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Pain in Children - 2




Rajesh Pande*. Maitree Pande*, A. Bhattacharya* (SPON: to be provided), Anaesthesiology & Critical Care, B P Koirala Inst of Health Sciences, Dharan, Nepal.

Aim of Investigation: To evaluate the efficacy of regional analgesia techniques in providing safe and prolonged postoperative analgesia in paediatric day care surgery.

Methods: Eighty-seven children aged 1-12 yr. were randomly divided into three groups. Group I (n=67) received genera] anaesthesia with regional analgesia; group II (n=10) and group III (n=10), received regional analgesia or general anaesthesia along for day care surgery. Anaesthesia was induced in children less than 5 yr. with halothane and those above 5 yr. with thiopentone. Anaesthesia was maintained with halothane in oxygen and nitrous oxide (mask /LMA or ETT with or without muscle relaxation). Appropriate regional blocks were given immediately after induction of anaesthesia in group I. Postoperative pain assessment was done using Oucher's faces rating scale in children less than 5 yr. of age and using 100 mm. VAS scale in older children. Behaviour changes like cry, parent's observation and the nurse's observation were also recorded. Data was analyzed using one tailed student's 't' test and 'Z' text.

Results: Postoperative pain was significantly less in patients receiving regional analgesia as compared to general anaesthesia. The time to first analgesic in the postoperative period was significantly less in the patients receiving general anaesthesia alone and the analgesic requirement was significantly high.

Conclusion: Our study shows that degree and duration of postoperative pain relief is very satisfactory in children receiving regional anaesthesia. The techniques were safe, simple and we recommend the use of regional techniques wherever possible in similar situations.


Lisabelle Mariano Rossato, Margareth Angelo, School of Nursing at Sao Paulo Univ, Sao Paulo, Brazil.

Aim of Investigation: The aim of this study was to assess the utilization of tools for pain perception assessment in 41 hospitalized pre-school children submitted to painful procedures: care of wounds or blood extraction.

Methods: The utilized tools were the faces scale, behavioral indicators and words which describe the pain. Results: Most of the pre-schoolers understood and correctly answered to the faces scale, which can be noticed by the crescent movement 0 (no pain) > 4 (maximum pain) during the choice of faces before and after the painful procedure.

Conclusions: Crying, immobility and forehead wrinkling were the predominant behavioral indicators, intensified during the procedure. Pre-schoolers verbalizations about their pain showed up to be concrete terms or evaluative-indicative nature, resulting in variable or weakly precise concepts.


E, Sieh*. B.C. McClain, Z.N. Kain* Dept. ofAnesthesiology, Yale Univ School of Medicine, New Haven, Connecticut 06520, USA

Aim of Investigation: To compare the efficacy of around the clock (ATC) to as needed (PRN) use of belladonna and opium (B&O) suppositories in children for the control of surgically induced bladder spasm.

Methods: Children admitted to the Pediatric Pain Service (PPS) prior to October 1998 received B&O suppositories on a PRN eight hourly schedule and comprise group I. Those children admitted after October 1998 received ATC eight hourly B&O suppositories and comprise group II. The dose was based on patent weight. Patients with preoperative respiratory compromise, age less than 6 months or ASA class of III or greater were excluded. A total of 34 ASA I and II status patients ages 6 months to 13 years old were studied. All patents received continuous epidural infusion of 0.0625% bupivacaine admixed with either fentanyl or hydromor-phone at equipotent doses for 72 hours. Assessments of the number ofunplanned adjuvant administrations and the number of reported bladder spasms were also performed. Events of profound sedation or bradypnea were reviewed.

Results: Patients in group II had a significantly lower number of bladder spasms as compared to group I (0.80.4 vs. 2.60.4, p=0.004). Similarly, patents in group II required a significantly lower number of adjuvant interventions as compared to patents in group I (1.60.2 vs. 3.00.3, p=0.001). Respiratory depression was minimal in both groups and no interventions were made.

Conclusions: Our findings suggest that prophylactic treatment of surgically induced bladder spasm with B&O is beneficial and has few untoward effects. Data collection is ongoing to assess additional support of treatment efficacy,


Jennifer Stinson. Basem Naser*, Dept of Anaesthesia, The Hospital for Sick Children, 555 Univ Ave, Toronto, Ontario, Canada M5G 1X8

Aim of Investigation: To examine the pain management experience of children with sickle cell disease (SCD) hospitalized for vaso-occlusive crisis (VOC) requiring PCA.

Methods: Using File Maker Pro data base, charts of 26 patients hospitalized on 54 different occasions over a 28 month period, in which PCA was used, were analyzed.

Results: Sample consisted of 16 females and 10 males. Age ranged from 7.2-18.5 years (X= 14.6). VOC Pain presentation on 52 admissions was: chest (N=18), extremity (N=16), total body (N=13), and back (N=5). Fifty (92%) admissions had morphine infusions in emergency Dept (X =38.9, range 10-80'hr''). Time to start PCA was 1 day (X=1.2, range = 0-5 days). Fifteen patients received PCA bolus only, while 39 received bolus plus infusion. Mean starting bolus dose was 21.6'' (range = 11.8-44.9 and mean background infusion rate was 21.6 (range=8.1-77.7'W). Duration of PCA ranged from 1 to 22 days (X=5.28 days) and mean length ofhospitalization was 7.8 days (range 2-23 days). Nausea (N=6), vomiting (N=6) and pruri-tus (N=6) occurred in 11% of admissions. There was no respiratory depression.

Conclusions: Study findings will be used to guide continuous quality improvement ofPCA use in patients with SCD.


Sue A'. Izard* P', Rouzaud* A, Me Peyroulet*', Grandjean* H2, Lazorthes Y 3, 'Hopital des Enfants, 330 Av de Grande Bretagne, BP3119, 31026 Toulouse, ^nite INSERM CJF 94-06, Faculte de Medecine. Allees J Guesde, 31000 Toulouse. 'Hopital de Rangueil, 1 av J Poulhes. 31403 Toulouse. France

Aim of Investigation: Integration of pain assessment into everyday clinical pratice is the first step to improve pain management. Despite the availability of appropriate scales to assess pain in children, underassessment is still the rule. Therefore, we conducted a prospective prevalence survey in order to enhance nurses' awareness on pain management. Prior to the study, an educational program was developed on state of the art of pain assessment.

Patients and Methods: On a 24 hour period, nurses were asked to systematically assess the pain of each child they had to take care of, at least every 8 hours. Three different scales were used. The EDIN scale (Echelle Douleur et Inconfort du Nouveau-Ne) for newbom and premature. Objective Pain Scale for children between a month and 4 years of age, and Visual Analog Scale for those aged above.

Results: On the 198 hospitalized children, 155 (78%) were evaluated (347 scores were collected). The results show that 38 % of the children experienced mild to severe pain. Significant pain was differently experienced depending on the child's age: 66% of the population of the premature and newbom experienced pain versus 34% for the children older than four years (p<0.001). Detailed analyzis of the caracteristics of their pain will be reported.

Conclusion: Daily clinical use ofpediatric pain scales by nurses is feasible in a pediatric general hospital. When pain is assessed, it appears that little children are the one who suffer the most. This survey will help us to build up a new policy focused on alievating pain.

Acknowledgments: Supported by a grant from The Institut Elec-tricite Sante.


Anna Taddio. Neil Pollock*, Cheryl Gilbert-MacLeod*, Kristma Ohisson*, Gideon Koren*, Depts of Pharmacy and Paediatrics, The Hospital for Sick Children, Toronto, Ontario M5G 1X8, Canada, and Dept of Psychology, IWK Grace Health Centre, Halifax, Nova Scotia B3J 3G9, Canada

Aim of Investigation: To investigate the combined effectiveness of dorsal penile nerve block (DPNB), lidocaine-prilocaine cream, sugar-covered pacifier/gauze and a Mogen clamp technique to minimize pain during circumcision.

Methods: Healthy male infants undergoing circumcision participated in a cohort study. Infants were circumcised using either DPNB, lidocaine-prilocaine, sugar-covered pacifier and the Mogen clamp (Group 1, intervention group) or lidocaine-prilocaine and the Gomco clamp (Group 2, standard care). Pain was assessed in a blinded fashion using the Neonatal Facial Coding System (NFCS), cry duration and heart rate.

Results: Eighty-six infants participated. Preliminary results demonstrate lower pain scores for infants in Group 1 compared to infants in Group 2. No serious adverse events were observed.

Conclusion:Previous studies have not evaluated the pain responses of infants circumcised with the benefits of an analgesic regimen that includes DPNB, lidocaine-prilocaine, a sugar-covered pacifier, and a technique that is associated with a short surgery duration. This study provides preliminary evidence for the effectiveness and safety of combined analgesia and Mogen clamp technique for minimizing the pain from circumcision.

Acknowledgments: CGM is supported by a student fellowship by SSHRC.


Ljubinko Tonic*. Univ Children's Hospital, Tirsova 10, 11000 Belgrade, Yugoslavia

Aim of Investigation: Children are often victims of bums that may have widespread systemic effects. In such cases optimal analgesia is one of the imperatives of treatment.

Methods: To estimate the intensity of bum pain in children is most difficult. Assessment tools we used were visual analogue scales, self-report scoring test, face scale, behavior rating scale.

Results: The study involved 450 burned children, from the neonate to 15-year old, treated at this hospital. Immediate estimation of the degree and extent of the bum (Rule of 9) determined therapy including relief of pain, which must be present during all phases, including every day open or close type of local treatment, operative procedures with application of split thickness graft and acute phase, with repeated anesthesia for plastic and reconstructive surgery. Constant nursing supervision must be provided, so that generous dosage ofanxyolytics and analgesics can be safely administered. Rational use of analgesics relies on an individual approach to each child to allow for variability of pain, depending on the bum degree, childhood differing pharmacokinetics and pharmacodynamics. The author used Ketamine as a very reliable agent. It was found highly suitable for repeated use by approximate premedication. with atropine and central acting analgesic Tramadol HCL. Profound analgesia was provided without respiratory, cardiovascular system depression and immunosuppressive action.

Conclusion: A more scientific definition is that bum pain presents a multifactorial syndrome of behaviors, including neuro-anatomic, sensory perception and emotional damage. Bum pain results from tissue damage or disruption, which is associated with an increase in small fiber and decrease of large fiber activity. A good plan should be determined for optimal pain control and discussed with parents and those children who are old enough to understand. The author stresses out severe emotional problems resulting from the accident, disfigurement and repeated surgical procedures. Related with his experience, the author suggests protocol for the use of Ketamine, central acting analgesic Tramadole HCL and anxyolytic Midazo-lam in the bum pain relief in children as a safe drug with minimal adverse events.


Valero A.*. Vargas-Schaffer G., (SPON: Mejia N.), Hospital de Ninos "J.M. de los Ri'os", Caracas-Venezuela

Aim of Investigation: To establish the number of consulted oncological patients in a specialised consultation of children's pain. To know the use ofopioids medicaments in the oncological Dept of our Hospital. To begin Palliative Care for children.

Material and Methods: We conducted speeches regarding the management of pain in children in the oncology Dept. We started the management of painful procedures in children with cancer. We passed a survey to physicians, residents and nurses, to evaluate the degree of satisfaction of the personal with the analgesic techniques that we introduced.

Results: We made a medical educational program for the oncology personal to demonstrate the benefits and the way of prescription of opioids. During the first 18 months we made 2347 pain consultations, of which 348 were done in the Oncology Dept; of these consultations 28,16% were for the management of pain for painful procedures on pediatric oncology patients, 57.47% for management and treatment of cancer pain, and 14.37% for palliative care. Children with oncological pathologies frequently are put under diverse painful procedures during the course of their illness. Among these procedures we find lumbar puncture, biopsies and bone marrow suction. All these children were treated with: Mida-zolam+Ketamine+Ketoprofen during painful procedures. 57.47% consultation for management and treatment of cancer pain were treated with morphine and an association ofamitryptiline and clo-nazepam for neuropathic pain.

Conclusions: The adequate management of pain in children with cancer pain is an ethical obligation, and includes the treatment of diverse painful procedures and the treatment in palliative care.


Lois Van Cleve. Elizabeth Bossert, Marilyn Savedra, School of Nursing, Loma Linda, CA 923 50, USA

Aim of Investigation: The aims are to: 1) describe the pain of children for one year following diagnosis of acute leukemia; 2) describe strategies used by children/parents to manage the pain; 3) examine the differences in pain before and after management strategies; 4) explore predictors of pain outcomes; and 5) explore relationships between management and outcomes.

Methods: Using a longitudinal design, 97 children, ages 4 through 16 years are being studied from four pediatric oncology centers in California. The children are of any ethnicity, English or Spanish speaking, have any type of acute leukemia, and have no cognitive disability, additional chronic illness associated with pain, fulminating disease process at diagnosis, or unable to cope with participation. Data collection: Seven in-depth interviews plus self report instruments to elicit data from the child/ parent. Interviews/instruments are available in English and Spanish. Data collected includes inquiries regarding the location, intensity, frequency, quality and temporal nature of pain, management strategies, and outcomes relating to pain status and functional status.

Results: Preliminary impressions indicate 1) pain does exist, 2) the most common locations are abdomen, head, face, back and legs, 3) management of strategies include: stressor-modifications, social support, distraction, spiritual support and endurance.

Acknowledgments: Support: R01, NR04201.


Margarita Yem. Oleg Shchelochkov*, Shuhrat Solihodjaev*. Intensive Care Unit, Dept ofAnaesthesiology, Clinic of Tashkent Pediatric Medical Inst, Tashkent, Uzbekistan.

Aim of Investigation: To estimate postoperative period after high thoracic epidural anesthesia (TEA) plus Propofol versus total IV anesthesia with Remifentanil plus Propofol in children.

Methods: We investigated 26 pediatric cardiosur-gical patients who underwent surgical correction without cardiopulmonary bypass. They were allo-cated into two groups (12 and 14 children). In the group I the endotracheal anesthesia with high TEA and Propofol was induced, in the group II total endotracheal IV anesthesia with Remifentanil and Propofol were used. Pipecuronium bromide was used for muscle relaxation in both groups. The groups were controlled for other variables.

Results: The course of anesthesia had a markedly stable hemody-namics in both groups. The mana-gement of postopreative pain in group II required an early analgesic intervention. A prolonged epidural anesthesia (PEA) with low-dose opiates given epidurally in 60% of patients or PEA with xylocaine every 2 hours given in 40% ; patients were equally effective pain releif schedules in group I.

Conclusion: We conclude that a high TPA and PEA provided a better postoperative analgesic control and allowed to reduce an amount of anesthetics.


B. Zemikow*. A. Bauer*, E. Michel* (Spon: U. Drechsel), Vestische Kinderklinik, Witten/Herdecke Univ., D-45704 Dattein, Germany

Aim of Investigation: To evaluate the quality of pain control in German pediatric oncology before (year 1998), and after (year 2000) intervention by a nationwide quality improvement program.

Methods: Questionnaire-based nationwide survey addressing 1 attending, 1 fellow, 1 resident, 1 nurse, and 1 psychologist in each of 76 Depts.

Results: 60/76 Depts responded to the first survey. According to 17% of the physicians (41% of the nurses, p=0.004) there still exists (very) often pain despite pain therapy. Procedures are seen as the main causes of pain. According to 58% of the physicians (35% of the nurses, p=0.005), faces scales are regularly used to score pain intensity. In 80% of the Depts a written therapy protocol addressing procedure-related or postoperative pain is lacking. In 95% of the Depts bone marrow aspiration is performed under analgesia-pethidine and ketamine are the leading analgesics. The preferred route for opioid administration is i.v. and oral as long-acting preparation in larger Depts, whereas i.m.-injections are exclusively performed in smaller ones (p=0.01). 5% of the physicians regard morphine, but 25% regard antidepressants/antiepileptics ineffective in the treatment of neuropathic pain. 72% of the physicians (39% of the nurses, p=0.001) are convinced that addiction seldom/never develops during opioid pain therapy. Nurses are less satisfied with pain therapy than are physicians, and they feel more frequently that pain therapy (very) often starts too late (p<0.005). Physicians and nurses generally report a high need for education in pain control.

Conclusions: Deficits in daily routine pain therapy are obvious and addressed by pediatric oncology staff themselves. Meanwhile guidelines on pain management were mailed to all national pediatric oncology Depts. 10 selected Depts participate in a specific continuous education program that will be evaluated by a nationwide survey scheduled for the year 2000

Acknowledgments: Supported in part by DLFH, Bonn and Mundi-pharma GmbH, Limburg, Germany.


E.N.G. Bandell-Hoekstra. H. Huijer Abu-Saad, J. Passchier, C. Frederiks, F. Feron, P. Knipschild, Maastricht Univ, Dept of Nursing Science, PO Box 616, 6200 MD Maastricht, The Netherlands. Inez.Hoekstra@VW.Unimaas.NL

Aim of Investigation: To investigate the specific and non-specific effects of the training "Help Yourself cope with stress and headache" in Dutch children, on headache frequency, intensity and duration, at post-test and after 3, 6 and 12 months.

Methods: Children (9-16 years of age) with frequent headaches were selected from a cross-sectional study on headache in school children and were randomly assigned to one of two groups. The experimental group (n=l 11) received the "Help Yourself training, which consists of relaxation exercises and cognitive training (positive thinking, assertiveness, problem solving, distraction). The control group (n=106) received the "Leam More" training, which consists of registration of possible headache triggers. The "Leam More" training was specifically designed as an attention control training. Training in both groups lasted 7 weeks. Children received chapters with information and exercises weekly by mail and were phoned for guidance and motivation. Children kept a 4 week headache diary at pre- and posttest and a 2 week diary at follow-up.

Results: The majority of the sample consisted of girls (68%). Mean age was 12.1 (2.0), with two-third aged between 9 and 12. At baseline, there were no differences in demographic and headache characteristics between groups. T-tests and Chi^analysis showed no differences in headache frequency, intensity and duration between groups at post-test and all follow-ups. Within both groups, headache frequency had decreased from 10-11 times in four weeks at pretest to 3-4 times in four weeks after the training. Mean headache intensity had decreased with 9-19 millimeters on a 0-100 mm Visual Analogue Scale. Headache duration had decreased most in the experimental group with a decrease of 31-51 hours in four weeks, versus a decrease of 16-28 hours in four weeks in the control group. More children in the "Help Yourself group achieved complete headache relief, specifically at 3 and 12 months follow-up. Results at post-test remained at follow-up.

Conclusions: A self-help approach in children with frequent headaches has positive effects on headache experience. The specific effect of the "Help Yourself training needs further investigation, e.g. on coping strategies and Quality of Life.


Marta Isabel D'iaz, Alejandra Suarez, Maria Fernanda Gomez', and Pedro F. Bejarano2. Psychology Faculty, El Bosque Univ1 and Pain Medicine Section, Dept. of Anesthesiology, Fundacion Santa Fe de Bogota2, Bogota, Colombia.

Aim: To establish the efficacy of a behavioral intervention program on the postoperative pain control in a pediatric population. Also we study the differential efficacy of this complete program compared to other different behavioral intervention centered in cognitive and physiological techniques.

Methods: 30 children, aged 6 to 12 year-o1d, were randomized into active and control group 15 each. Interventions in the active group were: information, familiarization with operating rooms and equipment, relaxation, and cognitive strategies. Other three samples of 15 children each, were taken in an odontologic clinic. This samples received three behavioral interventions centered in cognitive or physiological or both combined strategies.

Results: Lesser pain perception scores were found in the interven-tional group (p<0.001). The efficacy of this program was compared to results obtained in three programs carried out in odontologic pediatric patients using different techniques.

Conclusions: The key efficacy factors in these programs are discussed in relation to the psychological characteristics of the children (depression, anxiety, or socio-demographic factors) and the behavioral strategies used in each program.


Suely Guimaraes. Debora Nogueira*, Shyrlene Brandao*, Adriane Reis*, Laboratorio de Desenvolvimento em Condicoes Adversas, Institute de Psicologia, Universidade de Brasilia, Brasilia, DF, 79710-9000, BRA

Aim of Investigation: To investigate the impact ofhospitalization and age on Brazilian children's concept and understanding of pain.

Methods: Individual six-item-interviews with 149 inpatient and 320 non-hospitalized children aged 7 to 12 years were conducted at a hospital nurse and at children's schools. Two clusters of questions were formed to investigate children's (a) concept and (b) understanding of pain.

Results: Children's answers were placed in 17 different categories. The most frequent answers to conceptualize pain referred to its origins or causal events (24,5%), followed by the feeling associated with pain (15,9%) and the perception of it (9,1%). On the understanding of causes and consequences of pain, most answers also referred to the origins and causal events of pain (35%) followed by descriptive answers of what happens when one is in pain (27%). Emotional and quality of pain answers were also given for the two clusters of questions. Inpatient younger children used more concrete references and the perception of pain to conceptualize it than their non-hospitalized all ages and inpatient older pairs (ns<05). Older hospitalized children used more descriptive answers of the consequences of pain than the younger and the non-hospitalized ones (ns=<05).

Conclusions: Results suggest that children's recent experience of hospitalization mediates their concept of pain and, when associated with aging, it changes children's understanding from a more concrete to a more abstract perception of the painful experience. The way children conceptualize and understand pain is an important guidance for developing behavioral intervention programs on pain control.

Acknowledgments: Supported in part by CNPq Grant 520248/95.3


Celeste Johnston, Francoise Pillion*, Annette Majnemer*, Laurie Snider*, Cathy Limperopoulos*, Kristi Boyer*, Adam Sherrard*, McGill Univ: Nursing, Rehabilitation, Montreal, Quebec, Canada H3A 2A7

Aim of Investigation: To determine the effect of sucrose analgesia for all painful procedures in the 1s1 week of life ofnewboms <31 weeks gestational age on development, severity of illness, state, and weight.

Methods: In a double-blind RCT, infants admitted to the NICU < 31 weeks of age were recruited within 48 hours of birth and randomized to receive either 0.1-0.3 ml 24% sucrose or sterile water for every painful procedure. Development was assessed at 32, 36, and 40 weeks of age (term) using the Neurobehavioral Assessment for Preterm Infants (NAPI). Severity of illness was measured daily within the week using the Score for Neonatal Acute Physiology (SNAP). State scores were scored according to Brazleton's stages from continuous videotapes of the study week Results: Preliminary results from 15 infants showed no differences in total NAPI scores, SNAP, state or weight gain. There was a nonsignificant trend (p=.09} at term for the infants who received sucrose to have lower Irritability scores on the NAPI.

Conclusions: While giving preterm neonates sucrose for procedural pain relief has been shown to have an analgesic effect for the short duration of the procedure, giving sucrose for every painful procedure in the first week of life may not have longer term effects on health status or overall development. However, treating procedural pain in preterm neonates in the first week of life with sucrose analgesia may lead to less irritability at term.

Acknowledgments: Sponsored by grants from the FRSQ and NHRDP. Study syringes supplied by Becton-Dickenson.


C. Masterson*. A. Laher*. N.T. Barlow*, B.J. Collett, Pain Management Service, Leicester Royal Infirmary & Centre for Applied Psychology, Univ of Leicester, Leicester, LEI 7RH, UK.

Aim of Investigation: To investigate the relationship between children's and parents' pain beliefs and children's adjustment to chronic pain. This area is presently under-researched. The available literature suggests that internal attributions will be associated with higher perceived pain control, use of positive coping strategies and good adjustment. A further hypothesis is that parents' beliefs are at least as strongly related to adjustment as children's.

Methods: Participants are children aged 11-18 with non-pathological chronic or recurrent pain, and their parents. At least 30 families will be recruited, via paediatricians and a paediatric pain clinic. The child and one parent are interviewed to elicit attributions, which will be coded using a post-hoc system. Control beliefs are measured using visual analogue scales. Pain coping strategies are assessed with the Pain Response Inventory (Walker et al 1997). Functional adjustment is measured using Walker and Greene's (1991) Functional Disability Inventory (child and parent forms). The Child Behavior Checklist and Youth Self-Report (Achenbach, 1991) are administered to assess psychological adjustment.

Results: A pilot study has been completed. The main study, currently underway, will be completed by July 1999. Analysis will be largely based on non-parametric tests of association (e.g. chi-square) to look for relationships between attribution categories and the control, coping and adjustment measures.

Conclusions: The results have potential implications for the cognitive-behavioural management of paediatric pain, and the theoretical assumptions underlying this.

Acknowledgments: This study is being performed as a partial fulfillment of the requirements for the Doctorate in Clinical Psychology at Leicester Univ.


F.R. Margolius. K.H. Rankine*, Y. Michel*, S.H. Gueldner*, Medical Univ of South Carolina, CON, 99 Jonathan Lucas St, Rm. 319, Box 250160, Charleston, S.C. 29425

Aim of Investigation: To describe and explore the stress levels and coping responses of preschoolers, diagnosed with cancer, undergoing a painful medical procedure and their attending parent.

Methods: A comprehensive measurement and coding protocol was instituted using unobtrusive biofeedback equipment, physiological parameters of muscle activity (EMG), galvanic skin responses (GSR) and videotaping of each dyad before, during and after a painful medical procedure (i.e. lumbar puncture, bone marrow aspiration). EMG and GSR graphs were developed for each pre-schooler-parent dyad. The Dyadic Prestressor Interaction Scale (DPIS) and the Observation Scale of Behavioral Distress (OSBD) were used to analyze the videotapes. Consent forms were obtained for those dyads agreeing to participate.

Results: EMG graphs depicted matching dyad patterns when parents demonstrated successfully comforting their child vs unmatched EMG dyad patterns for parents who were unsuccessful in comforting their child. Crying, verbal resistance and information seeking questions were the most frequent coping behaviors noted for the preschoolers. The most frequent coping behaviors noted for parents were positioning themselves close to their child, assisting health professionals with procedures and yelling at child. Health professionals offered little support or suggestions in enhancing coping for the dyads.

Conclusions: Parents who perceive their child's needs before, dur- . ing and after painful medical procedures and then effectively inter- , vene/communicate with their child were successful in comforting and enhancing the preschooler's coping behaviors significantly more than parents who did not demonstrate successful interventions. Development of educational/awareness programs for children, parents and health professionals needed to enhance effective coping behaviors.


K.H. Rankine*. F.R. Margolius (SPON: S. Benedict), Medical Univ of South Carolina, CON, 99 Jonathan Lucas St, Rm. 319, Box 250160, Charleston, SC 29425

Aims: Promote evidence based teaching related to pain management practices. Prevent, relieve or reduce pain and suffering. Implement collaborative clinical studies supporting current or advanced pain management practices.

Methods: A new role for staff nurses (CARE Resource Nurse (CRN)) was developed to focus on improving pain management practices. A staff nurse from each clinical unit was selected and became a member of the Children's Analgesia, Research & Education (CARE) Pain Management Team. Inservices, discussions, clinical insights & experiences helped prepare each CRN for their role. Pain team meetings focused on sharing current information, innovative interventions and clinical projects for promoting excellence in pain management practices. CRN's assessed current practices using surveys, medical record audits, and nursing/medical staff discussions.

Results: Numerous improvements in pain management practices were evident. These included the development of a Pain Management for Children Policy, revision of the pediatric data base and nurses notes to include a pain assessment and intervention area, development and piloting of an assessment tool for infants and toddlers, initiation of the Wong-Baker Pain Rating Scale for ages 3 years and older for all clinical units, random medical record audits to assess changes in pain practices, development of a Pain Resource Manual for each clinical area and collaborative clinical studies addressing specific areas of concern such as use ofEMLA for lumbar punctures.

Conclusions: Involving staff nurses on a pain management team is an effective mechanism for assessing, developing, initiating and implementing successful strategies for improving pain management practices for children of all ages.

9th WORLD CONGRESS ON PAIN, 1999, Vienna, Austria, p.552 - 556


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