Good Practice in Postoperative and Procedural Pain Management ...

In order to assess pain, effective communication shouldoccur between the child whenever feasible, their family orcarers, and the professionals in the multidisciplinary team.Standardized instruments should be used in their finalvalidated form. Even minor modifications alter the psychometricproperties of the tool and render comparisonsbetween studies invalid and clinical assessment biased.RecommendationsNo individual measure can be broadly recommended forpain assessment across all children or all contexts:Grade B (12–14).Children’s self-report of their pain, is the preferredapproach, where feasible: Grade B (13).An observational measure should be used in conjunctionwith self-report with 3–5 year olds as there is limited evidencefor the reliability and validity of self-report measuresof pain intensity in this age group: Grade B (15).Sole use of physiological measures in clinical practice isunproven and therefore not recommended: Grade D (16,17).EvidenceThe results of pain assessment must be documented,acted upon, reassessed, and re-evaluated to determinethe effectiveness of interventions (1,18–21). Improveddocumentation can result in improved pain management(22–25). Studies demonstrate that there is low utilizationof pain tools and policies (26) and that pain isunder-assessed (3,27) and poorly documented (28,29),resulting in children being under-medicated and/ortheir pain being poorly managed (3,27,30–32). Regularpain evaluation can contribute to the safety and efficacyof the management of acute pain (33).Self-report: Pain is a highly complex and multidimensionalexperience, and pain intensity scores are a necessaryoversimplification. Children’s self-report of pain isregarded as the gold standard, and in most circumstances,it is the preferred approach. Children’s selfreportof pain may differ to that of their parents or thenurse caring for them (34). However, it must also berecognized that self-report in both children and adultsis complex (13,35), dependent upon age and/or level ofcognition (36), affected by a range of social and otherinfluences (37–39), and is subject to biases (15,37,40).Nevertheless, although children’s subjective reports ofpain are probably the best way of documenting the presenceand intensity of pain, it requires quite advancedcognitive skills (including classification, seriation, andmatching) for children to be able to provide reliable andvalid self-reports of pain intensity. Faces scales may notrequire the ability to seriate or estimate quantitiesbecause the task can be handled by matching how onefeels to one of the faces, which is presumed to be easierthan quantitative estimation (41). However, self-reportis subject to individual response biases, reflecting theperson’s appraisal of the consequences of the pain report(36). Although children of preschool age are often askedto confirm or deny that they are feeling internal statessuch as hunger or thirst, they are rarely, if at all, askedto make quantitative estimates of these states. Thus,using a self-report pain scale is an unusual experiencefor most young children (15). Alternative strategies foranswering confusing questions are frequently adoptedby young children. Response bias is a propensity torespond systematically to test items in ways unrelated tothe item content. Response biases that have been documentedin the pediatric literature include:l Anchor effects which refer to the influence of surroundingconditions or prior experience on the estimationof a quantity. For example, pain ratings on facesscales are influenced by whether the lower anchor faceis smiling or not.l Sequence bias such as the child selecting (for example)the leftmost face to answer the first question, andthen picks the adjacent face to the right in response toeach successive question, in a sequence of responsesthat would be scored in an ascending or descendingseries (e.g., 0–2–4–6–8).l Giving the same answer to all questions (15,42–44).In experimental situations where children were askedto rate hypothetical pain situations, it has been demonstratedthat young children from four to seven cannotdistinguish as many faces as proposed by the majorityof available faces scales (45). These results stronglyrecommend a reduction in the number of response levelsof faces scales for pain assessment in children.It should be noted that not all inaccurate responsesindicate the occurrence of response biases as inaccurateresponses can occur for other reasons such as failureto understand the question, deliberate random orincorrect responding, lack of motivation and attentionto the task, or undetected learning or cognitive difficulties(15). Clinicians should be aware that young children’spain scores can be misleading, particularly whena pain scale is used only once to measure pain on asingle occasion, making it difficult for the clinician todetect any underlying response bias. Therefore, selfreportpain scores from children below 5 years of ageshould generally be treated with caution and should becorroborated by observational measures.ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79 11