Acute pain in pedatric patients : aspects of pain management and pain assessment

Despite advances in pain management, children's pain continue to be frequently unrecognized, dismissed and ineffectively managed while children are hospitalized. The overall purpose of this thesis was to evaluate and improve pain management and pain assessment among pediatric patients with acute pain. Children in all ages and their parents seeking care at an emergency department, children nursed at surgical wards and children from a rheumatology clinic at a university pediatric hospital were included in this thesis.

In order to evaluate efficacy and complications related to epidural analgesia (EDA) for postoperative pain, data from 518 epidural infusions in 476 children were analyzed retrospectively (study I). Epidural infusion for postoperative pain may provide effective pain relief with minimal complications for most children. Fairly high proportions of epidurals were removed earlier than planned because of inadequate pain relief This occurred predominantly in children having protracted surgery. In a randomized, controlled study, the equipotent doses and adverse effects of intravenous ketobemidone and morphine were compared (study II) in 54 children. Patient controlled analgesia (PCA) was used to manage post-surgical pain. The analgesic efficacy and frequency of adverse effects of ketobemidone and morphine were comparable when PCA was used for postoperative pain management in children.

Children (n=129) treated in the emergency room assessed their pain during procedure related treatments (study III). Parents and nurses also performed pain assessment of the children. Pain induced by procedures in the emergency room was unacceptably high. The nurses' assessment of the child's pain intensity was scored lower than the assessment of made by children and their parents. Procedures e.g. irrigation of inflamed foreskin (balanitis) and nail evulsion as well as administration of local anesthetics were judged as painful.

The applicability of pain descriptors on Pain-O-Meter (POM-WDS) for pain assessment in children with acute and chronic pain was evaluated (study IV). The majority of children knew most of the words presented, although younger children (age 6-11 years) knew fewer words than older children (age 2-16 years) did. Grinding was known by less than 50 % of the children in both age groups. Aching and sore were the most commonly used pain descriptors. The words included in POM-WDS provide health care personnel with a tool for assessing sensory and affective dimensions of pain in children. Further testing of validity and reliability of the instrument is needed.

Four years after the implementation of an Acute Pain Treatment Service, parents' expectation of their children's postoperative pain and their opinion of pain treatment had not changed and the majority of parents were satisfied with pain treatment (thesis). After implementation of an Acute Pain Treatment Service, more parents had received information about the pain treatment their child was going to have.

Continues epidural analgesia and patient controlled analgesia with ketobemidone provided safe and effective postoperative pain relief for most children. However, close monitoring is necessary. Children's self-report of pain has to be solicited and pain descriptors may give extended information about the child's experience of pain.

List of scientific papers

I. Jylli L, Lundeberg S, Olsson GL (2002). Retrospective evaluation of continuous epidural infusion for postoperative pain in children. Acta Anaesthesiol Scand. 46(6): 654-9.
https://pubmed.ncbi.nlm.nih.gov/12059887

II. Jylli L, Lundeberg S, Langius A, Olsson GL (2004). A comparison of ketobemidone and morphine using patient controlled analgesia for postoperative pain in children: a randomised double blind controlled study. Acta Anaesthesiol Scand. [Accepted]

III. Jylli L, Olsson GL (1995). Procedural pain in a paediatric surgical emergency unit. Acta Paediatr. 84(12): 1403-8.
https://pubmed.ncbi.nlm.nih.gov/8645959

IV. Jylli L, Brostrom E, Hagelberg S, Stenstrom CH, Olsson GL, Langius-Eklof A (2004). Sensory and affective components of pain as recorded with the Pain-O-Meter (POM) among children with acute and chronic pain. Acta Paediatr. [Manuscript]