Pediatric Anesthesia 2008

18: 412419

doi:10.1111/j.1460-9592.2008.02458.x

Procedural pain and distress in young children as perceived by medical and nursing staff
F R A N Z E . B A B L M D M P H F R A C P F A A P , C H R IS T IN E MANDRAWA BSC, RONAN OSULLIVAN MB FRCSI A N D D I A N N E C R E LL I N R N B N M N N P
FCEM

Emergency Department, Royal Childrens Hospital, Murdoch Childrens Research Institute and University of Melbourne, Melbourne, Australia

Summary
Introduction: Currently there is no comparison of pain and distress experienced by young children undergoing a range of procedures. This would be important when considering choices between alternative management approaches and to facilitate development of measures to reduce procedural pain and distress. We set out to determine staff perceptions of pain and distress across a range of common emergency procedures. Methods: Standardised survey of medical and nursing staff in the emergency department (ED) of a large urban tertiary childrens hospital. Staff perceptions of pain and distress of common ED procedures were measured using a 10 cm visual analogue scale. It included 15 common ED procedures, ranging from suprapubic aspiration (SPA) to measurement of oxygen saturation when performed in a child aged 1218 months. It included four trauma related procedures. Respondents were stratied by their experience level with the procedures (50 procedures or less = less experienced, greater than 50 procedures = more experienced). Results: Ninety-two of 150 medical and nursing staff in the ED (61%) responded including almost all full time staff. Twenty-one percent of respondents were senior nurses, 17% senior physicians. The procedure considered the most painful was SPA [5.7 (4.07.2)cm]; as well as intramuscular injection (IMI) and lumbar puncture (LP). The procedures considered the most distressing were nasogastric tube (NGT) insertion [7.8(6.68.7)cm] as well as i.v. insertion and LP. All procedures were rated overall as more distressing than painful. Pain and distress were overall rated similarly regardless of staff experience level. Conclusions: SPA, IMI and LP are perceived by emergency staff as most painful and NGT insertion, i.v. insertion and LP are perceived as most distressing. These ndings are important for clinicians when choosing alternative treatment strategies and for researchers in planning future investigations to reduce procedural pain and distress. Keywords: pain; distress; child; procedure; emergency department
Correspondence to: F.E. Babl, MD, MPH, FRACP, FAAP, Paediatric Emergency Physician, Clinical Associate Professor, Emergency Department, Royal Childrens Hospital, Parkville, Vic. 3052, Australia (email: franz.babl@rch.org.au). 2008 The Authors Journal compilation 2008 Blackwell Publishing Ltd

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Introduction
Studies have shown inadequate pain management in the emergency department (ED), particularly in the pediatric ED (13). Children undergo many painful procedures both in the ED (4,5) and in inpatient settings (6,7). To reduce pain and distress in individual procedures, it would be important not only to accurately measure pain and distress (810) but also to compare between procedures as some can be used alternatively: urinary specimens can be obtained by catheter or suprapubic aspiration (SPA); rehydration can be achieved intravenously or by nasogastric intubation. This is a particular issue in preverbal and early verbal children, who require a high number and large variety of procedures and are unable to verbalize their pain and distress. When adult ED patients and clinicians were asked to rate pain on a visual analogue scale (VAS), nasogastric tube (NGT) insertion was rated as more painful than other common procedures such as incision and drainage of an abscess, fracture reduction and urethral catheterization (11). Yet, currently no similar comparison data are available in children to create a hierarchy of procedural pain and distress. The primary objective of our study was to determine staff perceptions of pain and distress during common procedures in young children at a large pediatric emergency department using observer VAS scales. Secondary objectives were to determine the impact of staff experience level on staff perceptions of pain and distress.

The piloted survey was distributed directly to all medical and nursing staff in the ED during a onemonth period (February 2007). There are approximately 100 nurses and 50 doctors working full-time, part-time or on a sessional or locum basis in the ED. Respondents were asked to detail their position in the department.

Outcome measures
Staff perceptions of the pain and distress experienced during common ED procedures were measured on a 10 cm VAS scale as described in the Appendix. VAS scales were also used in a previous study of patient and practitioner assessment of pain in commonly performed ED procedures in adults (11). The VAS scale is ideally used to self-report pain but has also been used to measure pain and distress in children by an observer (12,13). Clinicians were asked to assess the pain and distress of each procedure using their usual procedural practice e.g. use of topical anesthesia. Eutectic mixture of lignocaine and prilocaine (EMLA) and adrenaline, lignocaine, and amethocaine (ALA) are frequently used for intact skin and wounds respectively. Fifteen common ED procedures were investigated (Appendix). Staff were also asked to indicate how often they had participated in each procedure and whether they routinely used topical anesthesia where this is a management option (Appendix).

Data management and statistical analysis

The survey results were entered into an EpiData 3.1 (The Epidata Association, Odense, Denmark) database and analyzed using Stata Intercooled 9.0 (Stata Corporation, College Station, TX, USA). Respondents who had not witnessed or participated in a certain procedure were excluded from analysis. Pain and distress data were often not normally distributed. When simple transformations were attempted (such as a log transformation) to make the data normally distributed, many values were missing (because of a pain or distress score of 0.0) or the transformation did not assist data distribution. We therefore present median pain and distress scores with interquartile ranges (IQR).

Methods Study design and setting

The questionnaire was a standardized anonymous survey (Appendix) completed by medical and nursing staff in the ED at the Royal Childrens Hospital (RCH), Melbourne, Australia. The ED at RCH, a free standing tertiary childrens hospital, has an annual census of 56 000 and is the only pediatric trauma centre for the state of Victoria (population of 5 million). This study was approved by the hospital ethics committee.

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Data were stratied by experience of the respondents (50 procedures or less = less experienced; greater than 50 procedures = very experienced) irrespective of status as a nurse or doctor. Finally, we compared pain and distress assessments by levels of experience. VAS scores were dichotomized at the median and very experienced and less experienced staff were compared using odds ratios. The level of statistical signicance for all statistical tests was set at P = 0.05.

Results
There were 92 survey respondents in total. With the estimated 150 medical and nursing staff in the ED (including part-time, sessional and casual), response rate was 61% overall, 85% excluding casual staff and 100% of senior medical and nursing staff (Table 1). Twenty-one percent of respondents were senior nurses and 17% senior physicians. All procedures were widely used by the respondents (Table 2). Respondents used topical anesthesia for i.v. insertion (98.8%), lumbar puncture (LP) (88.7%), SPA (63.0%), urethral catheterisation (21.2%), intramuscular injection (IMI) (14.3%) and NGT insertion (9.5%). Staff perceptions for pain and distress for individual procedures are presented as median, range and IQR in Table 2. Staff responses were only included in the analysis if they had at least seen or performed a certain procedure once. The most painful procedures were SPA [5.7 (4.07.2)cm] as well as IMI and LP. The most distressing procedures were NGT insertion [7.8(6.68.7)cm] as well as i.v. insertion and LP. All procedures were rated by staff as more distressing than painful. As expected, some painless procedures such as administration of a

metered dose inhaler (MDI) or nebuliser had very low median pain scores with relatively high distress scores. Respondents were stratied by their experience level with the procedures (50 procedures or less = less experienced; greater than 50 procedures = very experienced) and excluding staff who had not participated in a certain procedure (Table 2). We compared pain and distress scores of less experienced and very experienced staff for the 15 procedures (see Methods). Pain and distress assessments by experience level were only statistically different in 5 of the 30 comparisons (data not shown). Procedures with higher pain or distress scores in particular were strikingly similar between the two groups. More experienced staff judged the distress of NGT insertion higher [OR 2.7 (1.07.2), P = 0.03], the pain of gluing of lacerations [OR 0.4 (0.11.0), P = 0.03] and suture removal lower [OR 0.2 (0.10.6), P < 0.01], and blood pressure measurement more painful [OR 2.7 (1.08.0), P = 0.03] and less distressing [OR 3.3 (1.29.6), P = 0.01] than their less experienced colleagues; however, in no cases did the measured differences in median VAS scores exceed 1.2 cm.

Discussion
This is the rst study to develop a hierarchy of the measure of pain and distress for common pediatric procedures in young children as perceived by ED staff. Although self-report of pain would be ideal (9,14) this is not possible in preverbal and early verbal children, the age group most likely to experience a painful procedure in the ED. Parents will usually not be familiar with a range of procedures or have witnessed the same procedure repeatedly. Scores based on staff perceptions of pain and distress behaviors in young children are poorly validated for procedural use (9) and in older children parents and practitioners have been found to be poor judges of childrens pain (10,12). Even considering these limitations, our data indicate that ED doctors and nurses were able to differentiate between pain and distress and that they perceive all ED procedures to be more distressing than painful in young children. The procedure considered the most painful was SPA, followed by IMI and LP. The most distressing procedure was NGT

Table 1 Demographics of respondents to pain and distress questionnaire Staff member Associate Unit Manager Clinical Nurse Specialist Registered nurse Consultant Fellow Registrar Junior Senior Resident Total Respondents, n (%) 9 (10%) 10 (11%) 33 (36%) 13 (14%) 3 (3%) 14 (15%) 10 (11%) 92 (100)

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Table 2 Staff assessment of pain and distress of common ED procedures by VAS scores (median, range, IQR); n = 92 Procedure Staff (Number) n > 1* Suprapubic aspiration Intramuscular injection Lumbar puncture Intravenous insertion Nasogastric tube insertion Urethral catheterisation Fracture reduction under N2O Plaster of Paris to undisplaced fracture Gluing of laceration Suture removal Measurement of blood pressure Administration of a nebulizer Administration of metered dose inhaler Cardiac monitoring Measurement of oxygen saturation 89 91 90 90 89 88 79 88 89 81 90 90 91 90 92 n > 50** 44 53 50 73 55 59 36 57 59 48 60 57 70 55 76 VAS score (median, range [IQR]) Pain 5.7, 1.210.0 [4.07.2] 5.6, 0.610.0 [4.17.6] 5.4, 0.710.0 [3.47.3] 5.2, 0.310.0 [4.16.8] 4.6, 0.310.0 [2.56.8] 4.4, 0.810.0 [2.96.4] 3.8, 0.310.0 [2.36.0] 2.6, 0.17.9 [1.63.7] 2.2, 0.09.0 [1.23.4] 2.2, 0.09.3 [1.23.2] 1.9, 0.07.9 [0.92.9] 0.3, 0.06.2 [0.11.0] 0.3, 0.05.3 [0.10.9] 0.3, 0.04.6 [0.00.8] 0.2, 0.03.7 [0.00.4] Distress 6.6, 2.510.0 [5.08.0] 6.1, 0.410.0 [4.47.8] 7.1, 2.110.0 [5.38.3] 7.3, 2.710.0 [5.68.1] 7.8, 2.810.0 [6.68.7] 6.6, 2.210.0 [5.18.3] 4.2, 0.910.0 [2.76.5] 3.7, 0.59.8 [2.85.3] 5.0, 0.69.7 [2.66.1] 4.3, 0.79.7 [2.95.8] 3.8, 0.19.4 [2.65.4] 5.9, 1.510.0 [4.27.4] 5.9, 0.510.0 [3.47.4] 2.4, 0.07.9 [1.43.7] 2.8, 0.07.8 [1.84.9]

N2O, nitrous oxide sedation; VAS, visual analogue scale; IQR, interquartile ranges, ED, emergency department. *Procedures seen or performed at least once by a staff member. **Procedures seen or performed more than 50 times by a staff member.

insertion followed by i.v. insertion and LP. In an observational study of a range of common adult emergency procedures NGT insertion was similarly perceived by both patients and by staff as the most painful procedure, followed by abscess drainage, fracture reduction and urinary catheterization (11). It is noteworthy that overall, perceptions of pain and distress during procedures in children in our study appear stable with increasing level of staff experience. Our data also allow comparisons of staff perceived pain and distress between procedures which could be used alternatively. Nebuliser and MDI medication administration were perceived by staff as equally distressing. The median score for the pain caused by SPA was 1.3 cm greater than that for urinary catheterization; however, distress scores were identical. Comparing NGT and i.v. insertion as two alternative methods for rehydration, we found the median pain score for i.v. insertion to be 0.6 cm greater than that for NGT, with the median distress score by comparison being 0.5 cm less for i.v. insertion. These comparisons will be of interest for clinicians as well as for researchers planning comparative trials of these modalities. Procedural pain and distress in children can be reduced through a number of interventions. In our

study, staff reported customarily using topical anesthesia for most SPAs, i.v. insertions and LP; however, not for NGT insertions, urethral catheterizations and IMI. For i.v. insertions and LP there is good evidence supporting the efcacy of this practice (1517). Results of studies on the efcacy of urethral lidocaine gel to reduce the pain of urinary catheterization have been mixed (18,19). There are no evidence-based topical interventions available in children to reduce the pain and distress of nasogastric tube insertion. A recent randomized placebo controlled trial of NGT insertion in adults showed a signicant reduction in pain scores after nebulization with lidocaine (20). Even efcacious topical anesthesia, however, will not alleviate the fear and anxiety of small children faced with strangers invading their personal space or the use of restraints during procedures. Judicious use of procedural sedation has been shown to be safe and efcacious in reducing pain and distress (21,22). Additionally, the role of nonpharmacologic techniques in alleviating pain and anxiety has been well documented. A recent Cochrane review (23) of these techniques for needle related procedural pain and distress in children and adolescents concluded that techniques such as distraction, hypnosis and several combined cognitive-behavioral interventions can be

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used successfully to reduce pain and distress. Although many of these techniques have been more extensively evaluated in pediatric oncology patients and in children with other recurrent painful conditions (2426), non-pharmacologic methods of pain and anxiety management have also been shown to play a complementary role in children undergoing painful procedures in the ED (16,27). The study has a number of limitations. Ideally, we would have had nurses and physicians directly score maximum pain and distress during actual procedures. Additionally, poor correlation of staff and patient assessments of pain has been discussed above. The ndings were also specically elicited for procedures in 1218 month old children. We chose a narrow age range as pain and distress behaviors and perceptions are likely to change with patient age. We chose the age range of 1218 months as they still require many of the invasive diagnostic tests of younger patients such as invasive urinary specimens and at the same time increasingly require injury related procedures such as laceration repair and fracture management. We excluded certain procedures also investigated by Singer et al (11) in adults such as abscess drainage or fracture reduction as they would almost invariably require deep sedation or general anesthesia in young children. The use of certain procedures over others, e.g. obtaining urine by SPA rather than by urinary catheter, the use of topical anesthesia as well as the seniority of staff in the department is to a degree site and medical system specic. However, all studied procedures were widely used by staff at the study site. Finally, practices surrounding procedures reect a tertiary pediatric centre and might not be generalisable to centers without specialist pediatric emergency staff. In conclusion, when comparing emergency staff perceptions of pain and distress across common procedures in young children, SPA, IMI and LP are perceived as the most painful and NGT insertion, i.v. insertion and LP are perceived as the most distressing. These ndings are important for clinicians when choosing alternative treatment strategies and for researchers in planning future investigations to reduce procedural pain and distress.

Acknowledgements
We acknowledge grant support from the Victor Smorgon Charitable Foundation, Melbourne, Australia.

References
1 Friedland LR, Pancioli AM, Duncan KM. Pediatric emergency department analgesic practice. Pediatr Emerg Care 1997; 13: 103106. 2 Alexander J, Manno M. Underuse of analgesia in very young pediatric patients with isolated painful injuries. Ann Emerg Med 2003; 41: 617622. 3 Petrack EM, Christopher NC, Kriwinsky J. Pain management in the emergency department: patterns of analgesic utilization. Pediatrics 1997; 99: 711714. 4 MacLean S, Opispo J, Young KD. The gap between pediatric emergency department procedural pain management treatments available and actual practice. Pediatr Emerg Care 2007; 23: 8793. 5 Magaret ND, Clark TA, Warden CR et al. Patient satisfaction in the emergency department a survey of pediatric patients and their parents. Acad Emerg Med 2002; 9: 13791388. 6 Cummings EA, Reid GJ, Finley GA et al. Prevalence and source of pain in pediatric inpatients. Pain 1996; 68: 2531. 7 Ellis JA, OConnor BV, Cappelli M et al. Pain in hospitalized pediatric patients: how are we doing?. Clin J Pain 2002; 18: 262 269. 8 Von Baeyer CL, Spagrud LJ. Systematic review of observational (behavioural) measures of pain for children and adolescents aged 318 years. Pain 2007; 127: 140150. 9 Crellin D, Sullivan TP, Babl FE et al. Analysis of the validation of existing behavioural pain and distress scales for use in the procedural setting. Pediatr Anesth 2007; 17: 720733. 10 Singer AJ, Gulla J, Thode HC Jr. Parents and practitioners are poor judges of young childrens pain severity. Acad Emerg Med 2002; 9: 609612. 11 Singer AJ, Richman PB, Kowalska A et al. Comparison of patient and practitioner assessments of pain from commonly performed emergency department procedures. Ann Emerg Med 1999; 33: 652658. 12 Kelly AM, Powell CV, Williams A. Parent visual analogue scale ratings of childrens pain do not reliably reect pain reported by child. Pediatr Emerg Care 2002; 18: 159162. 13 Humphrey GB, Boon CM, van Linden van den Heuvell GF et al. The occurrence of high levels of acute behavioral distress in children and adolescents undergoing routine venipunctures. Pediatrics 1992; 90: 8791. 14 Beyer JE, Wells N. The assessment of pain in children. Pediatr Clin North Am 1989; 36: 837854. 15 Zempsky WT, Cravero JP, American Academy of Pediatrics Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics 2004; 114: 13481356. 16 Young KD. Pediatric procedural pain. Ann Emerg Med 2005; 45: 160171. 17 Kaur G, Gupta P, Kumar A. A randomized trial of eutectic mixture of local anesthetics during lumbar puncture in newborns. Arch Pediatr Adolesc Med 2003; 157: 10651070.

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18 Gerard LL, Cooper CS, Duethman KS et al. Effectiveness of lidocaine lubricant for discomfort during pediatric urethral catheterization. J Urol 2003; 170(2 Pt 1): 564567. 19 Vaughan M, Paton EA, Bush A et al. Does lidocaine gel alleviate the pain of bladder catheterization in young children? A randomized, controlled trial. Pediatrics 2005; 116: 917920. 20 Cullen L, Taylor D, Taylor S et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med 2004; 44: 131137. 21 Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006; 9512: 766780. 22 Babl FE, Oakley E, Seaman C et al. High concentration nitrous oxide for procedural sedation in children: adverse events and depth of sedation. Pediatrics 2008; 121: e528e532. 23 Uman LS, Chambers CT, McGrath PJ et al. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database of Syst Rev 2006, Issue 4. Art. No.: CD005179. DOI: 10.1002 14651858.CD005179. pub2.

24 Kuttner L, Bowman M, Teasdale M. Psychological treatment of distress, pain, and anxiety for young children with cancer. J Dev Behav Pediatr 1988; 9: 374381. 25 Zeltzer L, LeBaron S. Hypnosis and non-hypnotic techniques for reduction of pain and anxiety during painful procedures in children and adolescents with cancer. J Pediatr 1982; 101: 1032 1035. 26 Ball TM, Shapiro DE, Monheim CJ et al. A pilot study of the use of guided imagery for the treatment of recurrent abdominal pain in children. Clin Pediatr (Phila) 2003; 42: 527 532. 27 Sinha M, Christopher N, Fenn R et al. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics 2006; 117: 11621168.

Accepted 23 November 2007

Appendix

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2. How painful or distressing do you judge procedures to be in an average 12 to 18 month old child who has NOT had the procedure done before?
Procedure (using your usual practice e.g. EMLA, ALA etc) Measuring oxygen saturation Administration of metered dose inhaler (MDI) Administration of a nebuliser Insertion of an IV How many times have you seen or done this procedure in a child? (please
circle)

Grade maximum pain

in an average 12 to 18 month old child who has NOT had the procedure done before (please mark each line with an X)

Grade maximum distress

in an average 12 to 18 month old child who has NOT had the procedure done before (please mark each line with an X)

0 110

1150 >50

No pain

Most pain

No distress

Most distress

0 110

1150 >50

No pain

Most pain

No distress

Most distress

0 110

1150 >50

No pain

Most pain

No distress

Most distress

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Suprapubic aspiration

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Nasogastric tube insertion

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Cardiac monitoring (attachment of ECG leads) Measurement of blood pressure

0 110

1150 >50

No pain

Most pain

No distress

Most distress

0 110

1150 >50

No pain

Most pain

No distress

Most distress

How painful or distressing do you judge procedures to be in an average 12 to 18 month old child who has NOT had the procedure done before?
Procedure (using your usual practice e.g. EMLA, ALA etc)
Intramuscular injection

How many times have you seen or done this procedure in a child? (please
circle)

Grade maximum pain

in an average 12 to 18 month old child who has NOT had the procedure done before
(please mark each line with an X)

Grade maximum distress

in an average 12 to 18 month old child who has NOT had the procedure done before
(please mark each line with an X)

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Urethral catheterization

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Application of plaster (undisplaced fracture) Reduction of a fracture under nitrous oxide

0 110

1150 >50

No pain

Most pain

No distress

Most distress

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Lumbar puncture

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Suture removal

0 110

1150 >50

No pain

Most pain

No distress

Most distress

Gluing of laceration

0 110

1150 >50

No pain

Most pain

No distress

Most distress

V6 10.01.07

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2008 The Authors Journal compilation 2008 Blackwell Publishing Ltd, Pediatric Anesthesia, 18, 412419