Assessment of pain by parents in young childrenfollowing surgery

JOANNA MORGAN B MB M e d Se d S c ic i * , VANESSA PEDEN B SB S cc* ,

KANTA BHASKAR*, MAIR VATER M B B CM B B C hh ,, F R C AF R C A  AND

IMTI CHOONARA M BM B CC hh B , M DB , M D*

*Academic Division of Child Health, University of Nottingham, Derbyshire Children's Hospitaland  Department of Anaesthesia, Derbyshire Children's Hospital, Derby, UK

SummaryBackground: We asked parents to assess pain in young children

following surgery.

Methods: Assessments were carried out by both parents and an

independent assessor using a behavioural observational scale.

Results: Forms were returned from the parents of 42 children aged

1±5 years. There were 123 joint assessments and there was a strong

correlation between the scores by the observer and the parents

(r2 � 0.84). Twenty-nine children experienced pain following

discharge from hospital.

Conclusions: Our ®ndings suggest that parents can assess pain in

young children following surgery. The management of pain following

discharge from hospital can be improved.

Keywords: analgesia; postoperative; assessment; parents;

young children

Introduction

The management of pain in infants and children in

hospital is far from satisfactory. There have been

major advances recently in the management of pain in

children in hospital by the establishment of paediatric

pain teams. More surgery is, however, being carried out

as daycase surgery and there is concern that the

management of pain in children following such surgery

and particularly after discharge is suboptimal (1±3).

In order to try and improve the management of

pain, it is essential that pain can be accurately

assessed. We were particularly interested in young

children in whom pain assessment is more dif®cult

(4). The Toddler-Preschooler Postoperative Pain

Scale (TPPPS) has been validated for use in children

aged 1±5 years following surgery (5). It is an obser-

vational scale, with the observer awarding scores for

each of seven pain behaviours observed during a

5-min period. The three aspects of the expression of

pain include verbal, facial and body movement. We

were interested in the ability of parents to assess

pain in their children and felt the TPPPS may be too

complex to use. We therefore used a simple pain

scale which incorporated the three main aspects of

the TPPPS, i.e. verbal, facial expression and body

movement, then modi®ed it into a 3-point scale

where 0 represented no pain, 2 represented consid-

erable pain and 1 represented the presence of mild to

moderate pain (Table 1).

Correspondence to: Imti Choonara, Academic Division of ChildHealth, University of Nottingham, Derbyshire Children's Hospi-tal, Uttoxeter Road, Derby DE22 3NE, UK (e-mail: imti.choonara@nottingham.ac.uk).

Paediatric Anaesthesia 2001 11: 449±452

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Several groups have carried out preliminary

studies showing that parents can play a role in the

assessment of pain in children (6±9). These studies

have involved older children and we wished to

evaluate whether parents can play a role in the

assessment of pain in young children following

surgical intervention.

Methods

Children between the ages of 12 months and 6 years

who were undergoing a variety of elective surgery

(adenotonsillectomy, correction of squint, hernia

repair, orchidopexy) as a daycase or with an antici-

pated overnight stay in hospital were considered for

the study. Their parents were approached for their

written informed consent. The study was approved

by the Southern Derbyshire Ethics Committee. Par-

ents were asked to use a pain scale which is in

current use in the hospital for the assessment of pain

and nursing staff have found simple to use (Table 1).

The score could range from 0 (no pain) to a

maximum of 6 (severe pain). The medical student

(JM) was taught the pain scale by the two research

nurses (VP, KB) who have considerable experience

in pain assessment in young children. The parents

were explained the nature of the scale by the medical

student, how to use it and were asked to carry out

pain assessments hourly until their child was dis-

charged from hospital. Once the patients were at

home the parents were asked to record scores: (i)

twice on the evening of discharge; (ii) three times the

following day; (iii) before and 30 min after admin-

istering analgesia; and (iv) if the child woke up

during the night. The parents were asked to return

the assessment forms in a stamped addressed

envelope. The medical student also carried out

independent assessments at the same time as their

parents while the children were in hospital.

Results

Fifty children were recruited into the study. The ages

of the children ranged from 1±5.9 years (median

4.1 years). Forms were returned from the parents of

42 children. In four cases, this only included parental

assessment of pain when the child was in hospital.

There were 123 assessments by the parent and the

observer simultaneously. Sixty-®ve of these assess-

ments scored 0 by both parent and observer. There

was a strong correlation between the scores by the

observer and the parents (Spearman's rank correla-

tion coef®cient 0.84, P<0.01). Subdivision of the

scores showed that the verbal scores correlated most

highly (r2 � 0.88). Facial scores also correlated

highly (r2 � 0.83) with body movement showing

the poorest correlation (r2 � 0.65). The scores and

correlation are shown in Figure 1.

On 72 occasions, parents recorded scores before

and 30 min after administration of analgesia. The

scores recorded before analgesia (2.93 � 1.57)

(mean � SD) were signi®cantly higher than the

scores recorded following analgesia (0.99 � 1.32)

(Student's paired t-test P<0.0001) (Figure 2).

Pain scale 0 1 2

Verbal scoreIf child is sleeping, put `S' ¢No pain¢ `It hurts a little bit' `It hurts a lot'If child is unable to tell you

about their pain, put `X'`Small hurt' `Medium hurt'

`Ow, ouch'Moaning, groaning

Facial expression scoreHappy Frowning UpsetSmiling Grimacing Crying because

of painNo frowning Eyes screwed upNo crying Unhappy face

Body movement scoreSettled Restless Very uncomfortableNormal movement Shifting Holding sore partComfortable A little uncomfortable

Table 1Pain scale

450 J . MORGAN ET AL .

Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452

Nine children consistently scored 0 while at home.

Twenty-nine children, however, experienced pain

with at least one positive pain score following

discharge. Twenty-one children received a score of

3 or more on at least one occasion following

discharge. Three children received the maximum

score of 6 on one occasion following discharge.

Discussion

In most situations, pain is an essential part of normal

life. Postoperative pain, however, serves no useful

function and therefore administration of analgesia is

aimed at reducing this pain to a minimum. It is not

possible to eliminate all pain, but it is possible to

minimize the pain. Several groups have previously

raised their concerns that the management of pain

following daycase surgery or discharge from hospi-

tal is poor (1±3). Our ®ndings are in agreement

suggesting that improvements can be made. The

majority of children following discharge experi-

enced some degree of pain.

The pain scale currently used by the nursing staff

on the ward for the assessment of postoperative pain

has not been formally validated. This is the situation

in many hospitals where a pain scale is used in order

to encourage the documentation of pain and hope-

fully the alleviation of pain. The current policy in

our hospital is that if a child scores positive on the

pain scale, then they receive analgesia. For a pain

assessment tool to be used by any observer, it must

be proven to be reliable in the circumstances in

which it is to be applied. The study found a strong

positive correlation between the assessment of pain

using this pain scale by a medical student and the

parents, which provides preliminary evidence for

the reliability of the scale when used by parents.

Construct validity of the pain scale is suggested by

the falling scores following the administration of

analgesia.

Others have questioned the ability of parents to

assess children's pain and, in particular, have felt that

they underestimate the degree of pain (10). Other

groups have shown the value of involving parents in

the assessment of pain using either visual analogue

scores (6,7) or even a speci®c pain scale devised for

the use of parents (8). Some of these studies excluded

children under the age of 6 years whereas others

included children aged 2±12 years (6,7,9).

Because we were interested in whether parents

can accurately assess pain in young children, we did

not include instructions for actions following assess-

ment by parents. The parents in this study received

different advice from different anaesthetists follow-

ing a variety of surgical procedures. Some were

advised to give analgesia on a regular basis, whereas

others were advised to administer analgesia if

required. One group has suggested that, even when

parents recognize that their child is in pain, they

give inadequate analgesia to control the pain (7).

Our results suggest that the use of a simple pain

Figure 1Comparison of parent and observer scores. The solid linerepresents a linear regression relationship between parents' andobserver's scores, with the number of datapoints also indicated ifgreater than one.

6

Mea

n sc

ore

Postanalgesia

1

5

4

3

2

Preanalgesia

Figure 2Mean scores before and after administration of analgesia (� SEM).

PARENTAL PAIN ASSESSMENT 451

Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452

scale with instructions to administer analgesia if any

of the features of pain are present could be utilized

to improve the management of pain following

discharge from hospital in young children undergo-

ing surgery. Pain assessment is particularly dif®cult

in young children. Further research needs to be

carried out involving parents in improving the

assessment and management of pain in this age

group.

References

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Accepted 15 November 2000

452 J. MORGAN ET AL .

Ó 2001 Blackwell Science Ltd, Paediatric Anaesthesia, 11, 449±452