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Revista chilena de pediatría

versão impressa ISSN 0370-4106

Rev. chil. pediatr. vol.89 no.1 Santiago fev. 2018

http://dx.doi.org/10.4067/S0370-41062018000100067 

ORIGINAL ARTICLE

Pain in children and adolescents hospitalized in a center of reference

C. ZuninoA  B 

M. NotejaneC 

M. BernadáD 

L. RodríguezE 

N. VanoliE 

M. RojasE 

L. BenechE 

I. MimbacasE 

A Pediatrician, Associate Professor of Pediatrics Department of Pediatrics. School of Medicine. Universidad de la República (UdelaR), Uruguay. Correspondence: careduzunino@gmail.com.

B Pediatric Hospital, Centro Hospitalario Pereira Rossell (HP-CHPR). Montevideo, Uruguay.

C Pediatrician, Pediatric Clinic Assistant. Pediatric Palliative Care Unit (PPCU). Department of Pediatrics. School of Medicine. UdelaR. HP-CHPR. Montevideo, Uruguay.

D Pediatrician, Associate Professor of Pediatrics, Coordinator of the PPCU. Department of Pediatrics. School of Medicine. UdelaR. HP-CHPR. Montevideo, Uruguay.

E Student of Medicine, Methodology II course. School of Medicine. UdelaR. Montevideo, Uruguay.

Abstract:

Introduction:

The evaluation and treatment of pain in hospitalized is still an important health pro blem.

Objective:

To know the prevalence, characteristics and approaches to pain management in children and adolescents hospitalized in the Pediatric Hospital of the Pereira Rossell Center (HP-CH- PR), a pediatric reference center in Uruguay.

Patients and Method:

Cross-sectional study, through survey and review of clinical records on 09/13/16. All hospitalized children under the age of 19 were included. Variables: age, gender, reason for admission, presence of cognitive disorder, the prevalen ce of pain at some time during hospitalization, in the last 24 hours and during the interview, cause of maximum pain, intensity, pharmacological and non-pharmacological treatment.

Results:

97.4% (152/156) hospitalized children were included. Pain prevalence at some point during hospitalization: 51.3% (78/152, 95% CI: 43.2-59.3); in the previous 24 hours: 39.5% (60/152, 95% CI: 31.7-47.2); during the interview: 15.8% (24/152, 95% CI: 10-21.5). Intensity: mild 13/24, moderate-severe 11/24. Maximum pain referred during hospitalization: needle punctures 48.5% (38/78). They had some analgesic prescription 47.3% of them had some analgesic prescription. Inadequate interdose inter val: 45.8%; adequate dose 98.9%; intravenous administration: 43.7%; contraindication to oral route: 40.5%.

Conclusions:

Regarding children and adolescents hospitalized, 39.5% reported pain 24 hours before being the interviewed and 15.8% reported pain during the interview. The maximum pain reported during hospitalization was due to needle punctures. Children in pain with inappropriate analgesic prescriptions are still detected.

Keywords: Pain management; analgesia; hospitalized child

Introduction

According to the International Association for the Study of Pain, this is an “unpleasant sensory and emo tional experience associated with actual or potential tis sue damage, or described in terms of such damage”1. It is challenging to identify and evaluate it in children due to the characteristics of their neuropsychological de velopment and their inability to express it verbally in the first years of life. However, this does not deny the possibility that they may be in pain and need an appro priate approach2. It is necessary for the healthcare team to recognize that different diseases, health conditions, treatments or diagnostic procedures can trigger pain, in order to detect it and treat it promptly. In addition, these situations cause anxiety, fear and even apprehen sion towards healthcare workers and, for their correct management, all their components must be conside red, including emotional, social and spiritual aspects3.

The importance of a correct assessment and treatment of pain is because this is one of the most fre quent symptoms of consultation in pediatrics4. Addi tionally, all children and adolescents have the right to receive adequate treatment and the healthcare team has the duty to be trained and to ensure quality care, avoiding unnecessary pain. “Pain management is a clinical act that requires the establishment of good clinical practices, and the lack of training can no longer be an excuse”5.

International publications note that despite efforts to improve care quality, the assessment and treatment of pain in hospitalized children is still a health problem6,7,8,9. There are studies in Uruguay that have identi fied the same problem10,11. In the Pediatric Hospital of Pereira Rossell Hospital Center (HP-CHPR), a national reference center of the public health subsector, a 34% of pain prevalence in hospitalized children was repor ted in 201110. In 2014, another national study, which included the same health center and other public and private institutions, found a similar prevalence11.

The objective is to know the prevalence, characte ristics, and practices of pain management in children and adolescents hospitalized in HP-CHPR intermedia te care units for one day.

Patients and Methods

A cross-sectional mixed method study was con ducted through a survey and review of clinical records on September 13, 2016. A single day was randomly selected to have a snapshot of the pain prevalence in hospitalized children and to avoid the bias of advanced audit knowledge that could change usual practices of the clinicians.

All children under the age of 19 hospitalized in intermediate care units were included: medical, sur gical, orthopedics, burn child unit and reconstructive surgery (UNIQUER) sectors, and the hemato-oncology sector of HP-CHPR. Patients who were unable to conduct the interview after three visits were excluded, as well as those who did not obtain informed consent from the caregivers or the child consent.

Information source

A survey and review of clinical records were con ducted.

It was considered a patient in pain when the child, adolescent or his or her caregiver reports feel or felt pain at the time of the interview, in the 24 hours be fore the interview or at some point during hospita lization. It was assessed the cause of maximum pain experienced during hospitalization (needle punctu res, procedures, postoperative period, treatments, others). In those patients who reported pain during the interview, the pain intensity was assessed using scales recommended by the World Health Organi zation (WHO), according to age and clinical condi tion of the child, applied by previously trained team members. In newborns, the scale NIPS (Neonatal Infants Pain Scale) was used12. For children between one month and three years of age, the FLACC scale (Face, Legs, Activity, Cry, Consolability) was used13. For children between three and eight years old, faces pain scale revised was used14. For those children over eight years of age, it was used the self-assessment vi sual analog scale for pain15. For children over three years of age, whose clinical record registered cogni tive disorder and were unable to respond to the fa ces pain scale, the r-FLACC scale (revised-FLACC) was used16. From the clinical record analysis, it was recorded: age (years, months), gender, weight (kg), presence of cognitive disorder, hospitalization sector (medicine, surgery, orthopedics, burn unit, hemato-oncology) and the reason for admission. The reason for admission was classified into: acute infectious disease, non-infectious disease, surgery or postope rative, social reasons, procedures or studies, trauma, burns. Pain management strategies (pharmacological and non-pharmacological) were recorded according to medical indications made in the last 24 hours. The pharmacological treatment was analyzed as dose, rou te of administration, contraindications to oral route, interdose interval, and adjuvant drugs. Drugs, doses, and interdose intervals used were compared with WHO recommended guidelines, as well as with those suggested by standard guidelines for the treatment of acute and persistent pain in pediatrics2,17,18,19. A data co llection sheet designed for the study was used which was tested in a pilot test.

Data analysis

The qualitative variables were expressed in absolute and relative percent frequencies, and the quantitative ones, in measures of central tendency and their ran ge. To compare proportions, the Chi-square test was used, considering significant p < 0.05. The statistical analysis was performed using IBM SPSS 20.0 statistical software for Windows.

Ethical considerations

This study was authorized by HP-CHPR manage ment and approved by the Medical School Research Ethics Committee of the University of the Republic. Informed consent was requested from caregivers (mother, father or guardian) and the consent of chil dren and adolescents. In order to ensure the care con tinuity, if the child or his or her caregiver referred pain during the interview, it was reported to the on-call healthcare team immediately.

Results

On the day of the study, 156 children and adoles cents were hospitalized, 152/156 (97.4%) of them were surveyed, two of them declined to participate and two were not in their rooms after three visits. The interview could be answered by the children and adolescents themselves in 24/152 (16%), in the rest of the inter views, the respondent was: the mother 100/152 (66%), the father 14/152 (9%), and another caregiver 14/152 (9%). Table 1 shows the characteristics of the children and adolescents included.

Table 1 Characteristics of children and adolescents included, hospitalized in a referral center in Uruguay. (n = 152). 

Pain prevalence reported at some point during hospitalization was 51.3% (78/152; CI 95%: 43.4%- 59.3%) and in the 24 hours before the interview, it was 39.5% (60/152; CI 95%: 31.7%-47.2%). The pain pre valence at the time of the interview was 15.8% (24/152; CI 95%: 10%-21.6%), 11/24 of them reported mode rate-severe pain.

Table 2 shows the pain prevalence in the included children according to their reason for hospitalization. There was no statistically significant difference between the presence of pain in patients admitted for surgical or potentially surgical reasons (surgery or postopera tive period, trauma, burns, procedures or studies) and those admitted for other reasons (acute infectious and non-infectious disease and social reasons) (p=0.25).

Table 2 Prevalence of pain regarding hospitalization reasons in children and adolescents admitted to a referral center in Uruguay. (n = 78). 

Out of the patients who reported pain at some point during hospitalization, 38/78 (48.5%) of them reported needle punctures such as intravenous acces ses and blood draw puncture as the cause of maximum pain, followed by other medical procedures (table 3).

Table 3 Causes of maximum pain reported during the stay in children and adolescents hospitalized in a national reference center in Uruguay. (n = 78). 

Out of the children who reported pain at the time of the interview, 14/24 had some analgesics prescrip tion. The most indicated analgesic was dipyrone or metamizole. Table 4 shows the analgesics prescribed in these children and adolescents according to the inten sity of pain reported.

Table 4 Analgesics prescribed to children and adolescents hospitalized in a referral center in Uruguay with pain during the in terview, according to the intensity of pain reported. (n = 24). 

With regard to analgesic prescriptions, suitable do sage indications were found in all of them, and ina dequate interdose interval in four out of 16 children, where the interval was “on demand” or “without sche dules”. The route of administration was intravenous in eight out of 16 patients. Four out of eight patients pre sented some contraindication to oral route (three due to vomiting and one due to immediate postoperative period).

Prescription of adjuvant drugs was found in one case (gabapentin). No record of indication of non pharmacological measures was found in any case.

Discussion

This study, which used similar operational defi nitions and methodology to previous studies, found that in children hospitalized in the HP-CHPR the pain prevalence in the last 24 hours and at the time of the interview did not vary from those reported previously. This represents a problem and a major challenge for both professionals who work directly with patients and the management team9,10,11. Despite the methodological heterogeneity of international research in this area, it is repeatedly pointed out that pain in hospitalized chil dren and adolescents is a complex health problem and that its approach is still a worldwide challenge6,7,8,9,10,11.

The literature reports that the most frequent cau ses of pain during hospitalization are surgical or po tentially surgical causes (surgery, postoperative period, trauma, burns, procedures or studies)6,8,9. However, no statistically significant differences between surgical and non-surgical causes of hospitalization were observed in this series. This may be related to multiple factors that could have acted as biases such as the period of the year in which the survey was conducted where hospitaliza tions due to acute infectious disease (acute lower respi ratory infections) predominated and the low number of children hospitalized for other reasons. It would be interesting to replicate this study at another time of the year and include more children hospitalized for surgi cal or other reasons.

When the children and their caregivers were asked about the cause of maximum pain during hospitali zation, both referred to medical punctures or proce dures as the most frequent cause. Friedrichsdorf et al had already documented this in a study conducted in the United States, where 40% of the hospitalized chil dren referred needle punctures and blood draws as the maximum or worst pain experienced during hospitalization7,20. It is necessary to establish action proto cols in order to avoid this cause of unnecessary pain, including the systematic use of local anesthetics and other non-pharmacological measures such as positio ning the child seated, maternal breast or oral sucralose in children under one year and distraction strategies according to age in all cases. Sometimes it is recom mended sedation and analgesia before punctures or procedures20.

Regarding the treatment of pain in the included children, it was detected the non-use of non-pharma cological strategies. However, the literature highlights the importance of a multimodal approach to pain. This involves the individualized combination of pharmaco logical strategies (non-opioid analgesics, opioids and adjuvant drugs) and non-pharmacological (psychothe rapy, guided breathing, aromatherapy, biofeedback, mindfulness, yoga, self-hypnosis, among others), and emphasizes its usefulness mainly by decreasing anxiety and fear, as well as being widely accepted by children and their families2,7,20,21.

Like previous national studies, children in pain du ring the interview were observed in this series, without any prescription for analgesics or with inadequate prescriptions. In addition, the route of administra tion of analgesics chosen still represents an aspect to be considered. In this series, half of the children who received intravenous analgesics have not contraindica tion to oral route. The WHO proposes, as one of its principles for an adequate analgesic prescription in children, the use of the oral route whenever possible. There are many reasons for this recommendation; in particular, the fact that children prefer it, the “fear” component of the oral route decreases, prevents ve nous access and potential complications, etc. To this date, the myth that the intravenous route is more effec tive than the oral one is still common among health professionals22,23. The intravenous route is safer in ca ses of digestive intolerance or diarrhea and achieves its therapeutic effect before the oral route, making it useful for the first dose in case of acute pain. However, in light of the results of this study, there is a need for wider dissemination and education about the WHO principles in order to prioritize, wherever possible, the use of the oral route for pharmacological treatment of pain in children, following these recommendations2.

Although the dose of the prescribed analgesics did not represent a problem in this series, indications of “on demand” analgesia were observed. In this regard, the WHO has also established as one of its principles the prescription of analgesic drugs “by the clock” and not “on demand”, “if suffer” or “if required”2. This phenomenon, which has already been reported in previous international and national publications, may have an adverse impact on the pain management of the child since it is necessary that the child or his or her caregivers recognize and express pain in order to trigger the mechanisms aimed at its control6,7,8,9,10. This, along with other reasons such as difficulty in determi ning the pain intensity, the lack of experience in the use of certain analgesics, not using non-pharmacological strategies, etc. could be at the base of what was found: patients who, despite having a prescription for analge sic, persisted with pain. This could also be related to the lack of a re-evaluation of the analgesic plan after the initial indication, with no possibility of necessary adjustment in the prescribed plan24. The objective of this study was not to assess these causes, although they would be of interest for further research.

With regard to prescribed analgesic drugs, it is wor th noting that dipyrone or metamizole was the most indicated, as reported in other national studies9,10. This fact is particularly different from that reported in other parts of the world, where the prescription of acetaminophen and ibuprofen predominate among non opioid analgesics following the WHO recommendations6,7,8,9,10. Low morphine use was also observed in chil dren with moderate-severe pain. National studies that explored the knowledge of resident physicians22,23 and nurses2 about opioids revealed significant deficiencies, and the existence of myths about morphine similar to those of the non-professional population that may be the basis of these findings which included: fear of respiratory depression, reserve it for terminally ill pa tients, fear of addiction, etc.22,23. Morphine is still the drug of choice according to WHO for the treatment of acute or persistent severe pain in children with medical conditions in both oncological and non-oncological patients, with extensive scientific evidence supporting its prescription and monitoring2,25,26,27.

In light of the repeated studies showing deficits in the detection and management of pain in the hospi tal center studied, it is essential to achieve consensus for a better care of children and adolescents in pain9,10. This implies the awareness and basic and continuous training of all professionals involved in the subject. Addressing this important health problem is a management challenge and requires a long-term institutio nal policy with the participation of all those involved: physicians, nurses, health managers, patients and their families21. The application of ISO 9001 Standards can be an effective method for integrating the different components of a well-organized multidisciplinary pro gram, including a quality manual, maps or flowcharts of care processes, procedures, quality indicators, and systematic records of all steps and processes28. Appro priate approach and monitoring of pain in children should be part of the skills and abilities of physicians and nurses and should be a goal of care for all health care institutions. This change in the care quality must necessarily include basic education and continuous updating of all health professionals involved. The con trol of pain is a human right that must be guaranteed29.

Conclusions

Out of the children and adolescents hospitalized in a national hospital of reference, 39.5% of them reported pain in the previous 24 hours and 15.8% during the survey.

The maximum pain reported during hospitaliza tion was due to needle punctures.

In the care center studied, children hospitalized in pain and without analgesic prescriptions or with errors according to WHO recommendations are still detected.

Ethical Responsibilities

Human Beings and animals protection: Disclosure the authors state that the procedures were followed ac cording to the Declaration of Helsinki and the World Medical Association regarding human experimenta tion developed for the medical community.

Data confidentiality: The authors state that they have followed the protocols of their Center and Local regu lations on the publication of patient data.

Rights to privacy and informed consent: The authors have obtained the informed consent of the patients and/or subjects referred to in the article. This docu ment is in the possession of the correspondence author.

Financial Disclosure: Authors state that no economic support has been asso ciated with the present study.

Conflicts of Interest: Authors declare no conflict of interest regarding the present study.

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Received: July 18, 2017; Accepted: October 30, 2017

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