Assessment, and Management
WHAT’S KNOWN ON THIS SUBJECT: Previous research
demonstrated that after outpatient surgery, many parents do not provide their children with prescribed analgesics. Reasons for undertreating may be related to attitudinal barriers in parents, such as incorrect knowledge and misconceptions regarding pain management for children.
WHAT THIS STUDY ADDS: This study demonstrated that parents provided few doses of postoperative analgesics. Many parents reported misconceptions regarding the utility and safety of analgesia. Parents who had more misconceptions about analgesia use in children provided fewer doses of analgesics at home.
abstract
OBJECTIVES:Previous studies suggested that parents frequently do not adequately treat postoperative pain that is experienced at home. Reasons for these parental practices have not been extensively stud-ied. Aims of this study were to examine parental postoperative pain assessment and management practices at home as well potential at-titudinal barriers to such pain practices.
METHODS:This was a longitudinal study involving 132 parents of chil-dren who were aged 2 to 12 years and undergoing elective outpatient surgery. Parental attitudes about pain assessment and management were assessed preoperatively, and children’s pain severity and anal-gesic administration were assessed postoperatively for the first 48 hours after discharge.
RESULTS:Although postoperative parental ratings indicated signifi-cant pain, parents provided a median of only 1 dose of analgesics (range: 0 –3) during the first 48 hours after surgery. In the attitudinal survey, parents’ responses have indicated significant barriers. For ex-ample, 52% of parents indicated that analgesics are addictive, and 73% reported worries concerning adverse effects. Also, 37% of parents thought that “the less often children receive analgesics, the better they work.” Regression analysis demonstrated that, overall, more preoper-ative attitudinal barriers to pain management were significantly asso-ciated with provision of fewer doses of analgesics by parents (P⬍.05).
CONCLUSIONS:Parents detected pain in their children yet provided few doses of analgesics. Parents may benefit from interventions that provide them with information that addresses individual barriers re-garding assessing and treating pain.Pediatrics2010;125:e1372–e1378
AUTHORS:Rachel Yaffa Zisk Rony, PhD, RN, MPH,a
Michelle A. Fortier, PhD,b,cJill MacLaren Chorney, PhD,b
Danielle Perret, MD,band Zeev N. Kain, MD, MBAb,c,d,e
aDepartment of Family Medicine, University of
Wisconsin-Madison, Wisconsin-Madison, Wisconsin; Departments ofbAnesthesiology
and Perioperative Care,dPediatrics, andePsychiatry and Human
Behavior, University of California-Irvine, Irvine, California; and
cDepartment of Psychology, Children’s Hospital of Orange
County, Orange, California
KEY WORDS
children, postoperative pain, pain assessment, pain management, attitudinal barriers, parents
ABBREVIATIONS
PPEP—Parental Pain Expression Perceptions MAQ—Medication Attitude Questionnaire PPPM—Parent Postoperative Pain Measure
www.pediatrics.org/cgi/doi/10.1542/peds.2009-2632
doi:10.1542/peds.2009-2632
Accepted for publication Feb 9, 2010
Address correspondence to Rachel Yaffa Zisk Rony, PhD, RN, MPH, Henrietta Szold School of Nursing, Hadassah-Hebrew University, PO Box 12000, Jerusalem 91120, Israel. E-mail: yaffazisk@gmail.com
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2010 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE:The authors have indicated they have no financial relationships relevant to this article to disclose.
Currently,⬃84% of all pediatric surgi-cal procedures in the United States are performed on an outpatient basis,1 and health care futurists predict that this number will continue to increase. These outpatient children are typically discharged within 4 to 5 hours after their surgical procedures, and par-ents are expected to manage chil-dren’s pain at home.2 Unfortunately, previous research demonstrated that after outpatient surgery, many par-ents do not provide their children with prescribed analgesics.2–7In fact, in 1 study, 70% of analgesic doses that chil-dren received at home were subthera-peutic, and 58.8% of children received less than the recommended daily dose.8 Underlying reasons for undertreating pain are not entirely clear but may be related to attitudinal barriers in parents, such as incorrect knowledge and mis-conceptions regarding pain manage-ment for children2,4,8–14; however, few studies have examined the relationship between parental attitudinal barriers to pain assessment and treatment with ac-tual postoperative parental pain man-agement practices at home.4,12
The purpose of this study was to exam-ine parental attitudinal barriers re-garding children’s pain expression and the use of analgesic medication for children and to connect these vari-ables to the actual practice of assess-ing and treatassess-ing children’s pain after outpatient surgery. We predicted that parental misconceptions about pain and analgesia in children would affect parental practices of assessing pain and administering analgesic medica-tion. Understanding the reasons for undermedicating children who are in pain can contribute to developing in-terventions aimed at facilitating ap-propriate management practices.
METHODS
The study population included a conve-nience sample of 132 parents of
chil-dren who were aged 2 to 12 years and undergoing outpatient elective sur-gery at a tertiary care hospital. Chil-dren underwent surgical procedures including tonsillectomy, bilateral her-nia repair, adenoidectomy, reset of fracture, orchiopexy, and urethral re-pair (Table 1). These particular proce-dures were chosen on the basis of pre-vious research that demonstrated that at least 50% of children who undergo these types of surgeries can be ex-pected to experience pain at home for the first 24 hours after surgery.2 All children were in the American Society of Anesthesiologists physical class I or II, and none of the children was known to have any diseases that could affect pain expression or pain sensation; none of the children required medica-tion that could impair pain sensamedica-tion. The institutional review board ap-proved the study, and all parents pro-vided written informed consent.
Measures
Parental Attitudinal Barriers
Pain Attitudes
The Parental Pain Expression Per-ceptions (PPEP)11was developed by Dr Zisk Rony and examines parental knowledge and attitudes regarding the expression of pain in children. This measure consists of 9 items rated on a 7-point Likert scale, and ratings are summed across items. Higher scores represent misinformation and greater attitudinal barriers. The PPEP has been shown to demonstrate good content and construct validity.11Cronbach’s␣ internal consistency of the scale is re-ported to be .7911and was found to be .78 in this study. To further our under-standing of pain-related attitudinal barriers, we asked parents to respond “yes” or “no” to the following 2 ques-tions: “Do you think that untreated pain can cause physical damage?” and, “Do
TABLE 1 Demographic Information
Parameter Full Sample (N⫽132) Analysis Sample (N⫽114) Child age, y
Mean⫾SD 5.2⫾2.3 5.3⫾2.4
Range 2–12 2–12
Child gender (M/F), % 67/33 65/35
Surgical procedure, %
Ear-nose-throat 61 59
Hernia repair 12 11
Circumcision and testicular 12 14
Plastic, orthopedic, and other 15 16
Relationship to child, %
Mother 93 94
Father 5 4
Grandparent 2 2
Mother’s age, y
Mean⫾SD 36.0⫾5.9 36.7⫾5.9
Range 21–68 21–68
Father’s age, y
Mean⫾SD 39.0⫾6.1 39.5⫾6.0
Range 26–56 28–56
Race, %
White 86.0 87.6
Hispanic 8.5 7.0
Black 3.0 3.5
Other 2.5 1.9
Parental marital status, %
Married/partnered 86.0 86.5
Single 6.0 6.0
Divorced/separated 6.0 5.5
Widowed 2.0 2.0
Medication Attitudes
The Medication Attitude Question-naire (MAQ)9,12examines parents’ atti-tudes about using analgesic medica-tion for treating children’s pain. Parents were instructed to consider their views on the specific analgesic(s) prescribed or recommended for a spe-cific event (eg, their child’s surgery) or over-the-counter analgesia any time. Higher scores indicate incorrect knowledge and greater attitudinal bar-riers toward providing children with analgesia. The MAQ demonstrates good content,9 predictive,9 and con-struct validity.9,11 The internal consis-tency for the scale is reported to range from .68 to .739,12and was calculated to be .77 in this study.
Pain Assessment
Parent Report
The Parent Postoperative Pain Mea-sure (PPPM)12,13 is a 15-item observa-tional checklist in which parents rate behavioral changes that correspond to pain severity. For each item, parents respond “yes” or “no” as to whether the child demonstrates pain-related changes in behaviors. The PPPM has been validated for children aged 2 to 12 years.12,15Using a cutoff score of 6, the PPPM has excellent specificity and sensitivity in identifying children who are in significant pain.16The sensitivity of the PPPM instrument in detecting a child’s pain was previously reported to be 88%, and the specificity was re-ported to be 80% on postoperative day 1. The internal consistency for the in-strument is reported to be 0.88 on postoperative day 116and was found to be 0.88 in this study.
Each time the parents completed the pain diary, they were asked to indi-cate whether they perceived their child to be in pain by using a yes/no rating as well as whether their child
Child Report
Child report was assessed by using the structured faces17 or numeric scale, which was provided by hospital staff to parents before discharge.
Pain Management
Parents were asked to document all analgesics that the child received at home (time, medication, and dose) by using a pain diary. The use of pain dia-ries provides real-time assessment of pain and pain management practices that minimizes recall bias and improves validity of pain ratings.2To assess chil-dren’s verbal expression of pain after treatment, we also asked parents to doc-ument the following: “After trying to help your child’s pain, did your child tell you (without you asking) that he/she had ‘no pain,’ ‘less pain,’ ‘same pain,’ ‘more pain,’ or ‘did not say anything.’ ”
Procedure
Parents were approached and re-cruited on the day of surgery in the preoperative holding area. After pro-viding informed consent, parents com-pleted a demographic questionnaire as well as the instruments that exam-ined barriers to pain assessment (PPEP) and pain management (MAQ). Children were discharged from the hospital with standardized instruc-tions to manage pain using acetamin-ophen (30%), ibuprofen (3%), or acet-aminophen with codeine (67%) every 4 to 6 hours on the basis of the type of surgery and the surgeon’s preference. After discharge, parents were in-structed in completing the pain as-sessment and management diary for the first 48 hours at home. Parents were asked to complete the pain diary every time they detected that their child was in pain or at least twice a day when no pain was detected (morning and evening). We chose to use the
day 1, because of the variation in data on the basis of time of surgery, time of discharge, and the distance that the family needed to travel home. Data from pain diaries were retrieved through daily telephone calls.
Statistical Analysis
Power analysis demonstrated that a sample size of 120 patients would re-sult in 80% power to detect a correla-tion of 0.25 between attitudinal barriers and pain assessment and manage-ment practices. To account for a 10% attrition rate, we increased the sample to 132 participants.
We hypothesized that parents who en-dorse more extreme attitudinal barri-ers regarding pain assessment and medication would be the most likely to administer fewer medication doses to their children and that these extreme attitudes would be most likely to affect pain assessment. Consequently, for the purposes of analyses, parental at-titudinal barriers to pain assessment and management were coded into quartiles and indicator variables were used to estimate differences in pain assessment and management prac-tices. Normally distributed data are presented as mean and SD, and skewed data are presented as median and range (25%–75%). All regression analyses were adjusted for child age and gender. Similar to previous re-search using the PPPM, we calculated the daily mean score for the purpose of analysis.12P⬍.05 was considered statistically significant.
RESULTS
A total of 114 parents completed pain di-aries and as such were included in the analyses. Demographic characteristics for the entire recruited sample (n ⫽
Pain Attitudinal Barriers
Parent responses to the PPEP are pre-sented in Table 2. Indeed, 36% of par-ents endorsed the perception that chil-dren always express pain by crying or whining, 30% of the parents agreed that children always tell their parents when they are in pain, and 22% of the parents thought that children who are experiencing pain report it immedi-ately. In addition, 11% of the parents were uncertain whether children feel less pain than adults.
In response to the 2 questions regard-ing the possible effects of untreated pain, some (39%) parents reported that they did not think that untreated pain could cause physical damage. Fewer (14%) parents reported that they did not think that untreated pain could cause psychological damage.
Analgesics Attitudinal Barriers
Table 3 presents data regarding con-cerns or uncertainty about addiction potential, adverse effects, and the util-ity of analgesics that were reported by parents on the MAQ. For example, 73% of parents agreed that adverse effects were something to worry about when giving children pain medication. In ad-dition, 52% of parents agreed and 25% were uncertain as to whether the pain medication that was prescribed to their child was addictive. Nearly half (42%) of the parents reported the be-lief that pain medication should be
used as little as possible because of adverse effects.
Postoperative Pain Assessment at Home
In terms of behavioral indicators of children’s pain, the majority of parents indicated that children expressed pain through quiet and withdrawn
iors rather than loud and active behav-iors on the PPPM (Table 4). According to the PPPM, 51% of children were rated as experiencing significant pain (scoreⱖ6) on postoperative day 1.
Although hospital staff provided parents with a developmentally appropriate structured pain scale, only 10 (7%) par-ents reported that they used it to assess children’s pain at home. In response to the categorical questions, 60% of par-ents endorsed the perception that their child was in pain, and 30% of the parents reported that their child verbally ex-pressed pain without being asked.
Postoperative Pain Management at Home
The median number of analgesic doses provided on the first full postoperative day was 1 (range: 0 –3), and 26% of
TABLE 2 PPEP Responses
PPEP Items Disagree, %a Uncertain, % Agree, %b
Children always express pain by crying or whining. 64 0 36 Children always tell their parents when they are in pain. 69 1 30
Children who are quiet are not in pain. 94 3 3
Children who are playing are not in pain. 84 4 12 Children experiencing pain report it immediately. 75 3 22
Children exaggerate pain. 61 14 25
Children complain about pain to get attention. 62 9 29
Children feel pain less than adults. 86 11 3
Children in pain have trouble sleeping. 8 10 82
aStrongly disagree⫹disagree⫹slightly disagree. bStrongly agree⫹agree⫹slightly agree.
TABLE 3 Parental MAQ Responses
MAQ Item Disagree, %a Uncertain, % Agree, %b
Children should be given pain medication as little as possible because of adverse effects.
52.0 6.0 42.0
Children who take pain medication for pain may learn to take drugs to solve other problems.
75.0 12.0 13.0
Pain medication works the same no matter how often it is used.
77.0 16.0 7.0
Pain medication works best when it is given as little as possible.
52.5 24.0 23.5
Pain medication has many adverse effects. 38.5 24.0 37.5 Children will become addicted to pain medication if they take
it for pain.
82.0 9.0 9.0
There is little need to worry about adverse effects from pain medication.
57.0 14.0 29.0
It is unlikely a child will become addicted to pain medication if taken for pain.
13.0 19.5 67.5
Pain medication is addictive. 21.0 27.0 52.0
Pain medication works best if saved for when the pain is quite bad.
62.0 9.0 29.0
Using pain medication for children’s pain leads to later drug abuse.
86.0 10.0 4.0
There is little risk of addiction when pain medication is given for pain.
22.0 18.0 60.0
Children learn how to use pain medication responsibly when it is given for pain.
8.0 14.0 78.0
Side effects are something to worry about when giving children pain medication.
17.0 10.0 73.0
The less often children take pain medication for pain, the better the medicine works.
48.0 15.0 37.0
Giving children pain medication for pain teaches proper use of drugs.
24.5 21.0 54.5
aStrongly disagree⫹disagree⫹slightly disagree. bStrongly agree⫹agree⫹slightly agree.
parents provided no analgesics. Only 17% of the parents providedⱖ4 doses of analgesics on the day after surgery.
Ninety-five percent of parents reported that they received specific instructions regarding analgesics at home. Of these parents, 69% administered the spe-cific prescribed analgesic medication, and 55% administered the prescribed dosage, yet only 35% administered the prescribed number of doses. Of the parents who did not provide the pre-scribed medication, 20% undermedi-cated by providing less potent, over-the-counter analgesia (acetaminophen or ibuprofen) instead of the prescribed acetaminophen and codeine. A small proportion (3%) of parents provided stronger-than-prescribed analgesia. In terms of doses provided, 12% of parents administered smaller-than-prescribed analgesic doses, whereas 2% provided larger-than-prescribed doses of the analgesia. The most fre-quently reported reason for not pro-viding acetaminophen and codeine was that the child refused (44%) be-cause of bad taste. Additional reasons reported were that it hurt to swallow, the child refused to take any
medica-Attitudinal Barriers as Predictors of Pain Assessment and
Management Practices
To examine the relationship between parental misconceptions about chil-dren’s pain expression (PPEP) and par-ents’ report of observed pain behav-iors (PPPM), we conducted a multiple linear regression analysis with total PPPM score as the outcome variable and child age, gender, and the top quartile on the PPEP entered as predic-tor variables. Results indicated that pain attitudinal barriers were not a significant predictor of parental pain assessment at home (F ⫽ 0.96,P ⫽
.436).
Next, we used a linear regression anal-ysis to examine the relationship be-tween parental attitudes about the use of analgesia in children (MAQ) and doses of analgesics provided to chil-dren by parents at home. In this analy-sis, number of doses provided on day 1 was the dependent variable, and child age and gender, parental report of ob-served pain behavior (PPPM), and par-ent attitudes about pain medication (top quartile on MAQ) were entered as predictor variables. We found that de-creased pain severity as well as higher MAQ score predicted the provision of fewer doses of analgesics postopera-tively (F⫽18.27,P⬍.01; Table 5).
DISCUSSION
Under the conditions of this study, we found that a significant number of par-ents exhibited multiple attitudinal
bar-children. We also found that the vast majority of parents undertreated their child’s pain both in terms of the dos-age of analgesics and the frequency at which analgesics were given. Previous studies that examined parental pain assessment and management re-ported similar findings.2–7,18Moreover, endorsement of attitudinal barriers was found to be a significant predictor of the actual behaviors involved in children’s pain management. That is, when parents had more misconcep-tions about analgesia use in children, they provided children with fewer doses of analgesics at home. To date, few studies have identified specific preoperative parental attitudes as barriers to parental postoperative pain assessment and management at home. On the basis of the answers to the categorical questions, 60% of the parents reported that they thought that their child was in pain, yet only 30% of children verbally reported pain without being asked. The notion that children do not always express pain verbally without being asked is further supported by findings of previous research.19,20
The discrepancy between parent rat-ings of children’s pain severity and pa-rental pain management practices was very evident in this study. For ex-ample, although the median pain score on the PPPM was 6, which indicates clinically significant pain, the median number of analgesics actually given to children was 1. Indeed, in this study, extreme attitudinal barriers were a strong predictor of the number of an-algesic doses given by parents. Many parents reported uncertainty and mis-conceptions regarding the utility and safety of analgesia as well as fear of adverse effects and addiction poten-tial of pain medication for children. These attitudinal findings are congru-Active and loud behaviors
Cry more easily than usual? 32.5 Whine or complain more than usual? 32.0 Groan or moan more than usual? 25.0 Quiet and withdrawn behaviors
Have less energy than usual? 64.0 Play less than usual? 60.0 Not do the things he/she normally
does?
51.0
Act more quiet than usual? 50.0 Other
Try not to bump or use the sore part of his/her body?
54.0
Eat less than usual? 53.0 Want to be close to you more than
usual?
47.0
Hold the sore part of his/her body? 33.0 Look more flushed than usual? 30.0
Refuse to eat? 29.0
Take medication when he/she normally refuses?
19.0
Act more worried than usual? 13.0
TABLE 5 Linear Regression: Doses of Analgesia as Dependent Variable
Parameter  SE P
PPPM score .22 0.03 ⬍.001 Child age .08 0.05 .100 Child gender ⫺.27 0.24 .263 MAQ top quartile ⫺.64 0.26 .017
ent with previous studies that docu-mented parental fear of adverse ef-fects,2,4,8,9,11 addiction potential,2,4,9,11 the belief that analgesics should be used only as a last resort,2,9,11and per-ception that acetaminophen works best when provided only for severe pain9,11; however, this study extends previous research that illustrated that parents who endorse these attitudinal barriers more strongly may be the most likely to undermedicate their children at home, thereby presenting an opportunity to improve postopera-tive pain management for children at home. That is, tailored education to change parental attitudes may im-prove actual administration of analge-sics. Unfortunately, previous research suggested that although providing parents of children who were under-going surgery with generic written in-formation improved parental atti-tudes, pain management practices by parents were not influenced.12,13Thus, it is likely that additional behavior change interventions will be required, such as scheduled reminders or inter-ventions that are tailored to parent and child personality characteristics, includ-ing beliefs about analgesic medications and the type of analgesia prescribed to the child. In addition, parents who hold more extreme misconceptions about an-algesia are the most important to target through intervention.
Other surprising findings were that al-though only 3% of the parents agreed
that children feel less pain than adults, it was disturbing that 11% reported uncertainty when faced with this ques-tionnaire item. These findings are un-expected, especially in light of the fact that this misconception had been re-futed⬎20 years ago.21In addition, our findings suggest that there has been little change in terms of parental knowledge and perceptions of pain medication for children and actual pain management practices in the past 10 years. These results illustrate that despite the significant change in practice in medical settings and ef-forts to increase public awareness of the need to manage children’s pain, there has been little success in trans-lation of this knowledge to home man-agement of children’s pain.
Several methodologic limitations re-lated to this study should be noted. First, the study examined a conve-nience sample that consisted of mostly white, married parents of boys and as such limits the external validity of the findings. Future research involving more diverse patient populations is needed. Second, because parents re-ceived instructions regarding pain as-sessment at home, they may have been alerted to behaviors that they may have not identified otherwise. In addi-tion, more research is needed regard-ing parental knowledge and attitudes of the use of analgesics in children. Specifically, the MAQ does not distin-guish between differences in parental
perceptions regarding the use of nar-cotic medications (eg, codeine) and over-the-counter medication (eg, acet-aminophen, ibuprofen).
CONCLUSIONS
Our results have significant implica-tions for both clinical care and re-search. Specifically, the findings of this study support the need to develop tai-lored interventions to provide parents with improved knowledge regarding the safety and utility of analgesia for use in children after surgery and studies that check the effect of real-time infor-mation that addresses parental con-cerns as they are managing their chil-dren’s pain at home. Given the large numbers of children who experience acute pain after surgery and that the ma-jority of postoperative pain is handled by parents, efforts to arm parents with ad-equate strategies to treat pain are vital.
ACKNOWLEDGMENTS
Dr Zisk Rony was supported by Univer-sity of Wisconsin, Department of Family Medicine grant T32PH10010 and by Yale School of Nursing grant T32NR008346.
We thank Dr Ward, Dr Wald, Dr Serlin, Ms M. Krause, Ms M. Ezenwa, Ms F. Naab from University of Wisconsin for their insightful comments and ongoing support, Dr M. Mundt and Dr T. Becker for the statistical consultation and as-sistance and Dr M. Gray from Yale School of Nursing for her guidance and support during study design and data collection.
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DOI: 10.1542/peds.2009-2632 originally published online May 24, 2010;
2010;125;e1372
Pediatrics
and Zeev N. Kain
Rachel Yaffa Zisk Rony, Michelle A. Fortier, Jill MacLaren Chorney, Danielle Perret
Management
Parental Postoperative Pain Management: Attitudes, Assessment, and
Services
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DOI: 10.1542/peds.2009-2632 originally published online May 24, 2010;
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