PAIN ASSESSMENT IN INFANTS AND CHILDREN

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Acute pain is a highly complex, dynamic, subjective experience that is useful to growing children, serving to warn them of danger and limiting exposure to additional injury. Children usually learn effective methods of preventing and coping with the everyday pains of growing up. However, untreated acute, recurrent, or chronic pain related to disease or medical care may have significant and lifelong physiological and psychological consequences.13 As with all other medical conditions, the first step in the treatment process is the accurate diagnosis of the problem. Thus, pain assessment provides the foundation for all pain treatment. This article reviews the developmental neurophysiology of pain, discusses methods to assess pain in infants and children, highlights factors that influence the pain experience, and emphasizes evidence-based strategies for improving pain assessment in the clinical setting.

Section snippets

DEFINING PAIN AND DISTRESS IN INFANTS AND CHILDREN

Pain is defined by the International Association for the Study of Pain as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”96 The International Association for the Study of Pain definition also states that pain is always subjective and is learned through experiences related to injury in early life. This definition is problematic when considering infants who are incapable of self-report and may not have had

DEVELOPMENTAL NEUROPHYSIOLOGY OF PAIN

The basic mechanisms of pain perception in infants and children are similar to those of adults and include (1) transduction and transmission and (2) perception and modulation. Because of neurophysiologic and cognitive immaturity, however, some differences exist. A brief review is presented here, emphasizing the developmental and maturational changes that occur during infancy and childhood. For a more in-depth discussion of the pathophysiology of pain, the reader is referred to the numerous

CLINICAL ASSESSMENT OF PAIN

Presently, no easily administered, widely accepted, uniform technique exists for assessing pain in children, especially infants, although pain assessment is an area of active research. Assessment techniques can be classified as self-reports, behavioral observation, or physiologic measures. Assessments that use multiple measures (behavioral and physiologic) and that assess different aspects of the pain experience (e.g., intensity, location, pattern, context, and meaning) may result in more

FACTORS THAT INFLUENCE PAIN

Pain is unique among neurologic functions because of the degree of plasticity in pain neurophysiology. Although structural and functional maturity is reached at an early age, anatomic and functional changes related to the effects of each pain experience occur throughout life. This plasticity means that the perception and meaning of pain are unique to each individual and not only are determined by maturation but also are influenced by many individual and contextual factors.134 Currently

RESEARCH PRIORITIES IN PAIN ASSESSMENT

Additional studies are needed to improve the validity and reliability of pain-assessment tools across all age groups and settings. Methods to quantify and incorporate the influence of contextual factors on the perception and response to pain are also needed. The application of existing technology, such as adaptation of video games, to the problem of child pain assessment may lead to more active involvement of children and their families in pain assessment. Additional research to understand the

IMPLEMENTING CLINICAL ASSESSMENT OF PAIN IN INFANTS AND CHILDREN

Despite the substantial evidence that pain experiences of infants and children can be assessed in the clinical setting, pediatric pain assessment is not routinely performed in most settings. Implementing an effective pain-assessment program is more complex than simply selecting an appropriate assessment tool. Pain assessment must be viewed by health care teams as an integral component of quality patient care, and numerous organizational, provider, and patient barriers must be overcome.5, 87

SUMMARY

The science of pain assessment for infants and children has grown substantially in the past several decades to the point that valid and reliable methods for pain assessment are available for use in clinical settings. Accurate pain assessment requires consideration of children's developmental level, type of pain experienced, history and context of pain, family influences, and interaction with the health care team. Research is needed to improve the sensitivity, specificity, and generalizability

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    Address reprint requests to Linda Sturla Franck, RN, RGN, RSCN, PhD, School of Nursing and Midwifery, James Clerk Maxwell Building, King's College London, 57 Waterloo Bridge Road, London SE18TX, e-mail: [email protected]

    Funding is acknowledged from the NIH: NINR (Grant NR 03916 RO1, B. Stevens and L. Franck) and Pediatric Clinical Research Center (MO1-RR01271; L. Franck) and the Ontario Ministry of Health (B. Stevens, Career Scientist Award).

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