Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals

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1 ORIGINAL ARTICLE Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals S. Walther-Larsen 1, M. T. Pedersen 1, S. M. Friis 1, G. B. Aagaard 1, J. Rømsing 2, E. M. Jeppesen 3 and S. J. Friedrichsdorf 4,5 1 Pediatric Pain Service, Department of Anesthesiology, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark 2 Department of Drug Design and Pharmacology, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark 3 Department of Pediatrics, Copenhagen University Hospital Herlev, Copenhagen, Denmark 4 Department of Pain Medicine, Palliative Care & Integrative Medicine, Children s Hospitals and Clinics of Minnesota, Minneapolis, MN, USA 5 Department of Pediatrics, University of Minnesota Medical School, Minneapolis, MN, USA Correspondence S. Walther-Larsen, Pediatric Pain Service, Department of Anesthesiology, The Juliane Marie Centre, Copenhagen University Hospital Rigshospitalet, 9-Blegdamsvej, DK-2100 Copenhagen, Denmark RH02090@RH.DK Conflict of interest No conflicts of interest. Funding No funding was obtained for this publication. Submitted 11 November 2016; accepted 19 November 2016; submission 5 August Citation Walther-Larsen S, Pedersen MT, Friis SM, Aagaard GB, Rømsing J, Jeppesen EM, Friedrichsdorf SJ. Pain prevalence in hospitalized children: a prospective crosssectional survey in four Danish university hospitals. Acta Anaesthesiologica Scandinavica 2016 doi: /aas Background: Pain management in hospitalized children is often inadequate. The prevalence and main sources of pain in Danish university hospitals is unknown. Methods: This prospective mixed-method cross-sectional survey took place at four university hospitals in Denmark. We enrolled 570 pediatric patients who we asked to report their pain experience and its management during the previous 24 hours. For patients identified as having moderate to severe pain, patient characteristics and analgesia regimes were reviewed. Results: Two hundred and thirteen children (37%) responded that they had experienced pain in the previous 24 hours. One hundred and thirty four (24%) indicated moderate to severe pain and 43% would have preferred an intervention to alleviate the pain. In children hospitalized for more than 24 hours, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day. The single most common painful procedure named by the children was needle procedures, such as blood draw and intravenous cannulation. Conclusion: This study reveals high pain prevalence in children across all age groups admitted to four Danish university hospitals. The majority of children in moderate to severe pain did not have a documented pain assessment, and evidence-based pharmacological and/or integrative ( non-pharmacological ) measures were not systematically administered to prevent or treat pain. Thus, practice changes are needed. Editorial Comment This multi-center snapshot survey from Denmark asked children in hospital about pain during one day in their hospitalization. Quite a few reported pain or painful procedures conducted without any analgesic intervention. Needle-related procedures were commonly named by subjects. Acute pediatric pain treatment and prevention is often inadequate and pain in children admitted to hospitals is common, under recognized and undertreated. 1 4 Unrelieved pain in children is associated with physiological, psychological and emotional adverse effects. 5 8 Clinicians have an ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd 1

2 S. WALTHER-LARSEN ET AL. obligation to relieve pain as stated by World Health Organization (WHO) and the 2012 guidelines on the pharmacological treatment of persisting pain in children with medical illnesses. 9 Our young patients and their families have high expectations toward pain treatment and prevention and knowledge about evidence-based multimodal pediatric pain management (incl. pharmacological, neuroaxial, interventional, rehabilitative, psychological and integrative non-pharmacological modalities) has increased over the last decades. However, it appears that there is still a gap between what we know and what we do. 14 Researchers at large North American hospitals have found a significant number of children in pain (27 64%) during hospital admission. 1,3,4,15 18 Due to national and international variation in pediatric pain management practice, the results from these studies may not be entirely generalizable to Danish pediatric departments. The purpose of this prospective multicenter study is to describe the general pain prevalence and subsequently to identify child- and procedure-associated characteristics, assessment and management related to significant pain as a basis for future interventions aimed to improve pain management in children. Methods On a random unannounced weekday, this prospective mixed-method cross-sectional survey took place at four university hospitals in the Capital Region of Copenhagen, Denmark with a general population of million people. The university hospitals are the only four hospitals in the Capital Region with associated pediatric departments providing medical care to almost all pediatric inpatients. The goal was to survey all pediatric patients 0 18 years of age. Children in psychiatric and maternity units and sedated/intubated patients in intensive care units were excluded. Children/ parents were also excluded if they were non- Danish or non-english speaking or if they were absent after up to three attempts to locate them throughout the day. We also excluded families in clinical scenarios that deemed too burdensome or inappropriate in the judgment of the interviewer. Four non-consecutive weekdays in late March/early April 2016 were chosen, representing a typical day at the hospitals thus providing a snapshot of pain prevalence. The survey was approved by The National Board of Health, The Danish Data Protection Agency ( ) and by the management of the involved departments. Children older than 5 years gave assent, and parents participated after a verbal and a written consent. In order to limit bias by increased vigilance to pain practices, the study was not announced to the staff. Five to six pairs of interviewers each comprising a nurse practitioner, a pain nurse practitioner, a pain physician or a pediatrician introduced the project to the family addressing the child between the age of 5 and 18 years old directly or addressing one of the parents for younger patients or in case of cognitive disabilities. Patients were identified by lists of pediatric in- and outpatients (including surgical patients) and the interviews were carried out between 8 am and 8 pm. Interviews lasted approximately 10 min and the answers were recorded on-line using a survey program (SurveyXact â ) on an electronic tablet. The survey tool was based on Taylor and Friedrichsdorf s audits. 1,4 If the child had been pain free during the current admission (up to 24 h), the interview was discontinued. In case of pain during the previous 24 h in hospital, we continued the survey with questions about hospital length, primary reasons for admission and procedures undertaken. Respondents, children ( 5 years) or parents (children <5 years), were asked to indicate any pain during the interview and worst pain during the previous 24 h using a visual analog scale (VAS)(0 10), (no pain = 0, mild pain > 0 4, moderate pain > 4 7, severe pain>7). 19,20 In order to personalize the pain intensity, we asked if the level of pain, according to the respondent, indicated a need for action to alleviate the pain. Information about pain assessment, management and overall satisfaction with pain management was recorded. A medical chart review of pain assessment and pain documentation was conducted for all patients who reported moderate to severe pain. Pharmacological pain management was recorded by a chart review. The use of non-pharmacological modalities for 2 ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

3 PAIN PREVALENCE IN HOSPITALIZED CHILDREN pain modulation was studied by asking children and parents about strategies used to manage pain. Finally, we asked the families about overall satisfaction as well as effective and less effective staff members interventions regarding pain management. Statistical analysis Pain prevalence was reported as a percentage with 95% confidence interval. We used the chisquare test to compare the prevalence of pain according to specific patient characteristics and the Kruskal Wallis test to compare pain scores for different painful conditions/procedures. We specifically compared pain scores for needle pokes with other painful conditions/procedures with the Mann Whitney s Test. We used SAS statistical software (Version 9.4; SAS Institute Inc, Cary, NC, USA) and P-values <0.05 were considered significant. Results Demographics Eight hundred fifty-four children (0 18 years) were on the lists of in- and outpatients and 570 patients were located and interviewed (response rate of 66.7%) (Fig. 1). Patient characteristics are shown in Table 1. Two hundred seventy-five (49%) of the children gave self-report, and in the remaining information was gathered by the caregivers. The primary respondent for children <5 years was the mother (75%). Ninety-two percent of respondents had Danish as their primary language and 7 percent of the interviews were completed in Danish despite not being primary language of the interviewed. In 1%, the interviews were completed in English. No interviews were cancelled due to linguistic barriers. General pain prevalence in the previous 24 hours Sixty-three percent of the hospitalized children experienced no pain (VAS = 0) in the previous 24 hours according to themselves or their caregivers (Fig. 2). Two hundred and thirteen children (37%) responded that they had experienced pain (VAS > 0) during the hospital admission in the previous 24 h (95% confidence interval %). One hundred and thirty four (24%) indicated moderate or severe pain (VAS > 4) (Fig. 2). Forty three percent of patients in pain would have preferred an intervention to alleviate the pain and 69 of the 570 children in the survey (12%) had pain during the interview rating the pain 4.4 (0 10). Thirty percent of the children described recurrent pain during a 3-month period before admission. Overall satisfaction with pain treatment was high and rated 8.2 on a 10-point scale (0 = not satisfied at all, 10 = very satisfied) and 79% of the respondents answered that the staff members listened to them, when confronted with questions or worries about pain management. Sources of pain The main reason for pain in the previous 24 h was an invasive procedure: Seventy-seven indicated needle pokes (36%) followed by other invasive procedures (20%) as the primary painful event (Table 2). Although needle pokes and other invasive procedures were reported to be the main cause of pain, the pain scores for procedural pain were recalled significantly lower than the scores for other painful procedures (P = 0.001). Specific patient characteristics related to moderate/severe pain prevalence In children hospitalized for more than 24 h, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day (P < 0.001)(Table 3). We found no significant correlation between moderate/severe pain and gender or age. In children with moderate/severe pain and a documented pain assessment, we found a staff members underestimation of children s pain (median patient score of 8 compared to staff members score of 6). Pain assessment in the 134 children with moderate/severe pain was documented in the charts of 61 children (46%). This was done by an institution-approved pain score (FLACC score (0-10)/VAS (0-10) in four children, narratively in 40 children and narratively combined with pain scoring in 17 children. We found no pain ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd 3

4 S. WALTHER-LARSEN ET AL. Fig. 1. Flowchart of patients included in the study. [Colour figure can be viewed at wileyonlinelibrary.com] Table 1 Patient characteristics, N = 570. n (%) Gender Male 314 (55) Age (years) <2 157 (28) 2to <6 104 (18) 6to < (25) (29) Primary respondent Child ( 5 years) 275 (48) Language during interview Danish 564 (99) Time in hospital at survey (hours) < (80) Reason for hospital visit Elective non-invasive diagnostic workup* 97 (17) Elective invasive procedure 96 (17) Acute illness 89 (16) Known disease 75 (13) Other elective consultation 64 (11) Accident/injury 43 (8) Prematurity 42 (7) Elective surgery 18 (3) Other reasons 46 (8) Hospitals involved Herlev Hospital 161 (28) Hvidovre Hospital 142 (25) Hillerød Hospital 127 (22) Rigshospitalet 140 (25) *X-ray, ultrasound, medical consultation. Skin breaking or other invasive procedures (blood sampling, peripheral intravenous access, bladder catheterization, suture removal, gastric tube insertion). assessment after intervention for moderate/severe pain. Median worst pain in previous 24 h score assessed by children was 8/10 (5 10) and by medical staff documented was 6/10 (0 9). Fig. 2. Worst pain intensity (VAS) in the past 24 h. [Colour figure can be viewed at wileyonlinelibrary.com] In children with moderate/severe pain, 93 (69%) did not receive any paracetamol, NSAID s or opioids. Paracetamol was administered to 25 children (19%) with moderate/severe pain. NSAID s were administered to 12 children (9%) and these drugs were mostly given round-theclock. Opioids were given to three children prn (pre re nata = as needed) and to one child scheduled round-the-clock (Table 4). Adjuvant analgesics were used in three children in the group of children with moderate/ severe pain (low-dose tricyclic anti-depressants, gabapentinoids, clonidine and/or a muscle relaxant). Non-pharmacological management of pain Strategies used to manage the most painful procedures/conditions in the previous 24 hours are summarized in Fig. 3. The medical staff members took advantage of several modalities 4 ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

5 PAIN PREVALENCE IN HOSPITALIZED CHILDREN Table 2 The most painful procedure/condition in children in the previous 24 h including a variety of non-pharmacological measures. The parents appreciated non-pharmacological interventions and 89 percent of the parents in our study answered that they would embrace these interventions. We encouraged the family to comment on positive and less positive actions by the staff members. We categorized these statements into main themes in Tables 5 and 6. Discussion N = 213 (VAS>0) Worst pain score * Needle pokes 77 (36%) 3.8 ( ) Other invasive 43 (20%) 4.4 ( ) procedures Accident/injury, other 42 (20%) 6.5 ( ) medical Acute illness 27 (13%) 7.5 ( ) Known disease 16 (8%) 6.3 ( ) Surgery 8 (4%) 6.5 ( ) *Median (25 75% range). Significantly different among groups (P = Kruskal Wallis Test). Needle pokes and other invasive procedures significantly lower score than other groups combined, P = Bladder catheterization, gastric tube insertion and non-skin breaking procedures. Table 3 Relationship between patient characteristics and moderate/severe pain prevalence. Characteristic N = 570 Moderate/severe pain; N = 134 Gender Male (55%) 1.0 Female (45%) Age (years) Infant (<2) (34%) 0.30 Child (2 to <6) (16%) Child (6 to <11) (22%) Teenager ( 11) (28%) Time in hospital 24 h (60%) < >24 h (40%) Pain prevalence This study is, to the best of our knowledge, the first European cross-sectional survey to P Table 4 Pharmacological pain management in children with moderate/severe pain Regime N = 134 (%) Paracetamol prn 7 (5) Round-the-clock 18 (13) NSAID s prn 3 (2) Round-the-clock 9 (7) Opioids prn 3 (2) Round-the-clock 1 (1) Continuous infusion 0 (0) None of these 93 (69) Prn, pre re nata ( as needed ); NSAID s, non-steroidal anti-inflammatory drugs. benchmark prevalence, assessment and management of pain in hospitalized children. Our response rate of 66.7% in pediatric patients admitted to university hospitals in the Capital Region of Denmark is comparable with international pain surveys of hospitalized children (64%, Friedrichsdorf, 66% Birnie). 1,17 The number of respondents was considerably higher compared to other surveys. The results obtained by child/parent interview revealed that of the 570 children included in this study, 63% experienced no pain in the previous 24 h. We found a pain prevalence of 37%, and 24% of the cohort experienced moderate to severe pain (VAS > 4) during the last 24 h. Sixty-nine children reported pain during the interview. Our results are similar to previous studies. In a study by Groenewald, 27% of children experienced moderate to severe pain. 15 Stevens, Ellis, Shomaker and Cummings reported 20 33% prevalence rate of clinically significant pain 3,16,18,21 and in a recent study by Friedrichsdorf, 20% experienced moderate and 30% severe pain in the 24-h time period. 1 Taylor reported almost 64% of in patients experiencing moderate/severe pain at some time in the previous 24 h and 23% experiencing significant pain during the interview. 4 We also found that in children being hospitalized for more than 24 h, the prevalence of moderate/severe pain was significantly higher compared to children admitted the same day. This may be due to children, admitted to hospital (vs. outpatients) generally having more severe morbidity, experience more procedures and consequently ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd 5

6 S. WALTHER-LARSEN ET AL. Pain management Posi oning Distrac on Numbing creme Sucrose/breas eeding Warm/cold pack Pacifier Informa on/instruc on Pa ent par cipa on Caregiver par cipa on Pain medicin Nothing Other 6% 9% 13% 17% 16% 18% 15% 16% 23% 23% 23% 34% Number of responses (several answers were allowed) Fig. 3. Strategies reported by parents used to manage most painful procedure/condition. [Colour figure can be viewed at wileyonlinelibrary.com] Table 5 Positive family response (qualitative) to staff members performance on pain management Non-pharmacological Communication and compassion Professional Demonstrating positioning Good at distraction Caring Caring attitude On child condition Parental involvement Professional management Communicative skills Informative Table 6 Negative family response (qualitative) to staff members performance on pain management. Organization Professional Pharmacological Waiting time and bustle Changing staff Lack of communication and planning Staff members not paying attention Restraining Management was personal dependent Insufficient pain management Management depending on family request Waiting for pain medication are more prone to pain. According to Bernie et al., being admitted to hospital constitutes a risk factor for significant pain and should be a target for vigorous assessment and management. 17 Pain assessment in children with moderate/ severe pain During the 24-h study period, the majority of children (54%) experiencing moderate/severe pain had no documented pain assessment (numerical or narrative). This is in contrast to hospital-policy stating pain assessment as a quality-indicator of good medical practice. Whether pain was never assessed, pain was assessed but not documented, or the child, parents or medical staff members found no reason for assessment, the infrequent documentation of pain contravenes local as well as international recommendations. 22 Taylor et al. recognized adequacy of pain assessment as the cornerstone of pain management and its documentation important to make the pain problem more visible. 4 In a subsequent Canadian study 3, 68.4% of the children in significant pain had a pain assessment documented at least once in a 24-h period, higher than 45% of the children in our study. This can be explained by our study population of both in- and out patients compared to the Canadian population of only children 6 ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

7 PAIN PREVALENCE IN HOSPITALIZED CHILDREN hospitalized for more than 24 h thus excluding outpatients. In the study by Friedrichsdorf 1, 58% of children had pain assessment and management documented during a 24-h period in a study population of both in- and out patients, with pain documentation for painful needle procedures usually missing. Among reasons for children to be admitted on an outpatient basis is a medical consultation or diagnostic setup in which cases pain assessment perhaps is less relevant. Pain management Pharmacological pain management with paracetamol and/or NSAID s was used in 18%/9% of children with moderate/severe pain and opioid s in only four children. These results are in accordance with results of Groenewald 15 where scheduled paracetamol and/or NSAID s were used in 22%/11% of the children in moderate/ severe pain. In our study, the intention was to describe pain prevalence in a general pediatric population of in- and out- patients. We did not intend to study pain assessment and management in children with well controlled analgesia (VAS 4) and we consider it positive that 63% of patients in the survey had no pain. The families also pointed out room for improvement (Tables 5 and 6). A small number of parents complained about physical restraint of their child during painful events. Restraining is associated with serious consequences for the child (and the parents) 23,24 and an institutional policy to prohibit restraining for elective painful procedures, as it was implemented with the Comfort Promise: We do everything possible to prevent and treat pain at Children s Hospitals and Clinics of Minnesota [ org/comfortpromise] should have highest priority. The parental remarks are important contributions to medical professionals when trying to adjust personal and organizational behaviors in order to improve pain management in a context of the interaction between child, parent and staff members. It is interesting and noteworthy that pharmacological measures represent only a small fraction of strategies reported though not rated by parents in managing the most painful event (Fig. 3). 1 In our opinion, it confirms that pain is a subjective and complex feeling and should be assessed and managed in a broader bio-psycho-social context by pharmacologicalin combination with non-pharmacological measures in particular. Procedure-related pain Procedure-related pain is continuously a challenge for children admitted to hospitals. A majority of children in our study reported that worst pain was caused by procedural pain like needle pokes and other invasive procedures (120 of the 213 children reporting pain (VAS > 0) in the previous 24 h). This is similar to what was reported by Friedrichsdorf and Bernie (42-56%). 1,17 Although an invasive procedure was reported to be the main cause of pain, the child s pain assessment was significantly lower than during other conditions/procedures, which is also found by others. 1,25,26 Pain and anxiety is closely linked in children. Therefore, to decrease the child s anxiety and to avoid restrain during procedures the use of non-pharmacological interventions is crucial. A number of non-pharmacological interventions can be used in neonates and children to manage pain associated with painful procedures. The most established evidence is for non-nutritive sucking, swaddling/facilitated tucking and rocking/ holding We found little documentation in our survey of these interventions. Possibly nonpharmacological measures were not used or more likely used to some extent but not documented. A simple 4-point intervention for needle pokes includes (1) topical anesthetic applied on the skin, (2) sucrose or breast-feeding for infants <12 months, (3) age-appropriate distraction and (4) positioning (including swaddling for infants and sitting upright without being held down for children >6 months) and represents evidence-based management of procedural pain. 1 A deferral process should be readily available (including pediatric pain team specialists, integrative measures, nitrous gas for mild sedation or alternatively moderate to deep sedation) if the four mentioned measures prove insufficient in comforting the child. Guiding parents in how to best support their child during procedures seems important and should be incorporated into clinical practice. 32 ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd 7

8 S. WALTHER-LARSEN ET AL. Clinical implications To improve the quality of pain management provided to hospitalized children, focus on recognition of pain, age-related assessment of pain intensity, access to safe and suitable interventions and evaluation of the efficacy of any intervention are targets for future improvement efforts. It is essential that interventions are adapted to each child and include a multimodal approach, combining both non-pharmacological and pharmacological interventions Even in academic hospitals in Denmark, despite good intentions and increasing knowledge about pharmacological and non-pharmacological measures, there seem to be a significant number of children suffering pain demonstrating inadequate or insufficient application of available knowledge and skills. Pain assessment needs to be integrated into routine pediatric pain practice. In our institution, our clinical assessment tools are Comfort Neo for neonates, the FLACC scale for minors, Wong- Baker faces pain scale and VAS or NRS for self-measuring pain in older children. Our study has, in accordance with other studies, shown that health professionals and parents have a tendency to underestimate children s pain prevalence. 1,36 Thus, the low documentation rate could be explained by the medical staff members estimating the child not to be in pain or the pain being so insignificant that assessment (and subsequent intervention) was not necessary or relevant in their setting. Narrative documentation was used more often than scoring, maybe because the staff members found a narrative assessment and documentation easier or more operational. The consequences of narrative pain assessment alone or in addition to scoring are uncertain in terms of quality of assessing the pain experience in children. 29 Self-assessment is recommended if possible depending of age and cognitive abilities of the child. In order to personalize the pain intensity and pain treatment threshold, recent studies have introduced an alternative assessment concept by considering the pain threshold at which each child desires intervention. 19,37 To improve the quality of pain management, focus on recognition of pain, age-related pain assessment, access to safe and suitable interventions and evaluation of the intervention are all targets for future improvement efforts. The purpose of this study was to describe pain prevalence in children admitted to university hospitals in Denmark and to identify the main sources of pain experience. What we did not intend to uncover was the pharmacologic and integrative ( non-pharmacologic ) pain management of the large group of well-managed children, the prevalence and main source of pain in the subgroup of children coming to the hospital for sole purpose of an elective invasive procedure vs. children admitted for other reasons, the correlation between pain intensity and the respondent (caregiver gender) and finally the correlation between pain intensity and previous pain experience. In conclusion, this study has revealed high pain prevalence in children across all age groups admitted to four Danish university hospitals. The majority of children in moderate to severe pain did not have a documented pain assessment and did not have evidence-based pharmacological analgesia administered to treat or prevent pain. In addition, integrative ( nonpharmacological ) therapies were not commonly utilized. The most common painful procedure named by the children was needle procedures. A multidisciplinary approach is deemed sharing ownership, taking ongoing educational initiatives, involving parents and implementing both appropriate quality-controls as well as evidence-based guidelines into routine practice at all pediatric units. 14,38 References 1. Friedrichsdorf SJ, Postier A, Eull D, Weidner C, Foster L, Gilbert M, Campbell F. Pain outcomes in a US children s hospital: a Prospective Crosssectional Survey. Hosp Pediatr 2015; 5: Kozlowski LJ, Kost-Byerly S, Colantuoni E, Thompson CB, Vasquenza KJ, Rothman SK, Billett C, White ED, Yaster M, Monitto CL. Pain prevalence, intensity, assessment and management in a hospitalized pediatric population. Pain Manag Nurs 2014; 15: Stevens BJ, Harrison D, Rashotte J, Yamada J, Abbott LK, Coburn G, Stinson J, Le May S, CIHR Team in Children s Pain. Pain assessment and intensity in hospitalized children in Canada. J Pain 2012; 13: ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd

9 PAIN PREVALENCE IN HOSPITALIZED CHILDREN 4. Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: a prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Res Manag 2008; 13: Anand KJ, Scalzo FM. Can adverse neonatal experiences alter brain development and subsequent behavior? Biol Neonate 2000; 77: Grunau RE, Tu MT. Long-term consequences of pain in human neonates. In: Anand KJS, Stevens BJ, McGrath PJ eds. Pain in neonates and infants: pain research and clinical management. Toronto: Elsevier, 2007: Holsti L, Grunau RE, Oberlander TF, Whitfield MF. Specific Newborn Individualized Developmental Care and Assessment Program movements are associated with acute pain in preterm infants in the neonatal intensive care unit. Pediatrics 2004; 114: Holsti L, Weinberg J, Whitfield MF, Grunau RE. Relationships between adrenocorticotropic hormone and cortisol are altered during clustered nursing care in preterm infants born at extremely low gestational age. Early Hum Dev 2007; 83: World Health Organization. World Health Organization supports global effort to relieve chronic pain Available at: int/mediacentre/news/releases/2004/pr70/en (accessed 15 October 2014). 10. Forgeron PA, Finley GA, Arnaout M. Pediatric pain prevalence and parents attitudes at a cancer hospital in Jordan. J Pain Symptom Manage 2006; 31: Ammentorp J, Mainz J, Sabroe S. Parents priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med 2005; 159: Tiedeman M. Anxiety responses of parents during and after the hospitalisation of their 5 - to -11 year old children. J Pediatr Nurs 1997; 12: Melnyk BM. Intervention studies involving parents of hospitalized young children: an analysis of the past and future recommendations. J Pediatr Nurs 2000; 15: Schechter NL. From the ouchless place to comfort central: the evolution of a concept. Pediatrics 2008; 122(Suppl 3): S Groenewald CB, Rabbitts JA, Schroeder DR, Harrison TE. Prevalence of moderate-severe pain in hospitalized children. Paediatr Anaesth 2013; 22: Ellis JA, O Connor BV, Cappelli M, Goodman JT, Blouin R, Reid CW. Pain in hospitalized pediatric patients: how are we doing. Clin J Pain 2002; 18: Birnie KA, Chambers CT, Fernandez CV, Forgeron PA, Latimer MA, McGrath PJ, Cummings EA, Finley GA. Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag 2014; 19: Shomaker K, Dutton S, Mark M. Pain prevalence and Treatment Patterns in a US Children s Hospital. Hosp Pediatr 2015; 5: Voepel-Lewis T, Burke CN, Jeffreys N, Malviya S, Tait AR. Do 0-10 numeric rating scores translate into clinically meaningful pain measures for children? Anesth Analg 2011; 112: von Baeyer CL, Spagrud LJ, McCormick JC, Choo E, Neville K, Connelly MA. Three new datasets supporting use of the Numerical Rating Scale (NRS-11) for children s self-report of pain intensity. Pain 2009; 143: Cummings EA, Reid GJ, Finley GA. Prevalence and source of pain in pediatric inpatients. Pain 1996; 68: Joint Commission on Accreditation of Healthcare Organizations. Improving the quality of pain management through measurement and action, Available at: Scribd.com/doc/ /Improving-the-quality-of painmanagement-through-measurement-and-action (accessed 11 June 2016). 23. McGrath P, Forrester K, Fox-Young S, Huff N. Holding the child down for treatment in paediatric haematology: the ethical, legal and practice implications. J Law Med 2002; 10: McGrath P, Huff N. Including the fathers perspective in holistic care. Part 2: findings on the fathers hospital experience including restraining the child patient for treatment. Aust J Holist Nurs 2003; 10: Simons LE, Kaczynski KJ, Conroy C, Logan DE. Fear of pain in the context of intensive pain rehabilitation among children and adolescents with neuropathic pain: associations with treatment response. J Pain 2012; 13: Cohen LL, Blount RL, Cohen RJ, Ball CM, McClellan CB, Bernard RS. Children s expectations and memories of acute distress: Short and long term efficacy of pain management interventions. J Pediatr Psychol 2001; 26: Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev 2012;12: CD ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd 9

10 S. WALTHER-LARSEN ET AL. 28. Chambers CT, Taddio A, Uman LS, McMurtry CM, HELPinKIDS Team. Psychological interventions for reducing pain and distress during routine childhood immunizations: a systematic review. Clin Ther 2009; 31(Suppl 2): S Stevens B, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev 2000; 2: CD Review. Update in: Cochrane Database Syst Rev Roback MG, Carlson DW, Babl FE, Kennedy RM. Update on pharmacological management of procedural sedation for children. Curr Opin Anaesthesiol 2016; 29: S Pillai RR, Racine NM, Gennis HG, Turcotte K, Uman LS, Horton RE, Ahola KS, Hillgrove SJ, Stevens B, Lisi DM. Non-pharmacological management of infant and young child procedural pain. Cochrane review, The Cochrane Collaboration and published in The Cochrane Library 2015, Issue Kain ZN, Caldwell-Andrews AA, Mayes LC, Weinberg ME, Wang SM, MacLaren JE, Blount RL. Family-centered preparation for surgery improves perioperative outcomes in children: a randomized controlled trial. Anesthesiology 2007; 106: Hohmeister J, Kroll A, Wollgarten-Hadamek I, Zohsel K, Demirakcßa S, Flor H, Hermann C. Cerebral processing of pain in school-aged children with neonatal nociceptive input: an exploratory fmri study. Pain 2010; 150: Weisman SJ, Bernstein B, Schechter NL. Consequences of inadequate analgesia during painful procedures in children. Arch Pediatr Adolesc Med 1998; 152: Taddio A, Katz J, Ilersich AL, Koren G. Effect of neonatal circumcision on pain response during subsequent routine vaccination. Lancet 1997; 349: Singer AJ, Gulla J, Thode HC Jr. Parents and practitioners are poor judges of young children s pain severity. Acad Emerg Med 2002; 9: Birnie KA, McGrath PJ, Chambers CT. When does pain matter? Acknowledging the subjectivity of clinical significance. Pain 2012; 153: Miakowski C. Improving pain management through leadership and interdisciplinary collaboration. Pain Manag Nurs 2004; 5: ª 2016 The Acta Anaesthesiologica Scandinavica Foundation. Published by John Wiley & Sons Ltd