Paediatric Pain Profile Research Articles

Postsurgical pain assessment in children and adolescents with cerebral palsy: A scoping review.

To investigate factors that influence the assessment of postoperative pain in children and adolescents with cerebral palsy (CP) and the tools available to determine pain intensity. The search was performed in January 2022 using six databases. Articles focused on paediatric patients with CP; we included instruments for postsurgical pain assessment in this population published in the last 11 years. Eight of 441 studies were included. Males and females behave differently; their families can be called on to describe their pain responses. Seven instruments for pain assessment were identified: the Non-Communicating Children's Pain Checklist and its Postoperative Version; the Paediatric Pain Profile; the revised Face, Legs, Activity, Cry and Consolability (FLACC) pain scale; the Douleur Enfant San Salvador scale; the Pain Indicator for Communicatively Impaired Children; the University of Wisconsin Children's Hospital Pain Scale; and the Individualized Numeric Rating Scale. The revised FLACC pain scale is suited to postsurgical units because of its ease of use and the fact that parental collaboration is not required. More studies are needed to demonstrate the clinical utility of these scales in postsurgical units and the factors that influence pain assessment. Families should be asked to collaborate when assessing pain in children and adolescents whenever possible. Larger studies that focus on the factors influencing pain assessment in this population are required.

Measuring Effects on Pain and Quality of Life after Abobotulinum Toxin A Injections in Children with Cerebral Palsy.

Sixty-seven percent of children with cerebral palsy (CCP) experience pain. Pain is closely interrelated to diminished quality of life. Despite this, pain is an overlooked and undertreated clinical problem. The objective of this study was to examine the analgesic effect of a single lower extremity intramuscular injection of Abobotulinum toxin A/Dysport in CCP. Twenty-five CCP with at least moderate pain (r-FLACC ≥ 4) during passive range of motion were included. Localized pain and pain in everyday living were measured by r-FLACC and the Paediatric Pain Profile (PPP), respectively. Functional improvements were evaluated by the goal attainment scale (SMART GAS). Quality of life was evaluated by either the CPCHILD or the CP-QOL. The subjects were evaluated at baseline before injection, then after 4, 12, and 28 weeks. Twenty-two subjects had a significant mean and maximum localized pain reduction (p < 0.001) at four weeks post-treatment in 96% (21/22). The reduction was maintained at 12 (19/19) and 28 weeks (12/15). Daily pain evaluated by the PPP was significantly reduced and functional SMART GAS goals were significantly achieved from 4 to 28 weeks. Quality of life improved significantly at four weeks (CPCHILD). Significant functional gains and localized and daily pain reduction were seen from 4 to 28 weeks.

An exploratory study: The effects of sleep systems on sleep quality, pain and carer goals for non-ambulant children and young people with cerebral palsy.

IntroductionSleep systems are supports used in lying, forming part of 24 h posture management programmes, for children and adults with severe motor disorders. Improved posture reduces likelihood of secondary complications such as pain and poor sleep quality, thus improving quality of life. The study aims are to investigate the effect of sleep systems on sleep quality and quantity, pain for young people with Cerebral Palsy and outcomes for carers.MethodsBaseline data were gathered for 1 month prior to sleep system provision. Comparative data with the sleep system in place, were gathered for 5 months. The sample comprised four children with Cerebral Palsy, GMFCS level V, average age of 11.5, who did not have a sleep system. Data on sleep quality and quantity was gathered using the Chailey Sleep Questionnaire and sleep diaries and pain levels using the Paediatric Pain Profile. GAS Light verbal outcome measure was used to measure carer goals.ResultsDescriptive statistics and paired sample t-tests were used, demonstrating pain levels remained static, improvements in sleep quality and quantity were found and carer goals achieved.ConclusionA small sample size and subjective data collection methods were used; further research is required to obtain more conclusive results.

Mental health and behaviour in children with dystonia: Anxiety, challenging behaviour and the relationship to pain and self-esteem

<h2>Abstract</h2><h3>Purpose</h3> To ascertain whether young people with dystonia are more likely than the general population to have mental health and/or behavioural difficulties, and to explore factors that may contribute to these difficulties. <h3>Method</h3> Using a quasi-experimental design, 50 young people with dystonia aged 7–17 and their carers were recruited from the Evelina London Children's Hospital. Young people completed the Beck Youth Inventories and the Strengths and Difficulties Questionnaire. Carers completed the Strengths and Difficulties Questionnaire-Parent version and the Paediatric Pain Profile. Important medical factors, such as age of onset, motor severity and manual function were obtained from medical records. <h3>Results</h3> One sample z tests showed young people with dystonia self-reported significantly higher levels of anxiety (<i>p</i> < .001) and prosocial difficulties (<i>p</i> < .01), with 48% experiencing clinically significant anxiety levels. They experienced significantly lower levels of anger, disruptive behaviour and conduct problems (all <i>p</i> ≤ .01). Carers reported significantly higher rates of emotional problems, hyperactivity and peer problems, and significantly lower prosocial behaviours (all <i>p</i> ≤ .01). Pearson's correlation coefficients showed lower levels of self-esteem were related to higher levels of anxiety (p = .015). High levels of pain were related to parent-rated conduct problems (p = .004). Age of dystonia onset and motor severity did not correlate with any of the psychological or behavioural measures. <h3>Interpretation/conclusions</h3> Our study suggests high rates of anxiety and behaviours that challenge in children with dystonia. Screening in movement clinics would be helpful in early identification and signposting for support.

Reliability and validity of the Japanese version of the Paediatric Pain Profile for children with severe motor and intellectual disabilities.

Children with severe motor and intellectual disabilities experience chronic pain but cannot communicate verbally. However, no Japanese tool currently exists for assessing pain in this population. This study aimed to develop and evaluate the reliability and validity of a Japanese version of the Paediatric Pain Profile, which is a behavioral rating scale to assess pain in children with severe neurological disabilities. The sample comprised 30 children with severe motor and intellectual disabilities at three hospitals in Japan. Three specialist nurses rated low and high pain video scenes of the children (twice at 1-week intervals) using the Face, Legs, Activity, Cry, Consolability behavioral scale and a translated Japanese version of the Paediatric Pain Profile. On the basis of their ratings, we calculated the internal consistency, test-retest reliability, and intra- and inter-observer reliabilities of the Paediatric Pain Profile. Additionally, we assessed concurrent validity using the Face, Legs, Activity, Cry, Consolability behavioral scale and construct validity using low versus high pain scenes. Both internal consistency (low pain: alpha = 0.735; high pain: alpha = 0.928) and test-retest reliability (r = 0.846) of the Japanese version of the Paediatric Pain Profile were good. Intra-observer reliability was substantial (r = 0.748), whereas inter-observer reliability was only moderate (r = 0.529). However, the concurrent validity with Face, Legs, Activity, Cry, Consolability scores was good (r = 0.629) and construct validity was confirmed (p < 0.001). We confirmed the validity of the Japanese version of the Paediatric Pain Profile, but reliable pain assessment may require repeated ratings by the same person. To accurately assess pain in children with severe motor and intellectual disabilities, healthcare staff must be properly trained and become more skilled in using the Japanese version of the Paediatric Pain Profile.

Deep brain stimulation reduces pain in children with dystonia, including in dyskinetic cerebral palsy.

To establish the prevalence of dystonic pain in children and their response to deep brain stimulation (DBS). Dystonic pain was assessed in a cohort of 140 children, 71 males and 69 females, median age 11years 11months (range 3y-19y 1mo), undergoing DBS in our centre over a period of 10years. The cohort was divided into aetiological dystonia groups: 1a, inherited; 1b, heredodegenerative; 2, acquired; and 3, idiopathic. Motor responses were measured with the Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS). Dystonic pain was identified in 63 (45%) patients, 38% of whom had a diagnosis of cerebral palsy (CP). Dystonic pain improved in 90% of children and in all aetiological subgroups 1year after DBS, while the BFMDRS motor score improved in 70%. Statistically significant improvement (p<0.01) was noted for the whole cohort on the Numerical Pain Rating Scale (n=27), Paediatric Pain Profile (n=17), and Caregivers Priorities and Child Health Index of Life with Disabilities questionnaire (n=48). There was reduction of pain severity, frequency, and analgesia requirement. Findings were similar for the whole cohort and aetiological subgroups other than the inherited heredodegenerative group where the improvement did not reach statistical significance. Dystonic pain is frequent in children with dystonia, including those with CP, who undergo DBS; this can be an important, realizable goal of surgery irrespective of aetiology. We encourage the use of multimodal approach in pain research to reduce the risk of bias.

Preoperative botulinum neurotoxin A for children with bilateral cerebral palsy undergoing major hip surgery: a randomized double-blind placebo-controlled trial.

To assess whether preoperative botulinum neurotoxin A (BoNT-A) affects pain after major hip surgery for children with bilateral cerebral palsy (CP). This was a randomized, parallel arms, placebo-contolled trial. Children with hypertonic CP aged 2 to 15years awaiting bony hip surgery at a tertiary hospital were randomized to receive either BoNT-A or placebo injections into the muscles of the hip on a single occasion immediately before surgery. The primary outcome was the paediatric pain profile (PPP), which was assessed at baseline and weekly for 6weeks. Treatment allocation was by minimization. Participants, clinicians, and outcome assessors were masked to group assignment. Twenty-seven participants (17 males, 10 females; mean 8y 8mo [SD 3y 9mo], range 3y 4mo-15y 10mo) were allocated to BoNT-A and 27 participants (14 males, 13 females; mean 8y 11mo [SD 3y 5mo], range 4y 1mo-15y 2mo) to placebo. Mean (SD) PPP at 6weeks for the BoNT-A group (n=24 followed up) was 10.96 (7.22) and for the placebo group (n=26) was 10.04 (8.54) (p=0.69; 95% confidence interval [CI] -4.82, 3.18). There were 16 serious adverse events in total during 6months of follow-up (n=6 in BoNT-A group). Use of BoNT-A immediately before bony hip surgery for reducing postoperative pain for children with CP was not supported. Botulinum neurotoxin A (BoNT-A) does not reduce postoperative pain following bony hip surgery. BoNT-A also does not affect postoperative quality of life.

Pain symptoms in patients with severe cerebral palsy: Prevalence among patients with higher degree of locomotor impairment

Purpose: To evaluate the presence of pain in patients diagnosed with severe cerebral palsy (CP) according to the degree of motor function impairment. Methods: A cross-sectional study was conducted on students of the Association of Parents and Friends of Exceptional Children (APAE) diagnosed with cerebral palsy and with severe locomotor disability (GMFCS levels IV and V). The study included students of both genders and of any age. After signing the consent form, a structured questionnaire was administered to parents or caregivers to collect data on the history of the illness and the Paediatric Pain Profile (PPP). A score ≥ 14 out of a possible 60 points suggests the presence of pain. Results: A total of 93 subjects were evaluated. Of the 44 subjects classified with GMFCS level IV, 12 (21.4 %) suffer pain and among the 49 subjects classified with level V, 44 (78.6 %) had pain symptoms (ICDDN ≥ 14, PR = 3.29, 95 % CI 2.01 - 5.38, p < 0.01). Conclusion: The results show that pain is prevalent in individuals with severe CP. Furthermore, it is more prevalent in patients with a higher degree of locomotor impairment (GMFCS – level V). Keywords: Cerebral palsy, Pain measurement, Locomotor disability, Gross motor function classification system (GMFCS)

Pain report and musculoskeletal impairment in young people with severe forms of cerebral palsy: A population-based series

BackgroundWhile pain is reportedly more prevalent in more functionally impaired children with cerebral palsy, information is scant in those with poor communication skills. MethodsYoung people (4–27 years) with severe forms of cerebral palsy were recruited from a population-based register. The Child Health Questionnaire (CHQ) provided information on general health and bodily pain; the Paediatric Pain Profile (PPP) was used for participants with limited communication; and the Spinal Alignment and Range of Motion Measure (SAROMM) described musculoskeletal impairment. Results123 young people (GMFCS IV=55 and V=68) and their families/carers participated. Fourteen percent of CHQ responses (n=123) reported severe/very severe pain in recent weeks, whilst 7% reported pain every/almost every day. CHQ pain report was significantly higher for young people in GMFCS level V and correlated significantly with both global health and musculoskeletal impairment. High levels of pain were recorded on the PPP for non-communicating children but only a weak correlation between PPP and CHQ scores was detected. ConclusionManaging pain in young people with severe musculoskeletal and cognitive impairment presents a huge challenge to carers and professionals. The PPP may represent a useful adjunct in those young people with severe communication difficulties.

Assessment of pain in children with cerebral palsy focused on translation and clinical feasibility of the revised FLACC score

Background and aimsAssessment of pain in children with cognitive impairment (CI) including cerebral palsy (CP) is difficult. Several pain assessment tools have been developed and validated for use in children with CI. The revised Face, Legs, Activity, Cry and Consolability score (r-FLACC) includes core behaviours of children with CI and adds an open-ended descriptor for individualisation (5 items assigned 0–2 points, total range 0–10). Other pain assessment tools including individual pain behaviours are the Individualised Numeric Rating Scale (INRS) and the Paediatric Pain Profile (PPP). Both the Noncommunicating Childrens's Pain Checklist – Postoperative version (NCCPC-PV) and the Echelle Douleur Enfant San Salvador (DESS) are developed from core pain behaviours for children with CI but have no possibility for individualisation. For successful clinical application a pain assessment tool should not only be reliable and valid, but also clinically feasible. The aim of this study was to select the most valid and feasible pain assessment tool for children with CI and translate that tool into Danish. MethodsA literature review on studies on pain, pain assessment tools, feasibility and CI was performed. Studies were evaluated with focus on children with CI not able to self-report pain and the r-FLACC was chosen for translation. A 10 step translation process guideline was used from the Translation and Cultural Adaptation Group, which describes preparation, forward translation, reconciliation, back translation, back translation review, harmonization, cognitive debriefing, review of cognitive debriefing, finalisation, proofreading, and final report. ResultsStudies show that the r-FLACC is superior regarding clinical feasibility. The r-FLACC is a useful tool for assessing pain in children with CI due to its ease to use in a clinical setting and its use of both core and individual pain behaviours. In the back translation review discrepancies of words between the original and the back-translated English versions were assessed and in three of nine discrepancies a word was changed. In the cognitive debriefing no issues were found regarding understandability, interpretation or cultural relevance of the translation. No other language translations of the r-FLACC score have been published; hence the harmonisation step with a comparison of the English back translations was not possible. ConclusionsThe r-FLACC is assessed to have the most preferable profile with use of core pain behaviours, flexibility regarding individualisation, good psychometric properties, and high clinical feasibility; hence suited for use in Danish children with CP. A Danish version of the r-FLACC score now exits and may be used in a clinical setting for the assessment of pain. ImplicationsIt is important for health-care professionals to be able to assess pain in hospitalized children with CP who are not able to self-report. The r-FLACC score is clinically feasible and has the potential for becoming the gold standard of pain assessments in children with CP. A standardised approach to pain assessment may lead to an increased focus on pain and help improve the treatment of pain in children with CP in Denmark.

Cross-Cultural Translation and Adaptation to Brazilian Portuguese of the Paediatric Pain Profile in Children With Severe Cerebral Palsy

ContextPain is a prevalent symptom in children with severe cerebral palsy (CSCP), mainly as a result of the progression of muscle contractures, bone deformities, gastroesophageal reflux, and recurrent infections. Considering the lack of verbal communication in this population, both pain diagnosis and assessment of the analgesic treatment are often neglected. Although the Paediatric Pain Profile (PPP), an instrument with 20 items, is used to assess behavior indicative of pain in CSCP, it is not validated in Brazil. ObjectivesTo translate, adapt, and evaluate the psychometric properties of the PPP to Brazilian Portuguese. MethodsThe study was carried out at a philanthropic institution for CSCP and a university hospital. The sample of CSCP unable to communicate through speech or any device, their respective parents or primary caregivers, and health professionals were included. First, the instrument was translated and then back translated, and its clarity was evaluated by parents, primary caregivers, and professionals. The psychometric properties of the final version were evaluated for internal consistency (Cronbach's α) and stability (test-retest). ResultsForty-five children with a mean (SD) chronological age of 16 (8.69) years, 26 of whom were male, were included in the study. A total of 150 applications of PPP were carried out: 30 to assess clarity and 120 to assess the psychometric properties. Each item of the translated version showed a median between 3.00 and 4.00, considered to be clear and very clear, respectively. The internal consistency of the items was α=0.864, with no significant difference between test and retest (P=0.271). ConclusionThe adapted version of the PPP in Brazilian Portuguese demonstrated good internal consistency (similar to the original instrument) and stability over time, decisive for the next step of clinical validation for CSCP.

Evaluation of the effects of botulinum toxin A injections when used to improve ease of care and comfort in children with cerebral palsy whom are non-ambulant: a double blind randomized controlled trial

BackgroundChildren with cerebral palsy (CP) whom are non-ambulant are at risk of reduced quality of life and poor health status. Severe spasticity leads to discomfort and pain. Carer burden for families is significant. This study aims to determine whether intramuscular injections of botulinum toxin A (BoNT-A) combined with a regime of standard therapy has a positive effect on care and comfort for children with CP whom are non-ambulant (GMFCS IV/V), compared with standard therapy alone (cycle I), and whether repeated injections with the same regime of adjunctive therapy results in greater benefits compared with a single injecting episode (cycle II). The regime of therapy will include serial casting, splinting and/or provision of orthoses, as indicated, combined with four sessions of goal directed occupational therapy or physiotherapy.Method/designThis study is a double blind randomized controlled trial. Forty participants will be recruited. In cycle I, participants will be randomized to either a treatment group who will receive BoNT-A injections into selected upper and/or lower limb muscles, or a control group who will undergo sham injections. Both groups will receive occupational therapy and /or physiotherapy following injections. Groups will be assessed at baseline then compared at 4 and 16 weeks following injections or sham control. Parents, treating clinicians and assessors will be masked to group allocation. In cycle II, all participants will undergo intramuscular BoNT-A injections to selected upper and/or lower limb muscles, followed by therapy.The primary outcome measure will be change in parent ratings in identified areas of concern for their child’s care and comfort, using the Canadian Occupational Performance Measure (COPM). Secondary measures will include the Care and Comfort Hypertonicity Scale (ease of care), the Cerebral Palsy Quality of Life Questionnaire (CP QoL–Child) (quality of life), the Caregiver Priorities and Child Health Index of Life with Disabilities Questionnaire (CPCHILD©) (health status) and the Paediatric Pain Profile (PPP) (pain). Adverse events will be carefully monitored by a clinician masked to group allocation.DiscussionThis paper outlines the theoretical basis, study hypotheses and outcome measures for a trial of BoNT-A injections and therapy for children with non-ambulant CP.Trial registrationAustralia New Zealand Clinical Trials Registry:N12609000360213

Special needs require special attention: A pilot project implementing the paediatric pain profile for children with profound neurological impairment in an in-patient setting following surgery

There is a lack of knowledge regarding the implementation of pain assessment tools for children with profound neurological impairment (PNI) in in-patient settings. This article describes a pilot project to evaluate the Paediatric Pain Profile (PPP) for children with PNI undergoing surgery. Five families of children 5 to 16 years of age with a primary diagnosis of cerebral palsy and admitted for surgical procedures were interviewed. Nineteen nurses completed questionnaires and children's pain management documentation was audited. The project identified issues in three areas of pain management: implementation process, individualised pain management and partnership. The PPP required pre-admission assessment and parental involvement, and was considered time-consuming by nurses. Individualised pain assessment and intervention was difficult to achieve, as was shared assessment and documentation among parents and nurses. Despite initial resistance to change, with greater use there was growing appreciation of the value of components of the PPP. Further exploration of the PPP tool in practice is required before its use can be widely recommended for children with PNI in in-patient settings. Future studies are required to determine which of the available pain assessment tools has the greatest accuracy and utility for assessment of post-operative pain in children with PNI.

Botulinum toxin type A injections can be an effective treatment for pain in children with hip spasms and cerebral palsy

Botulinum toxin type A (BoNT-A) injections were used in the treatment of lower-limb spasticity in children with cerebral palsy (CP). Anecdotal evidence suggests a reduction in pain after this treatment in children who had pain localized to a displaced hip joint. We report on our current clinical practice. Twenty-six children with non-ambulant quadriplegic CP (Gross Motor Function Classification System level V) were assessed as having significant spasticity and pain at the hip level. Twelve were males and 14 females, with an age range of 2 to 19 years (mean age 11y 6mo, SD 4y 9mo). Ten had functional difficulties secondary to predominant spasticity and 16 had a mix of a high-background peripheral tone with superimposed dystonia. Of the 26 children assessed, 10 had at least one hip which was dislocated and three had at least one hip which was subluxed. As part of their spasticity management programme they received targeted BoNT-A injections to the adductor magnus, medial hamstrings and iliopsoas muscle groups. The Paediatric Pain Profile was used as the primary outcome measure. All had highly significant improvement in their recorded pain profile scores measured at 3 months after treatment (p<0.001). There was equal efficacy in response to treatment in the children with subluxed or dislocated hips. In addition, families commented on improved quality of life for the children across several areas, including sleep, postural management, and activities of daily living. This report demonstrates that targeted BoNT-A injections reduced pain in children with significant spasticity and pain at the hip level. They may also improve quality of life of non-ambulant children with CP and a hip problem.

Development of the Paediatric Pain Profile: Role of Video Analysis and Saliva Cortisol in Validating a Tool to Assess Pain in Children with Severe Neurological Disability

The Paediatric Pain Profile (PPP) is a 20-item behavior-rating scale designed to assess pain in children with severe to profound neurological impairment. Three raters independently used the PPP to rate behavior of 29 children (mean age 9.6, SD 5.8) filmed during everyday morning activities. The validation process included assessment of interrater reliability and exploration of the relationship of PPP scores with saliva cortisol concentration. There was substantial agreement between raters. The PPP showed strong association with global pain assessments and differentiated between preselected high- and low-pain groups. PPP score showed moderate correlation with saliva cortisol concentration, but a single child explained the strength of the relationship and overall, saliva cortisol concentrations appeared low. The data provide additional evidence that the PPP is a reliable and valid instrument for pain assessment in neurologically impaired children. Cortisol levels are not a useful criterion for pain in this population and further study of cortisol response to stress/pain in children with severe neurological impairments is needed.

Clinical validation of the Paediatric Pain Profile

The Paediatric Pain Profile (PPP) is a 20–item behaviour rating scale designed to assess pain in children with severe neurological disability. We assessed the validity and reliability of the scale in 140 children (76 females, mean age 9 years 11 months, SD 4 years 7 months; range 1 to 18 years), unable to communicate through speech or augmentative communication. Parents used the PPP to rate retrospectively their child's behaviour when‘at their best’and when in pain. To assess interrater reliability, two raters concurrently observed and individually rated each child's behaviour. To assess construct validity and responsiveness of the scale, behaviour of 41 children was rated before and for four hours after administration of an‘as required’analgesic. Behaviour of 30 children was rated before surgery and for five days after. Children had significantly higher scores when reported to have pain than‘at their best’and scores increased in line with global evaluations of pain. Internal consistency ranged from 0.75 to 0.89 (Cronbach's alpha) and interrater reliability from 0.74 to 0.89 (intraclass correlation). Sensitivity (1.00) and specificity (0.91) were optimized at a cut‐off of 14/60. PPP score was significantly greater before administration of the analgesic than after (paired‐sample t‐tests, p &lt; 0.001). Though there was no significant difference in mean pre‐ and postoperative scores, highest PPP score occurred in the first 24 hours after surgery in 14 (47%) children. Results suggest that the PPP is reliable and valid and has potential for use both clinically and in intervention research.

Clinical validation of the paediatric pain profile.

The Paediatric Pain Profile (PPP) is a 20-item behaviour rating scale designed to assess pain in children with severe neurological disability. We assessed the validity and reliability of the scale in 140 children (76 females, mean age 9 years 11 months, SD 4 years 7 months; range 1 to 18 years), unable to communicate through speech or augmentative communication. Parents used the PPP to rate retrospectively their child's behaviour when 'at their best' and when in pain. To assess interrater reliability, two raters concurrently observed and individually rated each child's behaviour. To assess construct validity and responsiveness of the scale, behaviour of 41 children was rated before and for four hours after administration of an 'as required' analgesic. Behaviour of 30 children was rated before surgery and for five days after. Children had significantly higher scores when reported to have pain than 'at their best' and scores increased in line with global evaluations of pain. Internal consistency ranged from 0.75 to 0.89 (Cronbach's alpha) and interrater reliability from 0.74 to 0.89 (intraclass correlation). Sensitivity (1.00) and specificity (0.91) were optimized at a cut-off of 14/60. PPP score was significantly greater before administration of the analgesic than after (paired-sample t-tests, p<0.001). Though there was no significant difference in mean pre- and postoperative scores, highest PPP score occurred in the first 24 hours after surgery in 14 (47%) children. Results suggest that the PPP is reliable and valid and has potential for use both clinically and in intervention research.