Good Practice in Postoperative and Procedural Pain Management ...

Choice of assessment tool: No individual observational(14), self-report (13), or physiological measure isbroadly recommended for pain assessment across allchildren or all contexts. Some validated pain measures,primarily developed for use within pain research studies,do not transition easily in everyday practice as they canbe challenging to use in clinical settings (46). Therefore,healthcare professionals need to make informed choicesabout which tool to use to assess each individual child’spain. Composite measures using self-report and at leastone other measure may be a better approach (13).Table 3 provides guidance, as a function of a child’schronological age, on measures that have good psychometricproperties and can be used for the assessment ofprocedural and postoperative pain.Education: Healthcare professionals require appropriatelevels of education about pain (27,47–49). They alsoneed adequate training/preparation in the use of painassessment tools and proficiency in using them(23,50,51). Improved working practices (52), organizationalcommitment (23), quality improvement strategies(23), and one-to-one coaching (53) have been shown toenhance pain assessment. Studies have demonstratedthat health professionals’ assessment of children’s painis subject to a range of individual, social, and contextualinfluences (54–57). Professionals need to be flexible andwilling to develop more positive attitudes and beliefsregarding the attributes of children’s pain (19). Perceptionsabout the pain experienced by particular groups ofchildren, such as children with neurological impairmentmay need to be challenged (58,59).Parents and other carers should also be given appropriateinformation about their child’s pain (55,60–62)and emotional support and clarification of their role intheir child’s pain (61,63). Their beliefs about theirchild’s pain need to be taken into consideration asthese beliefs may impact their child’s care. Parents/Table 2 Recommended measures for procedural and postoperativepain assessment as a function of the child’s chronological ageChild’s age*MeasureNewborn–3 years oldCOMFORT or FLACC4 years old FPS-R +COMFORT or FLACC5–7 years old FPS-R7 years old + VAS or NRS or FPS-R*with normal or assumed normal cognitive developmentNote: Reliance on chronological age as the sole indicator of achild’s capacity to self-report will inevitably generate both falsepositives (invalid scores from children who do not understandthe scale) and false negatives (not obtaining valid scores fromchildren who do understand the scale but were not asked).carers of children with cognitive impairment may havemistaken beliefs about their child’s pain, which need tobe carefully explored (59). Parents/carers also needappropriate information and teaching in the use ofpain assessment tools if they are to be effective inassessing and managing their child’s pain (59,63,64).3.2 Pain measurement toolsA bewildering number of acute pain measurementtools exist. Tools vary in relation to three broadgroups of factors: child-related, user-related, and structural.For example, the age, cognitive level, language,ethnic/cultural background of the child, the setting forwhich they are to be used, and the tool’s psychometricproperties (e.g., validity and reliability) in that context(13,14,35,65–67). Such factors should be taken intoconsideration when making choices about which acutepain measurement tool to use.Despite the proliferation and availability of tools,they are not always used consistently or well (68–70)and inconsistencies have been identified betweenreported assessment practice and documented practice(3,26,27,29,71).The following provides a brief guide to some of thebest evaluated and commonly used tools in currentclinical practice. The tools are broadly divided intoself-report and observational/behavioral tools and thenfurther subdivided into their suitability for type of pain(acute procedural, postoperative, or disease-related)and/or setting. Brief information of the intended ageranges for which the tool has been developed and/orinformation on the ages for which the tool has beenvalidated are presented (look at the data extractiontables for more information on each measure’s psychometricproperties and relevant studies).3.2.1 Self-report tools (5 years and above)The most psychometrically sound and feasible selfreporttools, based on age/developmental level and typeof pain, have been recommended for use in clinical trials(marked * below) (13). However, other tools, while notnecessarily suitable for clinical trials, have been shownto have good clinical utility and have been validated.Procedural painl Wong and Baker FACES Pain Scale (72): intendedfor 3–18 year olds.l Faces Pain Scale-Revised* (44): see also (43,73):intended for 4–12 year olds.12 ª 2012 Blackwell Publishing Ltd, Pediatric Anesthesia, 22 (Suppl. 1), 1–79