There can be little doubt that for many healthcare professionals the recognition and assessment of pain in children is potentially fraught with difficulties.
Children of all ages present their own particular challenges to the pain assessment skills of those involved in their care:
- Is a baby crying because of pain, hunger, or anger, or simply because he likes the noise he is making?
- Can a child who has verbal skills be relied upon always to report accurately the absence or presence of pain and, equally important, the severity of that pain?
- Will the apparently self-confident and assertive adolescent maintain his ability to advocate for himself when faced with an alien healthcare situation, which includes the potential for experiencing pain?
For those working in paediatric pain care, the subject seems ripe for the development of clinical guidelines. However, the development of national clinical guidelines can be a resource-intensive and lengthy process. It is crucial that the subjects chosen reflect issues that are relevant to a broad cross-section of healthcare professionals.
The aim of the guideline development programme at the RCN is to focus on an area of care for which nurses have the main responsibility, but to approach the subject from a multiprofessional perspective.
Establishing the new area of care for guideline development involved surveying a range of nursing groups, to identify priority topics, and comparing these results with set criteria.
Although all of the 10 short-listed topics were felt to be equally important and to have equal merit as a guideline topic, the guidelines advisory project group decided that the first, in what was hoped to be a series of new developments, would be pain in children.
The exact focus of the guideline was established at a meeting held in summer 1997. Reflecting the RCN's belief that guideline development should be approached from a multiprofessional perspective, the meeting was attended by representatives from nursing, paediatric medicine, physiotherapy, pharmacology, and paediatric anaesthesiology.
Perhaps most importantly, the group also had representation from parents and also from Action for Sick Children. After much heated debate, it was decided that the guideline should focus on the recognition and assessment of pain in children.
Children were defined as stated in Article 1 of the UN convention: 'A child means every human being below the age of 18 years unless under the law applicable to the child majority is attained earlier.'1
The reason the group focused on the recognition and assessment of pain was that it was generally felt that this area underpinned all other aspects of pain care.
Although effective pain management was seen as crucial to providing quality care, this was difficult if not impossible without first establishing whether pain was present and secondly estimating the severity of the pain so that appropriate analgesia could be administered.
The group also recognised that the Royal College of Paediatric and Child Health had recently published guidance on the management of pain in children2 and that this new initiative could complement their work.
There is also a considerable amount of nursing literature that continues to identify the difficulties associated with assessment of pain in children and in clinical practice. This issue generates a great deal of discussion and anxiety among all healthcare professionals.
Although consideration was given to focusing on a specific age group within the guideline, it was felt that to have the most impact in the clinical situation,the guideline should reflect the age range of paediatric patients seen in all healthcare settings.
A literature search of MEDLINE, CINAHL, PSYCHLIT, SOCIOFILE, SIGLE and Cochrane databases identified thousands of possible research articles that were relevant to the topic and published after 1990. After exclusion of articles that were not relevant or were an opinionated review, 155 articles remained.
Data extraction forms and articles were sent out to paired reviewers, who considered them from a 'content' perspective and also for the 'robustness' of the methodology.
The evidence was graded using the following system (adapted from Waddell et al3):
- Generally consistent finding in a majority of multiple acceptable studies
- Based either on a single acceptable study, or on a weak or inconsistent finding in multiple acceptable studies
- Limited scientific evidence that does not meet all the criteria of acceptable studies or absence of directly applicable studies of good quality. This included published or unpublished expert opinion
A qualitative study of children's pain experiences was also undertaken and their views taken into account.4
The guideline has 26 recommendations in nine key areas (see summary, below). These include the role of the parents, carers and families and healthcare professionals in recognising and assessing pain in children and the use of scales and assessment tools in children of three age ranges:
- Neonates and infants
- Young children and older children
Although all the recommendations are endorsed equally, the evidence grade alerts the reader to the type of evidence supporting the recommendation: 42.3% of the recommendations are graded at level three, 46.15% at level two and only 11.53% at level one. This clearly has implications for future research in this subject.
Successful implementation of the guideline relies on it being used within a context that reflects a child-centred philosophy of care.
Key issues are as follows:
- Children are listened to and believed
- Children and their families are viewed as partners in care
- Care is individualised and holistic
- Care is family centred
- A collaborative, multiprofessional approach is provided by knowledgeable professionals
- Attention is paid to the organisational issues and systems that enable effective pain management to take place.
To reflect this child-centred approach a children's version of the guideline is currently being developed. It is hoped that this will result in the guideline being used in collaboration with the children, and that where appropriate they and their families will be active participants in the assessment process rather than passive recipients of healthcare professionals' 'assessment' of their pain.
This clinical guideline is the first evidence-based resource to be developed in the UK on the recognition and assessment of pain in children. It draws together the many differing pieces of the pain assessment jigsaw, and not only makes a whole but also provides evidence as to why this approach is appropriate.
Many nurses claim that they 'know' when a child is in pain. The use of the guideline will enable these nurses to clarify for others how they 'know' this, and in some instances may make them reconsider their judgment.
For healthcare professionals who have a limited amount of time in which to establish the condition of a child, e.g. the GP, the recommendations contained within the guideline and the explanations on the use of pain assessment tools may facilitate a more accurate estimation of a child's 'pain'.
Doubtless some professionals will read the recommendations and congratulate themselves on the standard of care they provide; indeed, the provision of quality care in any field should be a cause for celebration.
For others, however, the clinical guideline will provide a focus for future practice developments and also a wealth of research potential to test some of the recommendations in a more robust scientific manner.
Perhaps most importantly, the publication of this guideline will highlight to children and their families, and indeed to the healthcare professionals involved in their care, that:
- The recognition and assessment of pain in children is considered a high priority
- Only by effectively assessing pain can we begin to consider implementing appropriate pain management strategies
- For children, unrecognised and untreated pain should not be an inevitable consequence of coming into contact with the healthcare service of today.
- Copies of the guideline The Recognition and Assessment of Acute Pain in Children can be obtained from the RCN Publishing Co. Ltd, Distribution Department, PO Box 1, Portishead, Bristol BS20 9EG. Price £5.50 for RCN members, £7.50 for non-members, plus £1.50 p&p.
- The United Nations Convention on the Rights of the Child. London: HMSO, 1991.
- Prevention and Control of Pain in Children. A Manual for Health Care Professionals. London: BMJ Publishing, 1997.
- Waddell G, Feder G, McIntosh A., Lewis M, Hutchinson A. Low Back Pain: Evidence Review. London: Royal College of General Practitioners, 1996.
- Doorbar P, McClarey M. Ouch! Sort it Out. Children's Experiences of Pain. London: RCN Publishing, 1999.