Pain in Children

There are many reasons that may warrant the use of a behavioral scale to measure a child’s pain level. Considering the developmental stage a child may be currently in, it may be difficult, if not impossible, to ask a child to verbally state his or her pain. Children may be at a stage as well where their vocabulary is not well developed to precisely state how much it hurts or where it hurts. Nevertheless, even if they could, as Finley (2001) states in his paper, a child may tend not to reveal the presence or degree of pain he or she may be experiencing because of the fear of the consequences of this.

With their stay in the hospital, they more or less recognize how things operate – pain may warrant a painful procedure such as a repositioning, a traction, a mere movement that inflicts pain, or a vaccine. Thus, in order to escape such moments of pain, a child refuses to let his pain be known. Overt behavioral indicators of pain such as the CHEOPS may answer to such problems of the child’s incapacity to state pain or his tendency to deny his pain.

Certain weaknesses, however, have been identified in the use of such behavioral scales. During the course of the development of the tool, a group of 30 boys (1-7 years old) who have had their circumcision were assessed every 30 seconds by a trained observer one hour after the procedure. The nurses were asked to rate the children’s pain. The children’s pain level measured from the CHEOPS behavioral scale correlated with the nurse’s ratings.

However, McGrath (1990) notes in her book titled, Pain in Children: Nature, Assessment and Treatment , that while the two ratings correlated, such a phenomenon is to be expected if the nurses based their scores on their existing knowledge of the child’s surgical procedure, the time since the surgery and the children’s postoperative behaviors. McGrath (1990) claimed that a stricter reliability measure should have been to ask the nurses to rate the pain scale while they were unaware of the children’s condition, and to score these children in “different health and pain states” (n. p).

After the administration of a narcotic to relieve pain, the children were again assessed using the behavioral scale. A decrease in the pain ratings resulted. However, as McGrath (1990) critiques, the decrease in pain level might have been associated with the depressive effect on the motor activity of the child given that the pain scale measures the overt behavior responses of the child. It may have not covered the subjective state or feelings of the children towards pain. Given these points, McGrath (1990) suggested the conduct of further studies to ensure the validity of the tool.

In a study made by Suraseranivongse and associates in 2001, a cross validation of different behavioral scales was done. One of these scales was the CHEOPS where it has been seen, along with other tools, to have an acceptable content validity and excellent inter-rater and intra-rater reliability. Although all the scales proved to have an acceptable level of content validity, two behaviors in the CHEOPS score – “upright behavior” (which was an alternative in the item ‘torso’) and “standing behavior” (an alternative in the item “leg”) – resulted in difference of opinion among experts since the said behaviors are not common among Thai children.

This shows that the CHEOPS, if used in another culture, might not produce valid results unless similar terms or behaviors are identified to make the scale culture-sensitive (Suraseranivongse et al. , 2001). Moreover, in a study conducted by Beyer, McGrath, & Berde (1990), simultaneous use of self-reports and behavioral responses of pain was done through CHEOPS, the Oucher, and the Analogue Chromatic Continuous Scale, respectively. The pain level of the respondents was measured after a major surgery.

It was found out that while there was a strong correlation between the two self-report tools used, there was little relationship between the scores measured the self-report tools and the behavioral scales. The researchers suggested the concurrent use of self-report and a behavioral scale in accurately documenting pain levels of similar groups after such a procedure (Beyer et al. , 1990) Despite these flaws however, the CHEOPS have been used in certain studies where the use of other behavioral or non-behavioral scales alone might have been inadequate.

Elkahim, Ali, Rashed, Riad, and Refat (2003) studied the effect of dexamethasone on postoperative vomiting and pain after pediatric tonsillectomy. The respondents were a group of 120 patients who have undergone electrocautery tonsillectomy under standardized anesthesia. The sample was randomly assigned to receive dexamethasone IV and a control group was to receive a placebo in the form of saline. Both the dexamethasone and the placebo were administered preoperatively.

Among the key points assessed in the study were “incidence of early and late vomiting, need for rescue antiemetics, time to first oral intake, time to first demand of analgesia and analgesic consumption” (Elkahim et al. , 2003, n. p). The sample’s pain level was assessed through CHEOPS, “faces,” and a 0-10 visual analogue pain scale. The study concludes that the group who has received dexamethasone prior to the surgery had reduced incidence of postoperative vomiting and pain as compared to those to who received the placebo.

From this study it could be noted that the CHEOPS, along with the utilization of other objective measurement of pain, undesired postoperative complications and pain among children have been addressed (Elkahim et al. , 2003). Another study conducted by Hernandez-Reif and colleagues (2001) utilized the CHEOPS in identifying the distress level of children during burn treatment. The purpose of the study is to ascertain the relationship between the application of massage therapy and the level of distress among patients.

The study included a group of 24 young children as its sample, with a mean age of 2. 5 years. All patients were hospitalized for severe burns and were receiving standard dressing care at the time. The sample was randomly assigned to receive massage therapy in areas that were not burned, apart from the standard dressing care. It was found out that those who received massage therapy had minimal distress during dressing change, and that there was no increase in movement of the body other than that of the torso.

On the other hand, the children who did not receive massage therapy were observed to have “increased facial grimacing, torso movement, crying, leg movement, and reaching out” (Hernandez-Reif et al. , 2001, np). In addition, given these changes in the children’s reactions to the procedures, the nurse found it easier to conduct dressing changes to those who have had the massage therapy (Hernandez-Reif et al. , 2001). The need for behavioral scales such as the CHEOPS to measure pain arises when the developmental stage of the child makes him or her sensitive to non-behavioral scales or self-report tools.

It is important to note that a child’s pain interferes with his or her movement or activity, facial expression, or verbalizations. Thus, such indicators are important to gauge a child’s pain level. The inevitable infliction of pain brought about procedures that may cause physiologic, psychological, emotional, or social distress on the child. Nonattendance to the needs of the child when pain could have been alleviated might speak of the inefficiency of health care delivery of the entire team.

Through this study, it has been realized that it is important to study carefully any tool or instrument that is to be used in the clinical setting. Although these tools have been developed by people who are considered experts in their field, using the tool in a different setting, with a different population or culture may make the use of the tool a barrier in delivering quality care. It is important to note as well that there is no single tool that could be considered the gold standard in the assessment of pain among children.

There should be the recognition that alignment or parallelism between objective and subjective data – of what is seen by the observer and what is felt by the patient is important to adequately assess and manage pain. Assessment, being the first phase in the nursing process, plays a big part in identifying what needs to be addressed, and how it should be addressed. Further studies in this discipline should cover how the sensitivity of tools could be increased in identifying pain levels. Tools should likewise present and put appropriate weight on subjective and objective data.

They should be culture- and developmental stage-sensitive as these two concepts may play a part in effecting or inhibiting efficient assessment and ultimately, adequate management of a child’s pain. References Beyer, J. E. , McGrath, P. J. , & Berde, C. B. (1990). Discordance between self-report and behavioral pain measures in children aged 3-7 years after surgery. Journal of Pain and Symptom Management, 5 (6), 350-356. Elkahim, M. , Ali, N. , Rashed, I. , Riad, M. , & Refat, M. (2003) Dexamethasone reduces postoperative vomiting and pain after pediatric tonsillectomy.

Canadian Journal of Anesthesia, 50 (4), 392-397. Finley, G. A. (2001). How much does it hurt? Pediatric pain measurement for doctors, nurses and parents. Canadian Journal of Anesthesia, 48 (5), R1-R4. Gerik, S. M. (2005). Pain management in children: developmental considerations and mind-body therapies. Southern Medical Journal, 98 (3), 295-302. Hernandez-Reif, M. , Field, T. , Largie, S. , Hart, S. , Rdzepi, M. , Nierenberg, B. , Peck, M. (2001). Children’s distress during burn treatment is reduced by massage therapy. Journal of Burn Care and Rehabilitation, 22 (2), 191-195.

McGrath, P. A. (1990) Pain in Children: Nature, Assessment, and Treatment. New York: Guilford Press. Suraseranivongse, S. , Santawat, U. , Kraiprasit, K. Petcharatana, S. , Prakkamodom, S. , & Muntraporn, N. (2007) Cross-validation of a composite pain scale for preschool children within 24 hours of surgery. British Journal of Anaesthesia, 87 (3), 400-405. University of California and Los Angeles. (2007, September 4). UCLA Pain Assessment Tools: Children’s Hospital Eastern Ontario Pain Scale (CHEOPS) (Recommended for children 1-7 years old). Ucla Pain Management Clinical Resource Guide.

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