Authors:
Kim A. Sporrer,
Pharm.D.
Sherron M. Jackson, M.D.
Suzanne Agner, Pharm.D.
Joseph
Laver, M.D.
Miguel R. Abboud, M.D.
Am J Pediatr Hematol Oncol
1994;16:219-24
Commentary by Alyssa A. LeBel, M.D.
To (a) characterize pain reporting among children with sickle cell anemia (SCA) experiencing vasoocclusive crisis and (b) improve the care of patients with SCA by providing more appropriate analgesic therapy.
In this pilot study, 17 children hospitalized for SCA with vasoocclusive crisis (VOC) were asked to report their pain using the Faces Pain Scale, a tool that characterizes pain on a scale of 0 to 5. Subjects were selected by convenience and ranged in age from 3 to 18 years. Differences in pain reporting were evaluated according to age (Table 1) and number and type of painful body sites (Table 2). Pain was managed according to a protocol in which patients initially received i.v. morphine. Ketorolac or ibuprofen was administered if moderate or severe pain continued. Morphine infusions were considered for patients with persistent severe pain. Patients were gradually weaned from analgesics as pain scores improved. Scores were analyzed using the Mann Whitney method to identify differences in pain reporting between young children (3-12 years of age) and adolescents (13-18 years of age). The Kruskal-Wallis method was used to detect relationships between the number of painful body sites, pain scores, and length of hospitalization. Chi-square analysis was used to compare pain ratings and length of hospitalization.
Adolescent patients reported higher pain scores. This may reflect a tendency to over report because of fear that pain would return when analgesics were stopped. An other possible explanation is that VOC may have a cumulative effect, in which patients experience more severe pain with repeated episodes. However, frequency of VOC did not appear to influence the pain severity reported by these subjects. A protocol based on patient self-reports was successfully used to provide pain control during SCA crises. Pain intensity was not affected by location. However, patients with many painful sites had longer hospital stays. Pain scores were found to be an important predictor of length of hospitalization for SCA crises. Findings warrant further investigation in a larger group of patients.
In sickle cell disease, vasoocclusion in small blood vessels results in bone or joint pain that is variable in intensity and duration. Most frequently the pain is severe and warrants aggressive therapy. The accurate and reliable evaluation of pain is essential to the adequate treatment of painful episodes in children and adolescents. Recent data support the use of self-report instruments for best recording the subjective experience of pain in preschool and school-aged/adolescent children (3-18 years of age). Such readily accessible instruments are reliable and valid measures of pain intensity within specific age groups and include the Faces Scale used in this study. This pilot study from the Medical University of South Carolina, which characterizes pain reporting among children with sickle cell anemia, adds welcome data to the relatively nascent study of pediatric pain assessment and suggests a promising protocol for further use. In addition. the finding of longer hospital stays in patients with higher pain scores at >24 h is provocative as an outcome measure in this population. Of note, Sporrer at al. document that children (3- 12 years of age) report significantly less pain than do adolescents ( 13-18 years of age). In a study of 127 children 9-14 years of age who were undergoing tonsillectomy and adenoidectomy, Leikan et al. (1988) reported that younger children reported fewer symptoms and were perceived by their parents to have less pain than did older children. Older children, due to past painful experiences, may be effective in communicating their distress and more aware of the consequences of pain. Alternatively, older children, especially those with formal and logical thinking, have access to cognitive coping strategies for pain management. However, patients with sickle cell crises, including adolescents, may be more helpless due to their repetitive experiences of intermittent, severe, and unpredictable pain. In the present study, a larger patient population, allowing the comparison of pain scores of younger children to older children, would have been of interest.
*At time of publication, the corresponding author (MRA) was at the Division of Pediatric Hematology, Medical University of South Carolina, 171 Ashley Avenue, Charleston, SC 29425.
March 15, 2002
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