Talat Agzamhodjaev. Shamurad Takhirov*, Marganta Yem, Bahtijar Holmuhamedov* Dept ofAnaesthesiology, Tashkent Pediat-nc Medical Inst, Tashkent, Uzbekistan

Aim of Investigation To investigate requirement ofpropofol in xylocaine induced epidural anesthesia in children

Methods Forty-four consenting ASA physical status 1 or 2 children undergoing abdominal surgery were randomly selected After induction of anesthesia with propofol (3 mg/kg), single dose keta-mine (2 mg/kg) and Pipecuronium (0,07 mg/kg) the patients received an epidural anesthesia with xylocaine (5 mg/kg)

Results Optimal maintenance of anesthesia was achieved with propofol in dosage 256±12 ug/kg*min after maximum ofepidural anesthesia

Conclusions An epidural block reduced the amount ofpropofol required to produce the desired level ofsedatation and an epidural analgesia lasted much more

MIGRAINE PATTERNS IN 73 CHILDREN AND ADOLESCENTS REFERRED TO A FRENCH PEDIATR1C PAIN CLINIC

Daniel Annequin*. Nathalie Ravault, Unite d'Analgesie pediatnque Hopital d'enfants Armand Tousseau 75012 Pans

Aim of Investigation Migraine and tension type headaches are two diagnoses that are extensively underestimated and misdiagnosed in pediatnc population Especially in France, clinical studies in pedi-atnc headache field are rather poor

Methods: We examined 134 children and adolescents consecutively referred for recurrent headache to a pediatnc pain clinic through a 20 months period A semi-structured questionnaire was used to collect personal and headache history, and headache's features For migraine diagnosis, we chose IHS criteria excluding pain duration as recently proposed (Gherpelli JLD Cephalalgia 1998)

Results. Median age of children was 10 7 years (5-17 years range) median age of onset of headache was 6 years (1-14 years range) Atopy (36%), motion sickness (34%), somnambulism or equivalents (10%) have been found A family history of headache was present in 82% of children 50% and 17% were related to the mother and the father respectively Median headache duration was 4 hours, duration was short, infenor or equal to 1 hour (20 6%) Headache features location frontal or bilateral (80%), severe intensity (93%), pulsating quality (71%), aggravation by physical activity (83%), nausea (69%), vomiting (52%), phonophobia (83%), photophobia (76%), pallor (61%), improvement with sleep (73%), improvement dunng vacation (60%), aura (15%), visual aura (12%). Median monthly frequency of headache episodes reported was 3,5. Disturbance in school attendance was found (mean 4,6 days off among 57% of children) Using IHS definition corrected with headache duration at 1 hour, 41% migraine rate was found, excluding pain duration, migraine rate is 54,5%

Conclusion These first French data confirm previous studies in childhood headache. IHS diagnostic criteria are sensitive but poorly specific. Main revisions for child migraine diagnosis should include pain location and pain duration

EVALUATION OF TREATMENT OUTCOME AMONG CHILDREN, ADOLESCENTS, AND PARENTS SEEN IN A MULTIDISCIPLINARY COMPLEX PAIN CONSULTATION SERVICE: A PRELIMINARY RETROSPECTIVE INVESTIGATION

Susan M Bennett. Chnstme T Chambers*, Colleen A Court, Elizabeth Huntsman*, Carolyne Montgomery, Tim F Oberlander, Michelle Sheriff, Harold Siden*, The Univ of British Columbia and B C.'s Children's Hospital, 4480 Oak St, Vancouver, B C , V6H 3V4, CANADA

Aim of Investigation The purpose of the current study was to retrospectively evaluate the outcome of treatment among pediatnc patients and their parents who participated in a multidisciplmary treatment program for managing complex pain problems Children referred to this program typically have had pain for many years and are significantly disabled by pain Little is known about the efficacy of a multidisciplmary team approach with such children.

Methods Participants were 25 children and adolescents between the ages of 2 and 18 years, and their parents, who were seen over the previous 2 years by the Complex Pain Consultation Service at a provincial academic health centre Semi-structured interviews were conducted over the telephone with parents and children, when appropriate, by a research assistant not involved in direct clinical care Questions included both qualitative and quantitative ratings of degree of improvement, achievement of treatment goals, changes in pain and functioning, and overall program satisfaction The child's medical and demographic information was obtained from chart review

Results Interview results will be presented descnptively An exploratory analysis of factors related to outcome and treatment satisfaction, including child's age, type of pain, time elapsed since treatment termination, will be conducted Analyses will examine the concordance between child and parent reports of outcome and satisfaction with treatment

Conclusions This preliminary data will describe the degree of change and satisfaction following a team approach and will provide insights into factors related to positive outcome This data may have both clinical and research implications for professionals working with this population

EVALUATION OF REPEATED ADMINISTRATIONS OF PROPACETAMOL FOR TREATMENT OF POSTOPERATIVE PAIN IN CHILDREN. A DOUBLE BLIND, PLACEBO CONTROLLED STUDY

J Camboulives,L Cfisle, J H Insuasty², C Gliozzo²* (SPON J Wrobel) Dept of Pediatnc Anesthesiology, CHU La Timone, 13005 Marseille, France and clinical Research Dpt - Laboratoires UPSA / Bnstol-Myers Squibb Company, Rueil-Malmaison, France

Aim of Investigation To assess analgesic efficacy of repeated administrations ofpropacetamol (PPA), an injectable pro-drug of acetammophen, comparatively to placebo (P) in children with moderate to severe pain after appendectomy

Methods In a prospective, parallel, double-blind design, children (ASA I-II), age 6-14 years, were randomly assigned to receive every 6 hours, for up to 24 hours, either i v PPA 30 mg/kg (= 15 mg/kg acetammophen) or placebo i v Children self-rated pain intensity (VAS) during 6 hours after the first administration The postoperative opioid analgesic requirement was assessed by the number of rescue medication (nalbuphine 0 2 mg/kg) requested during the 24 hour evaluation period

Results. 107 children were randomized, PPA n = 54, P n - 53. PPA was significantly superior to P for the summed measure of pain intensity difference (SPID) over 4 hours (p = 0 03) Significant differences favoring PPA were observed in the PID up to 4 hours after the first administration Children in the PPA group used less rescue medication than did the P group 1 6 (± 1 4) and 2 1 (± 1 5) nalbuphine injections respectively In PPA group, 36 (66%) children reported at least one adverse event (AE) versus 33 (62%) children in P group No serious AE related to drug administration were reported. All AE were transient, mild or moderate in seventy.

Conclusion Propacetamol is a safe and effective analgesic agent to control postoperative pain in children having pain similar to that of appendectomy Used in combination with opioids, propacetamol reduced opioid requirements.

COMPARISON OF FACES SCALES FOR THE MEASUREMENT OF PEDIATRIC PAIN: CHILDREN'S AND PARENTS' RATINGS

Christine T Chambers*, Kelly Glesbrecht*, Kenneth D Craig, Susan M Bennett, & Elizabeth Huntsman*, Psychology, Univ of British Columbia, 2136 West Mall, Vancouver, BC, V6T 1Z4, Canada

Aim of Investigation Different versions effaces scales are available for eliciting children's self-reports of pain The present study examined a) the potential for bias in children's self-reported ratings of pain when using scales with smiling rather than neutral 'no pain' faces, b) levels of agreement between child and parent reports of pain using different scales; and c) preferences for scales by children and parents

Methods. Participants were 75 children (5 to 12 years) undergoing venepuncture and their parents Children and parents independently rated pain using five randomly presented faces scales and indicated which of the scales they preferred and why

Results: Children's ratings across scales were very highly correlated, however, they rated more pain when using scales with a smiling rather than a neutral 'no pain' face Parents' ratings across scales were also highly correlated, parents also had higher pain ratings using scales with smiling 'no pain' faces Level of agreement between child and parent reports of pain was low and did not vary as a function of the scale type used Children and parents preferred scales that were happy and cartoon-like

Conclusions The results of this study indicate that subtle variations in the format effaces scales do influence children's and parents' ratings of pain in clinical settings. Acknowledgments Supported by a SSHRC grant

POST-OPERATIVE PAIN IN CHILDREN: A COMPARISON OF FOUR DIFFERENT SELF-REPORT MEASURES OF PAIN INTENSITY AND PAIN-RELATED AFFECT

GD Champion. D Perrott*, B Goodenough, JE Taplin*, JB Zieg-ler*. Pain Research Unit, Sydney Children's Hospital, Randwick, NSW 2031, Australia

Aim of Investigation To examine the relationship between children's ratings of post-operative pain on the Faces Pain Scale (a pain intensity measure), the Facial Affective Scale (a broader measure of pain-related affect), and a paired Coloured Analogue Scale (CAS) method for measuring pain intensity and pain unpleasantness.

Methods: 97 children aged 4 to 16 years (56 male, 41 female) used four parent-administered scales to rate pain on the first two days after surgery. These scales were: the Faces Pain Scale (FPS) and the Coloured Analogue Scale for rating pain intensity (CAS-i), and the Facial Affective Scale (FAS) and a modified Coloured analogue scale, for rating pain unpleasantness (CAS-u)

Results The Faces Pain Scale correlated more highly with the CAS ratings for intensity (r= 87) than the CAS ratings for unpleasantness (r= 72) Conversely, the correlation between the Facial Affective Scale and the CAS ratings for unpleasantness (r= 70) tended to be greater than its correlation with CAS ratings for pain intensity (r= 66) Despite these correlation patterns, when all four measures were subjected to a principal components analysis, a single intensity/distress factor accounted for 79% of the total variance

Conclusions The results corroborate recent data from the postoperative context in adults that there is little evidence for separately measurable constructs of pain intensity and pain unpleasantness Whilst the Faces Pain Scale appears to provide a more sensitive measure of intensity than affect, it would seem that a useful composite index of post-operative pain intensity and concomitant distress can be obtained with most self-report scales

EVALUATION OF A CHILDREN'S COMMUNITY HOSPICE PROGRAM: DEVELOPMENT OF A TOOL

Tomasz Dangel. Susan Fowler-Kerry. Marek Karwacki *, Joanna Bereda*, Dept of Palliative Care, National Research Inst of Mother & Child, Warsaw, Poland, college of Nursing, Univ of Saskatchewan, Saskatoon, SK, Canada, S7N 5E5

Aim of the Investigation Program evaluation is a necessary means to evaluate the quality of care Currently there are no published formats for the evaluation ofpediatnc hospice programs The aim of this study was to develop and evaluate a tool for the assessment of the quality of palliative care provided by the Warsaw Hospice for Children

Methods A survey questionnaire consisting of 29 questions giouped into 5 categories was developed and pilot tested The questionnaire was mailed to 85 parents or primary caregivers representing 59 children who died in the care of the Hospice Fifty-one questionnaires (60%) were completed and returned

Results The majority of parents and caregivers were concerned about controlling their child's suffering and adequate medical support at home Controlling pain and other symptoms was most frequently (n=32) mentioned as a problem the Hospice was able to help with. The majority of parents (82%) did not tell their children that they were dying As well, 41% ofresponders did not participate in bereavement programs, some due to the distance required to attend

Conclusions The results demonstrate that effective pain and symptom control can be achieved with children in their home A significant number of parents were not able to have open conversations with their child about dying This may reflect Polish attitudes, which question children's autonomy, or parents may avoid this conversation to protect themselves and their child from distress The results also revealed that some components of parental suffering may be so personal that Hospice services cannot affect change The presented questionnaire is recommended for evaluation of different models ofpediatnc palliative care Acknowledgments' Supported in part by Association of Universities & Colleges of Canada

THE PARENTS' POSTOPERATIVE PAIN MEASURE DISCRIMINATES BETWEEN PAIN AND ANXIETY

G Alien Fmley. Christine T Chambers, Patrick J McGrath, Trudi Walsh*; Depts of Anaesthesia and Psychology, Dalhousie Univ, Halifax, B3J 3G9 Canada

Aim of Investigation The Parents' Postoperative Pain Measure (PPPM) was developed to use the behaviours charactenstic of continuing postoperative pain that were most easily identified by parents An initial validation study showed good correlation with child pain self-report. The purpose of the present study was to examine the specificity of the PPPM to pain, rather than anxiety. We expected that, while children's anxiety scores would remain relatively high both pre- and postoperatively, children's pain scores and parental PPPM scores would both follow the same pattern and be low preoperatively and high postoperatively

Methods. 75 children (30 females), ages 7-12 years (mean=8 79, SD=\ 69), undergoing day surgeries known to cause at least moderate amounts of pain, were studied with their parents (7 fathers, 1 aunt, 67 mothers). Pain scores (Faces, 0-6), child anxiety (STAI-C), and PPPM (0-15) were recorded on the 2 days before and the 2 days after surgery

Results As shown in the table, mean (SD) anxiety scores remained relatively constant across pre- and postoperative days. Child pain and PPPM both followed the expected pattern, with significant differences between preop and postop days Both scores also decreased from postop day 1 to postop day 2

	Child pain	Child anxiety	PPPM
2 days pre	043 (093)	31 12(740)	1 15(1 95)
1 day pre	0 57 (0 89)	32 36 (8 84)	1 32(1 57)
1 day post	1 83(1 51)	3209(846)	6 99 (3 34)
2 days post	1 12 (1 44)	2939(775)	4 89 (3 60)

Conclusions The Parents' Postoperative Pain Measure discriminates between pain and anxiety This finding supports its construct validity.

Acknowledgments Supported by grant XG97-016 from the Hospital for Sick Children (Toronto) Foundation

QUANTITATIVE SENSORY EXAMINATION IN CHILDREN WITH BURNS

O Gall, D Annequin, P.Marsol, M Granaclos, J B Dufourq, I Murat, Dept d'Anesthesie-Reanimation Hopital d'Enfants Armand Trousseau 75571 Pans Cedex

Aim of the Study To assess comparatively quantitative threshold changes in cutaneous sensation of children with acute bum trauma

Methods. After obtaining institutional approval and written informed consent, 28 children (aged 6 to 66 mo ) hospitalized for severe bum injury were examined at day 2 or 3 for perception and pain threshold determinations Mechanical threshold (pinprick with von Frey filaments) was defined as the lowest force that evoked pain or a reflex escape of the stimulated area in more than 50% of trials Thermal pain threshold (30 x 30 mm thermode, Medoc) was the mean of 3 consecutive determinations by the method of limits All stimuli were applied at 3 distinct sites 1. inside bumed area, 2 in surrounding tissues, and 3 as control, in an homonymous unle-sioned controlateral area. Demographics collected included site and depth of the injury, total body surface area bumed, morphine consumption and behavioral pain scores at rest and during nursing

Results Almost all subjects had significantly higher mechanical pain threshold in bumed skin as opposed to the homonymous controlateral area Interestingly 6 patients had also a lower mechanical pain threshold in the surrounding unlesioned area than in the homonymous controlateral area In these patients cold pain thresholds were also lowered whereas heat pain thresholds were unchanged Area of secondary hyperalgesia measured 12 to 28 cm2 The presence of secondary hyperalgesia was not related to the age, to the depth or the surface of the bumed area, nor to morphine doses administered. In contrast it was significantly associated with elevated pain scores during nursing.

Discussion. Quantitative sensory changes in tissue surrounding bum injury are commonly observed in such preliminary series It might be interesting to further characterize the relationship between secondary hyperalgesia and the clinical expression of pain in this setting.

Acknowledgments This work was supported by la Fondation de 1'Avenir

CAN INJURY PREVENTION BE TAUGHT TO CHILDREN WITH CONGENITAL INSENSITIVITY TO PAIN? DEVELOPMENT OF NEW PROGRAM FOR A CHALLENGING POPULATION

Yon Gidron*. Foad Al-Sana*, Jacov Levy*, Pessah Shvartzman Faculty of Health Sciences, Ben-Gunon Univ, Be'er Sheeba, 84015, Israel

Aim of Investigation Congenital msensitivity to pain with anhi-drosis (CIPA) is a rare hereditary sensory autonomic neuropathy characterized by analgesia, anhidrosis and mental retardation The southern region of Israel includes one of the largest numbers of CIPA cases in the world, all of Bedouin origin. Children with CIPA experience severe and frequent home injuries, finger and oral biting and hyperpyrexia In this poster we wish to present the rationale and preliminary results of a new program aimed at trying to reduce the incidence of injuries among children with CIPA

Methods A pre-post, repeated-measures design is used Bedouin children diagnosed with CIPA are assessed for their IQ, and parents complete questionnaires assessing family resources/inputs and incidence of home injuries Number of injury-related visits to the health clinic one month before and after the program are obtained from medical records Each child and his/her parents are taught the following injury-prevention techniques: 1) Pairing cues. Pairing of tactile-sensations of different objects with facial expressions (children learn to pair pleasant and unpleasant tactile sensations with pleasant and unpleasant facial expressions, respectively, using a faces pain-scale), 2) Modeling Children view and then imitate injury-prevention behaviors modeled by a staff member and a doll passing through a path with obstacles, 3) Parent safety education Parents are taught about the disease and how to take safety measures in their home environment One and two months later, parents complete again the measure of home injuries, and medical records are checked for clinic visits Changes in injury incidence will be tested after statistically controlling for any significant covanate of injuries (child's IQ, age or family resources/input) The poster will include a detailed descnption of a pilot study with one family undergoing this new procedure

USE OF TRANSDERMAL FENTANYL (DUROGESIC™) IN THE TREATMENT OF CHILDREN WITH CHRONIC PAIN REQUIRING LONG-TERM OPIOIDS

A Goldman.A.M Hunt. J Baird², T Devine³, M B Phillips⁴, on behalf of FEN-GBR-14 Study Group, Inst of Child Health, London WC1N 1EH, England, Janssen-Cilag Ltd , Saunderton, Bucks HP14 4HJ, England, Oncology Dept, Royal Marsden Hospital, Sutton SM2 5PT, England, Dept ofPaediatnc Haematology/Oncology, Llandough Hospital, Penarth, Wales CF64 2XX

Aim of Investigation To evaluate safety and efficacy of Durogesic™ in children requinng strong opioids for pain from life- threatening disease

Methods In an open, multi-centre study, children receiving at least 30 mg morphine daily were transferred to a fentanyl patch Immediate-release morphine was available for breakthrough pain Pam was assessed twice daily, side effects and satisfaction with the patch were assessed every three days.

Results Forty-one children (median age 10.5 yrs, range 26-188) entered Median fentanyl dose at transfer was 25 ug/hr (maximum 150 ug/hr) Median time using the patch was 21 5 (range 0-460 days) Twenty-six patients completed the 15 day treatment phase (median fentanyl dose 75 ug/hr; range 25-250 u.g/hr) and all opted to continue using the patch Of the remaining 15, 7 used the patch until their death from the underlying disease and 8 withdrew due to inadequate analgesia or need for parenteral opioids in the terminal phase No senous adverse events were attnbuted to fentanyl Compared with pnor morphine treatment, the trend was for improved side effects and convenience Of those completing, 23/26 parents (3 missing) and 25/26 investigators considered Durogesic™ to be better than previous treatment

Conclusions Durogesic™ appears to be safe, effective and acceptable to children and families Success relies on close supervision, regular assessment and appropriate use of breakthrough medication

Acknowledgments The study has been sponsored by Janssen-Cilag Ltd

CHILDREN'S REPORT OF NEEDLE PAIN: COMPARING THE FACES PAIN SCALE AND THE FACIAL AFFECTIVE SCALE

B Goodenoueh. GD Champion, K van Dongen*, N Brouwer*, HH Abu-Saad, Pain Research Unit, Sydney Children's Hospital, Randwick, NSW 2031, Australia

Aim of Investigation To examine the relationship between the Faces Pain Scale, the Facial Affective Scale, and a paired visual analogue method (VAS) for children's report of the intensity and unpleasantness of needle pain

Methods. Participants were 80 children scheduled for blood sampling (41 venipuncture, 39 fmger-pnck), selected in two age groups 4 to 6 years (n=41) and 7 to 10 year (n=39) Children rated the needle pain using each of the four measures in the following order' Faces Pain Scale, VAS-mtensity, Facial Affective Scale, VAS-unpleasantness This fixed order of scale administration included training in how to apply the paired VAS concept as well as the difference between pain intensity and pain unpleasantness

Results As hypothesised. Faces Pain Scale ratings correlated more highly with the VAS scores for intensity (r= 77) than for unpleasantness (r= 52), while Facial Affective Scale ratings showed a higher correlation with the VAS for unpleasantness (r= 64) than for intensity (r= 51) Factor analysis indicated that 'pain dimension' (intensity versus affect) was a weak factor as compared with shared instrument vanance (VAS versus facial expression scales) and the high correlation between intensity and affect There was little evidence of age effects on the relationships between ratings on the four pain scales

Conclusions The Faces Pain Scale and the Facial Affective Scale may partly measure different aspects of the pain expenence in children, although it remains to be determined to what degree the obtained differences are clinically meaningful in terms of directing treatment interventions for pain relief

THE EFFECTS OF A PAIN MANAGEMENT PROTOCOL ON PEDIATRIC OUTCOMES

Nancy O. Hester., Carol P Vojir, Roxie L Foster, Su-Fen Cheng, Karen Miller, School of Nursing, Umv of Colorado Health Sciences, Denver, CO 80262, USA

Aim of Investigation The aim of this study was to determine the effect of a pain management protocol on outcomes related to pain, satisfaction, and length of stay

Methods Two trials were conducted Each trial included three pediatnc units, one of which was the experimental unit and three phases (baseline for four months, implementation for six months, and maintenance for five months), thus providing both within hospital and across hospital controls The goal of the pain management protocol was to increase nurse surveillance of pain and to have nurses promptly and appropriately treat pain The sample for the two trials included 1,053 children (0-21 years) and their parents Parents and children provided data for pain and satisfaction outcomes Pain was measured with the Poker Chip Tool (range 0- 4) while letter grades (A, B, C, D, and F) were used to capture measures of satisfaction with pain care by nurses and by physicians Length of stay was measured in hours

Results MANOVA was used for each trial to examine whether the experimental pediatnc unit had better outcomes than the control units Differences among the hospitals were not significant (a of 05)

Conclusions The lack of significance among the hospitals in the two trials may have occurred for several reasons First, the six month time frame for implementing the intervention may have been too short and the effects of the intervention may not have been realized within the five month maintenance phase Second, while the units were interested in the policy, implementation was not mandatory Third, contextual factors such as hospital philosophy, nurse demographics, nurse attitudes and beliefs about pain, and stress secondary to health care reform may have affected the overall implementation of the policy Acknowledgment Funded by the National Institute of Nursing Research, National Institutes of Health, R01NR02919

THE PREVALENCE AND EFFECTS OF CHRONIC PAIN IN AN 11 YEAR OLD SCHOOLCHILD POPULATION

Dr Linda Huggins. Dr Cathy Stannard, Dr Alison Pearce* Frenchay Hospital Pain Clinic, Bristol BS16 1LE UK

Aims of Investigation To discover the prevalence and effects of chronic headache, abdominal pain, backache and lower limb pain in a normal 11 year old school child population Methods A questionnaire asking about the prevalence, frequency and seventy of pain was distributed by school nurses to 2076 11-year old school children The questionnaire also asked how long pain had been experienced and what impact it had made to their everyday life

Results 1315 valid questionnaires were returned - a response rate of 63% The majonty of the questionnaires (70 3%) were completed by both the child and their parents The overall prevalence of all types of chronic pain in boys was 39 4% and in girls was 44 4% Chronic pain was defined as pain that had been present for at least 3 months The chronic pain was reported as 'mild' in 45 1%, 'moderate' in 45 3% and 'severe' in 8 0% Pain occurred once a week or more in 32 4% Sleep was affected in 46 7% of the children with chronic pain and 58 5% took 'painkillers' on a regular basis School attendance was disrupted in 24 4% of these children

Conclusions This study looked in detail at the patterns of chronic pain in an accessible 11 year old population of children looked after by motivated school nurses The prevalence of moderate or severe chronic pain was found to be 22 3%

Acknowledgments Supported by a Frenchay Healthcare Trust Research Grant

PRESCRIPTION AND ADMINISTRATION OF ANALGESICS IN CHILDREN

Eufemia Jacob & Kathleen Puntillo, Univ of California San Francisco, San Francisco, CA 94143-0606, Children's Hospital Oakland, 747 52^nd St, Oakland, CA 94602

Aim of Investigation To examine the differences in the prescnp-tion and administration of analgesics in eight pediatnc specialty units

Methods Medical records of patients (N=153) who were reported by nurses to be having pain were reviewed for patterns of analgesic administration and for evidence of pain relief

Results Children were frequently prescribed opioids (morphine, demerol, and codeine with acetaminophen), NSAID's (tyienol, ibuprofen, and ketorolac), and adjuvants (aiivan or benadryl) for pain Mean doses of opioids were frequently subtherapeutic, while the NSAID's and adjuvants were all within the therapeutic range There were no significant differences in the mean dosages of medications prescribed among the eight different specialty units There were, however, variations in the types of analgesics prescribed and administered There were also large intervals between doses of medications Few patients had pain scores documented before and after analgesic administration Evidence of relief was therefore inconclusive and the actual effectiveness of these practices could not be consistently evaluated

Conclusions Under-treatment may result from substandard dosing practices, long intervals between administration of doses, inappropriate type of analgesic, or a combination of these We recommend that analgesics be prescribed and administered according to standard dosages and that effectiveness be evaluated after administration and at least every four hours, so that corrective adjustments can be made in dosing amounts and frequency Acknowledgment Funding was provided by a research grant from Samuel Memtt College and an Institutional Pre-Doctoral Award within the Nurse Training Grant in Symptom Management (T32-NR07088-01) from the Umv of California San Francisco

POST-OPERATIVE PAIN IN CHILDREN: FACTORS RELATED TO SATISFACTION WITH PATIENT-CONTROLLED ANALGESIA

L Keogh*, JE Taplm*, B Goodenough. School of Psychology, Univ of New South Wales, and the Pain Research Unit, Sydney Children's Hospital, Randwick, NSW 2031, Australia

Aim of Investigation To examine the significance of variables hypothesised to be related to children's satisfaction with the method of Patient Controlled Analgesia (PCA) for coping with post-operative pain.

Methods' The participants were 44 children aged 6 to 17 years (22 male, 22 female) who used PCA following abdominal or orthopae-dic surgery Morphine consumption and pain ratings on each of the first 3 post-operative days were recorded Following discharge, children's satisfaction with the hospital procedures available to help them cope with their pain was assessed The Nowicki-Stnckland Internal-External Locus of Control Scale, the State-Trait Anxiety Inventory for Children, the Pain Coping Questionnaire, and two subtests of the Stanford-Bmet Intelligence Scale (4th edn) were also administered

Results When asked if they would use PCA again if they had another operation, 79 5% children indicated 'yes', 13 6% were uncertain, and 6 8% indicated 'no' A hierarchical multiple regression analysis showed that the hypothesised predictors of satisfaction with PCA accounted for 64 6% of the total variance Morphine consumption and pain ratings dunng the immediate postoperative period accounted for 28 9% of this variance in PCA satisfaction, the age and gender of the child predicted a further 14 2%, and the psychological measures of cognitive ability, trait anxiety, locus of control, and coping strategy explained another 21 5%

Conclusion Children presenting the least favourable reaction to PCA tend to be younger, to have a relatively low level of intelligence, an external locus of control, and high trait anxiety, and to experience high pain levels in the immediate post-operative period

ATTEMPTED CROSS-CULTURAL VALIDATION OF THE PARENTS' POSTOPERATIVE PAIN MEASURE

Prasong Khunsongkiet, G Alien Fmley. Christine T Chambers, Patrick J McGrath, Depts of Anaesthesia and Psychology, Chiang Mai Univ, Chiang Mai, Thailand and Dalhousie Univ, Halifax, B3J 309 Canada

Aim of Investigation The Parents' Postoperative Pain Measure (PPPM) is a 15-item behavioural measure of postoperative pain that was developed for use by parents in the at-home assessment of children's pain It has shown excellent correlation with child self-report in samples of Canadian children We attempted to validate a Thai version of the PPPM

Methods Participants were 64 children (ages 3-16 yrs, mean 9 7, SD 3 9), who had cleft lip repair, cleft palate repair, or other surgery as part of an Operation Smile volunteer medical mission in Lampang, Thailand A Thai nurse anaesthetist recorded child self-report of pain and parents' responses to the 15 question PPPM during the hospital stay

Results Many of the 15 key behaviours reported previously occurred more frequently in the Thai sample The PPPM scores correlated poorly with child self-report of pain, and the mean PPPM scores were higher than seen in previous studies (e g "Cries more easily than usual" original Canadian sample 12 0%, Thai sample, 40 8%)

	Observation #1	Observation #2
Child score (0-6) PPPM (0-15) Spearman's r	1 74 8 16 0 1826(p= 170)	1 39 886 02360(p= 137)

Conclusions Parents reported more behaviours present than in the original study, thereby restricting the range of correlations with child self-report This may be because of cultural differences in the assessment of behaviour, or because of the different (in-hospital) setting Clearly, further study of the PPPM and other tools in different cultural settings is essential

Acknowledgments Supported in part by a grant from the Hospital for Sick Children (Toronto) Foundation

CONTEXTUAL INFLUENCES ON THE FACIAL EXPRESSION OF PAIN IN NEONATES

Christine T Korol. John T Goodman, Pradeep Merchant*, Jocelyn Lawrence-Amdt,* Dept of Psychology & Division ofNeonatology, Children's Hospital of Eastern Ontano, Ottawa, Ontario, Canada, K.1H81-1

Aim of Investigation Several contextual variables have an impact on the expression of pain in neonates (e g , behavioural state, ges-tational age, illness seventy, analgesia, and pain experience) However, past research has either not considered these vanables simultaneously or used a restricted sample thereby preventing development of a comprehensive model of contextual influences on pain behaviour

Methods In the present study, facial expressions of neonates in a tertiary neonatal intensive care unit (NICU) were videotaped during a routine venipuncture to determine the degree to which gesta-tional age, illness severity, pain experience, analgesia, and behaviour state influence pain behaviour

Results Using covanance structure analyses, this study found support for a well-fitting model that explained 94% of the observed covanance in the data Specifically, 27% of the variance of the facial expression of pain was influenced by behavioural state, and illness seventy There was also an indirect effect of physical maturity on pain behaviour, mediated through illness severity The number of previous procedures was not found to impact on subsequent pain behaviour, and this path was removed from the model

Conclusions Support was found for a practical and meaningful model of the contextual factors influencing the expression of pain This study replicates the findings of previous research that state the importance of including behavioural state and illness severity when assessing pain in the neonate In addition, it extends that research by uncovering the indirect effect of physical maturity on pain, mediated through the infants' level of illness seventy Furthermore, this indirect effect provides further evidence that even very premature infants experience pain, but are unable to mount a response to an aversive event when they are ill.

Acknowledgments This project was supported by the Children's Hospital of Eastern Ontario Research Institute

PEDIATRIC PATIENT-CONTROLLED EPIDURAL ANALGESIA WITH BUPIVACAINE AND HYDROMORPHONE

Yuan-Chi Lin. Sandy Sentivany-Collins, Lisa Vischer*, Pain Management Service, Lucile Packard Children's Hospital at Stanford, Dept of Anesthesia, Stanford Univ School of Medicine, Stanford, California 94305, USA

Aim of Investigation We evaluate the usage of patient-controlled epidural analgesia (PCEA) in pediatnc patients for acute pain management

Methods' Prospective data were collected on 113 pediatnc patients consenting to epidural analgesia with PCEA using 0.1% bupiva-came and hydromorphone 25 .g/ml All patients received continuous infusions with lock out on demand dose of PCEA Epidural bupivacame infusions rate was limited to less than 0 4 mg/kg/hr Prospectively gathered data included visual analog scale (VAS) for pain ranged from 0 to 10, the epidural medication usage, and incidence of side effects. The Pain Management Service followed up all the patients on PCEA closely until patients were switched to conventional oral pain medications

Results One hundred and sixteen epidural catheters were placed in 112 patients (42 male and 70 female), The average age was 14 8 ± 4.5 (S D ) year-old, and the average weight was 51 3 ± 13 9 (S D ) kg Sixty-one catheters were placed in the thoracic region and 55 were in the lumbar region The sites of surgenes/pam were 23 (20%) in the thorax, 34 (28%) in the abdomen and pelvis, 23 (20%) in the lower extremities, and 37 (32%) for the correction of scoliosis The average VAS pain score were 1 1 ± 1 5 (S D ) The duration of PCEA infusions was 3 3 ± 1 4 (S D ) days Two cases PCEA were switched to intravenous opioids due to inadequate pain control Both cases were after scoliosis surgenes One of the patients' epidural catheters fell out accidentally during movement Side effects include nausea, vomiting and pruntis Patients with PCEA can be admitted to the regular floor None of the patient developed respiratory depression or other complications

Conclusions Our expenence suggests that PCEA can be provided for pediatnc patients with adequate analgesia and a low nsk of complications.

OUTPATIENT PEDIATRIC PAIN CONTROL PRACTICES OF NORTH AMERICAN BURN CENTERS

Susanne P Martm-Herz. David R Patterson, Carmel P Finch*, Univ of Washington School of Medicine, Seattle, WA 98195, USA

Aim of Investigation The purpose of this project was to investigate current pain control practices for pediatnc bum patients receiving wound care at home This project was part of a larger survey of pediatnc pain control in North Amencan bum centers

Methods Surveys were mailed to all 149 bum centers listed in the Amencan Bum Association resource guide, 122 responses were received from 85 centers Specific questions were asked regarding home care providers, analgesic choice and dosing, and perceived efficacy of current pain control practices for four specific age groups' infants/toddlers (0-2 yrs), pre-schoolers (3-6 yrs), school age children (7-12 yrs) and adolescents (13-17 yrs) Centers that reported discharging more than 15% of their hospitalized pediatnc patients to receive wound care at home were included in this evaluation

Results. Seventy-five percent of centers reported discharging more than 15% of their hospitalized pediatnc patients for outpatient wound care In the majonty of cases (60%), parents provided wound care and administered pain medications at home Thirty-two percent of centers contacted parents prior to the first clinic visit to evaluate the child's discomfort or medical condition Home-visit nurses were frequently utilized by 28% of centers Acetammophen with Codeine was the most widely prescribed analgesic in all age groups (range 60-71% of centers), followed by acetaminophen alone (31-47%) and nonsteroidal anti-mflammatones (23-26%) Home intravenous medications were prescnbed by less than 5% of centers and intramuscular injections by less than 10% The most common prescription instructions were dosing as needed plus one scheduled dose prior to wound care (74%). A visual analogue scale rating revealed moderate confidence in pain control efficacy for outpatients (61/100) Specific age related findings and comparison to inpatient care will be included

Conclusions This study provides an initial overview of outpatient pain control practices for pediatnc bum patients in North Amenca As this population continues to grow, careful evaluation of optimal pain management techniques will continue to increase in importance

Acknowledgments This research was supported by National Institutes of Health Grant 3R01 GM42725-08S1

THE APPLICATION OF GABAPENT1N IN THE MANAGEMENT OF NEUROPATHIC PAIN IN CHILDREN AND ADOLESCENTS

BC McClam.ZN Kam*. B H Lee Depts ofAnesthesiology, Yale Univ, New Haven, CT 06520 USA, Children's Hospital of Boston, Boston, Massachusetts, 02146 USA

Aim of Investigation This study reviews the dose requirements for gabapentin in children and adolescents who have experienced various neuropathic pain syndromes. Secondly, it compares the efficacy ofgabapentm in a sole anticonvulsant regimen to co-therapy administration with carbamazepme in the treatment of mechanical allodynia and spontaneous pain

Methods 14 children and adolescents ranging in age from 9-17 years (13 33, ± 0 99 SE) were treated with systemic gabapentin for neuropathic pain due to CRPS type I, CRPS type II, diabetic neu-ropathy or postthoracotomy syndrome. Two cases were excluded due to noncompliance Inclusion cntena required the presence of mechanical allodynia and spontaneous pain In group 1, gabapentin was introduced as co-therapy to carbamazepme (10-15 mg/kg/day) and in group 2, gabapentin was the sole anti-convulsant Gabapen-tin was increased q 48 h over 10 days with the maximum dose based on a clinical endpomt of tolerance to movement and touch of the affected region All patients received daily tncyclic antidepres-sants Pain scores were by self report (0=no pain, 10=worst pain) except for one patient where an observed scale (OPS=0-10) was used

Results There was no statistical difference in pain scores between groups pnor to the start of gabapentin Mechanical allodynia resolved in both groups by day 14 of gabapentin therapy Pain scores on mobilization after one month of gabapentin therapy were compared to pre-gabapentm results by paired T-test and showed significant reductions in both groups ( P= 0 002 in Group 1 and P=0 013 in Group 2) Adverse reactions were mild and did not require termination of gabapentin administration The effective mg/kg/day dose averaged 20 45 mg (±2 06 SE)

Conclusion. Adult studies site gabapentin doses of 30-40 mg/kg/ day in the treatment of neuropathic pain. Children appear to require a lower mg/kg daily dose for effective pain management In chil-dren, gabapcntm without carbamazepine is appropnate in managing neuropathic pain, however co-therapy is the treatment of choice

FURTHER VALIDATION OF THE PARENTS' POSTOPERATIVE PAIN MEASURE: EXTENSION TO 2-6 YEAR OLD CHILDREN

Patrick J McGrath, G. Alien Finley. Christine T. Chambers, Trudi Walsh*, Depts of Psychology and Anaesthesia, Dalhousie Univ, Halifax, B3J 3G9 Canada

Aim of Investigation The Parents' Postoperative Pain Measure (PPPM) is a 15-item behavioural measure of postoperative pain that was developed for use by parents in the at-home assessment of their school-aged children's pain The purpose of the present study was to determine the appropnateness of the PPPM as a parental measure of pain in younger children.

Methods Participants were 107 parents of children (2 to 6 years) undergoing day surgery For the two days following surgery, parents completed a pain diary which included ratings of their children's pain (using the Faces Pain Scale, FPS) and each of the 15 PPPM items (e g "Cries more easily than usual?")

Results Parents' PPPM scores were very highly correlated with their FPS ratings of their children's pain on both days following surgery (r = 72 and 62) PPPM scores also showed good internal consistency on both days following surgery (alpha = 86 and 87) As parent FPS scores decreased from Day 1 to Day 2, so did scores on the PPPM PPPM scores were also successful in discriminating between children who had undergone low to moderate pain surgeries and those who had undergone high pain surgeries There were no significant differences in PPPM scores as a function of child age or sex

Conclusions There is preliminary evidence for the reliability and validity of the PPPM as a parental measure of pain in children 2 to 6 years of age

Acknowledgments Supported by grant XG97-016 from the Hospital for Sick Children (Toronto) Foundation

POST-OPERATIVE PAIN IN CHILDREN: CAN PARENTS INTEGRATE ASSESSMENT AND MANAGEMENT?

P A. McGrath. D P Girvan*, L M. Hillier*, C.E Seifert*, Pain Program, Child Health Research Inst, Univ of Western Ontario, London, N6C 2V5, Canada

Aim of Investigation To determine the construct validity of the Coloured Analogue Scale (CAS) as a pain measure for children and to evaluate whether parents (caring for children after day surgery at home) benefit from learning how to use the CAS to regularly assess their children's pain and determine if administered analgesics were adequate

Methods A cohort of 40 children, 5-10 yrs, scheduled for elective day surgery learned how to use the CAS and a Facial Affective Scale to measure the intensity and affect of different pain situations Then, for ~24 hours after surgery, children's pain was assessed at regular intervals in hospital by research staff and at home by parents. Children's pain ratings were compared pre- and post-analgesia. (Sample size was calculated from observed changes in CAS ratings from pilot data )

Results All children could easily use the CAS All children required analgesics after surgery and 95% required analgesics at home Children's pain intensity decreased significantly after analgesic administration (paired t-test, p < 001) from a mean of 5.1 to 3 4 (CAS) 85% of parents indicated that the use of the CAS improved their ability to care for children after surgery Conclusions The CAS is a valid tool for assessing postoperative pain in children, when used by staffer parents Parents benefit from basic instructions on how to assess their child's pain and administer OTC analgesics.

Acknowledgments Supported by a grant from McNeil Consumer Products, Canada.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p. 195 - 201