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There has been little research on implementation of pediatric pain programs. These studies are part of a project to develop such a program for the King Hussein Cancer Centre in Jordan. Study 1 captured information on pain prevalence in 35 children using chart reviews and parent/child interviews to establish baseline pain burden. Forty-seven percent of children had pain at the time of interview; 11% had "a lot" of pain and only 22% received analgesics. Twenty-two parents were interviewed in Study 2 to identify attitudes toward pain management. Thematic analysis revealed six themes: 1) pain can and should be managed; 2) God's will; 3) parent's worst pain was emotional pain due to child's diagnosis; 4) belief that their presence could ameliorate their child's pain; 5) desire for shared decision making; and 6) the child's responsibility to express pain. These study results were used to inform the action research approach in the overall project.

Abstract: Previous research has found that pain can exert a disruptive effect on cognitive processing. This experiment was conducted to extend previous research with participants with chronic pain. This report examines pain's effects on early processing of auditory stimulus differences using the Mismatch Negativity (MMN) in healthy participants while they experienced experimentally induced pain. Event-related potentials (ERPs) were recorded using target and standard tones whose pitch differences were easy- or difficult-to-detect in conditions where participants attended to (active attention) or ignored (passive attention) the stimuli. Both attention manipulations were conducted in no pain and pain conditions. Experimentally induced ischemic pain did not disrupt the MMN. However, MMN amplitudes were larger to difficult-to-detect deviant tones during painful stimulation when they were attended than when they were ignored. Also, MMN amplitudes were larger to the difficult- than to the easy-to-detect tones in the active attention condition regardless of pain condition. It appears that rather than exerting a disruptive effect, the presence of experimentally induced pain enhanced early processing of small stimulus differences in these healthy participants.

Diagnosing cause of pain in children with severe cognitive impairments is difficult due to their problems with communication. Identification of risk factors for specific pain etiologies might help professionals in this task. The aim of this study was to determine whether child-related characteristics increase risk for specific types of pain. Participants were the caregivers of 41 females and 53 males with moderate to profound mental retardation,* who were aged 3 to 18 years 8 months (mean 10:1, SD 4:4) but who communicated at the level of a typical child of 13.8 months (SD 10 months): 44 of the children had cerebral palsy (CP) and 59 a seizure disorder. Caregivers reported the cause of children's episodes of pain for four 1-week periods over 1 year. Logistic regression analyses were used to predict occurrence of specific types of pain using children's demographic, medical, and physical characteristics. Children had 406 episodes of pain due to accident, gastrointestinal conditions, musculoskeletal problems, infection, recurrent conditions, and common childhood causes. Results indicated that a unique set of risk factors predicted each pain type in this sample. Significant risk factors for pain included: lack of visual impairment and leg impairment (accidental pain); seizures, leg impairment, and greater number of medications (non-accidental pain); being male and tube fed (musculoskeletal pain); age

Objectives To determine whether caregivers of children with cognitive impairment (CI) have systematic beliefs regarding the pain of this special group of children and whether these beliefs are related to their general attitudes towards people with mental challenges, or their experience with, or knowledge about, children with CI . Participants Sixty-five caregivers (52 parents and 13 health care providers) of children with significant CI. Measures Caregivers completed the Mental Retardation Attitude Inventory-Revised and provided information regarding their previous experience and learning about children with CI. They also completed the Pain Opinion Questionnaire, indicating the percentage of children with mild, moderate, or severe/profound CI that they believe experience 5 facets of pain "less than", "the same as", or "more than" children without CI: sensation, emotional reaction, behavioral reaction, communication, and frequency. Results Caregivers believed children's pain Sensation becomes greater, relative to children without CI, as severity of CI increases and that pain reaction is most consistent with pain sensation for children with severe CI. They also believed children with mild CI may over-react to pain. Caregivers' beliefs regarding pain were not influenced by their general attitudes about people with mental challenges or by their experience with children with CI, but those with more learning regarding children with CI believed that they experience pain less than children without CI. Conclusions Caregivers have a priori beliefs regarding pain in children with CI that vary with level of cognitive impairment and pain facet. These beliefs could impact children's care.

Objectives Pain assessment can be a challenging task for parents, who increasingly provide the care for their children after surgery. This research provides evidence of the construct validity of the Parents' Postoperative Pain Measure (PPPM), a 15-item behavioral scale. Methods Study 1 examined the ability of scores on the PPPM to discriminate between pain and anxiety in a sample of 75 children (30 girls) between the ages of 7 and 12 years undergoing day surgery. Study 2 examined the sensitivity of scores on the PPPM to analgesic intervention among a sample of 28 children (7 girls) between the ages of 7 and 12 years undergoing day surgery. Results In Study 1, scores on the PPPM closely followed the pattern of children's self-reported pain intensity and not state-related anxiety. Results from Study 2 showed that scores on the PPPM, like children's self-reported pain intensity ratings, were sensitive to analgesic intervention. Discussion The results of these studies provide further support for the construct validity of the PPPM and confirm that the measure is a valid pain assessment tool for use by parents at home following children's surgeries.

Many laboratory-based studies indicate that benzodiazepines impair explicit memory performance, increase sedation, and impair attention.The present study was designed to extend prior lab-based findings to an applied setting in which the amnestic effects of benzodiazepines may be beneficial for users. In addition, the study extended the previous adult-focused research by examining the cognitive effects of benzodiazepines in children.The present study examined the use of a specific benzodiazepine (midazolam) as a premedicant among 40 children aged 4-6 years old having ear tube (myringotomy) surgery, who were randomly assigned to receive midazolam or placebo.Consistent with previous studies, the results indicated that midazolam causes significant amnesia on a cued recall task. In addition, free recall for post-drug events were also impaired by midazolam relative to placebo, indicating that benzodiazepine-induced amnesia occurs even for highly salient information.Overall, it appears that benzodiazepines do impair memory in a pediatric population. This amnesia was not secondary to the inattention and sedation also caused by midazolam administration. The theoretical and clinical implications of these findings are discussed, as are potential future studies.

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 )

The non-communicating children's pain checklist (NCCPC) has displayed preliminary validity and reliability for measuring pain in children with severe cognitive impairments (Dev Med Child Neurol 42 (2000) 609). This study provides evidence of the psychometric properties of a revised NCCPC (NCCPC-R) with a larger cohort of children. Caregivers of 71 children with severe cognitive impairments (aged 3-18) conducted observations of their children using the NCCPC-R during a time of pain and a time without pain. Fifty-five caregivers completed a second set of observations. The score results on the NCCPC-R were: internally consistent, significantly related to pain intensity ratings provided by caregivers, consistent over time, sensitive to pain, and specific to pain. Analyses of children's individual scores indicated up to 95% of their scores were consistent. Receiver operating characteristic curves suggest a score of 7 or greater on the NCCPC-R as indicative of pain in children with cognitive impairments, with 84% sensitivity and up to 77% specificity. These results provide evidence of NCCPC-R having excellent psychometric properties.

Objective. To evaluate the effectiveness of audiovisual distraction compared with a blank TV screen in the reduction of pain associated with intramuscular immunization. Design. Subjects were randomly assigned to watch television (TV) (N = 29) or a blank TV screen (control) (N = 33) during immunization, and were videotaped. Immediately after the injection, the children rated their pain. Videotapes were coded for pain behaviors and for distraction. t tests determined between-group mean differences and chi-square tests compared proportions for clinically significant self-reported pain. Setting. Two urban pediatric practices in Halifax, Nova Scotia, Canada. Subjects. Five-year-old children (N = 62), undergoing diphtheria, polio, tetanus, and pertussis immunization, and their parents. Interventions. An age-appropriate musical cartoon or a blank TV screen. Outcome Measures. Pain measurements were the children's self-reports on Faces Pain Scale, facial actions on Child Facial Coding System, and Children's Hospital of Eastern Ontario Pain Scale. Distraction was measured by mean time spent watching the TV screen. Parents rated their own and their child's anxiety on a visual analogue scale. Results. There were no significant group differences for any pain or distraction measures. The relative risk estimate for clinically significant pain among the distraction group was 0.64 (range: 0.23–1.80). Higher levels of distraction (i.e., greater time looking at the TV screen) related to lower levels of pain on all three pain measures. Only correlations with objective pain measures were statistically significant. Conclusions. Watching cartoons did not distract children during needle injection nor reduce their pain. Looking at the TV screen was related to lower behavioral pain scores in the total sample.

Background This study evaluated the psychometric properties of the Non-communicating Children's Pain Checklist-Postoperative Version (NCCPC-PV) when used with children with severe intellectual disabilities. Methods The caregivers of 24 children with severe intellectual disabilities (aged 3-19 yr) took part. Each child was observed by one of their caregivers and one of the researchers for 10 min before and after surgery. They independently completed the NCCPC-PV and made a visual analog scale rating of the child's pain intensity for those times. A nurse also completed a visual analog scale for the same observations. Results The NCCPC-PV was internally reliable (Cronbach alpha = 0.91) and showed good interrater reliability. A repeated-measures analysis of variance indicated NCCPC-PV total and subscale scores were significantly higher after surgery and did not differ by observer. Postoperative NCCPC-PV scores correlated with visual analog scale ratings provided by caregivers and researchers, but not with those of nurses. A score of 11 on the NCCPC-PV, by caregivers, provided 0.88 sensitivity and 0.81 specificity for classifying children with moderate to severe pain. Conclusions The NCCPC-PV displayed good psychometric properties when used for the postoperative pain of children with severe intellectual disabilities and has the potential to be useful in a clinical setting. The results suggest familiarity with an individual child with intellectual disabilities is not necessary for pain assessment.

The Pain in Child Health (PICH) consortium is a Strategic Training Initiative in Health Research funded by the Canadian Institutes of Health Research. The PICH represents a community of interdisciplinary researchers whose goal is to support the education of highly qualified personnel and to promote research on the prevention and relief of pediatric pain. The authors of this article report on the success of the PICH since its inception in 2002., BACKGROUND AND OBJECTIVES: Pain in Child Health (PICH) is a transdisciplinary, international research training consortium. PICH has been funded since 2002 as a Strategic Training Initiative in Health Research of the Canadian Institutes of Health Research, with contributions from other funding partners and the founding participation of five Canadian universities. The goal of PICH has been to create a community of scholars in pediatric pain to improve child health outcomes. METHODS: Quantitative analyses enumerated PICH faculty, trainees, training activities and scientific outputs. Interviews with PICH stakeholders were analyzed using qualitative methods capturing perceptions of the program’s strengths, limitations, and opportunities for development and sustainability. RESULTS: PICH has supported 218 trainee members from 2002 through 2013, from 14 countries and more than 16 disciplines. The faculty at the end of 2013 comprised nine co-principal investigators, 14 Canadian coinvestigators, and 28 Canadian and international collaborators. Trainee members published 697 peer-reviewed journal articles on pediatric pain through 2013, among other research dissemination activities including conference presentations and webinars. Networks have been established between new and established researchers across Canada and in 13 other countries. Perceptions from stakeholders commended PICH for its positive impact on the development of pediatric pain researchers. Stakeholders emphasized skills and abilities gained through PICH, the perceived impact of PICH training on this research field, and considerations for future training in developing researchers in pediatric pain. CONCLUSIONS: PICH has been successfully developing highly qualified health research personnel within a Canadian and international community of pediatric pain scholarship.

G Allen Finley talks to Roshaine Gunawardana, Commissioning Editor: Dr Allen Finley is a pediatric anesthesiologist who has worked for over 20 years in pain research and management. He is Professor of Anesthesia and Psychology at Dalhousie University (NS, Canada), and holds the inaugural Dr Stewart Wenning Chair in Pediatric Pain Management at the IWK Health Centre in Halifax. He has published over 100 papers in peer-reviewed journals and has lectured widely, with more than 230 invited presentations on six continents. He started the PEDIATRIC-PAIN e-mail discussion list in 1993, bringing together pain researchers and clinicians from over 40 countries. His own research and educational projects have recently taken him to Jordan, Thailand, China, Brazil and elsewhere. His main interest is pain service development and advocacy for improved pain care for children around the world, and he is co-leader of the ChildKind International Initiative.

Regulations currently prohibit co-administration (through the same line) of red blood cell transfusions with continuous morphine infusions for pain management, resulting in additional intravenous access or interrupted analgesic therapy in seriously ill children. Packed cells that had been in contact with morphine 0.1 or 1.0 mg/mL and infused through a mock central venous catheter system showed no evidence of hemolysis when compared with control samples. There is thus no need to interrupt analgesic therapy or start another venous access line in order to give a coincident blood transfusion.

Although management of cancer pain is relatively easy to accomplish in most cases, patients in many developing and developed countries are deprived access to appropriate analgesic medications due to governmental, bureaucratic, and physician barriers, such as restrictions on quantity, type, and storage of drugs. Many of these governmental and bureaucratic barriers are discussed as are steps being taken to overcome them in the different countries.

To obtain a preliminary validation of the Non-Communicating Children's Pain Checklist for individuals with an inability to communicate verbally, 32 caregivers of individuals with cognitive impairments aged 3 to 44 years retrospectively completed the Non-Communicating Children's Pain Checklist and rated item usefulness (0 to 10). In the second part of the study 33 caregivers completed the Checklist after two painful (e.g. burns, falls, surgery), one distressful (e.g. unwanted grooming, feared animal/noise), and one calm event (e.g. watching television). Checklist scores did not correlate with the age, sex, or physical limitations of individuals with an inability to communicate verbally. In the first part of the study Cronbach's alpha was 0.66; all mean usefulness ratings exceeded 5 out of 10. In the second part of the study after four items were removed, Cronbach's alpha was 0.79. Checklist scores during pain correlated with numerical ratings of pain intensity did not differ between the two pain events, and differed significantly from calm scores. Differences in Checklist scores during pain and distress were found for two subscales. The Checklist exhibits internal consistency, and preliminary evidence suggests it can detect pain and is reliable over time.

The present report outlines key requirements that are central to helping patients manage pain effectively. Although current standards are available as guides for practice, the prevalence of pain suggests that many health professionals do not know and/or cannot relate to these standards. Therefore, a brief, pragmatic statement may be more useful initially for health professionals and patients learning about problematic pain outcomes. The principles in the brief statement produced by the Canadian Pain Society clarify and emphasize key underlying assumptions that have directed the development of many pain standards. The aim of the present paper is to increase awareness of ineffective pain practices and the importance of pain relief, and to stimulate further work in this area.

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This study was a randomized trial evaluating the effects of educating parents with the booklet Pain, Pain, Go Away: Helping Children With Pain on their attitudes and management of their children's postoperative pain. Eighty-two parents of children undergoing day surgeries were randomly assigned to a pain education group (n = 27), a pain assessment control group (n = 28), or a no pain education control group (n = 27). Parents in the pain education group had fewer concerns about the use of acetaminophen for children compared to the other two groups. Parents in the pain education group administered more doses of medication on the 3rd day following surgery than the other two groups; there were no group differences in medication dosages on either of the first 2 days following surgery. There were no group differences in parents' pain assessments on any of the 3 days following surgery. Fewer parental concerns about children's pain medications and higher parental pain assess- ments were related to higher numbers ...

This review article explores the need for specialized pain care for children and adolescents and provides some historical context for our current knowledge base and clinical practice. Pediatric patients have specialized needs with respect to assessment and management of pain. Acute pain care is modified by developmental considerations in both these areas; chronic pain encompasses a wide range of complex developmental, social, and psychological factors requiring the skills of different health disciplines to provide the best care. Awareness of children’s pain has increased dramatically over the past three decades, and Canadians have performed a leadership role in much of the research. Specific multidisciplinary teams are a more recent phenomenon, but they are shown to be more effective and probably more cost effective than traditional treatment models. Important gaps in availability of resources to manage these patients remain.

BACKGROUND: Adverse health care events are injuries occurring as a result of patient care. Significant acute pain is often caused by medical and surgical procedures in children, and it has been argued that undermanaged pain should be considered to be an adverse event. Indicators are often used to identify other potential adverse events. There are currently no validated indicators for undertreated pediatric pain.OBJECTIVES: To develop a preliminary list of indicators of undermanaged pain in hospitalized pediatric patients.METHODS: The Delphi technique was used to survey experts in pediatric pain management and quality improvement. The first round used an electronic questionnaire to ask: “In your opinion, what indicators would signify that acute pain in a child has not been adequately controlled?” Responses were grouped together in semantically similar themes, providing a list of possible adverse event indicators. Using this list, an electronic questionnaire was developed for round 2 asking respondents to indicate the importance of each potential indicator.RESULTS: All but one indicator achieved a level of consensus ≥70%. Separate indicators emerged for postoperative and procedural pain. An additional distinction was made between indicators that could be identified by chart review and those requiring observation of practice and assessment from the child or parent.DISCUSSION: The adverse care indicators developed in the present study require further refinement. There is a need to test their clinical usability and to determine whether these indicators actually identify undermanaged pain in clinical practice. The present study is an important first step in identifying undermanaged pain in hospital and treating it as an adverse event.CONCLUSION: The adverse care indicators developed in the present study are the first step in conceptualizing mismanaged pain as an adverse event.

Our knowledge of the prevalence and sources of pain within hospital is limited. The present study is an epidemiological investigation of pain in a pediatric hospital. All children who were inpatients in a tertiary care hospital (excluding Neonatal ICU and psychiatry patients) and one parent per child were potential subjects. Interviews were conducted on three weekdays. Parent interviews were used for children less than 5 years of age (n = 102); child interviews were used for children age 5 years and older (n = 98). Subjects reported the intensity and source of the worst, usual and current pain during the past 24 h, and help received for pain. Medical and demographic variables and analgesics prescribed and administered were obtained from the medical record. Forty-nine percent of subjects reported clinically significant levels of worst pain. Twenty-one percent of subjects had clinically significant levels of usual pain. Causes of pain were variable and included disease, surgery, and intravenous lines (I.V.). Pain intensity was not significantly related to age, gender, patient type (medical, surgical), or diagnostic category. Children were given significantly less medication than was prescribed, regardless of their reported pain level. Nurses, mothers, and 'no-one' were frequently reported as helping with pain. Medications and nonpharmacological methods were reported as helpful in managing pain. Many children endure unacceptable levels of pain during hospitalization. Pain prevention and management must be more aggressive. Pain assessment should be approached with the same attention as vital signs. Improvements in analgesic prescription and administration practices and non-pharmacological pain control methods are needed.

The aim of the investigation was to evaluate the prevalence, severity, and parents' management of children's pain following short-stay and day surgery. The subjects were 189 parents of children (2-12 years of age) who had undergone short-stay or day surgery. Parents completed a 3-day diary of their child's pain and the methods used to alleviate it. There were clear differences in pain reported according to type of surgery. Some surgery, such as insertion of myringotomy tubes, appeared to cause little pain. Other procedures, including tonsillectomy, circumcision, and strabismus repair, resulted in about one-half the children experiencing clinically significant pain (> or = 30 mm on a 100 mm VAS). Sixty-eight percent of the parents reported they had been instructed to use acetaminophen for pain 'if necessary', 13% had been told to use acetaminophen regularly, and 8% recalled no instructions. Of the parents who rated their child's pain as significant, 13% administered no pain medication and 47% gave 1-3 doses on day 2. On day 3, 17% gave no medication and 45% gave 1-3 doses. Some types of 'minor' surgery result in significant pain postoperatively. Even when parents recognise that their children are in pain, most give inadequate doses of medication to control the pain.

The purpose of this study was to explore nurses' aims when managing postoperative pain and whether reported aims reflect actual practices.Participant observation was used to collect data regarding nurses' (n = 17) pain management practices. Nurses (n = 19) were asked: When managing postoperative pain, what is your overall aim?Around half the participants (n = 10) aimed for patients to be comfortable while others aimed for a pain score of 2-3 (n = 7), or below 5 (n = 2). Observed practices matched aims for just more than half the participants (n = 9).There is evidence of individual variation in practices. This may impact on the care provided.

This study was an in-depth examination of pediatric postoperative pain care.Participant observational data were collected on the care of 10 children. Particular attention was paid to actions when pain scores were ≥5 and to the relationship between pain scores and medications administered.A pattern of care emerged of giving pain medications regularly even if they were prescribed pro re nata. Actions when pain scores were ≥5 varied. Recorded pain scores rarely guided treatment choices.The use of pain scores to guide treatment choices needs further debate. Future research should explore the implications of divorcing treatment from pain scores on children's pain experience.

Tramadol is a potent analgesic. However, the analgesia efficacy of tramadol, particularly its minimum effective dose (MED), is not clear. The aim of this study is to find MED of tramadol for postoperative analgesia in infants. The continual reassessment method (CRM) was performed to find MED. Infants undergoing surgeries were included in the 3 phases of this series. In each phase, 24 participants were allocated a different tramadol dose. Pain intensity was measured by face, legs, activity, cry, consolability (FLACC) measurement at 3-hour intervals. Tramadol was considered ineffective if the FLACC score was higher than 4 in 10 at anytime. In phase 1, seven dose levels were used within the range 0.1-0.4 mg·kg(-1)·h(-1). Phase 1 was insufficient to identify the MED, and we increased the dose to 0.4-0.8 mg·kg(-1)·h(-1) in phase 2. Phase 2 was insufficient to identify the MED. In phase 3, local anesthetic wound infiltration was introduced, and the tramadol dose levels tested were the same as in phase 1. The successful analgesia probability of tramadol 0.4 mg·kg(-1)·h(-1) was 82.1% (95% CI, 0.742-0.925) in phase 1. In phase 2, it was 84.7% (95% CI, 0.789-0.991) with the dose 0.8 mg·kg(-1)·h(-1). Phase 1 and phase 2 were insufficient to identify the MED. In phase 3, the successful analgesia probability for dose 0.35 mg·kg(-1)·h(-1) was 96.7% (95% CI, 0.853-0.997).We have demonstrated that tramadol provides insufficient analgesia for surgeries considered to cause moderate-to-severe postoperative pain in infants if used as the sole analgesic, and that local anesthetic wound infiltration enhances the efficacy of tramadol.

Adolescents with chronic pain are at risk for impairment in their friendships. They miss out on leisure activities, have increased school absence, may have fewer friends, are at an increased risk for victimization, and may be perceived by peers as less likeable. To help determine the source of these problems, the Social Information Processing Model (SIP) was adapted using narrative vignettes to determine if adolescents with chronic pain interpret friendship interactions differently in terms of supportive and nonsupportive behaviors compared to healthy peers. One hundred seven adolescents, 45 with chronic pain, completed the vignette questionnaire and a battery of measures. The vignette questionnaire included 12 vignettes to capture 3 steps in SIP processing: interpretation of cues, response construction, and response decision. Participants with chronic pain rated nonsupportive vignettes more negatively than healthy controls and indicated they would enact supportive behaviors towards the chronic pain character more often if they had been the healthy character. Age, sex, and internalizing measures did not significantly contribute to the findings. Chronic pain explained 6.5% of variance in the ratings of nonsupportive vignettes and 10.1% of the variance in supportive behavior selection. Adolescents with chronic pain may interpret nonsupportive social situations with close friends as more distressing. The endorsement of more supportive behaviors may indicate a need for, and expectation of, supportive behaviors from friends. When adolescents with chronic pain do not perceive friends as providing support, they may avoid these social situations.

In this qualitative descriptive study, we explored health care professionals’ perceptions of the influence of context (i.e., organizational culture, structure, resources, capabilities/competencies, and politics) on evidence-based pain practices. A total of 16 focus groups with 147 health care professionals were conducted in three neonatal intensive care units (NICUs) in central and eastern Canada. Three overarching themes emerged from the data, which captured influences on optimal pain practices in the NICU, including (a) a culture of collaboration and support for evidence-based practice, (b) threats to autonomous decision making, and (c) complexities in care delivery. These results were consistent with theoretical conceptualizations of how context influences practice, as well as recent empirical research findings. This study supports the importance of context in shaping evidence-based practices by health care professionals in the management of pain in the NICU.

To examine the utility of parental presence to alleviate anxiety in a narrow age range of children undergoing outpatient surgery. We hypothesized that parental presence would lower anxiety scores as measured by the modified Yale Preoperative Anxiety Scale (mYPAS) at two time-points during pediatric outpatient surgery, i.e., separation from parents and placement of the face mask for anesthetic induction. Sixty-one children ages three to six years scheduled for various day surgery procedures participated in this study. The children were assigned randomly to either parental presence (n = 30) or parental absence (n = 31) groups. Observer-rated anxiety was measured by the mYPAS at five time-points during the surgery experience. Child anxiety was significantly lower in the parental presence group than in the parental absence group at the time-point when the children in the parental absence group were separated from their parents, t[59] = 2.15 (P = 0.001). However, no significant group differences in anxiety scores were noted at other time-points. Our results suggest that anxiety levels in children undergoing day surgical procedures differ as a function of parental presence at the point when children are separated from parents. Future research should examine the types of interactions that occur during this time-point that may explain this finding.

The objectives of this study were to assess the clinical efficacy of a new oral ranitidine liquid preparation in reducing gastric acidity and volume, to determine the degree of absorption of the drug, and to determine the duration of drug effect. Eighty preoperative children between the ages of one and six years were enrolled in each of three centres. Each subject was allocated to one of the following groups: Group A — apple juice, 5 ml · kg−1 plus placebo liquid; Group B — apple juice, 5 ml · kg−1 plus ranitidine hydrochloride 2 mg · kg−1; Group C — water, 5 ml and placebo liquid; or Group D — water, 5 ml and ranitidine liquid 2 mg · kg−1. All study agents were administered at least two hours before surgery along with a dye marker, sulfobromophthalein 1 ml (50 mg · ml−1). Following induction of anaesthesia, gastric fluid was aspirated, and analyzed for pH, volume, and sulfobro-mophthalein content (as an index of the ingested fluids). A serum sample was also drawn and analyzed for ranitidine content by high performance liquid chromatography. Groups B and D had fewer subjects with pH below 2.5 and gastric volume >0.4 ml · kg−1. The duration of reduced volume and acidity was shown to be greatest from two to four hours after drug administration. Thirty-three percent of subjects receiving oral ranitidine, 2 mg · kg−1 hydrochloride as a single dose demonstrated no measurable effect on gastric pH and volume; 28 of those subjects had adequate ranitidine serum levels.

The experiential knowledge of pediatric health practitioners encompasses vital insights into the clinical efficacy of diagnostic and therapeutic methods for pediatric pain management. Yet, this knowledge is not readily disseminated to other practitioners and translated into practice guidelines. We argue that a peer-to-peer knowledge sharing mechanism can serve as a key change agent to improve the attitudes, beliefs and methods for pediatric pain management. We are using collaborative technologies, in the realm of Web 2.0, to develop a web-based knowledge sharing medium for fostering a community of pediatric pain practitioners that engages in collaborative learning and problem solving. We present the design and use of a web portal featuring a discussion forum to facilitate experiential knowledge sharing based on our LINKS knowledge sharing model.

Background: The Ilizarov technique is commonly used for lengthening and deformity corrections of the lower limbs in children. Postoperative pain can be significant, affecting quality of life and functional mobility, and often requiring prolonged medication use. Several studies have investigated the antinociceptive actions of botulinum toxin type A (BtX-A), yet evidence for its use in this population is limited. The objectives were to (1) establish the feasibility of a randomized clinical trial in children undergoing limb lengthening or deformity correction and (2) provide preliminary evidence of the beneficial effects of BtX-A in this population. Methods: Fifty-two patients with a mean age of 13.7 years (range, 5 to 21 y) were randomized to receive either BtX-A or an equivalent volume of sterile saline solution (placebo group), as a single dose during the surgical procedure. Pain, medication use, quality of life, and functional mobility outcomes were assessed in all patients. Adverse events were reported for all patients and classified as minor or major. Results: Differences between groups did not reach statistical significance; however, pain at mid-distraction was found to be slightly lower in the BtX-A group, as compared with the placebo group. Patients in the BtX-A group used less parenteral pain medication in the first 4 days after the surgery, had higher quality of life scores at 3 of the 5 time points assessed, and slightly higher functional mobility scores. All adverse events were expected complications of the lengthening process. No event was considered to be a serious adverse event related to the BtX-A injection itself. There was a trend toward fewer major adverse events in the BtX-A group. Conclusions: This pilot study established the feasibility of a randomized controlled trial design for in this population. Its findings indicate that BtX-A injections appear to be safe and effective for reducing pain and improving the quality of life and functional mobility of children undergoing lengthening or deformity corrections of the lower limbs. A larger-scale study is currently underway to confirm these preliminary findings. Level of Evidence: Level I. Multicenter prospective, randomized, double-blinded, controlled trial.

To describe how (i) risk of neurological impairment (NI) and (ii) procedure invasiveness influence health professionals' assessment and management of procedural pain in neonates in the Neonatal Intensive Care Unit (NICU).Prospective observational study.Three tertiary level NICUs in Canada.114 neonates, 25-40 weeks gestational age (GA) undergoing painful procedures.Physical and behavioural pain indicators and pharmacological and nonpharmacological pain interventions.114 neonates at high (Cohort A, n=35), moderate (Cohort B, n=25) and low (Cohort C, n=54) risk of NI were observed during 254 painful procedures performed by 147 health professionals. Physical pain indicators were used more frequently by health professionals to assess pain with Cohorts A and B than C (p.05). Behavioural pain indicators were used similarly across Cohorts. Nonpharmacological interventions were implemented most frequently for pain management. Physical interventions were used with 84% of procedures across Cohorts; particularly for the most invasive procedures. Infants with the highest NI risk (Cohort A) received the most behavioural interventions (p.05) irrespective of procedural invasiveness. Pharmacological interventions were implemented with 23.2% of procedures; Cohort B received pharmacological interventions most frequently (Cohort BA, BC, p.05) and for increasingly invasive procedures (p.05).Health professionals use multidimensional indicators to assess neonatal pain. Nonpharmacological interventions dominate pain management. NI risk status and procedure invasiveness are important contextual factors in neonatal pain assessment and management.

Culture is commonly regarded as a factor in pain behaviour and experience, but the meaning of the term is often unclear. There is little evidence that pain perception is modified by cultural or ethnic factors, but pain expression by children and interpretation by caregivers may be affected by the culture of the patient or the caregiver. The present paper examines some of the research regarding cultural influences on children’s pain assessment, and addresses directions for future research. A focus on cultural influences should not distract clinicians from the need to be sensitive to individual beliefs and attitudes.

Deficiencies in pain care within the developing world are starting to be realized. Children, in particular, are vulnerable, as preliminary studies suggest that these children receive less pain treatment because of health professionals' attitudes and beliefs. This article reports on some of the findings of the first study in a larger program of research aimed at improving pediatric pain care in Thailand. Improvements in practice are not simply the result of providing evidenced-based knowledge, but a complex process that includes the context of care. Given that little is known about the pain management experiences of Thai health professionals, including the challenges they face, we used focus groups to capture their stories. Data revealed a need for both updating pain knowledge and for supporting an increased use of appropriate practices. In this article, we focus on the issues concerning the assessment of pain resulting from underrecognizing children's pain and complex issues in communicating findings of children's pain.

Under the auspices of the Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (IMMPACT), 26 professionals from academia, governmental agencies, and the pharmaceutical industry participated in a 2-stage Delphi poll and a consensus meeting that identified core outcome domains and measures that should be considered in clinical trials of treatments for acute and chronic pain in children and adolescents. Consensus was refined by consultation with the international pediatric pain community through announcement of our recommendations on the Pediatric Pain List and inviting and incorporating comments from external sources. There was consensus that investigators conducting pediatric acute pain clinical trials should consider assessing outcomes in pain intensity; global judgment of satisfaction with treatment; symptoms and adverse events; physical recovery; emotional response; and economic factors. There was also agreement that investigators conducting pediatric clinical trials in chronic and recurrent pain should consider assessing outcomes in pain intensity; physical functioning; emotional functioning; role functioning; symptoms and adverse events; global judgment of satisfaction with treatment; sleep; and economic factors. Specific measures or measurement strategies were recommended for different age groups for each domain.Perspective: Based on systematic review and consensus of experts, core domains and measures for clinical trials to treat pain in children and adolescents were defined. This will assist in comparison and pooling of data and promote evidence-based treatment, encourage complete reporting of outcomes, simplify the review of proposals and manuscripts, and facilitate clinicians making informed decisions regarding treatment. (C) 2008 by the American Pain Society.

Background Skin-to-skin contact, or kangaroo mother care (KMC) has been shown to be efficacious in diminishing pain response to heel lance in full term and moderately preterm neonates. The purpose of this study was to determine if KMC would also be efficacious in very preterm neonates. Methods Preterm neonates (n = 61) between 28 0/7 and 31 6/7 weeks gestational age in three Level III NICU's in Canada comprised the sample. A single-blind randomized crossover design was employed. In the experimental condition, the infant was held in KMC for 15 minutes prior to and throughout heel lance procedure. In the control condition, the infant was in prone position swaddled in a blanket in the incubator. The primary outcome was the Premature Infant Pain Profile (PIPP), which is comprised of three facial actions, maximum heart rate, minimum oxygen saturation levels from baseline in 30-second blocks from heel lance. The secondary outcome was time to recover, defined as heart rate return to baseline. Continuous video, heart rate and oxygen saturation monitoring were recorded with event markers during the procedure and were subsequently analyzed. Repeated measures analysis-of-variance was employed to generate results. Results PIPP scores at 90 seconds post lance were significantly lower in the KMC condition (8.871 (95%CI 7.852–9.889) versus 10.677 (95%CI 9.563–11.792) p < .001) and non-significant mean differences ranging from 1.2 to1.8. favoring KMC condition at 30, 60 and 120 seconds. Time to recovery was significantly shorter, by a minute(123 seconds (95%CI 103–142) versus 193 seconds (95%CI 158–227). Facial actions were highly significantly lower across all points in time reaching a two-fold difference by 120 seconds post-lance and heart rate was significantly lower across the first 90 seconds in the KMC condition. Conclusion Very preterm neonates appear to have endogenous mechanisms elicited through skin-to-skin maternal contact that decrease pain response, but not as powerfully as in older preterm neonates. The shorter recovery time in KMC is clinically important in helping maintain homeostasis. Trial Registration (Current Controlled Trials) ISRCTN63551708

Background Recurrent pain is a common complaint among adolescents. Children learn to resolve or cope with pain largely through family dynamics, particularly maternal influences. By adolescence, young people possess an array of pain behaviors, the culmination of multiple opportunities for modeling and reinforcement of attitudes and beliefs about pain. Adolescence is a time of increased autonomy characterized by, among other complex factors, significant increases in peer influence. Although peers are influential in health-risk behavior, little is known how peers impact adolescents' pain experience. The present study explored the role of peers in adolescents' attitudes toward pain, pain behaviors and over-the-counter analgesics. Methods Sixty-minute focus groups were conducted with a sample 24 junior high school students from Halifax, Nova Scotia, Canada (11 male: mean age = 13.45 years, range = 12–15 years; 13 female: mean age = 13.31 years, range = 12–15 years). Participants were randomly assigned to one of five same-gender focus groups designed to explore a wide breadth and depth of information. Sessions were run until theoretical data saturation. Textual data, from transcribed audiotapes, were analyzed with the constant comparative method. Results Peer influences were apparent in how adolescents communicate about pain and how those communications effect pain expression. Overt pain responses to injury were primarily contextual and depended on perceived threats to peer-time and pain severity. Adolescents were intolerant of peers' pain behaviors when the cause was perceived as not severe. These attitudes impacted how adolescents responded to their own pain; males were careful not to express embarrassing pain in front of peers, females felt no restrictions on pain talk or pain expression. Evidence for peer influence on attitudes toward OTC analgesics was apparent in perceptions of over-use and ease of access. Findings are discussed within the context of social information-processing and gender role expectations. Conclusion Little research has addressed how young people experience pain within the context of the psychosocial influences that dominate during adolescence. The findings provide some insight into the role of peer influences via verbal and non-verbal communication, in adolescents' pain experience. This exploratory study is a necessary first step in understanding the socialization of adolescents' pain experiences.

This chapter examines the state of pain care for children in developing countries. Various barriers to pain care, such as knowledge deficits, bureaucratic issues, and types of pain, are discussed. Potential strategies for change are explored, including examples from a number of projects initiated in developing countries. Action research is presented as a scientific approach to produce change and build capacity for pediatric pain management in low- and middle-income countries in a contextually sensitive way.

Preoperative anxiety (anxiety regarding impending surgical experience) in children is a common phenomenon that has been associated with a number of negative behaviors during the surgery experience (e.g., agitation, crying, spontaneous urination, and the need for physical restraint during anesthetic induction). Preoperative anxiety has also been associated with the display of a number of maladaptive behaviors postsurgery, including postoperative pain, sleeping disturbances, parent-child conflict, and separation anxiety. For these reasons, researchers have sought out interventions to treat or prevent childhood preoperative anxiety and possibly decrease the development of negative behaviors postsurgery. Such interventions include sedative premedication, parental presence during anesthetic induction, behavioral preparation programs, music therapy, and acupuncture. The present article reviews the existing research on the various modes of intervention for preoperative anxiety in children. Clinical implications and future directions are discussed.

Prescribing medications for children requires considerable creativity. When working in the field of paediatric pain, creativity and adaptability are even more crucial because very few medications are either created specifically or labelled for use in children, especially for the treatment of pain. Orphan drugs are usually defined as drugs that have been abandoned, or ‘orphaned’, by major drug companies. However, this definition can be extended to medications that could be useful to a minority of the population (ie, orphan group), such as children, physically or cognitively disabled patients, or the elderly, if the medications were available and approved for those groups. The practice of paediatrics requires frequent ‘off-label’ use of medication (ie, outside of the terms of the product approval). The younger the patients are, the more frequently this happens, with 80% to 97% of infants in neonatal wards receiving at least one off-label or unlicensed drug (1). As if those issues were not enough, children face another challenge when it comes to pain medication: few companies offer ‘child-friendly’ paediatric formulations, such as suspensions, small dosage tablets or capsules, that can easily be opened. This last factor results in an even greater reduction in the number of medications that are practical or approved to treat pain in children. Why are licensed and labelled medications to treat paediatric acute and chronic pain so rare? Why are data from clinical trials lacking? Although we know that treating paediatric pain has an immediate positive effect and can prevent long-term consequences (2), the financial market for pain medication for children and youth remains limited compared with the adult one. This limited market is nevertheless substantial, especially with increased availability and use of pain medication for children. Until recently, there was little incentive for major pharmaceutical companies to produce paediatric dosing guidelines and indications. Clinical analgesic trials in children still represent ethical, logistical, financial and legal challenges (3) that no company wishes to undertake without the potential for financial gain or legal requirement. Legislation on this subject has evolved over the past two decades (4). In the United States, paediatric labelling has been required since 1994. Starting in November 1997, the Food and Drug Administration Modernization Act (FDAMA) offered six months of marketing exclusivity to manufacturers for voluntarily conducting paediatric studies for certain drugs identified as potentially beneficial for children by the United States Secretary of Health and Human Services. This successful program provided important information on medications used for children, including ibuprofen, gabapentin and sevoflurane (5), and has been extended until October 2007 via the Best Pharmaceuticals for Children Act (BPCA) (6). This 2002 Act also added neonates as a specific age group and extended the FDAMA to off-patent drugs. Finally, in 2003, the Pediatric Research Equity Act (PREA) (7) gave power to the FDA to request paediatric data for all applications for drugs and biologicals, even for off-label uses of a product, which is a common situation in paediatric pain management. The major difference between the PREA and the BPCA is that PREA excludes orphan drug products (for affected populations of less than 200,000) and is limited to medications under development. In Europe, the situation is a little different because there is still no legislation on paediatric studies. A draft regulation was presented in 2004 with an estimated date for adoption as a law in 2006 (8). This law would require paediatric data for all medications with an active patent, whether in development or already approved, and would include orphan drugs. Off-patent drugs could be included on a voluntary basis. A European paediatric clinical trial register has also been created and is accessible through the Internet (9). There is still no specific Canadian law that requires paediatric data for new drug approval, although a proposal was published in June 2006. This new legislation would be similar to the BPCA, offering a six-month patent extension to companies who submit description and results of clinical trials in relevant paediatric populations within the first five years of the patent (10). When we look more closely at the medications most often used to treat paediatric pain in Canada, it is unfortunate to see how few of them are approved for use in children, or even contain good data from clinical studies. In fact, many of the products we commonly use for chronic pain management or as adjuvants for acute pain (eg, gabapentin or amitriptyline) are not even labelled for pain treatment in adults. When they are labelled for the treatment of pain (eg, celecoxib, pregabalin or diclofenac), the indication is only for adults (11). In 2007, children and youth are still therapeutic orphans for pain medication. The FDAMA/BPCA legislation proved that a combination of law and financial incentive can motivate pharmaceutical companies to provide paediatric data. This was a first step toward equity between adults and children. However, stronger regulations, with mandatory rather than optional requirements, are necessary to ensure the safe use of existing and under-development analgesics for children. In addition, internationally harmonized legislation would not only protect children of countries who are not under the legislation of the FDA or the European Medicines Evaluation Agency, but would also facilitate collaboration in international multicentre trials, the latter being necessary to achieve an adequate number of patients for study. As clinicians and researchers, we can help by informing politicians and the public of the need for legislation, by identifying those medications that need more investigation and by participating in pharmacological studies and clinical trials.

Placebo-controlled studies show that midazolam impairs explicit memory in children undergoing surgery (Buffett-Jerrott et al., Psychopharmacology 168:377–386, 2003; Kain et al., Anesthesiology 93:676–684, 2000). A recent within-subjects study showed that midazolam impaired explicit memory while leaving implicit memory intact in a sample of older children undergoing painful medical procedures (Pringle et al., Health Psychol 22:263–269, 2003). We attempted to replicate and extend these findings in a randomized, placebo-controlled design with younger children undergoing surgery. Children aged 3–6 years who were undergoing ear tube (myringotomy) surgery were randomly assigned to receive midazolam (n=12) or placebo (n=11). After surgery, they were tested on explicit (recognition) and implicit (priming) memory for pictures encoded before surgery. Relative to placebo, the midazolam-treated children showed poorer recognition memory on the explicit task but equivalent priming on the implicit task. Overall, it appears that midazolam induces a dissociation between explicit and implicit memory in young children in the pediatric surgery setting. Theoretical and clinical implications of the findings are discussed along with directions for future research.

Objective: To determine whether healthcare professionals believe the pain of infants at risk for neurologic impairment differs from that of typical infants. Setting: Neonatal intensive care units at 2 tertiary pediatric centers in Canada. Participants: Ninety-nine healthcare professionals who practice in the neonatal intensive care unit (51 nurses, 19 physicians, 18 respiratory therapists, 11 other). Major Measures: Participants completed the Pain Opinion Questionnaire. It elicits beliefs regarding the similarity of the pain experienced by infants at mild, moderate, and severe risk for neurologic impairment relative to those without risk for neurologic impairment along 5 pain facets (ie, sensation, emotional reaction, behavioral reaction, communication, incidence). Results: Pain Opinion Questionnaire scores varied by level of risk of neurologic impairment (mild, moderate, severe) and pain facet. Respondents believed infants with risk were overall less likely to experience pain similar to infants without risk as the level of risk increased [F(2,97) = 66.0, P < 0.001] and were more likely to have a reduced pain experience relative to infants without risk as the level of risk increased [F(2,97) = 62.2, P < 0.001]. Pain Opinion Questionnaire scores did not vary due to profession, experience, gender, or age. Conclusion: Professionals expressed the belief that neurologically impaired infants' pain experience is reduced, relative to infants without impairment, as their level of risk for neurologic impairment increases. This belief did not vary due to professional experience or personal factors. Future studies should investigate the source of these beliefs and their impact on the pain management provided to infants with risk for neurologic impairment.

The goal of this research is to provide a means by which the tacit knowledge in an e-mail archive can be browsed in an organized manner and linked directly to the explicit knowledge found in PubMed. The Pediatric Pain Mailing List (PPML) is an international Internet-based forum for informal discussion of any topic related to pain in children. There are now over seven hundred members, including clinicians, researchers and patients from at least forty countries on six continents. Currently, the archive contains more than ten thousand messages. This paper reports on SOM-based approaches to the taci-knowledge organization and an MMTx-based approach that links the e-mail threads directly into the MeSH hierarchy and links to PubMed.

Clinical decision-making can be improved if healthcare practitioners are able to leverage both the tacit and explicit modalities of healthcare knowledge, yet at present there do not exist knowledge management systems that support any active and direct mapping between these two knowledge modalities. In this paper, we present a healthcare knowledge-mapping framework that maps (a) the tacit knowledge captured in terms of email-based discussions between pediatric pain practitioners through a Pediatric Pain Mailing List (PPML), to (b) explicit knowledge represented in terms of peer-reviewed healthcare literature available at PubMed. We report our knowledge mapping strategy that involves methods to establish discussion threads, organize the discussion threads in terms of topic-specific taxonomy, formulate an optimal search query based on the content of a discussion thread, submit the search query to PubMed and finally to retrieve and present the search results to the user.

To investigate the effects of midazolam on emotional reactivity during induction of anesthesia in a pediatric day surgery setting. A secondary purpose was to determine if these effects were influenced by child temperament factors. Forty children (age four to six years) scheduled for myringotomy were randomly assigned, in a double blind fashion, to receive either oral midazolam 0.5 mg·kg-1 mixed with acetaminophen suspension or acetaminophen alone. The Emotionality, Activity, Sociability, and Impulsivity (EASI) scale was used as a measure of child temperament. The modified Yale Preoperative Anxiety Scale (m-YPAS), an observer-rated measure of state anxiety, was employed to assess anxiety preand post-drug, and also at induction of anesthesia. Children who received midazolam reacted significantly less to induction of anesthesia than did children in the placebo control group, F (1, 38) = 7.46, P = 0.01. A significant positive association was observed between baseline levels of anxiety and observer-rated anxiety at anesthetic induction, but only in the placebo group, r = 0.58, P < 0.01. A significant positive association was observed between levels of impulsivity at baseline and observer-rated anxiety at anesthetic induction, but only in the midazolam group, r = 0.42, P < 0.05. Midazolam dampened adverse reactivity during anesthetic induction, particularly among children with high baseline levels of anxiety. Baseline level of impulsivity was positively associated with adverse reactions to anesthesia induction in the drug group, but not in the placebo group, suggesting that high levels of trait impulsivity may contraindicate the use of midazolam as a preoperative medication.