Children and their parents’ assessment of postoperative surgical pain: Agree or disagree?

https://doi.org/10.1016/j.ijporl.2019.04.005Get rights and content

Abstract

Objective

The purpose of this study is to compare postoperative pain scores between children undergoing tonsillectomy and adenoidectomy (T&A) surgery and their parents, identify potential predictors for this disagreement, and determine possible impact on analgesic administration.

Methods

This is a prospective longitudinal study conducted with children undergoing outpatient T&A in 4 major tertiary hospitals and their parents. Children and their parents were enrolled prior to surgery and completed baseline psychological instruments assessing parental anxiety (STAI), parental coping style (MBSS), child temperament (EAS) and parental medication administration attitude questionnaire (MAQ). Postoperatively, parents and children completed at-home pain severity ratings (Faces Pain Scale-Revised, children; Numeric Rating Scale, parents) on postoperative recovery days 1, 2, and 3, reflecting an overall pain level for the past 24 h. Parents also completed a log of analgesic administration. Based on postoperative pain scores, parent-child dyads were classified as overestimators (i.e., parents rated their child's pain higher than children rated their own pain), in agreement (i.e., rating in agreement), or underestimators (i.e., parents rated their child's pain lower than children rated their own pain).

Results

A significant proportion of parent-child pairs disagreed on pain ratings on postoperative days 1–3 (30.05%–35.95%). Of those pairs in disagreement, the majority of parents overestimated their child's pain on all three postoperative days, specifically such that a total of 24–26% parents overestimated their child's pain on postoperative days 1, 2, and 3. Repeated measures ANOVA demonstrated that parents in the overestimator group administered higher, though still within safe limits, amounts of ibuprofen and oxycodone (mg/day) than did the underestimator or agreement groups. Multiple regression models showed hospital site as the only independent predictor for postoperative pain rating disagreement between children and parents.

Conclusions

Since parents overestimate their child's postoperative pain and may administer more analgesics to their child, it is essential to develop a standardized method of child pain assessment and a tailored recommended postoperative analgesic regimen amongst medical providers for children undergoing T&A.

Introduction

Research indicates that up to 75% of all children undergoing surgery in the United States experience significant postoperative pain [1]. A large proportion of these children suffer from pain following discharge from the hospital in the home recovery phase [[2], [3], [4], [5], [6], [7], [8]]. In addition to the hardship associated with this clinical phenomenon, children who suffer from significant postoperative pain are more likely to experience delayed behavioral and clinical recovery [2,[9], [10], [11]].

It is well established that successful management of postoperative pain requires both reliable assessment of pain levels, as well as administration of the right analgesics in the right dosage and at the right time [[12], [13], [14], [15], [16]]. Within home settings, parents are most often responsible for managing their child's pain following surgery [9,10] and as such, parental assessment of child pain along with child assessment is of high significance. Previous research revealed conflicting results regarding agreement of pain ratings between parent-child dyads [11,14,[17], [18], [19]]. These previous studies suffer from a number of methodological flaws and have focused on describing pain rating disagreement and not predictors or clinical impact of such disagreement. We submit that assessing the impact of disagreement on actual clinical practice is of paramount importance and, if it is discovered that such a disagreement does not have any impact on clinical care or outcomes, then pain rating discrepancies between parents and children are less significant. In contrast, if such disagreement has clinical impact, it is highly important to identify predictors for such disagreement.

The primary aim of this study was to compare postoperative pain assessment between children and their parents in a population of children undergoing tonsillectomy and adenoidectomy (T&A), given this procedure is one of the most common pediatric surgeries and has been found to be associated with high levels of postoperative pain [12,20,21]. The study's secondary aims were to determine if any disagreement found had clinical impact in terms of analgesic administration by parents and to identify potential predictors for any disagreement found between children and parents.

Section snippets

Participants

This prospective longitudinal 5-year study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) and was conducted from 2012 to 2017. The study included children undergoing outpatient T&A surgery and their parents and was aimed at evaluating a newly developed behavioral intervention that targeted reduction of preoperative anxiety in children. This 5-year study consisted of: 1) a baseline phase which lasted 2.5 years and consisted of only data

Results

A total of 311 parent-child dyads were included in this study. The reader is referred to Table 2 for a full description of the various demographic characteristics of the population reported in this manuscript. Participants primarily consisted of male children (50.2%) with a mean age of 6 ± 3 years, parent respondents were primarily mothers (85.2%), and English was the primarily language (74.0%).

Discussion

The goals of the study were to identify if there is disagreement on pain rating between children undergoing surgery and their parents, as well to examine if we can predict those parents and children who disagreed and to examine the potential impact of this disagreement on the administration of analgesics. Under the conditions of this study, we found that a significant proportion of parents and children were in disagreement in determining the children's postoperative pain severity in the first 3

Funding

This study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD)(R01HD048935).

Declarations of interest

ZNK is a paid speaker for Edwards Life Sciences, Medtronic, and the Studer Group.

Authorship & declaration of interest

Author namesAuthorshipConflict of interest:
Corresponding:
Zeev N. Kain, MD MBA
Conception/design of study, conduct study, analyze/interpret data; draft and revise manuscript; final approval; accountability for the work.ZNK is a paid speaker for Edwards Life Sciences, Medtronic, and the Studer Group
Olivia Kaminsky, BSConception/design of study, conduct study, analyze/interpret data; draft and revise manuscript; final approval; accountability for the work.None
Michelle A. Fortier, PhD

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