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A multidisciplinary approach is recommended for patients with complex chronic pain (CP). Many multidisciplinary pain treatment facilities (MTPFs) use patient exclusion criteria but little is known about their characteristics. The objective of this study was to describe the frequency and characteristics of exclusion criteria in public Canadian MTPFs.We conducted a cross-sectional study in which we defined an MPTF as a clinic staffed with professionals from three disciplines or more (including at least one medical specialty) and whose services were integrated within the facility. We disseminated a web-based questionnaire in 2017-2018 to the administrative leads of MPTFs across the country. They were invited to complete the questionnaire about the characteristics of their facilities. Data were analyzed using descriptive statistics and correlation measures.A total of 87 MTPFs were included in the analyses. Half of them (52%) reported using three exclusion criteria or more. There was no significant association between the number of exclusion criteria and wait time for a first appointment or number of new consultations in the past year. Fibromyalgia and migraine were the most frequently excluded pain syndromes (10% and 7% of MPTFs, respectively). More than one MPTF out of four excluded patients with mental health disorders (30%) and/or substance use disorders (29%), including MPTFs with specialists in their staff.Multidisciplinary pain treatment facility exclusion criteria are most likely to affect CP patients living with complex pain issues and psychosocial vulnerabilities. Policy efforts are needed to support Canadian MPTFs in contributing to equitable access to pain management.RéSUMé: OBJECTIF: Une approche multidisciplinaire est recommandée pour les patients souffrant de douleur chronique (DC) complexe. De nombreux centres multidisciplinaires de traitement de la douleur (CMTD) utilisent des critères d’exclusion des patients, mais on ne sait que peu de choses sur leurs caractéristiques. L’objectif de cette étude était de décrire la fréquence et les caractéristiques des critères d’exclusion dans les CMTD publics canadiens. MéTHODE: Nous avons mené une étude transversale dans laquelle nous avons défini un CMTD comme une clinique composée de professionnels de trois disciplines ou plus (y compris au moins une spécialité médicale) et dont les services étaient intégrés à l’établissement. En 2017-2018, nous avons fait parvenir un questionnaire en ligne aux responsables administratifs des CMTD partout au pays. Ils ont été invités à remplir le questionnaire sur les caractéristiques de leurs établissements. Les données ont été analysées à l’aide de statistiques descriptives et de mesures de corrélation. RéSULTATS: Au total, 87 CMTD ont été inclus dans les analyses. La moitié d’entre eux (52 %) ont déclaré utiliser trois critères d’exclusion ou plus. Il n’y avait pas d’association significative entre le nombre de critères d’exclusion et le temps d’attente pour un premier rendez-vous ou le nombre de nouvelles consultations au cours de la dernière année. La fibromyalgie et la migraine étaient les syndromes douloureux les plus fréquemment exclus (10 % et 7 % des CMTD, respectivement). Plus d’un CMTD sur quatre excluait les patients atteints de troubles de santé mentale (30 %) et/ou de troubles liés à l’utilisation de substances (29 %), y compris les CMTD comptant des spécialistes dans leur personnel. CONCLUSION: Les critères d’exclusion des centres multidisciplinaires de traitement de la douleur sont plus susceptibles d’affecter les patients atteints de douleur chronique vivant avec des problèmes de douleur complexes et des vulnérabilités psychosociales. Des efforts au niveau des politiques sont nécessaires pour aider les CMTD canadiens à favoriser un accès équitable à la prise en charge de la douleur.

BACKGROUND Social context has been found to influence pain intensity and tolerance. The aims of this study were to determine the impact of one type of social context on the painful experiences of adolescents with and without chronic pain by examining interactions within and across friendship dyads during experimental pain. METHODS Each adolescent in 61 same-sex friendship dyads (30 dyads with a chronic pain member) across three sites participated in the cold pressor task and acted as the observer during their friend's participation. They also completed a battery of measures to capture friendship features and pain outcomes. Pain intensity was measured using an 11-point numeric scale. Pain tolerance was measured by the length of time in the cold pressor device. Videotapes of their interactions were coded for verbal and non-verbal behaviours. A series of Actor Partner Independence Modelling, Hierarchical Multiple Regression and Multivariate Analysis of Covariance was used to analyse the data. RESULTS Friendship features were not associated with pain intensity or tolerance. Both members of dyads with a chronic pain member used fewer non-attending behaviours when they were observing their friend resulting in participants in those dyads having lower pain tolerance. Moreover, within dyads, one's friend's behaviours when experiencing pain influenced pain tolerance but only for those dyads with a chronic pain member. CONCLUSIONS Strategies aimed at improving social interactions for adolescents with chronic pain while they are experiencing pain are discussed. Research is needed to understand how different peer relationships influence pain tolerance in adolescents with chronic pain. SIGNIFICANCE OF THE RESEARCH During pain, patterns of interactions differ within and between adolescent friendship dyads when one has chronic pain (CP) versus controls. Dyads with a CP member use fewer non-attending behaviours despite non-attending behaviours rated as more helpful. Pain intensity was solely related to the participant's behaviour. Amongst dyads with a CP member, pain tolerance was also influenced by their friend's behaviours. Friends of adolescents with pain engage in more unhelpful behaviours perhaps decreasing the ability of CP adolescents to engage in social activities.

Stakeholder engagement in knowledge mobilization (KMb) activities can bridge the knowledge to action gap within children’s pain but may be influenced by how well stakeholder needs and barriers to evidence-based resources are addressed. The needs of different Canadian stakeholder groups related to children’s pain have not been examined, limiting the degree to which KMb efforts can be tailored to each group.The study aim was to identify shared and unique needs, barriers, and accessibility of evidence for children’s pain across three stakeholder groups: knowledge users (i.e., health professionals, administrators, policymakers, educators), researchers (including trainees), and patients, caregivers, and family members.This study comprised an online needs assessment survey. Analyses included descriptive statistics, one-way analyses of variances, and chi-square tests to examine differences between stakeholder groups. Open-ended responses were analyzed using conventional content analysis.A total of 711 stakeholders completed the survey. Educational materials were the most utilized evidence-based resources among all stakeholders. Researchers and patients/caregivers/family members found resources significantly less accessible than knowledge users (Though stakeholders experience common barriers to evidence-based resources for children’s pain, their needs to address these barriers are diverse. Evidence-based resources should be tailored for stakeholders’ contexts, with diverse audiences in mind.

Health-Related Quality of Life (HRQL) can be used to measure the impact of Sickle Cell Disease (SCD) on the child and their family and is generally reduced. No research has yet measured HRQL in Portuguese pediatric SCD patients. Objectives: (1) Describe and compare HRQL of children with SCD reported by them and their parents; (2) Compare with a pediatric population with no SCD; (3) Find predictive factors of HRQL in SCD children. Methods: Descriptive, case-control study that included sixty-eight children and adolescents with SCD (aged 3 to 18 years) and their parents. Control group—children with no SCD, matched by age, gender and ethnic background. HRQL was assessed using the multidimensional self-report PedsQL® 4.0 Generic Scales. Summary scores for overall HRQL and subscale scores for physical, emotional, social and school functioning were compared within groups (children-parents) and with the control group. Clinical and socio-demographic variables were analyzed to find predictive factors of HRQL in pediatric SCD patients. Results: Children with SCD and their parents had significantly lower overall and all subdomains of HRQL, compared with the control group. Children with SCD also rated lower when compared with their parents (only significant for social functioning), with low to moderate correlations. Children and parent reports declined with increasing age. Higher pain frequency was associated with worse total and psychosocial domains of HRQL. The number of hospitalizations was a predictor of worse school score, and female gender was a predictor of worse emotional score. Conclusions: SCD significantly affects children’s HRQL. Parents can provide a good proxy report, although both evaluations are beneficial. Disease status, like number of hospitalizations and frequency of pain, influences HRQL. Interventions in SCD should consider improvements in HRQL as an important outcome.

Chronic pain affects 1 in 5 youth, many of whom manage their pain using a biopsychosocial approach. The COVID-19 pandemic has impacted the way that healthcare is delivered. As part of a larger program of research, this study aimed to understand the impact of the pandemic on pediatric chronic pain care delivery including impact on patients’ outcomes, from the perspective of pediatric healthcare providers. A qualitative descriptive study design was used and 21 healthcare providers from various professional roles, clinical settings, and geographic locations across Canada were interviewed. Using a reflexive thematic analysis approach 3 themes were developed: (1) duality of pandemic impact on youth with chronic pain (i.e., how the pandemic influenced self-management while also exacerbating existing socioeconomic inequalities); (2) changes to the healthcare system and clinical practices (i.e., triaging and access to care); (3) shift to virtual care (i.e., role of institutions and hybrid models of care). These findings outline provider perspectives on the positive and negative impacts of the pandemic on youth with chronic pain and highlight the role of socioeconomic status and access to care in relation to chronic pain management during the pandemic in a high-income country with a publicly funded healthcare system.

Background: The 2018 Global Year for Excellence in Pain Education, an initiative of the International Association for the Study of Pain, brought worldwide attention to the need for education that crosses narrow disciplinary boundaries, addresses up-to-date research methods and findings, and encourages teamwork among trainees and mentors at different levels of training and with different perspectives. Aims: This commentary describes the development of Pain in Child Health (PICH), an interdisciplinary training program for researchers in pediatric pain at the undergraduate, graduate, and postdoctoral levels of training. Methods: Based on documentation of the structure, training processes, leadership, and membership of PICH, we outline its organization and its challenges and accomplishments over the first 12 years of its growth into a well-known international program. Results and Conclusions: Pain in Child Health began as a Strategic Training Initiative of the Canadian Institutes of Health Research in 2002 and developed into an international research training consortium featuring cross-site and cross-discipline mentorship and collaboration. PICH trainees and alumni have contributed extensively to the current scientific literature on children’s pain. PICH could serve as a possible model for training and mentorship in other specialized health research domains within and outside thestudy of pain.

Purpose: The purpose of this study was to explore the transition experience of young adults with chronic pain in Canada from the pediatric health care setting to the adult health care setting. Materials and Methods: A qualitative descriptive approach using semistructured interviews was used to capture the transition experiences of young people with chronic pain who have recently transferred from the pediatric setting to the adult health care setting. Participants were recruited from west, central, and the east coast of Canada to situate the findings within the context of Canada. Interviews were transcribed and analyzed using qualitative inductive content analysis. Results: Nine participants were interviewed, three from each part of Canada (west, central, and east). Five common categories were determined to describe the transition experience of young adults with chronic pain which include (1) independence (I can do it, maybe?), (2) pain trajectory (stress and pain along for the ride), (3) social support networks (need a shoulder to lean on), (4) parental support (obviously they are there), and (5) collaborative systems (the bridge). Conclusion: Young people with chronic pain experience unique challenges when faced with transitioning to the adult health care setting. Supporting the young person and his or her family in preparation and readiness and collaboration between the pediatric and adult health care settings are essential to ensure a smooth transition and avoid negative transition outcomes. Further research is needed to determine the best ways to prepare young people for transition and the care activities required in both pediatric and adult health care settings to improve pain-related outcomes posttransition.

This study describes the minimum incidence of pediatric complex regional pain syndrome (CRPS), clinical features, and treatments recommended by pediatricians and pain clinics in Canada. Participants in the Canadian Paediatric Surveillance Program reported new cases of CRPS aged 2 to 18 years monthly and completed a detailed case reporting questionnaire from September 2017 to August 2019. Descriptive analysis was completed, and the annual incidence of CRPS by sex and age groupings was estimated. A total of 198 cases were reported to the Canadian Paediatric Surveillance Program, and 168 (84.8%) met the case definition. The minimum Canadian incidence of CRPS is estimated at 1.14/100,000 (95% confidence interval 0.93-1.35/100,000) children per year. Incidence was highest among girls 12 years and older (3.10, 95% confidence interval 2.76-3.44/100,000). The mean age of CRPS diagnosis was 12.2 years (SD = 2.4), with the mean time from symptom onset to diagnosis of 5.6 months (SD = 9.9) and no known inciting event for 19.6% of cases. Most cases had lower limb involvement (79.8%). Nonsteroidal anti-inflammatory drugs (82.7%) and acetaminophen (66.0%) were prescribed more commonly than antiepileptic drugs (52.3%) and antidepressants (32.0%). Referrals most commonly included physical therapy (83.3%) and multidisciplinary pain clinics (72.6%); a small number of patients withdrew from treatment because of pain exacerbation (5.3%). Pain education was recommended for only 65.6% of cases. Treatment variability highlights the need for empiric data to support treatment of pediatric CRPS and development of treatment consensus guidelines.

IntroductionChronic pain, defined as persistent or recurring pain or pain lasting longer than 3 months, is a common childhood problem and can profoundly impact children’s physical, psychological and social functioning. The last comprehensive systematic review estimating the prevalence of chronic pain in children and adolescents was published in 2011. Since then, the literature on paediatric chronic pain has grown substantially. This manuscript outlines a protocol for an updated systematic review to provide updated estimates of the prevalence of various forms of chronic pain in children and adolescence. The review will also examine the relationship between sociodemographic and psychosocial factors related to chronic pain prevalence.Methods and analysisThis review will follow Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We will search EMBASE, PubMed, CINAHL and PsycINFO for observational studies published in English between 2009 and 2020 reporting population-based estimates of chronic non-disease-related pain prevalence in children or adolescents (age ≤19 years). Two independent reviewers will screen the titles and abstracts retrieved from the search based on predefined eligibility criteria. The full texts of relevant studies will then be assessed by two reviewers. Studies meeting inclusion criteria will be categorised according to the type of pain investigated: headache only, abdominal pain only, back pain only, musculoskeletal pain, combined pain, general pain and other pain. Data will be extracted using customised forms and studies will be assessed for risk of bias using a 10-item tool developed by Hoy et al (2012). A narrative synthesis will summarise the prevalence estimates of paediatric chronic pain and associated sociodemographic and psychosocial correlates. Meta-analyses and meta-regressions will be performed if the data permit.Ethics and disseminationEthical approval is not required. Findings will be disseminated through publication in an academic journal, presentations at conferences and in various media.PROSPERO registration numberCRD42020198690.

A multisite cross-sectional study was conducted to examine dyadic friendship features between adolescents with chronic pain (ACP) and their friends compared with non-pain adolescent friendship dyads and the association of these friendship features with loneliness and depressive symptoms. Participants completed a battery of standardized measures to capture friendship features (friendship quality, closeness, and perceived social support from friends) and indices of social-emotional well-being. Sixty-one same sex friendship dyads (122 adolescents) participated; 30 friendship dyads included an adolescent with chronic pain and 52 dyads were female. Adolescents with chronic pain scored significantly higher on measures of loneliness and depressive symptoms compared with all other participants. Hierarchical Multiple Regression analysis revealed that friendship features predicted loneliness and depressive symptoms. Chronic pain predicted loneliness and depressive symptoms above and beyond friendship features. Actor Partner Interdependence Modeling found perceived social support from friends had differing associations on loneliness and depressive symptoms for dyads with a chronic pain member compared with pain-free control dyads. Friendship features were associated with loneliness and depressive symptoms for adolescents, but friendship features alone did not explain loneliness and depressive symptoms for ACP. Further research is needed to understand whether pain-related social support improves loneliness and depressive symptoms for ACP. Furthermore, a more nuanced understanding of loneliness in this population is warranted. Strategies to help ACP garner needed social support from friends are needed to decrease rates of loneliness to improve long-term outcomes.

Introduction/Aim: Studies suggest that cultural models of parenting (CMP) influence parental behaviors. Predominant cultural values are believed to inform the parenting styles caregivers adopt. Cultural values were expected to affect parental behaviors indirectly through parenting styles. We believed this would be moderated by ecosocial context. The present study aimed to examine cultural influences on pain-related parent-behaviors (PRPB). We hypothesized that ecosocial context would moderate the relationship between cultural values, parenting styles, and PRPB; and parenting styles would mediate the effect of cultural values on PRPB. Methods: A cross-cultural survey design was employed using a convenience sample of 547 caregivers of 6–12-year-olds living in Canada (n = 183), Iceland (n = 184), and Thailand (n = 180). The individualism-collectivism scale measured verticaland horizontal individualism, and collectivism. The parenting styles and dimensions questionnaire measured authoritative, and authoritarian parenting styles. The inventory of parent/caregiver responses to the children’s pain experience scale measured solicitousness and discouraging.Results: Multigroup structural equation modeling, showed that country did not affect which CMP caregivers adopted. Parenting styles mediated the relationship between cultural values and PRPB. Vertical/horizontal individualism, collectivism, and authoritative and authoritarian-parenting styles positively predicted solicitousness. Vertical individualism and authoritarian-parenting style positively predicted discouraging, whereas other predictors did not. Discussion/Conclusions: Unexpectedly, ecosocial context did not influence which CMP caregivers adopt, including their PRPB. As expected, parenting styles were mediators. Results supports others’ claims of solicitousness universality in a pediatric pain context. However, solicitousness may have different cultural meanings among individuals, and may be used in conjunction with discouraging.

BACKGROUND: Indigenous youth have higher rates of chronic health conditions interfering with healthy development, including high rates of ear, dental, chest and musculoskeletal pain, as well as headache, arthritis and mental health issues. This study explores differences in pain-related diagnoses in First Nations and non–First Nations children. METHODS: Data from a study population of age- and sex-matched First Nations and non–First Nations children and youth were accessed from a specific region of Atlantic Canada. The primary objective of the study was to compare diagnosis rates of painful conditions and specialist visits between cohorts. The secondary objective was to determine whether there were correlations between early physical pain exposure and pain in adolescence (physical and mental health). RESULTS: Although ear- and throat-related diagnoses were more likely in the First Nations group than in the non–First Nations group (ear 67.3% v. 56.8%, p < 0.001; throat 89.3% v. 78.8%, p < 0.001, respectively), children in the First Nations group were less likely to see a relevant specialist (ear 11.8% v. 15.5%, p < 0.001; throat 12.7% v. 16.1%, p < 0.001, respectively). First Nations newborns were more likely to experience an admission to the neonatal intensive care unit (NICU) than non–First Nations newborns (24.4% v. 18.4%, p < 0.001, respectively). Non–First Nations newborns experiencing an NICU admission were more likely to receive a mental health diagnosis in adolescence, but the same was not found with the First Nations group (3.4% v. 5.7%, p < 0.03, respectively). First Nations children with a diagnosis of an ear or urinary tract infection in early childhood were almost twice as likely to have a diagnosis of headache or abdominal pain as adolescents (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.1–3.0, and OR 1.7, 95% CI 1.2–2.3, respectively). INTERPRETATION: First Nations children were diagnosed with more pain than non–First Nations children, but did not access specific specialists or mental health services, and were not diagnosed with mental health conditions, at the same rate as their non–First Nations counterparts. Discrepancies in pain-related diagnoses and treatment are evident in these specific comparative cohorts. Community-based health care access and treatment inquiries are required to determine ways to improve care delivery for common childhood conditions that affect health and development.

There is a scarcity of work examining the relationship between culture and pain-related caregiver behaviors. Moreover, no pediatric pain studies have examined the relationship between caregiver cultural values and pain-related caregiver behaviors nor discern if this process is mediated by caregiver parenting styles and moderated by ecosocial context. Based on cross-cultural developmental theories, this study hypothesized that ecosocial context would moderate the relationship between cultural values, parenting styles, and pain-related caregiver behaviors; and that parenting styles mediate the effect of cultural values on pain-related caregiver behaviors. A cross-cultural survey design was employed using a convenience sample of 547 caregivers of 6 to 12 year olds living in Canada (n = 183), Iceland (n = 184), and Thailand (n = 180). Multigroup structural equation modeling showed that ecosocial context did not affect which cultural model of parenting the caregiver adopted. Parenting styles mediated the relationship between cultural values and pain-related caregiver behavior. Vertical/horizontal individualism, collectivism, and authoritative- and authoritarian-parenting styles positively predicted solicitousness. Vertical individualism and authoritarian-parenting style positively predicted discouraging behavior, whereas other predictors did not. The findings support the sociocommunication model of children's pain by showing that cultural context does affect parents' behaviors. They also corroborate with others' claims of solicitousness universality in a pediatric pain context. However, solicitousness may have different cultural meanings among individuals and may be used in conjunction with discouraging behavior. The findings from this study have implications for the theory development about culture and pediatric pain, but do not provide specific clinical recommendations.

This report may be useful for health care professionals and policy makers concerned with improving the care of children with chronic pain and their families., Introduction: The treatment of youth with chronic pain has improved in recent years. However, because pediatric chronic pain programs are not governed by international standards, the development and implementation of new initiatives may be limited. Objectives: The objectives of this study were to identify the features of programs as they exist at present and to determine what features they should have in an ideal state. Methods: A web-based international survey was used to collect information. The survey contained 86 questions seeking respondent professional demographic data and information about the pain program with which the respondent was affiliated at the time (program organization, types of pain problem treated, professionals involved, services provided, size of the program, research, professional training, public education and advocacy, and funding sources). Results: Respondents were 136 pediatric pain experts representing different specialties located in 12 countries. Most respondents indicated that ideal programs would have a multidisciplinary staff; provide a wide range of treatments for different chronic pain problems; integrate research, formal clinical training of specialists, and public education and advocacy into their activities; and be an accredited part of the public health system. Conclusions: The results of this survey may be useful for health care professionals interested in treating chronic pain in children and adolescents and for policy makers concerned with improving the care given to these children and their families.

Parental presence is often employed to alleviate distress in children within the context of surgery under general anesthesia. The critical component of this intervention may not be the presence of the parent per se, but more importantly the behaviors in which the parent and child engage when the parent is present. The purpose of the current study was to examine the sequential and reciprocal relationships between parental behaviors and child distress during induction of general anesthesia. Participants were 32 children (3-6 years) receiving dental surgery as a day surgery procedure, and their parents. A modified Child Adult Medical Procedures Interaction Scale-Revised was used to code parent and child behaviors. Initial child distress led to increased parental provision of reassurance and decreased provision of physical comfort. Our findings may inform the development of preoperative preparation programs whereby parents can be appropriately educated about what behaviors will be helpful/unhelpful for their child during induction of general anesthesia.

Children experience moderate to severe pain post-operatively. Nurses have been found to have a variety of aims in this context. Surgeons’ aims when managing post-operative pain have not been explored. This qualitative study set out to explore paediatric surgeons’ aims when managing post-operative pain in one paediatric hospital in Canada. Consultant surgeons ( n = 8) across various specialities took part in semi-structured interviews. Surgeons’ overarching aim was to keep the child comfortable. Various definitions of comfortable were given, relating to the child’s experience of pain itself and their ability to undertake activities of daily living. Children’s behavioural pain cues seem to be a primary consideration when making treatment decisions. Parents’ views regarding their child’s pain were also seen as important, suggesting children may not be seen as competent to make decisions on their own behalf. The need to maintain a realistic approach was emphasised and pain management described as a balancing act. Surgeons may draw on both tacit and explicit knowledge when assessing children’s pain. There appears to be an expectation among surgeons that some pain is to be expected post-operatively and that the diagnostic value of pain may, in some cases, supersede concerns for the child’s pain experience.

All children experience body pain as a result of medical procedures, vaccinations, and a variety of chronic conditions. Children are a vulnerable population and may be even more at risk to experience pain in under-resourced environments. We know that physical pain in childhood causes suffering to the child, family, and caregivers, and can also cause prolonged physiological and immune effects lasting into adulthood. There is evidence that Aboriginal children and youth experience pain at higher rates than their non-Aboriginal counterparts. First Nations youth report that pain issues have kept them from participating in essential developmental activities such as school and sports. Effective pain care increases a child’s ability to participate in activities that are meant to enhance well-being and prepare them to be healthy adults. Currently, there is no reliable way for First Nations children and youth to convey the intensity and quality of their pain. This makes it difficult for health professionals to measure it and likely influences whether it is adequately treated or not. In this paper, we will discuss some of the historical and cultural perspectives that may be helpful in understanding pain in Aboriginal children. In addition, we will discuss what is known about pain expression, assessment, management, and health professionals’ empathy for pain cross-culturally as well as the next logical steps to address some of these issues.

AIMS AND OBJECTIVES: To explore children's and parents' perceptions about the quality of postoperative pain management. BACKGROUND: Children continue to experience moderate to severe pain postoperatively. Unrelieved pain has short- and long-term undesirable consequences. Thus, it is important to ensure pain is managed effectively. Little research has explored children's and parents' perceptions of pain management. DESIGN: Exploratory study. METHODS: Children (n = 8) were interviewed about their perceptions of pain care using the draw-and-write technique or a semi-structured format and asked to rate the worst pain experienced postoperatively on a numerical scale. Parents (n = 10) were asked to complete the Information About Pain questionnaire. Data were collected in 2011. RESULTS: Most children experienced moderate to severe pain postoperatively. Children reported being asked about their pain, receiving pain medication and using non-pharmacological methods of pain relief. A lack of preoperative preparation was evident for some children. Most parents indicated they had received information on their child's pain management. Generally, participants were satisfied with care. CONCLUSION: Participants appeared satisfied with the care provided despite experiencing moderate to severe pain. This may be attributable to beliefs that nurses would do everything they could to relieve pain and that some pain is to be expected postsurgery. RELEVANCE TO CLINICAL PRACTICE: Children are still experiencing moderate to severe pain postoperatively. Given the possible short- and long-term consequences of unrelieved pain, this is of concern. Knowledge translation models may support the use of evidence in practice, and setting a pain goal with parents and children may help improve care.

PURPOSE: The purpose of this study was to explore nurses' aims when managing postoperative pain and whether reported aims reflect actual practices. DESIGN AND METHODS: 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? RESULTS: 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). PRACTICE IMPLICATIONS: There is evidence of individual variation in practices. This may impact on the care provided.

The relation between parent-rated temperament and behavior and observer-rated child preoperative anxiety was examined in 61 children undergoing a day surgery procedure. Parents completed measures of child temperament and behavior prior to surgery. Child preoperative anxiety was observer-rated throughout the day surgery process. Results demonstrated that subscales of the child temperament measure had relatively lower internal consistencies. Subscales from measures of temperament and behavior showed the expected convergent validity in the assessment of inhibition and impulsive constructs, respectively. The anxious-shy subscale from the behavior measure was the only subscale that significantly predicted child anxiety at anesthetic induction (r = .24). Parent-rated measures of child behavior may be useful in identifying children at risk of developing preoperative anxiety.

Purpose This study was an in-depth examination of pediatric postoperative pain care. Design and Methods 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. Results 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. Practice Implications 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.

I often say that when you can measure what you are speaking about, and express it in numbers, you know something about it, but when you can not measure it, when you cannot express it in numbers, your knowledge is of a meager and unsat isfactory kind; it may be the beginning of knowledge, but you have scarcely, in your thoughts, advanced to the state of science whatever the matter may be. Lord Kelvin quoted by Lewis Thomas I In order to manage pain in any patient, it is essen tial to be able to measure the outcomes of treatment. Without measurement, it is impossible to research new drugs or treatment techniques, just as it is impos sible to treat individual patients without knowing whether the treatment is working. Health centre accreditation now requires that processes for assessing and documenting pain be in place, 2 and patients and their families are being educated about the need for proper pain assessment and management. The Canadian Pain Society has issued a position paper which states, in part, that "routine assessment is essen tial for effective management" and that "health pro fessionals have a responsibility to assess pain routinely, to believe patients' pain reports, to document them, and to intervene in order to prevent pain" .3 The International Society for the Study of Pain has defined pain as ...an unpleasant sensory and emo tional experience associated with actual or potential tis sue damage, or described in terms of such damage...", and goes on to say that "pain is always subjective". 4 The gold standard for pain measurement is selfireport; the patient's own description of his or her own sensa tions and the personal interpretation of those feelings. With children, it can be a complex task to acquire that data, and developmental level, behaviour, and family influences must be taken into consideration. Why are children special? It has been recognized for almost two decades that children are frequently under medicated for postoper ative and disease pain.5 Although this pattern resulted in part from an unsubstantiated fear of potent anal gesics, it was, to a large extent, a result of the failure to recognize the degree, or even the presence, of pain in children. Children often can't or won't express their feelings and degree of pain if anything, they may underrate their own pain because of fear of the conse quences. However, we have a professional obligation and a social responsibility to protect children. Looked at objectively, one cannot imagine a situation in which one would say "it would be a good idea to cause that child some pain", yet health professionals often ratio nalize the "benefits" either of the pain ("he might as well get used to it"), or of the intervention that is causing the pain. It has never been demonstrated that pain has a beneficial effect, and the evidence for harm from pain itself is mounting. Even brief episodes of pain in the newborn period may have profound long term consequences. Taddio showed that un anes thetized circumcision of newborns resulted in increased crying and behavioural response to the pain of the immunization needle four to six months later. G Anand's landmark work demonstrated the increases in morbidity and mortality that result from inadequate opioid use during and after major surgery in infants. 7,8 Thus, it becomes extremely important to ensure that we recognize and treat pain in infants and children to the greatest extent possible, and to do that, we have to measure it. A recent edited text has brought together work by many of the experts in the field. 9 Measurement techniques What pa Hen ts say... Selfireport is the "gold standard" for pain measure ment. The concept that only the patient can really understand what he/she is feeling is embodied in the From the Department of Anesthesia, Dalhousie University, IWK Health Centre, Halifax, Nova Scotia, Canada. Address correspondence to: Dr. Allen Finley, Pediatric Anesthesia, IWK Health Centre, 5850 University Avenue, Halifax, Nova Scotia, Canada B3J 3G9. Phone: 902 428 2708; Fax: 902 428 2709; E mail: allen.itnley@dal.ca CAN J ANESTH 2001 / 48:6 / pp R1 R4

Purpose: To elicit the experiences of parents in providing care for their hospitalized child's acute pain needs.Design: Phenomenology, using in-depth interviews with 45 parents whose children were being cared for in five hospitals in Northeastern (Isan) Thailand.Findings: The findings address Thai cultural beliefs regarding the experience of pain and the role societal expectations have on parental behavior in trying to meet their child's acute pain needs. Two themes emerged- "Understanding my child's pain: it's karma" and "Maintaining Kreng Jai"- which identify parent beliefs toward pain and pain treatment, as well as perceived barriers in securing pain management for their children. Together these two themes describe the essence of this study as parents experienced an "inner struggle in providing pain care." Pain was perceived as an inescapable part of life, and participants identified a preference for traditional remedies. Parents experienced a tension as they wanted to provide and secure pain care for their child but at the same time were reticent to approach staff with concerns about their child's care.Conclusions: Thai parents viewed pain as a normal consequence of life, and one had to use traditional remedies in addition to medicine to successfully treat pain. Societal behavioral expectations required children to have patience. Nevertheless, parents wanted professionals to show more empathy and provide more effective pain care.Clinical Relevance: Improvements in pediatric pain care must formally include parents. Culturally sensitive approaches that do not stereotype parents and children are needed to ensure that evidence-informed pain care is available for all children.Key wordsPediatric pain, family nursing, low and middle income countries, descriptive phenomenology, cultural nursingPain is a universal phenomenon and is a major concern for children and parents when they come to the hospital (Johnston, Gagnon, Peplar, & Bourgault, 2005). One of the fundamental responsibilities of parents is to keep their child free from harm. Pain represents a challenge to this, especially in the hospital setting, where parents are no longer the only caregivers. Although hospitalized children everywhere experience pain, children living in some low- and middle-income countries (LMIC) are especially at risk for undermanaged pain due to the attitudes and beliefs of healthcare professionals (Finley, Forgeron, Arnaout, 2008; McCarthy, Chamman, Wilimas, Alaoui, & Harif, 2004). Recently published guidelines for the pharmacological management of pain in children (World Health Organization, 2012) identify gaps in health professional knowledge as a potential barrier to children accessing pain care in health systems. Additionally, the majority of the world's children live in less developed countries (World Health Organization, 1998), and studies suggest the suffering endured by hospitalized children in some LMIC is considerable (Forgeron, Finley, & Amaout, 2006; Jongudomkam, Aungsupakorn, Camfield, 2006). Thus, parents of these children frequently witness undermanaged pain.Parent involvement improves pain care in children i.e.. Power, Liossi, & Franck, 2007). However, the parental role in providing pain care has mostly focused on their abilities to help their child cope with procedural pain i.e., Blount, Sturges, & Power, 1990). Chronic pain in children and adolescents has a disruptive effect on the family unit and contributes to emotional distress in parents (Jordan, Eccleston, & Osborn, 2007; Palermo, 2000), but there are no studies that provide an in-depth understanding of the experience of parents (including perceived barriers to care) while caring for their child in acute pain during hospitalization.Previous research has illustrated that health profession - als in another LMIC (Jordan) have inaccurate views of parents' desires with respect to their child's pain management (Forgeron et al. …

Background Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management. Methods We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ2) analyses. Results Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered. Interpretation For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

The utility of the self-report Children’s Anxiety and Pain Scale Anxiety subscale (CAPS-A) in comparison to the widely used, observer-rated Modified Yale Preoperative Anxiety Scale (mYPAS) in assessing anxiety in children undergoing day surgery procedures was examined. The CAPS-A test-retest reliability, concurrent validity with the Modified Yale Preoperative Anxiety Scale (mYPAS), and sensitivity to expected increases in anxiety at stressful times during the preoperative period were examined. Levels of observer-rated (mYPAS) and self-reported anxiety (CAPS-A) were obtained from 61 children (3 to 6 years) undergoing day surgery procedures. The CAPS-A demonstrated adequate test-retest reliability. Concurrent validity between the CAPS-A and mYPAS scores was poor. The CAPS-A failed to show sensitivity to the expected increases in anxiety at stressful time-points. Thus, an alternative scoring strategy for the CAPS-A was proposed (i.e., child’s refusal to point was scored as high anxiety). Post-hoc analyses demonstrated good concurrent and adequate convergent validity with the alternative scoring strategy.

Approximately 10% of infants admitted to a Neonatal Intensive Care Unit (NICU) are at risk for Neurological Impairment (NI). While we have limited knowledge on the influence of NI risk on pain responses, we have no knowledge of how these responses change over time.To compare physiological and behavioural pain responses of infants at three levels of NI risk during the NICU neonatal period (Session 1) and at 6 months of age (Session 2).Prospective observational design with 149 preterm and term infants at high (Cohort A, n=54), moderate (Cohort B, n=45) and mild (Cohort C, n=50) risks for NI from 3 Canadian tertiary level NICUs. Infants were observed in the NICU during 3 standardized phases of a heel lance: baseline, stick and return-to-baseline. At 6 months, infants were observed during the same three phases during an intramuscular immunization injection. Physiological (heart rate, oxygen saturation) and behavioural (9 facial actions, cry) responses were continuously recorded.A significant interaction of Phase by Session was found with less total facial activity observed during Session 2 (all p values0.04). A significant interaction for Session by Cohort was found, showing that infants in Cohort A had significantly more change from baseline-to-stick phase for brow bulge, eye squeeze, nasolabial furrow and open lips between sessions with less facial actions demonstrated at Session 2 (all p0.02). There were significantly lower mean and minimum heart rate (all p0.02) and higher minimum and maximum oxygen saturation (p0.04) at Session 2. Significantly higher mean and minimum fundamental cry frequencies (pitch) in Cohort B (p0.04) were found in Session 1. Cohort A had significantly longer cry durations, but no significant differences in cry dysphonation.Behavioural and physiological infant pain responses were generally diminished at 6 months of age compared to those in the neonatal period with some differences between NI risk groups in cry responses. Future exploration into the explanation for these differences between sessions and cohorts is warranted.

Children's pain is undertreated worldwide. Using a model of pediatric cancer pain management in Amman, Jordan, the authors demonstrated that an action research approach to pain service development resulted in a sustainable program of pain control. Barriers to care were due more often to health professionals' misconceptions concerning pain and opioid use than to concerns related to cultural, religious, or societal beliefs. Successful implementation of a pain management program requires education, policy development, and support from several levels of hospital administration. Role-modeling and mentorship are important factors. Established knowledge translation theories explained some but not all of the findings. Outcomes included consistent pain assessment and documentation by nursing staff, increased consultation for pain management, and increased use of intravenous opioids.

The family, particularly mothers, has been shown to have a profound impact on children's pain expression and coping. However, the cumulative effect of maternal influences on adolescents' pain experiences is unknown. By adolescence, young people demonstrate independence concerning their own health; this is apparent in decisions to self-medicate for recurrent pain. How adolescents acquire independence in pain management has not been addressed adequately in the literature. The present study assessed maternal influences in adolescents' autonomy in pain management choices by employing a qualitative methodology. Face-to-face semi-structured interviews were carried out with 20 mother–adolescent dyads. Although adolescents reported self-medicating for recurrent pain, analgesic use was largely mother-assisted. Intergenerational transmission of information about pain and pain management was clear. Mothers transmitted information to adolescents through pain management practices and knowledge of analgesics. ...