Pain Behavior In Children Research Articles

Pain Reduction During Pediatric Immunizations: Evidence-Based Review and Recommendations

The pain associated with immunizations is a source of anxiety and distress for the children receiving the immunizations, their parents, and the providers who must administer them. Preparation of the child before the procedure seems to reduce anxiety and subsequent pain. The limited available data suggest that intramuscular administration of immunizations should occur in the vastus lateralis (anterolateral thigh) for children <18 months of age and in the deltoid (upper arm) for those >36 months of age. Controversy exists in site selection for 18- to 36-month-old children. A number of studies suggest that the ventrogluteal area is the most appropriate for all age groups. Longer needles are usually associated with less pain and less local reaction. During the injection, parental demeanor clearly affects the child's pain behaviors. Excessive parental reassurance, criticism, or apology seems to increase distress, whereas humor and distraction tend to decrease distress. Distraction techniques vary with the age, temperament, and interests of the child, but their efficacy is well supported in the literature. Sucrose solution instilled directly into the mouth or administered on a pacifier reduces evidence of distress reliably in children <6 months of age and should be used routinely. Although there is no perfect topical anesthetic available at this time, selective use for children who are particularly fearful or who have had negative experiences in the past is highly endorsed. Pressure at the site, applied with either a device or a finger, clearly reduces pain. Finally, in the era of multiple injections, it seems that parents prefer that multiple injections be given simultaneously, rather than sequentially, if there are enough personnel available. Immunizations are stressful for many children; until new approaches are developed, systematic use of available techniques can significantly reduce the burden of distress associated with these procedures.

Computerized anesthesia delivery provides some benefit to less anxious children

Computerized anesthesia delivery system vs traditional syringe: comparing pain and pain-related behavior in children. Versloot J, Veerkamp JS, Hoogstraten J. Eur J Oral Sci 2005;113(6):488-93. 1b To compare the behavioral reaction of children who receive local anesthesia with a traditional syringe with the behavioral reaction of children who receive local anesthesia with a computerized device (Wand), and to differentiate between the reactions of highly anxious children with those of low anxiety. Information not available Randomized controlled trial

Mothers' Responses to Children's Pain

This study was aimed at identifying mothers' responses to children's pain, evaluating whether these could be organized into different types of responses, and developing a questionnaire to assess these responses. Common responses to children's pain were identified on the basis of a review of the literature and interviews with mothers of pediatric patients with pain. Categories reflecting these parenting behaviors were generated for a questionnaire on Adult Responses to Children's Symptoms, which was administered to 145 mothers of pediatric patients aged between 8-18 years referred for medical evaluation of abdominal pain. Factor analysis using principal components extraction with oblique rotation yielded 3 factors. Factor 1, Protect, reflected caretaking behaviors that placed the child in a passive sick role. Factor 2, Minimize, reflected criticism of the child's pain behavior. Factor 3, Encourage and Monitor, reflected encouragement of the child's activity while monitoring the child's symptoms. Subscales based on these correlated factors had good internal consistency. Results suggest that mothers' responses to children's pain behavior may be classified into 3 distinct categories. Additional research is needed to assess whether observational methodologies would yield a similar typology of parents' responses to children's pain. Psychometric properties of the Adult Responses to Children's Symptoms should be examined in larger samples and in studies of the relation of the subscales to related constructs (eg, measures of parenting beliefs and behavior) and to children's pain behavior.

Effectiveness of computerized delivery of intrasulcular anesthetic in primary molars

Pain measures associated with computerized delivery of intrasulcular anesthestic have not been reported. The authors evaluated a computerized delivery system for intrasulcular (CDS-IS) anesthesia in primary molars. METHODS; The study population consisted of children aged 2 to 13 years who received CDS-IS injections, 159 in mandibular molars and 48 in maxillary molars. Children were treated by one of three modes of behavioral management: behavior modification (BM) only, inhalation of nitrous oxide (N2O) in addition to BM or intrarectal sedation. Variables evaluated included the subjective perception of the child's well-being before and after administration of the anesthetic, the child's pain behavior during anesthetic administration, effectiveness of the anesthetic during dental treatment, incidence of reported postoperative dental pain (PDP) and analgesic use after the CDS-IS injections. The effectiveness of CDS-IS anesthesia in mandibular molars was 97 percent, 92 percent, 63 percent and 71 percent for restorations, preformed stainless steel crowns, extractions and pulpal therapies, respectively (mean effectiveness, 89 percent). The effectiveness of CDS-IS anesthesia in maxillary molars was 96 percent, 50 percent, 92 percent and 78 percent, respectively (mean effectiveness, 90 percent). CDS-IS was less effective in children aged 2 to 4 years who received sedation than it was in older children. The authors found no differences between children's subjective self-reports of well-being before and after anesthetic administration, between the sexes and/or between modes of behavioral management (that is, BM or N2O). Most children exhibited low pain-related behavior during anesthetic administration, with no differences between boys and girls. The overall incidence of PDP was 31.4 percent; 64.9 percent of these patients received pain-relieving medications as a result, with no correlation to age, tooth treated, effectiveness of anesthesia or type of treatment. CDS-IS is effective for anesthetizing primary molars, mainly for amalgam, resin-based composite and stainless steel crown restorations.

Expression of pain in children with autism.

Reduced pain sensitivity is widely reported to be a common feature of children with autism, yet this conclusion frequently has been based on anecdotal observations and questionable measures of pain. The aims of the study were to (1) characterize the behavioral response of children with autism experiencing a venepuncture using objective observational measures of pain and distress, (2) examine parents' assessments of pain behavior in children with and without autism, including comparison of the relationship of parental reports with behavioral measures, and (3) compare the behavioral reactions and parental assessments of children with autism with children without autism undergoing venepuncture. Pain reactions to the invasive procedure of venepuncture were videotaped, systematically described and compared in 21 children with autism (3-7 years old) and 22 nonimpaired children, the latter providing a chronological age and gender equivalent comparison group. Parents provided observer reports of pain, and facial activity was used as an objective behavioral measure of pain. The children with autism displayed a significant facial pain reaction in response to the venepuncture procedure. There was a lack of concordance between parental reports of pain and observed pain responses for the children with autism. Behavioral responses of the children with autism were generally similar to the comparison group, except the substantial facial pain reactivity instigated by the venepuncture in the children with autism exceeded that displayed by the nonimpaired comparison children. Parent reports of pain severity did not differ between the autism and comparison groups. The degree of concordance between parental report and observed pain responses was consistently better for the comparison group. The findings demonstrate that children with autism display a significant behavioral reaction in response to a painful stimulus, and these findings are in sharp contrast to the prevailing beliefs of pain insensitivity described in the literature to date. The findings also raise questions about the appropriateness of parental global report as an assessment tool for pain in children with autism.

Relation between pain and self-injurious behavior in nonverbal children with severe cognitive impairments

Objectives To explore whether self-injurious behavior (SIB) alters pain expression in children with severe cognitive impairments and the relation between SIB and chronic pain. Study design Caregivers of 101 nonverbal children 3 to 18 years of age (55% boys) completed the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R) retrospectively and for an observed pain episode. Caregivers of children with SIB (n = 44) completed the Behavior Problems Inventory, the Self-Injury Grid, and the Self-Injury and Self-Restraint Checklist. Results Multivariate analysis of variance indicated that NCCPC-R scores did not differ between children with and those without SIB. However, t tests indicated that children with chronic pain (n = 13) self-injured less body surface (P =.01) and fewer body sites (P =.04) than did children without (n = 31). Multiple Correspondence Analysis generated 2 dimensions (49% variance), suggesting a distinction between two SIB forms: (1) high frequency of SIB to the head/hand and absence of chronic pain and (2) less frequent SIB near the site of pain. Conclusions Children with severe cognitive impairments who display SIB do not have reduced pain expression, and chronic pain may influence the frequency and location of SIB. Further research should examine the usefulness of these findings for management of SIB and pain. (J Pediatr 2003;142:498-503 )

Mothers’ modeling influences children's pain during a cold pressor task

We set out to determine whether observing one's mother's reaction during a cold pressor test changes ratings of pain threshold, pain intensity, and observed pain-related facial behavior during a cold pressor test, using a Repeated Measures Mixed Factorial design in the setting of the Psychology Department, Dalhousie University, Halifax, Canada. The participants were: 96 mothers (mean age 41 years,) and 96 children (48 males, mean age 12.6 years), all in good general health. Pain intensity was measured using a 0–10 rating scale. Pain threshold was measured by asking participants to signal the moment any pain began and recording time elapsed since immersion. The Child Facial Coding System (CFCS; Revised manual for the child facial coding system (unpublished). Dalhousie University and University of British Columbia; Chambers et al., 1996) measured pain-related facial behavior. Mothers assigned to the Exaggerate condition were instructed, via videotape, to slightly exaggerate their display of pain and indicate a pain threshold within the first 10–20 s of a 4-min cold pressor task using water at 10 °C. Mothers in the Minimize condition were instructed to minimize their display of pain. Mothers assigned to the Control condition were given no specific instructions. All mothers privately rated their own pain intensity every 30 s. Children then completed a similar cold pressor task and made similar ratings. Children assigned to the Exaggerate Group (mean 21.7 s; SD 3.9) had lower thresholds than did children in the Control Group (mean 35.6 s; SD 21.8; t(1,76)=2.515, P=0.014). No difference in threshold was observed between the Control and the Minimize Groups (mean 32.2 s; SD 4.2; t(1,76)=0.610, P=0.544). No differences were observed in the self-report pain ratings of children between groups ( F<1). CFCS Scores were significantly lower in the Minimize group compared to the Control group (95% CI 4.98–20.19, P=0.001), but no difference was noted between the Exaggerate and Control groups (95% CI −8.03–6.93, P=0.884). Children's pain threshold and their facial behavior are altered by exposure to mother's behavior during a cold pressor task suggesting that modeling has an impact on a child's pain behavior.

Does cartoon movie distraction decrease burned children's pain behavior?

The purpose of this study was to evaluate cartoon movie viewing as a practical and low-cost intervention to decrease burned children's pain behavior during dressing changes. Thirteen children, 4 to 12 years of age, with a mean TBSA burn of 7.9% were assessed using a reversal, single-subject experimental design. The experimental condition consisted of the presentation of a cartoon movie as a nonpharmacologic intervention in conjunction with a standardized analgesic medication. In the control condition children's pain was treated with the standardized analgesic medication only. Behavioral distress was measured during the first six dressing changes postburn with the Observational Scale of Behavioral Distress. No significant effect of cartoon movie distraction on observed behavioral distress in patients was found. Interrater reliability of the Observational Scale of Behavioral Distress was good (kappa =.87-.98). Wound debridement was found to be the most painful part of the dressing change. A simple, easily applicable, and low-cost distraction intervention such as presenting cartoon movies does not seem to be sufficiently powerful to measurably reduce burned children's distress during dressing changes. Findings are based on purely observational data. Inclusion of self-report measures in future studies might reveal intervention effects on anxiety and subjective pain perception.

There is no Shame in Pain: Coping and Functional Ability in Adolescents with Sickle Cell Disease

Despite the tremendous resilience of children with sickle cell anemia, this chronic illness has a significant impact in adaptation in every major area of functioning—personal care, emotional, recreational, educational, and vocational. Assessment of functional ability may help us to develop a fuller understanding of the relationships among illness severity, pain, physical dysfunction, and psychosocial adjustment in this group. A major challenge in the assessment of sickle cell disease (SCD) pain still lies in finding a reliable behavior referent of pain. Unlike the experience in other pain states (procedure-related pain), physical impairment and functional disability are salient characteristics in chronic SCD pain and, therefore, may contribute significantly to evaluations of pain states (pain ratings, pain characteristics, and pain quality). This article seeks to explore the utility of functional ability as an index of pain and pain behavior in children and adolescents with sickle cell anemia.

Illness behavior in children of chronic pain patients.

Recent studies on pain behavior have pointed to a relationship between expression of illness in patients with chronic pain and reports of physical complaints in other family members. This article includes two related studies. The aim of the first study was to determine whether, among pain patient families, parents who exhibited higher levels of illness behavior and emotional distress were more likely to report that their children had frequent pain complaints. The aim of the second study was to assess whether children of patients with chronic pain were perceived by their parents to have more pain and illness behavior than children of non-pain parents. In the first study, forty-two primary caregivers in families with a parent with chronic pain completed questionnaires regarding their children's pain and illness behavior. In the second study, report of somatic complaints in children of chronic pain parents was compared to complaints in fifty-five children of parents without chronic pain. Results of the first study showed that frequently reported pain in the child was associated with significantly higher levels of parent disability, pain behavior and emotional distress. Results of the second study showed that children of patients with chronic pain were reported to have more frequent abdominal pain and to use more medication than children of parents without pain. The findings of these studies suggest that children of parents with chronic pain may be at risk for illness behavior, especially when the parents exhibit emotional reactions to their pain.

The Toddler-Preschooler postoperative pain scale: an observational scale measuring postoperative pain in children aged 1–5. Preliminary report

This study evaluates the reliability and validity of the Toddler-Preschooler Postoperative Pain Scale (TPPPS), an observational scale developed to be a clinically useful measure of postoperative pain in children aged 1–5 years. The TPPPS consists of 7 items divided among 3 pain behavior categories: (1)Vocal pain expression; (2) Facial pain expression; and (3) Bodily pain expression. These items were derived from preliminary studies by the authors and from other observational studies of children's pain behavior. Seventy-four children between the ages of 12 and 64 months seen for inguinal hermia or hydrocele repair were the subjects of the study. Subjects were observed postoperatively for six 5-min intervals, commencing with their awakening from anesthesia, using the TPPPS. Two raters independently observed 28 of the children to assess inter-rater reliability. Validity was assessed by relating TPPPS scores to the timing and type of analgesics used, visual analog and numerical scale pain ratings made by parents and nurses, and perioperative vital signs. The TPPPS was found to possess satisfactory internal reliability (Cronbachs's alpha = 0.88). Inter-rater reliability was good, with kappas for the pain behavior items ranging from 0.53 to 0.78. Preliminary evidence of the scale's validity is provided by the sensitivity of the scale to analgesic regimen, the convergence between TPPPS scores and nurse and parent ratings of postoperative pain, and the associations found between TPPPS scores and perioperative vital signs.

Cultural components of pain behavior in vietnamese refugee children

Cultural components of pain behavior in vietnamese refugee children

Somatic Complaints and Pain Behavior in Children of Chronic Pain Patients

Jamison, Robert N.1; Walker, Lynn S.2; Philpo, Barbara2; Lindsey, Karen A.2 Author Information

The role of social modeling in unexplained pediatric pain.

Interviewed 20 children with recurrent unexplained pain (UP) and 20 children with recurrent explained pain (EP) secondary to sickle cell anemia and their parents to determine the presence of models of pain or illness behavior in the child's environment. The location, intensity, frequency, and environmental consequences of the children's and the models' pain were also assessed. The hypothesis that UP Ss would identify more models was supported. In addition, UP Ss identified more positive consequences of the child's pain behavior while EP Ss identified more negative consequences. Children perceived the frequency and intensity of their pain to be similar to their models', while parents did not report such a relationship. Body location data suggest that children may model either general illness behavior or exact symptoms. Implications for future research are discussed.