS(obs) < 3. The interrater reliability was high for COMFORT-B and FLACC (kappa 0.71 and 0.63, respectively). For bedside nurses' assessment of pain, the interrater reliability was high (kappa 0.63) but low for the level of sedation (kappa 0.20). After administration of analgesics, the FLACC median score decreased significantly from 5 to 0. The COMFORT-B scale was a more reliable measure of children's sedation than bedside subjective assessment and gives more substantial information about sedation than the FLACC scale. Concurrent validity for assessment of pain was supported for both scales. The modified FLACC showed construct validity for measuring pain. The use of validated scales may improve the assessment and management of pain and sedation in intubated children.

Validação de escalas de sedação em crianças submetidas à ventilação mecânica internadas em uma unidade de terapia intensiva pediátrica terciária

Sedation scores are important tools for use in pediatric intensive care units. The Comfort-Behavior scale is a valid method for the assessment of children although it is considered an extensive scale. The motor activity assessment scale is validated for an adult population. We considered it simpler then the one above and suitable for application in children. None of these scores had been translated into Portuguese. Our objective was to apply both scales in Portuguese to a pediatric population under mechanical ventilation. Secondary objectives were to evaluate the sedation level of children on mechanical ventilation in tertiary pediatric intensive care units and to compare the Comfort- Behavior and motor activity assessment scales in this population. After translating the scales into Portuguese, both were simultaneously applied to 26 patients by 2 pediatricians. Each scale was applied 116 times in total. The intraclass correlation coefficient was 0.90 (0.85 - 0.93 CI 95%) for the Comfort-Behavior and 0.94 (0.92 - 0.96 CI 95%) for the motor activity assessment scale. When applying the Comfort-Behavior scale, the Crombach's alpha was 0.81 for observer A and 0.92 for observer B. The Spearman coefficient was 0.86 for observer A and 0.91 for observer B. These patients were found to be deeply sedated, showing low values in both scales. The scales were successfully translated into Portuguese and both were adequate to assess pain and sedation in the pediatric population under mechanical ventilation. Sedation level was high in this sample of applications.

Pharmacokinetics and analgesic effects of intravenous propacetamol vs rectal paracetamol in children after major craniofacial surgery

The pharmacokinetics and analgesic effects of intravenous and rectal paracetamol were compared in nonventilated infants after craniofacial surgery in a double-blind placebo controlled study. During surgery all infants (6 months-2 years) received a rectal loading dose of 40 mg.kg(-1) paracetamol 2 h before anticipated extubation. On admittance to the pediatric surgical ICU, the children were randomized to receive either a 15 min intravenous infusion of 40 mg.kg(-1) propacetamol, a prodrug of paracetamol, or 20 mg.kg(-1) paracetamol rectally every 6 h. A population pharmacokinetic analysis of the paracetamol plasma concentration time-profiles was undertaken using nonlinear mixed effects models. The visual analogue scale (VAS) (score 0-10 cm) and COMFORT Behavior scale (score 6-30) were used to monitor analgesia in the 24-h period following surgery. Twelve infants received intravenous propacetamol and 14 paracetamol suppositories. Paracetamol pharmacokinetics were described according to a two-compartmental model with linear disposition. Pharmacokinetic parameters were standardized to a 70 kg person using allometric '1/4 power' models. Parameter estimates were: absorption half-life from the rectum 4.6 h, propacetamol hydrolysis half-life 0.028 h, clearance 12 l.h(-1).70 kg(-1), intercompartmental clearance 116 l.h(-1).70 kg(-1), central and peripheral volume of distribution 7.9 and 44 l.70 kg(-1), respectively. During the 24-h study period 22 infants exhibited VAS scores <4 cm, which was considered a cutoff point. On single occasions four patients, two in each group, exhibited a VAS score >/=4 cm. Nine patients in the rectal treatment group and three patients in the intravenous treatment group received midazolam for COMFORT-B scores exceeding 17 (P < 0.05). Intravenous propacetamol proved to be more effective than rectal paracetamol in infants after craniofacial surgery. Midazolam was more frequently administered to patients receiving paracetamol suppositories, indicating that these children experienced more distress, possibly caused by pain.

Objective and continuous measurement of peripheral motor indicators of pain in hospitalized infants: A feasibility study

Measurement of pain in pre-verbal infants is complex. Until now, pain behavior has mainly been assessed intermittently using observational tools. Therefore, we determined the feasibility of long-term, objective and continuous measurement of peripheral motor parameters through body-fixed sensors to discriminate between pain and no pain in hospitalized pre-verbal infants. Two pain modes were studied: for procedural pain 10 measurements were performed before, during and after routine heel lances in 9 infants (age range infants: 5–175 days), and for post-operative pain 14 infants (age range 45–400 days) were measured for prolonged periods (mean 7 h) using the validated COMFORT-behavior scale as reference method. Several peripheral motor parameters were studied: three body part activity parameters derived from acceleration sensors attached to one arm and both legs, and two muscle activity parameters derived from electromyographic (EMG) sensors attached to wrist flexor and extensor muscles. Results showed that the accelerometry-based parameters legs activity and overall extremity activity (i.e. mean of arm and legs) were significantly higher during heel lance than before or after lance ( p ⩽ 0.001), whereas arm activity accelerometry data and wrist muscle activity EMG data showed no significant change. For the post-operative pain measurements, relationships were found between accelerometry-based overall extremity activity and COMFORT-behavior ( r = 0.76, p < 0.001), and between EMG-based wrist flexor activity and COMFORT-behavior ( r = 0.55, p < 0.001, for a subgroup of 7 infants). We conclude that long-term, objective and continuous measurement of peripheral motor parameters is feasible, has high potential, and is promising to assess pain in pre-verbal hospitalized infants.