Assessment of pain by parents in young children following surgery
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Assessment of pain by parents in young childrenfollowing surgery
JOANNA MORGAN B MB M e d Se d S c ic i * , VANESSA PEDEN B SB S cc* ,
KANTA BHASKAR*, MAIR VATER M B B CM B B C hh ,, F R C AF R C A AND
IMTI CHOONARA M BM B CC hh B , M DB , M D*
*Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospitaland Department of Anaesthesia, Derbyshire Children's Hospital, Derby, UK
SummaryBackground: We asked parents to assess pain in young children
following surgery.
Methods: Assessments were carried out by both parents and an
independent assessor using a behavioural observational scale.
Results: Forms were returned from the parents of 42 children aged
1±5 years. There were 123 joint assessments and there was a strong
correlation between the scores by the observer and the parents
(r2 � 0.84). Twenty-nine children experienced pain following
discharge from hospital.
Conclusions: Our ®ndings suggest that parents can assess pain in
young children following surgery. The management of pain following
discharge from hospital can be improved.
Keywords: analgesia; postoperative; assessment; parents;
young children
Introduction
The management of pain in infants and children in
hospital is far from satisfactory. There have been
major advances recently in the management of pain in
children in hospital by the establishment of paediatric
pain teams. More surgery is, however, being carried out
as daycase surgery and there is concern that the
management of pain in children following such surgery
and particularly after discharge is suboptimal (1±3).
In order to try and improve the management of
pain, it is essential that pain can be accurately
assessed. We were particularly interested in young
children in whom pain assessment is more dif®cult
(4). The Toddler-Preschooler Postoperative Pain
Scale (TPPPS) has been validated for use in children
aged 1±5 years following surgery (5). It is an obser-
vational scale, with the observer awarding scores for
each of seven pain behaviours observed during a
5-min period. The three aspects of the expression of
pain include verbal, facial and body movement. We
were interested in the ability of parents to assess
pain in their children and felt the TPPPS may be too
complex to use. We therefore used a simple pain
scale which incorporated the three main aspects of
the TPPPS, i.e. verbal, facial expression and body
movement, then modi®ed it into a 3-point scale
where 0 represented no pain, 2 represented consid-
erable pain and 1 represented the presence of mild to
moderate pain (Table 1).
Correspondence to: Imti Choonara, Academic Division of ChildHealth, University of Nottingham, Derbyshire Children's Hospi-tal, Uttoxeter Road, Derby DE22 3NE, UK (e-mail: [email protected]).
Paediatric Anaesthesia 2001 11: 449±452
Ó 2001 Blackwell Science Ltd 449
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Several groups have carried out preliminary
studies showing that parents can play a role in the
assessment of pain in children (6±9). These studies
have involved older children and we wished to
evaluate whether parents can play a role in the
assessment of pain in young children following
surgical intervention.
Methods
Children between the ages of 12 months and 6 years
who were undergoing a variety of elective surgery
(adenotonsillectomy, correction of squint, hernia
repair, orchidopexy) as a daycase or with an antici-
pated overnight stay in hospital were considered for
the study. Their parents were approached for their
written informed consent. The study was approved
by the Southern Derbyshire Ethics Committee. Par-
ents were asked to use a pain scale which is in
current use in the hospital for the assessment of pain
and nursing staff have found simple to use (Table 1).
The score could range from 0 (no pain) to a
maximum of 6 (severe pain). The medical student
(JM) was taught the pain scale by the two research
nurses (VP, KB) who have considerable experience
in pain assessment in young children. The parents
were explained the nature of the scale by the medical
student, how to use it and were asked to carry out
pain assessments hourly until their child was dis-
charged from hospital. Once the patients were at
home the parents were asked to record scores: (i)
twice on the evening of discharge; (ii) three times the
following day; (iii) before and 30 min after admin-
istering analgesia; and (iv) if the child woke up
during the night. The parents were asked to return
the assessment forms in a stamped addressed
envelope. The medical student also carried out
independent assessments at the same time as their
parents while the children were in hospital.
Results
Fifty children were recruited into the study. The ages
of the children ranged from 1±5.9 years (median
4.1 years). Forms were returned from the parents of
42 children. In four cases, this only included parental
assessment of pain when the child was in hospital.
There were 123 assessments by the parent and the
observer simultaneously. Sixty-®ve of these assess-
ments scored 0 by both parent and observer. There
was a strong correlation between the scores by the
observer and the parents (Spearman's rank correla-
tion coef®cient 0.84, P<0.01). Subdivision of the
scores showed that the verbal scores correlated most
highly (r2 � 0.88). Facial scores also correlated
highly (r2 � 0.83) with body movement showing
the poorest correlation (r2 � 0.65). The scores and
correlation are shown in Figure 1.
On 72 occasions, parents recorded scores before
and 30 min after administration of analgesia. The
scores recorded before analgesia (2.93 � 1.57)
(mean � SD) were signi®cantly higher than the
scores recorded following analgesia (0.99 � 1.32)
(Student's paired t-test P<0.0001) (Figure 2).
Pain scale 0 1 2
Verbal scoreIf child is sleeping, put `S' ¢No pain¢ `It hurts a little bit' `It hurts a lot'If child is unable to tell you
about their pain, put `X'`Small hurt' `Medium hurt'
`Ow, ouch'Moaning, groaning
Facial expression scoreHappy Frowning UpsetSmiling Grimacing Crying because
of painNo frowning Eyes screwed upNo crying Unhappy face
Body movement scoreSettled Restless Very uncomfortableNormal movement Shifting Holding sore partComfortable A little uncomfortable
Table 1Pain scale
450 J . MORGAN ET AL .
Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452
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Nine children consistently scored 0 while at home.
Twenty-nine children, however, experienced pain
with at least one positive pain score following
discharge. Twenty-one children received a score of
3 or more on at least one occasion following
discharge. Three children received the maximum
score of 6 on one occasion following discharge.
Discussion
In most situations, pain is an essential part of normal
life. Postoperative pain, however, serves no useful
function and therefore administration of analgesia is
aimed at reducing this pain to a minimum. It is not
possible to eliminate all pain, but it is possible to
minimize the pain. Several groups have previously
raised their concerns that the management of pain
following daycase surgery or discharge from hospi-
tal is poor (1±3). Our ®ndings are in agreement
suggesting that improvements can be made. The
majority of children following discharge experi-
enced some degree of pain.
The pain scale currently used by the nursing staff
on the ward for the assessment of postoperative pain
has not been formally validated. This is the situation
in many hospitals where a pain scale is used in order
to encourage the documentation of pain and hope-
fully the alleviation of pain. The current policy in
our hospital is that if a child scores positive on the
pain scale, then they receive analgesia. For a pain
assessment tool to be used by any observer, it must
be proven to be reliable in the circumstances in
which it is to be applied. The study found a strong
positive correlation between the assessment of pain
using this pain scale by a medical student and the
parents, which provides preliminary evidence for
the reliability of the scale when used by parents.
Construct validity of the pain scale is suggested by
the falling scores following the administration of
analgesia.
Others have questioned the ability of parents to
assess children's pain and, in particular, have felt that
they underestimate the degree of pain (10). Other
groups have shown the value of involving parents in
the assessment of pain using either visual analogue
scores (6,7) or even a speci®c pain scale devised for
the use of parents (8). Some of these studies excluded
children under the age of 6 years whereas others
included children aged 2±12 years (6,7,9).
Because we were interested in whether parents
can accurately assess pain in young children, we did
not include instructions for actions following assess-
ment by parents. The parents in this study received
different advice from different anaesthetists follow-
ing a variety of surgical procedures. Some were
advised to give analgesia on a regular basis, whereas
others were advised to administer analgesia if
required. One group has suggested that, even when
parents recognize that their child is in pain, they
give inadequate analgesia to control the pain (7).
Our results suggest that the use of a simple pain
Figure 1Comparison of parent and observer scores. The solid linerepresents a linear regression relationship between parents' andobserver's scores, with the number of datapoints also indicated ifgreater than one.
6
Mea
n sc
ore
Postanalgesia
1
5
4
3
2
Preanalgesia
Figure 2Mean scores before and after administration of analgesia (� SEM).
PARENTAL PAIN ASSESSMENT 451
Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452
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scale with instructions to administer analgesia if any
of the features of pain are present could be utilized
to improve the management of pain following
discharge from hospital in young children undergo-
ing surgery. Pain assessment is particularly dif®cult
in young children. Further research needs to be
carried out involving parents in improving the
assessment and management of pain in this age
group.
References
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2 Wolf AR. Tears at bedtime: a pitfall of extending paediatricday case surgery without extending analgesia. Editorial II. Br JAnaesth 1999; 82: 319±320.
3 Jolliffe DM. An audit of paediatric day care surgery in adistrict general hospital. Paed Anaesth 1997; 7: 317±323.
4 Beyer JE. Key issues surrounding the assessment of pain inchildren. Paed Perinatal Drug Ther 1998; 2: 3±13.
5 Tarbell SE, Cohen IT, Marsh JL. The Toddler-PreschoolerPostoperative Pain Scale: an observation scale for measuringpostoperative pain in children aged 1±5. Preliminary report.Pain 1992; 50: 273±280.
6 Wilson GAM, Doyle E. Validation of three paediatricpain scores for use by parents. Anaesthesiology 1996; 51:1005±1007.
7 Finley GA, McGrath PJ, Forward SP et al. Parents' manage-ment of children's pain following `minor' surgery. Pain 1996;64: 83±87.
8 Chambers CT, Reid GJ, McGrath PJ et al. Development andpreliminary validation of a postoperative pain measure forparents. Pain 1996; 68: 307±313.
9 Romsing J. Postoperative pain in children after day casesurgery. Children's and parents' ratings. Eur Hosp Pharm 1996;2: 21±23.
10 Bellman MH, Paley CE. Parents underestimate children's pain.BMJ 1993; 307: 1563.
Accepted 15 November 2000
452 J. MORGAN ET AL .
Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452