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Special Issue on Pain in the Developing World (Guest Editor, Daniel Ciampi de Andrade)

An audit of paediatric pain prevalence, intensity, and treatment at a South African tertiary hospital

Velazquez Cardona, Caridada,b,*; Rajah, Chantala,c; Mzoneli, Youley Nosisia,c; Friedrichsdorf, Stefan Joergd,e; Campbell, Fionaf; Cairns, Carela,b; Rodseth, Reitze Nilsc,g

Author Information
doi: 10.1097/PR9.0000000000000789
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Abstract

1. Introduction

The poor recognition and substandard management of paediatric pain has been a long-term concern; already in 1992, Johnston et al.40 found that pain in a randomly selected population of hospitalized children was underrecognized and/or undertreated, and in 1996, Cummings et al. executed the very first study looking at the prevalence of pain on an unselected population of an entire paediatric hospital, finding similar results and calling for a more aggressive management of paediatric pain.23

A joint statement issued by the World Health Organization and the International Association for the Study of Pain (IASP) on October 11, 2004, declared: “The relief of pain should be a human right.”27,76 The 2010 Declaration of Montreal went even further, stating that access to pain management is a fundamental human right and it is a human rights violation not to treat pain.39 However, researchers at a large children's hospital in North America and Western Europe reported that inpatient pain was common, underrecognised, and undertreated, even in well-resourced tertiary referral paediatric centres.9,27,56,60,64,76,80,84 Moreover, one of the largest paediatric health centres in the United States found that, despite the existence of a busy inpatient and outpatient paediatric pain consult team, there was significant room for improvement in how pain was managed.27

Assuming that the ability to manage pain is one of the factors that divide low-income countries from high-income countries,11 we might expect at its best, similar results if not worse in countries with fewer resources. The African continent bears 24% of the global burden of disease, but only 3% of the health care force; for example, the United States and Canada have 2.6 and 2.5 doctors per 1000 patients, respectively, whereas South Africa only has 0.8.87

In a review of challenges associated with paediatric pain management in Sub-Saharan Africa, Albertyn et al.1 stated that paediatric pain management in the region has been left largely unaddressed; many factors such as limited resources, inadequate training, cultural diversity, and language barriers result in sick and injured children not receiving basic pain treatment. Other researchers have found that children face exclusion from adult palliative care services even if paediatric ones are nonexistent, and their pain management is in general neglected. Moreover very limited data on paediatric pain are available in this region.37

Grey's Hospital is a referral hospital in Pietermaritzburg, KwaZulu-Natal, South Africa. It offers tertiary services to the western half of the province, which includes 5 health districts serving a total population of 3.5 million. With a total of 505 staffed beds, approximately 30 are for surgical paediatric patients and 48 for medical paediatric patients, most of the older children and adolescents commonly get admitted to the adult wards.33 Pain management is provided by the primary care team for the majority of paediatric patients. In 2015, an unpublished paediatric postoperative pain audit was conducted over 10 months and included 505 patients. Unexpectedly, it found that 81% children experienced pain in the postoperative period, and in more than half, the pain was moderate to severe. However, this audit was limited in that it did not record patient sex, presence of chronic pain, and only focused on surgical patients. To address these limitations, we planned to conduct an audit of paediatric pain assessment and management across the whole hospital, hypothesizing that pain, both acute and chronic, was an unresolved problem in our paediatric inpatients.

2. Methods

We conducted a single-day unannounced prospective observational cross-sectional survey and medical chart review of all paediatric inpatients younger than 18 years of age admitted at Grey's Hospital, Pietermaritzburg, on Monday, March 13, 2017. Patients admitted into the neonatal intensive care or paediatric intensive care were excluded due to logistic reasons. The survey aimed to benchmark both patient outcomes (ie, pain prevalence, pain intensity, and satisfaction with pain management) and process outcomes (ie, pain assessment documentation and pain management interventions).

The study was approved by the Umgungundlovu Health Ethics Review Board on October 2016 (Reference UHERB160701) and KwaZulu-Natal Department of Health on January 2017 (HRKM Ref: 231/16; NHRD Ref: KZ-2016RP18-692).

The survey and methodology used was derived from a tool used by Friedrichsdorf et al. (2015, 2018) and Taylor et al. (2008).27,56,76 Research assistants were trained before administering the survey in a workshop organised by the main researcher (C.V.C.). On the morning of the survey, the interviewer introduced the project directly to patients and their parents using a short script. If the child and parent provided verbal assent/consent to participate, the interviewer administered a 5- to 10-minute questionnaire and recorded the answers. Interpreters were used for all non–English-speaking families because such patients are known to be at greater risk of receiving substandard pain management.27,76

Patients were interviewed directly if older than 5 years, and were judged by the interviewer to be cognitively able to understand the questions. If this was not the case, the parent or caregiver was interviewed as proxy for the child. The children/parents were asked about their pain experience, the single “worst pain” in the past 24 hours, and they were asked to rate their satisfaction with how their pain was treated.

Once the interview was completed, a chart review was conducted for all the patients in the final sample to obtain information about documentation of pain assessment, and pharmacological and nonpharmacological pain interventions provided by staff. A unique number was assigned to each patient listed on the morning registration list, which was recorded on the survey and chart review form to maintain a link between the patients and their survey/chart review data.

Data were transcribed into an electronic database, and Stata 15.1 was used for analysis. Frequency and percentage were used to describe the study sample. Parametric and nonparametric tests were used for normally and nonnormally distributed data, respectively. χ2 tests were used for categorical data. A P-value of <0.05 was deemed to be statistically significant.

3. Results

Of a total of 68 children inpatient at 8:00 hours on the chosen day, 63 patients (93%) were included in the survey. In more than half of the cases (52%), the child was the main respondent followed by the mother (44%), and the rest was answered by other caregivers. The mean patient age was 9.7 years (SD 6.17 years; range 1 month–17 years; interquartile range 12.07 years). Both surgical and medical patients, and females and males were equally represented (Table 1).

T1
Table 1:
Demographic characteristics of paediatric patients recruited (Grey's hospital).

Eighteen children (29%) reported routinely having pain before the current admission: half experienced abdominal pain, followed by musculoskeletal pain and headache. The majority of children experienced some pain during their hospitalisation (87%). A quarter of patients were experiencing pain during the interview with 37% being in severe pain (Table 2).

T2
Table 2:
Prevalence of pain before admission, during admission, and at the time of survey, and “worst cause of pain” in the 24 hours preceding the survey.

There was no difference in pain prevalence and intensity between different age groups during preadmission, admission, and during the survey (P = 0.08; P = 0.485; P = 0.184). No difference was found between prevalence and intensity of pain according to sex (P = 1.0) (t = −0.8288; degrees of freedom = 14) or between medical or surgical patients (P = 0.136) (1-sided Fisher exact 0.100).

Out of the 55 patients who experienced pain during the admission, more than a third of those children and families considered pain caused by needle stick to be their worst pain experience while in hospital (34%). Surgery was considered the worst pain by 22%, followed by acute illness (18%), procedures (14%), and trauma and injury (11%).

Although needle stick was the most common cause of “worst pain,” its intensity was the lowest of all the “worst pain.” Procedures and surgery had the highest intensity with a median pain score of 10 and 9, respectively (Fig. 1). For venipuncture, drip insertion, and abdominal surgery (the most common causes of worst pain), there was no difference in pain score when patients were forewarned as compared to not being forewarned (P = 0.552) (t = −0.6061; degrees of freedom = 18).

F1
Figure 1.:
Intensity of the “worst cause of pain” in the 24 hours preceding the survey.

On a scale from 0 (not satisfied at all) to 10 (most satisfied), satisfaction with pain management was rated as high (mean 8, median 8, range 0–10). Seventy-five percent of respondents who had questions and concerns about pain reported that staff listened to them and eased their worries, but 2 children felt ignored when they were in pain. The rest of the children and/or caregivers did not have questions related to their pain or did not remember if they did. The majority of patients (71%) indicated that they would move to a different health facility if better pain management was offered there.

When considering process outcomes, 80% of files contained some pain narrative, the overwhelming majority written by nurses. For the 55 patients who experienced pain, only 9 surgical patients (16%) were assessed using a validated pain scoring tool and most of them (11%) had only one pain assessment within the past 24 hours; no medical patient was assessed with a validated tool. Of children who experienced pain during the past 24 hours, 82% had been prescribed analgesic medication (45/55), 44 of them around the clock (all of them surgical patients) and only one as needed (medical patient). The majority of those without prescribed analgesia were medical patients (80%). More details on the prescribed pharmacological treatments are shown in Figure 2. Documentation of integrative “nonpharmacological” pain management techniques occurred less frequently than for pharmacological options.

F2
Figure 2.:
Pharmacological treatment prescribed to patients who experienced pain during admission. NSAIDs, nonsteroidal anti-inflammatory drugs; tilidine, synthetic opioid analgesic.

Medication was the most commonly used pain treatment (34 patients) and was found to be moderately useful (median of 5). Positioning was offered to 11 children with a median helpfulness of 4.5. Caregiver presence and distraction were found to be very helpful (median score of 8) and used in 10 and 11 patients, respectively. Swaddling was executed only in 4 patients, but was found to be the most helpful nonpharmacological treatment with a median score of 9. Sucrose was only administered to one infant.

4. Discussion

To the best of our knowledge, this is the first prospective observational cross-sectional pain survey and medical chart review of all paediatric inpatients in a hospital in Africa, a previous study in the South African setting was executed in 2011 by Thiadens et al.,77 although it was a great start was only restricted to a Paediatric Trauma Unit and chronic pain was not assessed. This study highlights that unfortunately pain treatment and prevention in paediatric inpatients remain an unresolved challenge more than 2 decades after Cummings sought its improvement.23 The majority of the children experienced pain during admission, with many having moderate to severe pain. These findings are similar to those previously reported by studies in high- and upper-middle income countries.27,44,46,64,76,84 Extensive evidence about the prevention and treatment of pain in children exist,87 and multiple paediatric pain guidelines have been developed.66,68 However, there remains a significant knowledge translation gap (“between what we know and what we do”) when it comes to paediatric pain.65,89

Nearly one-third of patients experienced pain routinely before their admission, possibly chronic in nature, in keeping with epidemiological studies showing rates of chronic and recurrent pain in children of 15% to 30%.18,36,47,60 Five percent of children and teenagers in the general population experience significant pain-related dysfunction, depression, and anxiety.22,28 Chronic pain may have a better prognosis if treated early in life than if it is allowed to persist into adulthood,61 which is unfortunately the norm at present.

According to the IASP recommendations, children with chronic pain should be treated in multidisciplinary outpatient clinics where the biopsychosocial model of pain prevails, but a large number of patients do not have access to them.27,28,51,76 There is currently no paediatric pain clinic and an urgent need for such a service in our setting.

Studies assessing sex differences in paediatric pain had shown ambiguous results. Some have shown a higher prevalence and/or pain intensity in female patients,28,43,44,48,52,83 whereas others were unable to find any sex differences.21,76 Our results agreed with the latter, but our small sample size might preclude finding a difference. It is not known whether females experience greater pain, or if they verbalize it more often, and cultural factors could be contributing.53,55,85

There were no differences by age in the prevalence of pain or its intensity during either preadmission, admission, or during the survey. Although similar results were found by Noll et al.,52 most studies have found differences based on age.11,43,48 Once again, it is possible that our findings were affected by the small size of the sample.

Our study did not include neonates, thereby excluding a vulnerable and historically neglected subgroup of children at higher risk of experiencing pain.4 Unrelieved pain in infancy and early childhood can lead to persistent and chronic pain, as well as other physiological and psychological deleterious effects.18,60,78,89 The prevalence of pain in neonates as well as its management in our population deserves to be explored in further studies.

Pain caused by needles was found to be the most prevailing cause of “worst pain,” which has been described before.9,27,63,68,84 As with Friedrichsdorf27,56 and others,19,62,84 we noted that although needle pain was mentioned as the most painful experience, the reported pain intensity was actually lower than postsurgical pain and some postprocedural pain. Reasons for this discrepancy are likely multifactorial. Factors such as fear, anxiety, lack of control, memory of previous painful procedures, or the trauma of being excessively restrained can reinforce pain.54 The lower intensity of the pain does not make it less disturbing, pain associated with needle poke is often worse than the underlying reason for hospitalisation and makes the children feel helpless, anxious, and irritable, can sensitise them to pain, and can trigger “needle phobia” and PTSD9; the presence of procedural pain is particularly concerning, given the fact that is purely iatrogenic and preventable.

Current best evidence,71,73,74 supported by clinical guidelines13,34,38,49,50,72 and science-to-social media campaigns (eg, “Be Sweet to Baby”17 and “It Doesn't Have to Hurt”15), provide evidence for a 4 bundled modality. The successful “Comfort Promise” (a protocol offered as a bundle to all children for all elective needle procedures all the time) has been recently published by Friedrichsdorf et al.,29 and includes:

  • (1) Topical anesthesia75
  • (2) Sucrose32,67 or breastfeeding59 for infants17
  • (3) Comfort positioning41
  • (4) Age-appropriate distraction81

The paediatric pain team should be available to provide analgesia and sedation if the above-mentioned approach fails to comfort the child.30,84

For venipuncture, venous catheter insertion, and abdominal surgery, the 3 most common causes of “worst pain,” there were no differences in pain intensity regardless of whether the patient was warned about the possibility of experiencing pain or not. Although some researchers have arrived at the same conclusion,45,70 others found that reassuring words improved the subjective experience during invasive procedures.82 Ideally, the child should be provided with both procedural and sensory information at the right time and in an age-appropriate format.20,69

Interestingly, although most of our patients experienced pain during admission, satisfaction with pain treatment was high. This has been formerly depicted, but the contributing factors are poorly understood.14,58 Treatment expectations as well as past pain experiences are known to correlate more with patient satisfaction than the treatment used, and the actual reduction in pain symptoms.5

Most of the medical files reviewed included some pain narrative, with the overwhelming majority written by nurses, in keeping with previous surveys.44 Although some studies have found better pain knowledge in doctors than in nurses,3,88 patients spend significantly more time with nurses than with any other health care provider.24

It was disappointing to find that most patients who experienced pain during their admission had no validated tool used for their pain assessment, a problem already discovered by other researchers.27,76,84 Validated developmentally appropriate pain measurement tools are available for all ages, and should be used for every child.57

Eighty-two percent of the children who experienced pain during admission were prescribed medication, most of them around the clock. This was better than results from previous studies,27,76 and similar to others.44 The majority of those without prescribed pain medication were medical patients. During the past few decades, awareness of the deleterious effects of suboptimal postoperative pain management has grown exponentially,31 the IASP nominated 2017 as the Global Year Against Pain After Surgery, and many events and initiatives were held all over the world increasing awareness of surgical pain. Medical patients experiencing nonsurgical nociception suffer from pain as well as their surgical counterparts,44 it is just less recognized.

The WHO Guidelines on the Pharmacological Treatment of Pain in Children86 and The South African Acute Pain Guidelines8 were followed adequately in most of the patients. The majority received regular paracetamol; the second most prescribed drug was tilidine, followed by nonsteroidal anti-inflammatory drugs (NSAIDs)—mostly ibuprofen, and tramadol. Although all the patients receiving morphine (24%) were also receiving paracetamol and either NSAIDS or a weak opioid, 75% of them were administered morphine intramuscularly in violation of the above-mentioned guidelines.

Tilidine was administered orally in more than 3/4 of the patients, although the South African Guidelines recommend the sublingual route. This is a controversial recommendation; sublingual administration allows direct access of drugs to the systemic circulation decreasing the onset of action,42 but tilidine's therapeutic activity is mainly related to its active metabolite nortilidine. Its formation mainly occurs during the intestinal and hepatic first-pass metabolism of tilidine by N-demethylation.26 Further research should look at this polemic to help us decide the ideal route of administration of this drug.

In line with other studies,27,46,84 “nonpharmacological” pain techniques were not commonly documented. Pain management often excludes evidence-based nonpharmacological modalities because patients and health care providers might be unaware of their availability, are sceptical about their efficacy, or fear possible complications from their use.7 The lack of well-designed clinical trials might also be contributing.79

Although the pharmacological was the most common used pain management modality, 3 nonpharmacological techniques were reported by children and parents as being effective (distraction, caregiver presence, and swaddling); similar results were found by Friedrichsdorf.4,27,56 All these techniques are simple, safe, and cost-effective, and should be a mandatory component of the multimodal approach to pain management.2,6,12,35

Dissemination and implementation of knowledge into practice is challenging; parental and health care misconceptions and attitudes towards pain are some of the barriers to effective pain management in our setting but so are the lack of resources and qualified staff. The prevalence of paediatric pain according to family caregivers is the closest to children reports, followed by the assessment done by physicians and nurses25; then, it makes sense to train parents to assess their children's pain, the initiative we are trying to implement in our hospital. In a similar study executed in Brazil, 68% of the parents were present when data were collected; unfortunately, during our study less than half of the parents were available due to specific socioeconomic and cultural characteristics of our population. Social media, internet-based applications, and web-based platforms have been used successfully in high-income countries,10,16 but booklets and posters are our main mean of instruction for obvious reasons.

4.1. Limitations

This was a single-center study taking place on a single albeit representative day with a small sample size, which may limit generalizability of our findings. A national multicentre audit is being planned to address these limitations.

5. Conclusion

The prevalence of pain in hospitalised paediatric patients in Grey's Hospital is unacceptably high, including a big subgroup of children with possible chronic pain, for whom the hospital does not provide an Interdisciplinary Rehabilitative Pain Clinic at present. Pain assessment is poorly performed and documented. Procedural pain is the worst cause of pain according to most of the children and their parents, and nonpharmacological modalities of pain treatment are underutilised. There is an urgent need for pain training and education, and the implementation of guidelines and protocols for pain assessment, prevention and treatment, procedural pain, and medical patients in particular needs more attention. This audit will be repeated as part of a quality-improvement initiative.

Disclosures

The authors have no conflict of interest to declare.

Acknowledgements

The authors thank Sr Leona Thomas, Mr Simphiwe Gumede, and Grey's Hospital Anaesthetic Department for helping with the data collection.

References

[1]. Albertyn R, Rode H, Millar AJ, Thomas J. Challenges associated with paediatric pain management in Sub Saharan Africa. Int J Surg 2009;7:91–3.
[2]. Al-Khotani A, Bello L, Christidis N. Effects of audiovisual distraction on children's behaviour during dental treatment: a randomized controlled trial. Acta Odontol Scand 2016;74:494–501.
[3]. Al-Quliti K, Alamri M. Knowledge, attitudes, and practices of health care providers in Almadinah Almunawwrah, Saudi Arabia. Neurosciences 2015;20:131–6.
[4]. American Academy of Pediatrics, Canadian Paediatric Society. Prevention and management of pain in the neonate: an update. Pediatrics 2006;118:2231.
[5]. Andrews R, Browne A, Wood F, Schug SA. Predictors of patient satisfaction with pain management and improvement 3 Months after burh injury. J Burn Care Res 2012;33:443–52.
[6]. Bagnasco A, Pezzi E, Rosa F, Fornonil L, Sasso L. Distraction technique in children during venipuncture an Italian experience. J Prev Med Hyg 2012;53:44–8.
[7]. Becker W, Dorflinyer L, Edmond SN, Islam L, Heapy AA, Fraenkel L. Barriers and facilitators to use of non-pharmacological treatment in chronic pain. BMC Fam Pract 2017;18:41.
[8]. Benger JR, Pearce V. Simple intervention to improve detection of child abuse in Emergency Departments. BMJ 2002;324:780.
[9]. Birnie KA, Chambers CT, Fernandez CV, Forgeron PA, Latimer MA, McGrath PJ, Cummings EA, Finley GA. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag 2014;19:198–204.
[10]. Birnie KA, Nguyen C, Amaral TD, Baker L, Campbell F, Lloyd S, Ovellette C, von Baeyer C, Lalloo C, Gerstle JT, Stinson J. A parent-science partnership to improve postsurgical pain management in young children: co-development and usability testing of the Achy Penguin smatphone-based app. Can J Pain 2018;2:280–91.
[11]. Bosenberg A. Paediatric anaesthesia in developing countries. Curr Opin Anaesthesiol 2007;20:204–10.
[12]. Campbell-Yeo M, Fernandes A, Johnston C. Procedural pain management for neonates using nonpharmacological strategies. Part 2: mother-driven interventions. Adv Neonatal Care;11:312–18.
[13]. Canadian Paediatric Society. Reduce the pain of vaccination in babies. 2014. Available at: http://www.caringforkids.cps.ca/uploadas/handout_images/3p_babiesto1yr_e.pdf. Accessed September 16, 2018.
[14]. Carlson J, Youngblood R, Dalton J, Blau W, Lindley C. Is patient satisfaction a legitimate outcome of pain management? JPSM 2003;25:264–75.
[15]. Centre for Pediatric Pain Research. It doesn't have to hurt. 2016. Available at: https://itdoesnthavetohurt.ca. Accessed September 23, 2018.
[16]. Chambers CT. From evidence to influence: dissemination and implementation of scientific knowledge for improved pain research and management. PAIN 2018;159(suppl 1):S56–64.
[17]. CHEO's Be Sweet to Babies research team and the University of Ottawa's School of Nursing. Be sweet to babies. 2014. Available at: http://www.cheo.on.ca/en/BeSweet2Babies. Accessed September 23, 2018.
[18]. Chiaretti A, Pierri F, Valentini P, Russo I, Gargiullo L, Riccardi R. Current practice and recent advances in pediatric pain management. Eur Rev Med Pharmacol Sci 2013;17(suppl 1):112–26.
[19]. Cohen LL, Blount RL, Cohen RJ, Ball CM, McClellan CB, Bernard RS. Children's expectations and memories of acute distress: short- and long-term efficacy of pain management interventions. J Pediatr Psychol 2001;26:367–74.
[20]. Cohen L. Behavioral approach to anxiety and pain management for pediatric venous access. Pediatrics 2008;122:S134–9.
[21]. Couceiro TC, Valenca MM, Lima LC, de Menezes TC, Raposo MC. Prevalence and influence of gender, age, and type of surgery on postoperative pain. Rev Bras Anestesiol 2009;59:314–20.
[22]. Cucchiano G, Schwartz J, Ornelas B, Hutchason A. Chronic pain in children: a look at the referral process to a pediatric pain clinic. Int J Pediatr 2017;2017:8769402.
[23]. Cummings EA, Reid GJ, Finley GA, McGrath PJ, Ritchie JA. Prevalence and source of pain in pediatric inpatients. PAIN 1996;68:25–31.
[24]. De Lucia P, Ott T, Palmieri P. Chapter 1. Performance in nursing. Rev Hum Factors Ergon 2009;5:1–40.
[25]. Doca FNP, Costa Junior AL, Finley GA, Linhares MB. Pain in pediatric inpatients: prevalence, characteristics, and management. Psychol Neurosci 2017;10:394–403.
[26]. Eichbaum C, Mathes K, Burhenne J, Markert C, Blank A, Mikus G. Pre-systemic elimination of tilidine: localization and consequences for the formation of the active metabolite nortilidine. Basic Clin Pharmacol Toxicol 2015;116:129–33.
[27]. Friedrichsdorf SJ, Postier A, Eull D, Weidner C, Foster L, Gilbert M, Campbell F. Pain outcomes in a US Children's Hospital: a prospective cross-sectional survey. Hosp Pediatr 2015;5:18–26.
[28]. Friedrichsdorf S, Giordano J, Desai Dakoji K, Warmuth A, Daughtry C, Schulz C. Chronic pain in children and adolescents: diagnosis and treatment of primary pain disorders in head, abdomen, muscles and joints. Children (Basel) 2016;3:42.
[29]. Friedrichsdorf SJ, Eull D, Weidner C, Postier A. A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology. PAIN Rep 2018;3(suppl 1):e671.
[30]. Friedrichsdorf SJ. Nitrous gas analgesia and sedation for lumbar punctures in children: has the time for practice change come? Pediatr Blood Cancer 2017;64:e26625.
[31]. Gan T. Poorly controlled postoperative pain: prevalence, consequences, and prevention. J Pain Res 2017;10:2287–98.
[32]. Gao H, Gao H, Xu G, Li M, Du S, Li F, Zhang H, Wang D. Efficacy and safety of repeated oral sucrose for repeated procedural pain in neonates: a systematic review. Int J Nurs Stud 2016;62:118–25.
[33]. GREY'S hospital annual report. Department of Health Province of kwazulu-natal, 2017–2018. Available at: www.kznhealth.gov.za>2017-2018-Annual-Report. Accessed September 23, 2018.
[34]. Help ELiminate pain in kids & adults. 2018. Available at: http://phm.utoronto.ca/helpinkids/index.html. Accessed September 13, 2018.
[35]. Ho S, Ho L. Effects of facilitated swaddling for controlling procedural pain in premature neonates: a randomized controlled trial. J Pain 2012;13:559.
[36]. Howard R, Wiener S, Walker S. Neuropathic pain in children. Arch Dis Child 2014;99:84–9.
[37]. Huang K, Owino C, Gramelspacher G, Monahan PO, Tabbey R, Hagembe M, Strother RM, Njuguna F, Vreeman RC. Prevalence and correlates of pain treatment in a western Kenya referral hospital. J Palliat Med 2013;16:1260–7.
[38]. Immunize Canada. Reduce the pain of vaccination in kids and teens. 2014. Available at: https://immunize.ca. Accessed October 17, 2018.
[39]. International Association for the Study of Pain (IASP). Declaration of Montréal. 2010. Available at: http://www.iasp-pain.org/DeclarationofMontreal?navItemNumber=582.
[40]. Johnston CC, Abbott FV, Gray-Donald K, Jeans ME. A survey of pain in hospitalized patients aged 4-14 years. Clin J Pain 1992;8:154–63.
[41]. Karlson K, Darcy L, Enskär K. The use of restraint is never supportive (poster). Nordic Society of Pediatric Hematology/Oncology (NOPHO) 34th Annual meeting 2016 and 11th Biannual Meeting of Nordic Society of Pediatric Oncology Nurses (NOBOS). Reykjavik, Iceland, 2016.
[42]. Khan A, Kingsley T, Caroline P. Sublingual tablets and the benefits of the sublingual route of administration. Review article. J Pharm Res 2017;16:25.
[43]. King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, MacDonald AJ. The epidemiology of chronic pain in children and adolescents revisited: a systematic review. PAIN 2011;152:2729–38.
[44]. Kozlowski LJ, Kost-Byerly S, Colantuoni E, Thompson CB, Vasquenza KJ, Rothman SK, Billett C, White ED, Yaster M, Monitto CL. Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Manag Nurs 2014;15:22–35.
[45]. Lang EV, Hatsiopoulou O, Koch T, Kettenmann E, Logan H, Kaptchk TJ. Can words hurt? Patient provider interactions during invasive procedures. PAIN 2005;114:303–9.
[46]. Linhares MB, Doca FN, Martinez FE, Carlotti AP, Cassiano RG, Pfeifer LI, Funayama CA, Rossi LR, Finley GA. Pediatric pain: prevalence, assessment, and management in a teaching hospital. Braz J Med Biol Res 2012;45:1287–94.
[47]. Liossi C, Howard RF. Pediatric chronic pain: biopsychosocial assessment and formulation. Pediatrics 2016;138:1–14.
[48]. Lynch A, Kashikar-Zuck S, Goldschneider K, Jones BA. Sex and age differences in coping styles among children with chronic pain. J Pain Symptom Manag 2007;33:208–16.
[49]. McMurtry CM, Pillai Riddell R, Taddio A, Racine N, Asmundson GJ, Noel M, Chambers CT, Shah V; HelpinKids, Adults T. Far from “just a poke”: common painful needle procedures and the development of needle fear. Clin J Pain 2015;31(10 suppl):S3–11.
[50]. McMurtry CM, Taddio A, Noel M, Antony MM, Chambers CT, Asmundson GJ, Pillai Riddell R, Shah V, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin S, Bowles S, Halpert C, Ipp M, Rieder MJ, Robson K, Uleryk E, Votta Bleeker E, Dubey V, Hanrahan A, Lockett D, Scott J. Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research. Cogn Behav Ther 2016;45:217–35.
[51]. Miro J, McGrath P, Finley A, Walco GA. Pediatric chronic pain programs:current and ideal practice. PAIN 2017;2:e613.
[52]. Noll M, Candotti C, Rosa B, Loss JF. Back pain prevalence and associated factors in children and adolescents: an epidemiological population study. Rev Saude Publica 2016;50:1–10.
[53]. Nortje N, Albertyn R. The cultural language of pain: a South African study. South Afr Fam Pract 2015;57:24–7.
[54]. Petovello K. Pediatric procedural pain management: a review of the literature. Int J Child Youth Fam Stud 2012;4:569–899.
[55]. Pillay T, van Zyl H, Blackbeard D. Chronic pain perception and cultural experience. Procedia Soc Behav Sci 2014;113:151–60.
[56]. Postier AC, Eull D, Schulz C, Fitzgerald M, Symalla B, Watson D, Goertzen L, Friedrichsdorf SJ. Pain experience in a US Children's Hospital: a point prevalence survey undertaken after the implementation of a system-wide protocol to eliminate or decrease pain caused by needles. Hosp Pediatr 2018;8:515–23.
[57]. Schug S, Palmer G, Scott D, Halliwell R, Trinca J; APM:SE Working Group of the Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute pain management scientific evidence, 2015 (4th edition). Med J Aust 2016;204:315–317.
[58]. Schwenkglenks M, Gerberhagen H, Taylor R, Pogatzki-Zahn E, Komann M, Rothaug J, Volk T, Yahiaoui-Doktor M, Zaslansky R, Brill S, Ullrich K, Gordon DB, Meissner W. Correlates of satisfaction with pain treatment in the acute postoperative period: results from the international PAIN OUT registry. PAIN 2014;155:1401–11.
[59]. Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev 2012;12:CD004950.
[60]. Shoemaker K, Dutton S, Mark M. Pain prevalence and treatment patterns in a US Children's Hospital. Hosp Pediatr 2015;5:363–70.
[61]. SIG position statement. Children's pain matters. IASP. PAIN 2005;XIII:1–6.
[62]. Simons L, Kaczynski K, Conroy R, Logan D. Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response. J Pain 2012;13:1151–61.
[63]. Stevens B, Abbott L, Yamada J, Harrison D, Stinson J, Taddio A, Barwick M, Latimer M, Scott SD, Rashotte J, Campbell F, Finley GA; CIHR Team in Children's Pain. Epidemiology and management of painful procedures in hospitalized children across Canada. CMAJ 2011;183:E403–10.
[64]. Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, Stinson J, Le May S. Pain assessment and intensity in hospitalized children in Canada. J Pain 2012;13:857–65.
[65]. Stevens BJ, Yamada J, Estabrooks CA, Stinson J, Campbell F, Scott SD, Cummings G; Pain CTiCs. Pain in hospitalized children: effect of a multidimensional knowledge translation strategy on pain process and clinical outcomes. PAIN 2014;155:60–8.
[66]. Stevens BJ, Yamada J, Promislow S, Stinson J, Harrison D, Victor JC; Members of the CTiCsP. Implementation of multidimensional knowledge translation strategies to improve procedural pain in hospitalized children. Implement Sci 2014;9:120.
[67]. Stevens B, Yamada J, Ohlsson A, Haliburton S, Shorkey A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2016;7:CD001069.
[68]. Stinson J, Yamada J, Dickson A, Lamba J, Stevens B. Review of systematic reviews on acute procedural pain in children in the hospital setting. Pain Res Manag 2008;13:51–7.
[69]. Suls J, Wan CK. Effects of sensory and procedural information on coping with stressful medical procedures and pain: a meta-analysis. J Consult Clin Psychol 1989;57:372–9.
[70]. Taddio A, McMurtry CM. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Paediatr Child Health 2015;20:195–6.
[71]. Taddio A, Appleton M, Bortolussi R, Chambers C, Dubey V, Halperin S, Hanrahan A, Ipp M, Lockett D, MacDonald N, Midmer D, Mousmanis P, Palda V, Pielak K, Riddell RP, Rieder M, Scott J, Shah V. Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline. CMAJ 2010;182:E843–855.
[72]. Taddio A, McMurtry CM, Shah V, Riddell RP, Chambers CT, Noel M, MacDonald NE, Rogers J, Bucci LM, Mousmanis P, Lang E, Halperin SA, Bowles S, Halpert C, Ipp M, Asmundson GJ, Rieder MJ, Robson K, Uleryk E, Antony MM, Dubey V, Hanrahan A, Lockett D, Scott J, Votta Bleeker E; HelpinKids, Adults. Reducing pain during vaccine injections: clinical practice guideline. CMAJ 2015;187:975–82.
[73]. Taddio A, Parikh C, Yoon EW, Sgro M, Singh H, Habtom E, Ilersich AF, Pillai Riddell R, Shah V. Impact of parent-directed education on parental use of pain treatments during routine infant vaccinations: a cluster randomized trial. PAIN 2015;156:185–91.
[74]. Taddio A, Shah V, McMurtry CM, MacDonald NE, Ipp M, Riddell RP, Noel M, Chambers CT; HelpinKids, Adults T. Procedural and physical interventions for vaccine injections: systematic review of randomized controlled trials and Quasi-randomized controlled trials. Clin J Pain 2015;31(10 suppl):S20–37.
[75]. Taddio A, Pillai Riddell R, Ipp M, Moss S, Baker S, Tolkin J, Malini D, Feerasta S, Govan P, Fletcher E, Wong H, McNair C, Mithal P, Stephens D. Relative effectiveness of additive pain interventions during vaccination in infants. CMAJ 2017;189:E227–34.
[76]. Taylor E, Boyer K, Campbell F. Pain in hospitalized children, a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian Pediatric Teaching Hospital. Pain Res Manag 2008;13:25–32.
[77]. Thiadens T, Vervat E, Albertyn R, Van Dijk M, Van As AB. Evaluation of pain incidence and pain management in a South African Paediatric Trauma Unit. S Afr Med J 2011;101:533–6.
[78]. Thrane S, Wanless S, Cohen S, Danford C. The assessment and non-pharmacologic treatment of procedural pain from infancy to school age through a developmental lens: a synthesis of evidence with recommendations. J Pediatr Nurs 2016;31:e23–32.
[79]. Tick H, Nielsen A, Pelletier K, Bonakdar R, Simmons S, Glick R, Ratner E, Lemmon RL, Wayne P, Zador V; Pain Task Force of the Academic Consortium for Integrative Medicine and Health. Evidence-based nonpharmacologic strategies for comprehensive pain care: the Consortion Pain Task Force White Paper. Explode 2018;14:177–211.
[80]. Twycross A, Collis S. How well is acute pain in children managed? A snapshot in one English hospital. Pain Manag Nurs 2013;14:e204–215.
[81]. Uman LS, Birnie KA, Noel M, Parker JA, Chambers CT, McGrath PJ, Kisely SR. Psychological interventions for needle-related procedural pain and distress in children and adolescents. Cochrane Database Syst Rev 2013;10:CD005179.
[82]. Varelmann D, Pancaro C, Cappiello E, Camann WR. Nocebo-induced hyperalgesia during local anaesthesia injection. Anesth Analg 2010;110:868–70.
[83]. Walker S. Pain in children: recent advances and ongoing challenges. Br J Anaesth 2008;101:101–10.
[84]. Walther-Larsen S, Pedersen MT, Friis SM, Aagaard GB, Romsing J, Jeppesen EM, Friedrichsdorf SJ. Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals. Acta Anaesthesiol Scand 2017;61:328–37.
[85]. Wegner L, Rhoda A. The influence of cultural beliefs on the utilization of rehabilitation services in a rural South African context: therapists's perspective. Afr J Disabil 2015;4:1–8.
[86]. World Health Organization. WHO priciples of acute pain management for children. 2012. Available at: https://www.ncbi.nlm.nih.gov/books/NBK138354.
[87]. World Health Organization. Global health observatory (GHO) data. 2018. Available at: https://www.who.int/gho/en. Accessed August 26, 2018.
[88]. Zanolin ME, Visentin M, Trentin L, Saiani L, Brugnolli A, Grassi M. A questionnaire to evaluate the knowledge and attitudes of health care providers on pain. J Pain Symptom Manage 2007;33:727–36.
[89]. Zhu L, Stinson J, Palozzi L, Weingarten K, Hogan ME, Duong S, Carbajal R, Campbell FA, Taddio A. Improvements in pain outcomes in a Canadian Pediatric Teaching Hospital following implementation of a multifaceted, knowlwdge translation initiative. Pain Res Manag 2012;17:173–9.
Keywords:

Paediatric inpatients; Pain prevalence; Pain intensity; Pain management; Pain assessment

Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The International Association for the Study of Pain.