Study: persistent pain still common in hospitalized children

July 3, 2012, Johns Hopkins University

(Medical Xpress) -- Despite advances in the understanding and treatment of pediatric pain, many hospitalized children continue to experience serious pain, according to a Johns Hopkins Children’s Center study published online ahead of print in the journal Pain Management Nursing.

The research — a survey and medical chart review of 199 patients, aged seven days to 21 years, treated at Johns Hopkins between 2007 and 2008 — found that 86 percent of the children experienced pain. For 40 percent of them, the pain was moderate or severe. The study revealed that most patients received appropriate and timely therapy, but that even with aggressive treatment, some children continued to experience persistent pain.

“This study was designed as a pulse check to gauge our own progress,” says lead investigator Lori Kozlowksi, R.N., M.S., C.P.N.P., a pediatric pain specialist at Hopkins Children’s Center. “Our verdict is that while we’ve made tremendous strides, there’s still work to be done.”

The researchers say their findings reflect the need for improvements even in hospitals with a long tradition in pediatric pain care, such as Johns Hopkins Children’s Center, which has had a pediatric pain service since 1991 and a legacy of research in pediatric pain management.

Although some of the shortcomings noted in the study reflect the need to better understand pain in children, others point to the need for more effective treatment protocols, the researchers say. The results are likely relevant to other pediatric hospitals, and should be heeded as a call to action by clinicians everywhere, the Hopkins team say.

Previous studies show that intense pain during infancy and childhood can create an exaggerated response to pain and make people more sensitive to pain for life. Research also shows that untreated or undertreated pain can exacerbate injury, delay healing, make people more prone to infection and, in rare cases, increase the risk of death.

“Pain is the fifth vital sign which, together with blood pressure, heart rate, breathing and temperature, can provide important clues about a patient’s wellbeing,” says senior investigator Constance Monitto, M.D., a pediatric anesthesiologist at Hopkins Children’s Center.

“Treating a child in pain is a fundamental responsibility of every physician and nurse,” she adds.

Specific goals for better pain management identified in the Hopkins study include reducing the overall number of hospitalized children who experience pain, understanding why some children experience disproportionately worse pain, and improving pain treatment among those with persistent pain that defies conventional treatment.

In the meantime, physicians and nurses can take some basic steps to ensure timely and appropriate pain therapy, the Hopkins team says. These include taking the time to talk to patients and involving parents in the assessment and treatment of a child by using their insight into the child’s behavior and idiosyncrasies. Another step is factoring in gender, age and individual patient differences.

Other findings:

  • Children undergoing surgery experienced pain more often and more intensely than nonsurgical patients
  • A small subset of children — such as children undergoing cancer treatment — continued to experience pain despite aggressive therapy
  • Girls reported higher pain scores than boys, even in same-age patients who underwent the same procedures — a finding that suggests hormonal and cultural differences may be at play
  • Older children, who self-reported their pain, had higher pain scores than infants, toddlers and children with developmental delays. The finding may reflect the less-than-perfect pain-scoring tools that physicians and nurses use to assess pain in very young and nonverbal children
  • Only one-third of the children who were prescribed opioids “as needed” actually received the medication, which suggests the patient’s “need” may not be always properly assessed, verbalized or conveyed to the health care team
  • Protocols that allow patients preemptive, around-the-clock access to pain medication should be favored over “as needed” treatment, a cumbersome practice that requires to contact a nurse or physician and request medication and can result in substantial delays or no treatment at all.
The research was funded by the Jacob and Hilda Blaustein Foundation and by the Richard J. Traystman endowed chair in pediatric anesthesiology, critical care and management.

Other investigators involved in the research were Sabine Kost-Byerly, M.D.; Elizabeth Colantuoni, Ph.D.; Carol B. Thompson, M.S., M.B.A.; Kelly Vasquenza, R.N., M.S., C.P.N.P.; Sharon Rothman, R.N., M.S., C.P.N.P.; Carol Billett, R.N., M.S., C.P.N.P.; Elizabeth White, R.N.; and Myron Yaster, M.D., all of Hopkins.

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