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Characteristics of pain episodes in infants and young children with sickle cell disease
A BSTRACTS
FOR
O RAL P RESENTATIONS
Paper Session 306: Pediatric Pain C. Disease Entities (Human) C11 - Pain in Children (306) Depressive symptoms predict persistence of pain and disability in children with disease-related pain
D. Treatment Approaches (Medical/Interventional) D17 - Perioperative Pain - Opioids (306) Postoperative behavioral changes in children after tonsillectomy
T. Palermo, A. Hoff, M. Schluchter, D. Drotar, K. Zebracki; Case School of Medicine, Cleveland, OH Pain secondary to chronic disease can be disabling for some children. The objective of this longitudinal study was to identify predictors of the persistence of pain and disability among children with disease-related pain. Specifically, we examined the effects of depressive symptoms at Time 1 (T1) on persistence of pain and functional disability over a one-year period among children with either sickle cell disease (SCD) or juvenile idiopathic arthritis (JIA). We hypothesized that depressive symptoms would function as a general risk factor across pain and health conditions. Participants included 119 children, 63 with JIA and 56 with SCD, (mean age ⫽ 12.28 years, 63% female) who completed measures of depressive symptoms, pain (frequency, intensity, duration, and bother) and functional disability at T1 and at 6-month (T2), and 12-month (T3) follow-ups. Caregivers also rated their child’s pain and functional disability at each time point. Child-reported depressive symptoms at T1 significantly predicted childrated pain (frequency, intensity, duration, and bother) and functional disability across time and disease group (all p’s ⬍ .05). A two-way interaction between depressive symptoms and time significantly predicted caregiver-rated functional disability (p ⬍ .01). As hypothesized, depressive symptoms were found to be a generalized risk factor, predicting concurrent perceptions and persistence of pain and functional disability over one-year among children with diseaserelated pain. Importantly, depressive symptoms were in the subclinical range for this cohort of children, indicating that even milder symptoms of negative mood are related to enduring problems with pain and disability. Screening for negative mood and depressive symptoms among children with disease-related pain may be useful for identifying children who may benefit from behavioral intervention to reduce emotional distress, improve the child’s ability to cope with pain, and enhance daily functioning.
K. Sutters, C. Miaskowski, M. Savedra, S. Paul, D. Holdridge-Zeuner, S. Waite, B. Lanier; Children’s Hospital Central California, Madera, CA The purpose of this randomized clinical trial, with children undergoing tonsillectomy, was to compare changes in the child’s postoperative behavior with “as needed” or around-the-clock analgesic dosing. Children were randomized to receive acetaminophen with codeine (12mg/5ml) for 3 days after surgery every 4 hours “as needed” (PRN Group: N⫽28) or every 4 hours around-theclock (ATC Group: N⫽52). Parents were asked to compare each behavior listed in the home log with the child’s normal behavior before surgery, and record observed behavioral changes once a day, beginning on the day of surgery and for the first three days after surgery. Each behavioral change was coded into a dichotomous response (i.e., 0⫽no problematic change, 1⫽problematic change). No significant differences were found between the PRN and ATC groups in the proportion of children who demonstrated problematic behavioral changes for each of the 4 postoperative assessments, except on postoperative day 3, where children in the ATC group were less active, energetic and playful than before surgery, compared to children in the PRN group (p⫽0.03). For the total sample, statistically significant decreases over time were found in the proportion of children who were seeking more attention (Cochran’s Q⫽14.44, p⫽0.002), irritable, cranky and fussy (Cochran’s Q⫽9.80, p⫽0.02), or quiet or withdrawn (Cochran’s Q⫽10.00, p⫽0.02); and, statistically significant increases over time were found in the proportion of children who were active, energetic, playing (Cochran’s Q⫽29.14, p⫽0.0001), and happy, cheerful (Cochran’s Q⫽22.61, p⫽0.0001). Scheduled administration of acetaminophen with codeine for the first three days following tonsillectomy does not effect observed changes in behavior, except for decreased activity, energy and play on the third postoperative day. Children undergoing tonsillectomy, regardless of the prescribed analgesic dosing regimen, demonstrate significant behavioral changes over time for the first 3 days after surgery. This study was supported by a grant from the NINR (NR04826).
(306) Family factors related to disability in adolescents with headaches
(306) Characteristics of pain episodes in infants and young children with sickle cell disease
T. Palermo, J. Putnam, T. Koch; Oregon Health & Science University, Portland, OR Headaches are common in adolescents, and often interfere with their daily lives. Although increased family problems have been reported in adolescents with headaches, limited research has been conducted to link family factors to functional outcomes such as disability. This has hindered the development and testing of family-based interventions for chronic headaches. The aims of this pilot study are to: 1) examine the relationship between family factors and headache-related disability, 2) evaluate whether depressive symptoms mediate the relationship between family factors and functional disability, and 3) test the validity of an observational assessment of parent-adolescent interactions. A sample of 30 adolescents, ages 11 to 16 years, (mean age ⫽ 13.3 years, 66% female) receiving treatment through pediatric neurology for recurrent headaches have been enrolled. Adolescents and their parents completed measures of pain, functional disability, depressive symptoms, and family functioning (i.e., McMaster Family Assessment Device). Videotaped parent-teen interactions are currently being completed to assess expressions of autonomy and warmth in their relationship. Correlational analyses show moderate relationships between family factors and functional disability. Specifically, poor affective responsiveness (r ⫽ .41, p ⬍ .05) and poor general functioning (r ⫽ .42, p ⬍ .05) are associated with increased functional disability. Moreover, increased depressive symptoms are linked to increased family dysfunction (r ⫽ .49, p ⬍ .01). Mediational tests are significant for the total effect (family functioning to disability) and indirect effects (family functioning to depression and depression to disability). However statistical tests for mediation using Sobel’s equation are not significant, indicating that depression may not be the primary mechanism by which family functioning affects adolescent disability. Preliminary findings suggest that family factors and depression are strongly linked to headache-related disability in adolescents. Further analyses will examine parent-teen interactions to determine the effect of autonomy and intimacy in family interactions on adolescent functional disability.
B. Ely, C. Dampier, D. Brodecki, P. O’Neal, C. Coleman; St. Christopher’s Hospital for Children, Philadelphia, PA We are describing the incidence, occurrence and characteristics of sickle cell pain in infants and young children using a longitudinal, prospective design. Data from parent/guardian report are collected using monthly phone calls, and more recently, with a daily electronic pager system. Data reported here were collected from February, 2001 to December 2003 for 60 children over 1,226 months. The majority of the 60 children were homozygous SS (SCD-SS n⫽32, 53.3%; SCD-SC, n⫽21, 35%; SCDSbeta⫹Thal n⫽ 6, 10%; SCD-Sbeta0Thal n⫽1, 1.7%); slightly more than half were male (n⫽37, 61.7%); and 95% (n⫽57) of the children were Black. Age in months at data collection entry ranged from 3 to 60 months (Mean⫽20.8 mos., Median⫽16.0 Mos., SD⫽17.3 mos.). Thirtyseven of the 60 children had at least one reported sickle pain episode in the time period reported (1,226 mos). The mean age for this group of 37 children was 22.1 months and there were more children with the SCD-SS phenotype (n⫽ 24, 65%). A total of 231 pain episodes were reported over the 1,126 months representing 20.5% of all months with at least one reported pain episode for these 37 children. Length of reported pain ranged from a half day to 19 days, with the majority (52%) lasting 2 days or less. Presence of swelling with pain was noted for 66 (28.6%) of the episodes, while change in movement was noted in almost half of the episodes (47.6%). Location of pain was quite variable both within and between episodes, but abdomen and legs were the most frequently reported pain locations. Parent/guardians reported giving pain medication for 203 (87.9%) of the episodes and providing a variety of nonpharmacologic pain management interventions (e.g. massage, warm bath) 83% of the time. Results of this study will improve our knowledge of sickle pain in young children.
The Journal of Pain, Vol 6, No 3S (March), Supplement 1, 2005: pp S1-S8
S1
FOR
O RAL P RESENTATIONS
Paper Session 306: Pediatric Pain C. Disease Entities (Human) C11 - Pain in Children (306) Depressive symptoms predict persistence of pain and disability in children with disease-related pain
D. Treatment Approaches (Medical/Interventional) D17 - Perioperative Pain - Opioids (306) Postoperative behavioral changes in children after tonsillectomy
T. Palermo, A. Hoff, M. Schluchter, D. Drotar, K. Zebracki; Case School of Medicine, Cleveland, OH Pain secondary to chronic disease can be disabling for some children. The objective of this longitudinal study was to identify predictors of the persistence of pain and disability among children with disease-related pain. Specifically, we examined the effects of depressive symptoms at Time 1 (T1) on persistence of pain and functional disability over a one-year period among children with either sickle cell disease (SCD) or juvenile idiopathic arthritis (JIA). We hypothesized that depressive symptoms would function as a general risk factor across pain and health conditions. Participants included 119 children, 63 with JIA and 56 with SCD, (mean age ⫽ 12.28 years, 63% female) who completed measures of depressive symptoms, pain (frequency, intensity, duration, and bother) and functional disability at T1 and at 6-month (T2), and 12-month (T3) follow-ups. Caregivers also rated their child’s pain and functional disability at each time point. Child-reported depressive symptoms at T1 significantly predicted childrated pain (frequency, intensity, duration, and bother) and functional disability across time and disease group (all p’s ⬍ .05). A two-way interaction between depressive symptoms and time significantly predicted caregiver-rated functional disability (p ⬍ .01). As hypothesized, depressive symptoms were found to be a generalized risk factor, predicting concurrent perceptions and persistence of pain and functional disability over one-year among children with diseaserelated pain. Importantly, depressive symptoms were in the subclinical range for this cohort of children, indicating that even milder symptoms of negative mood are related to enduring problems with pain and disability. Screening for negative mood and depressive symptoms among children with disease-related pain may be useful for identifying children who may benefit from behavioral intervention to reduce emotional distress, improve the child’s ability to cope with pain, and enhance daily functioning.
K. Sutters, C. Miaskowski, M. Savedra, S. Paul, D. Holdridge-Zeuner, S. Waite, B. Lanier; Children’s Hospital Central California, Madera, CA The purpose of this randomized clinical trial, with children undergoing tonsillectomy, was to compare changes in the child’s postoperative behavior with “as needed” or around-the-clock analgesic dosing. Children were randomized to receive acetaminophen with codeine (12mg/5ml) for 3 days after surgery every 4 hours “as needed” (PRN Group: N⫽28) or every 4 hours around-theclock (ATC Group: N⫽52). Parents were asked to compare each behavior listed in the home log with the child’s normal behavior before surgery, and record observed behavioral changes once a day, beginning on the day of surgery and for the first three days after surgery. Each behavioral change was coded into a dichotomous response (i.e., 0⫽no problematic change, 1⫽problematic change). No significant differences were found between the PRN and ATC groups in the proportion of children who demonstrated problematic behavioral changes for each of the 4 postoperative assessments, except on postoperative day 3, where children in the ATC group were less active, energetic and playful than before surgery, compared to children in the PRN group (p⫽0.03). For the total sample, statistically significant decreases over time were found in the proportion of children who were seeking more attention (Cochran’s Q⫽14.44, p⫽0.002), irritable, cranky and fussy (Cochran’s Q⫽9.80, p⫽0.02), or quiet or withdrawn (Cochran’s Q⫽10.00, p⫽0.02); and, statistically significant increases over time were found in the proportion of children who were active, energetic, playing (Cochran’s Q⫽29.14, p⫽0.0001), and happy, cheerful (Cochran’s Q⫽22.61, p⫽0.0001). Scheduled administration of acetaminophen with codeine for the first three days following tonsillectomy does not effect observed changes in behavior, except for decreased activity, energy and play on the third postoperative day. Children undergoing tonsillectomy, regardless of the prescribed analgesic dosing regimen, demonstrate significant behavioral changes over time for the first 3 days after surgery. This study was supported by a grant from the NINR (NR04826).
(306) Family factors related to disability in adolescents with headaches
(306) Characteristics of pain episodes in infants and young children with sickle cell disease
T. Palermo, J. Putnam, T. Koch; Oregon Health & Science University, Portland, OR Headaches are common in adolescents, and often interfere with their daily lives. Although increased family problems have been reported in adolescents with headaches, limited research has been conducted to link family factors to functional outcomes such as disability. This has hindered the development and testing of family-based interventions for chronic headaches. The aims of this pilot study are to: 1) examine the relationship between family factors and headache-related disability, 2) evaluate whether depressive symptoms mediate the relationship between family factors and functional disability, and 3) test the validity of an observational assessment of parent-adolescent interactions. A sample of 30 adolescents, ages 11 to 16 years, (mean age ⫽ 13.3 years, 66% female) receiving treatment through pediatric neurology for recurrent headaches have been enrolled. Adolescents and their parents completed measures of pain, functional disability, depressive symptoms, and family functioning (i.e., McMaster Family Assessment Device). Videotaped parent-teen interactions are currently being completed to assess expressions of autonomy and warmth in their relationship. Correlational analyses show moderate relationships between family factors and functional disability. Specifically, poor affective responsiveness (r ⫽ .41, p ⬍ .05) and poor general functioning (r ⫽ .42, p ⬍ .05) are associated with increased functional disability. Moreover, increased depressive symptoms are linked to increased family dysfunction (r ⫽ .49, p ⬍ .01). Mediational tests are significant for the total effect (family functioning to disability) and indirect effects (family functioning to depression and depression to disability). However statistical tests for mediation using Sobel’s equation are not significant, indicating that depression may not be the primary mechanism by which family functioning affects adolescent disability. Preliminary findings suggest that family factors and depression are strongly linked to headache-related disability in adolescents. Further analyses will examine parent-teen interactions to determine the effect of autonomy and intimacy in family interactions on adolescent functional disability.
B. Ely, C. Dampier, D. Brodecki, P. O’Neal, C. Coleman; St. Christopher’s Hospital for Children, Philadelphia, PA We are describing the incidence, occurrence and characteristics of sickle cell pain in infants and young children using a longitudinal, prospective design. Data from parent/guardian report are collected using monthly phone calls, and more recently, with a daily electronic pager system. Data reported here were collected from February, 2001 to December 2003 for 60 children over 1,226 months. The majority of the 60 children were homozygous SS (SCD-SS n⫽32, 53.3%; SCD-SC, n⫽21, 35%; SCDSbeta⫹Thal n⫽ 6, 10%; SCD-Sbeta0Thal n⫽1, 1.7%); slightly more than half were male (n⫽37, 61.7%); and 95% (n⫽57) of the children were Black. Age in months at data collection entry ranged from 3 to 60 months (Mean⫽20.8 mos., Median⫽16.0 Mos., SD⫽17.3 mos.). Thirtyseven of the 60 children had at least one reported sickle pain episode in the time period reported (1,226 mos). The mean age for this group of 37 children was 22.1 months and there were more children with the SCD-SS phenotype (n⫽ 24, 65%). A total of 231 pain episodes were reported over the 1,126 months representing 20.5% of all months with at least one reported pain episode for these 37 children. Length of reported pain ranged from a half day to 19 days, with the majority (52%) lasting 2 days or less. Presence of swelling with pain was noted for 66 (28.6%) of the episodes, while change in movement was noted in almost half of the episodes (47.6%). Location of pain was quite variable both within and between episodes, but abdomen and legs were the most frequently reported pain locations. Parent/guardians reported giving pain medication for 203 (87.9%) of the episodes and providing a variety of nonpharmacologic pain management interventions (e.g. massage, warm bath) 83% of the time. Results of this study will improve our knowledge of sickle pain in young children.
The Journal of Pain, Vol 6, No 3S (March), Supplement 1, 2005: pp S1-S8
S1