Treating Very Young Pain Patients Brings Unique Challenges

A questionnaire of Emergency Department (ED) physicians in Norway reveals that the clinicians would like more comprehensive pain assessment procedures for children and reveals some interesting insights into how they assess and deliver patient care. The results of the study were published in BMC Emergency Medicine.

Pain is the most common symptom in children and youth attending EDs, due to a variety of conditions including ear infections, appendicitis, fractures, or wounds. Evaluating that pain in children can be challenging, in part because of communication challenges with very young children. In Norway, as elsewhere, children’s pain is often underestimated and under-treated. “Many Norwegian hospitals have no specific routines or procedures for how to manage pain in children,” the study authors observe.

The current study used a structured questionnaire among 75 emergency primary care physicians in a busy Norwegian accident and emergency department (AED) over 17 days. The survey measured use of a pain scale and the use of weight and age when dosing pain medication, with a focus on areas of development needed. A pain scale with a visual analogue scale (VAS) had been used by 59% of physicians in young patients aged 9 to 19 years. But that number dipped significantly for younger children; only 23% of physicians used the VAS in children aged 3 to 8 years, and only 3% in children below 3 years.

Another interesting dimension revealed the research was that while most physicians reported that they used the child’s weight instead of the age interval when estimating the needed dose of painkillers for children, as is strongly recommended. But, they often relied on parents’ weight estimation and seldom measured the child’s weight at attendance. And other research has suggested that parents often underestimate the weight of their children. This can lead to an insufficiently low dosage of medications.

Additional findings:

• 93 % of physicians wanted more knowledge about pain management in children
• 88 % wanted to have a fixed procedure for assessment
• 91 % wanted a fixed procedure for treatment of pain in children
• 75 % wanted alternative options to the available analgesics for children in Norway
• 63 % of the physicians said that they were satisfied to some extent with their own management of pain in children. Eight percent were little satisfied (five women, one man), while 29 % were largely satisfied (five women, 17 men). Significantly more female than male physicians were less satisfied with their own management of pain in children (p = 0.013).

Limitations of the study include small sample size and that the data are based on self-report where recall bias may have taken place. “We have no information about the physicians’ actual practice,” the authors cautioned. “Some answers may have been influenced by the fact that pain treatment of children had been in focus in our AED ahead of this study, and pain intensity scales for children had been demonstrated. Our questionnaire was not previously validated, and for this reason the physicians’ responses should also be interpreted with some caution.”

Still, they note that overall the results suggest that there is a “large potential” for improvement with regard to pre-hospital management of pain in children.