An evaluation of instruments for identifying acute pain among hospitalized pediatric patients: a systematic review protocol

Review question/objective The objectives of the review are to evaluate evidence on: the accuracy of self-report pain assessment tools; the accuracy of a bundled approach (combined self-report and behavioral/observational pain assessment tools) in identifying acute pain intensity among hospitalized pediatric patients between the ages of six and 15 years. More specifically, the review question is: Is a bundled self-report and behavioral pain assessment tool more accurate in identifying acute pain intensity among hospitalized children aged six to 15 years of age compared to a self-report pain assessment tool? Background Pain is a pervasive and complex phenomenon, a universal experience that is unique to each individual.1 The International Association for the Study of Pain defines pain as an unpleasant sensory and emotional experience.2 An individual's perception and response to pain is unique and depends on several factors including biological, psychological, and social factors.1 Further, there are two commonly accepted constants in relation to pain - pain is always subjective and always unpleasant.3 In children, assessing for the presence of pain is a challenge. Like adults, infants and children do experience pain yet pain in children is often under-treated.4 In the past, assumptions about the experience of pain in infancy were related to nervous system immaturity. Over the years, those assumptions have been proven wrong; healthy term neonates are able to respond to pain from birth.5 Despite the fact that pain in children has been studied for more than three decades, pain in hospitalized children continues to be underreported and hospitalized children continue to suffer due to inadequate pain control.5,6,7 Pain is estimated to impact 15-25% of children and adolescents.8,9 The most common types of pain experienced by children and adolescents are: headache, abdominal pain and musculoskeletal pain.9 In 2001, in the United States, the Joint Commission developed standards of care for pain management in hospitalized children and adults.10 Effectiveness of pain management is also an important concept evaluated via patient and family satisfaction surveys.10 Pain is also a symptom. Acute pain can indicate a worsening condition or signify the need for pain relieving interventions, such as distraction or the administration of analgesics.11 While clinicians are aware that pain occurs because of injury, illness or medical procedures and that pain is a common symptom experienced during hospitalization, identification of pain in children remains challenging. Accurate assessment is a key component of pain management. Even though several valid tools for rating pain intensity in children are available for use in clinical practice, none of these tools have been identified as the most suitable to use in all circumstances.12,13 This represents a practice gap. The ramifications of inconsistent pain assessment practices are significant; uncontrolled pain impacts a child's future experience with pain. Pain assessment Self-report pain assessment tools: Because pain is a subjective experience, self-reporting of pain is considered the gold standard. One strategy for describing pain is to quantify the pain intensity using a tool. In children, pain is difficult to quantify due to several child-related factors: the child's developmental level, the current medical condition, and the child's previous experience with pain.14 From a developmental perspective, to use a tool, a child needs to be able to classify, order, match and estimate. Developmentally these skills begin to emerge by the age of three to four years. Currently, several self-report pain assessment tools designed for children are available for use. For example, the Poker Chip tool (also known as the Pieces of Hurt tool)15, the Oucher scale16, and the Wong-Baker FACES scale17 are all reliable and valid tools that may be used on children as young as three to four years of age. For older children, numeric rating scales (NRS) and visual analog scales (VAS) may be used. Variations of VAS for use in children include the use of numbers or words to describe increasing pain intensity, as well as the use of a finger span scale. Pediatric self-report scales should be reasonably reliable and valid, developmentally and culturally appropriate, easy to use and understand, well-liked by patients and clinicians, inexpensive, easy to disinfect, and available with instructions in different languages.18 Behavioral/observational pain assessment tools: The two primary methods of behavioral assessment of pain are direct observation and ratings by others. Direct observation is the preferred method for assessing the rate and duration of pain while pain intensity can be assessed using a rating scale.11 Behavioral observation is primarily used to assess pain in children with limited verbal and cognitive skills. Key observations included in behavioral pain assessment tools include vocalization (crying and groaning), facial expression, body posture, rigidity, undue quietness, and an inability to be consoled. Examples of commonly used behavioral pain assessment tools are the Children's Hospital of Eastern Ontario Pain Scale (CHEOPS)19, the Faces, Legs, Activity, Cry, Consolability (FLACC)20 and the COMFORT Scale.21 An important conceptual issue related to behavioral assessment is specificity of the scales in measuring pain versus behavioral distress.11 Therefore it is important to consider the context of a child's behavior when using behavioral assessment tools to guide pain therapies. Use of combined self-report and behavioral pain assessment tools: In 2006, von Baeyer posited that self-reports of pain are an oversimplification of the complexity of the pain experience; there are many sources of bias and error in self-reports of pain.18 Because of this, self-report pain assessments in children should be considered along with other sources of information about the child's pain experience, such as direct observation, knowledge of the circumstances of the pain, and parent reports to ensure accurate assessment. The use of a combination of self-report and behavioral assessment (also known as a bundled approach) as a best practice is recommended, due to the fact that assessing pain in children can be complicated by anxiety, fear and stress.12,23 Contributing factors There are also other factors that are likely to contribute to inconsistent assessment of pain in children. For example, Melby identified inadequate assessment skills, failure to use available pain assessment tools, failure to listen to the child's report of pain, and a failure to use pharmacological and non-pharmacological interventions creatively as clinician-related factors that contribute to under-reporting of pain in children.12 Abu-Saad and Hamers identified a nurse's personal experience with pain as a source of influence on his/her response to assessment of a child's pain.24 Further in healthcare settings, there are no validated indicators of under-managed pain. Because of this, Twycross suggests that under-managed pain be viewed as an adverse event.25 The outcome measures of interest in the study include: the instrument used to identify pain, characteristics of the instrument, comparison of the variables assessed, and psychometric properties of the instruments including reliability and validity. Importance of this review In summary, pain is one of the most common symptoms that hospitalized children face. Over the last three decades, pediatric pain management has been a focus in pediatric acute care. Professional healthcare and hospital accrediting organizations have developed standards and regulations addressing pain management in children and adults. We also see pain relief as a factor being addressed in patient and family satisfaction surveys. Despite this, pediatric pain remains under-estimated and under-treated. Implications of this project include identification of best practice related to pain assessment for hospitalized children, which is a clinical practice priority. Two systematic reviews on pediatric pain assessment were identified in the literature.26,27 These reviews recommended pediatric pain tools, both self-report and observational, for use as outcome measures in clinical trials based on specified review criteria. Neither review addressed a bundled approach to assess pediatric pain. The proposed systematic review seeks to answer the question: is a bundled self-report and behavioral pain assessment tool more accurate in identifying acute pain intensity among hospitalized children aged six to 15 years compared to a self-report pain assessment tool?

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