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Inadequate pain management and associated morbidity in children at home after tonsillectomy
Inadequate Pain Management and Associated Morbidity in Children at Home After Tonsillectomy Kimberly A. Sutters, RN, PhD Christine Miaskowski, RN, PhD, FAAN A telephone interview with the parents of 84 children who underwent tonsillectomy was conducted within 24 hours after discharge from an ambulatory surgery center. Parents were asked to rate the intensity of their child's pal n and data were collected on the type, dose, and amount of analgesics administered, and the types of side effects the children experienced. The mean age of the children was 7 years (SD ~ 2.31), with an equal number of boys and girls. Overall mean pain intensity was 1.42 (SD = 0.71 ) and the worst pain intensity ranged from 0 to 3 (Mean = 1.93, SD = 0.83). Acetaminophen with codeine was the most common analgesic prescribed and administered. Children received an average of 3 doses in the first 24 hours after surgery. Seventy-seven percent of the parents stated that pain relief from the analgesic was adequate. Of the 23% who did not feel that pain control was adequate, only 7% contacted a physician. The majority of the children experienced restless sleep (62%), behavior changes (75%), and difficulty taking oral fluids because of complaints of pain (56%). Twenty-six percent of the children had one or more episodes of emesis. Our data suggest that children experience a significant amount of pain in the first 24 hours after tonsillectomy and that parents administer analgesics less frequently than the drugs are prescribed. In addition, children experience significant deleterious effects (i.e., poor oral fluid intake, sleep disturbance, behavioral changes, and emesis) associated with the undertreatment of pain, the analgesic administered, or the surgery itself. Copyright 9 1997 by W.B. Saunders Company
PPROXIMATELY 50% of all pediatric surgiA cal procedures are performed on an outpatient basis and that number is increasing (Bogetz, 1989). However, very little information is available on the early postoperative experience of children at home after discharge from an ambulatory surgery center. Areas that warrant investigation are the severity of the child's postoperative pain; the ability of parents to monitor and manage their child's pain; and the effect of pain on the child's progress towards resuming normal activities. Nearly one-third of all children in the United From the Valley Children's Hospital, Fresno, CA and the Department of Physiological Nursing, University of California, San Francisco, CA. Supported by research grants from the American Nurses Foundation; Alpha Eta and Alpha Gamma Chapters of Sigma Theta Tau International; the Graduate Student Research Award from the University of California, San Francisco, School of Nursing Century Club Funds; the Purdue Frederick Company; Novametrixs Medical Systems; and Critikon Corporation. Address reprint requests to Christine Miaskowski, RN, PhD, FAAN, Professor and Chair, Department of Physiological Nursing, University of California, Box 0610-N611Y, San Francisco, CA 94143-0610. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1203-000653. 00/0
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States undergo tonsillectomy and/or adenoidectomy (Schmitt & Berman, 1987). This procedure is performed on an outpatient basis for the majority of pediatric patients. To date, only a limited number of studies have evaluated the postoperative pain experience of children after tonsillectomy (Brodsky, Radmoski, & Gendler, 1993; Gedaly-Duff & Ziebarth, 1994; Nardone & Schuchard, 1991; Shutt, 1991; Spicher & Yund, 1989), or ambulatory surgery in general (Astfalk, Warth, & Leriche, 1991; Nardone & Schuchard, 1991; Schofield & White, 1989). Based on the existing literature, further descriptive data on the pediatric pain experience after tonsillectomy are necessary before appropriate interventions can be determined. Therefore, the purposes of this study were to determine: (1) the intensity of the overall and worst pain experienced by children in the first 24 hours after tonsillectomy; (2) the type and amount of analgesics prescribed for home management of posttonsillectomy pain; (3) the type and amount of pain medication administered by parents in the first 24 hours postoperatively; (4) the percentage of children experiencing adequate pain relief; and (5) the effects of pain on the child's sleep pattern, behavior, and ability to consume fluids. Journal of PediatricNursing,Vol 12, No 3 (June),1997
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UTERATUREREVIEW Much of the literature concerning morbidity after tonsillectomy in children has focused on postoperative hemorrhage (Kang, Brodsky, Danziger, Volk, & Stanievich, 1994; Kendrick & Gibbin, 1993; Roberts, Jayaramachandran, & Raine, 1992; Schloss, Tan, Schloss, & Tewfik, 1994), infection (Eid & Jones, 1994), or nausea and vomiting (Ferrari & Donlon, 1992; Furst & Rodarte, 1994; Pandit, Malviya, & Lewis, 1995; Schloss et al., 1994). However, significant unrelieved postoperative pain after tonsillectomy can result in potentially serious complications that require medical attention or warrant readmission to the hospital. Research on the management of pain and oral fluid intake in children undergoing tonsillectomy has largely addressed the efficacy of interventions executed within the perioperative period (Carabott, Javaheri, Keilty, & Manger, 1992; Jebeles, Reilly, Gutierrez, Bradley, & Kissin, 1991; 1993; Linden, Gross, Long, & Lazar, 1990; Rusy et al., 1995; Sutters, Levine, Dibble, Savedra, & Miaskowski, 1995). More recently, parental management of their children's postoperative pain and other parameters of postoperative morbidity associated with tonsillectomy, including inadequate oral intake and alterations in sleep, activity, and behavior are being evaluated subsequent to discharge from the hospital (Brodsky et al., 1993; Carabott et al., 1992; GedalyDuff & Ziebarth, 1994; Klausner, Tom, Schindler, & Potsic, 1995; Shutt, 1991). In one study (Gedaly-Duff & Ziebarth, 1994), mothers (N = 7) reported that pain associated with tonsillectomy persisted for up to 2 weeks, with the most severe pain (i.e., 5 to 9, on a 0 to 10 scale) occurring between the first 12 to 36 hours postoperatively. Pain was reported to be episodic, varying with time of day, analgesic administration, and oral intake. Mothers reported difficulties assessing their children's pain and verbalized concerns about overdosing, undermedicating, and addicting their children. Mothers administered acetaminophen or acetaminophen with codeine to their children. However, the prescribed drug, dose, and schedule of administration, as well as the actual amount of analgesic administered, was not reported. One could not determine from the data presented whether or not children were undermedicated and whether or not the undermedication was a consequence of prescription and/or administration inadequacies. In addition, the small sample size limits generalizability of the study findings. In another study (Shutt, 1991), parents (N = 10) were interviewed within 3 to 5 days after their
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child's tonsillectomy, using a semistructured interview guide with open-ended questions. The child's behavior, emotional response, and refusal to eat or drink were cited as the most frequent parental concerns during the immediate postoperative period. Although one of the major contributing factors to poor oral intake is pain, parental perceptions of their child's pain intensity were not reported. Specific information about the nature of the child's behavioral and emotional responses was not provided. In another study that investigated the effect of postoperative diet and activity instructions on recovery after tonsillectomy and adenoidectomy (Brodsky et al., 1993), parental evaluations (N = 92) of pain, activity, diet, and the use of pain medications were obtained, in addition to the incidence of postoperative hemorrhage. Parents rated pain once a day using a 0 to 3 scale (i.e., 0 = continuous, 1 = intermittent, 2 = rare, and 3 = absent). Mean pain ratings on days 3 and 7 were 0.9 (SD = 0.4) and 1.2 (SD = 0.5), respectively. Acetaminophen was the analgesic prescribed for all patients. The number of analgesic doses administered on the third and seventh postoperative days were reported as 3.3 and 2.9 respectively, suggesting a modest decline in analgesic administration over time. The amount of each dose administered and the total dose of analgesic administered during the first 24 hours after discharge home were not reported. Activity levels were reduced, with parents reporting that their children were somewhat lethargic, and tired easily with activity. Activity levels did not return to baseline normal activity by the end of the first week after surgery. Spicher and Yund (1989) evaluated the effects of a preadmission program, at the time of tonsillectomy, on the emotional state of the child and parent; on parental compliance with written home care instructions; and on the child's postoperative behaviors. A telephone interview was conducted with the parents (N = 40) 7 days after surgery to evaluate compliance with home care instructions and children's behavior. Most of the children did not receive the recommended amount of oral fluid during the first 24 hours after surgery and parents were concerned about eating difficulties and changes in activity levels. Of note, parents who attended the preparation program tended to disregard the instructions for pain control (i.e., they modified the dosage and administration schedule for acetaminophen and codeine, based on their perception of their children's need, rather than administer the analgesics on a 4-hour schedule as instructed). Measures of
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perceived pain intensity and dose and frequency of analgesic administration were not reported. In another study (Nardone & Schuchard, 1991), involving telephone interviews of parents (N = 75), parental perceptions of their children's pain after a variety of surgical procedures (e.g., tonsillectomy, adenoidectomy, myringotomy and tympanoplasty, and herniorrhaphy) were evaluated. Thirty-one percent of the parents reported that their children experienced moderate to severe pain during the postoperative period. The efficacy of the analgesic regimen was not reported for the various surgical procedures. However, five parents reported that the prescribed pain medications were inadequate in relieving either moderate or severe pain. In summary, the findings from these studies provide preliminary information about the trajectory of the postoperative pain experience and the recovery pattern of children at home after tonsillectomy. However, significant gaps exist in the literature about the intensity, quality, and pattern of pain; analgesic prescription and administration practices; as well as the influence of postoperative pain on specific outcome measures (i.e., sleep pattern, oral intake, and behavior) that influence the recovery of children after tonsillectomy.
MATERIALS AND METHODS
Sample This study is part of a larger study of 87 children admitted through ambulatory surgery for tonsillectomy that evaluated the effects of ketorolac compared with placebo on pain intensity and opioid use in the immediate postoperative period (Sutters et al., 1995). A total of 84 parents participated in the postdischarge portion of the study (i.e., three parents were unavailable at the time of the follow-up telephone call). Children were between the ages of 3 and 12 years (mean = 84.8 months; SD = 27.7). Additional descriptive data including the type of surgical procedure, weight, gender of the children, and ethnicity of the parents are reported in Table 1.
Instruments A demographic data sheet was completed by the parents preoperatively. The data collection instrument for this study was developed by the investigators based on an extensive review of the literature and consisted of a semistructured telephone interview guide (see Table 2). The interview guide consisted of 15 questions which queried the parents regarding pain intensity, the amount and type of analgesic ordered, the amount and type of analgesic administered, the effectiveness of the analgesic, the child's sleep and activity pattern, the adequacy of
Table 1. SampleDemographicsof Children and Parents
Mean(SD) Age (months) Weight (kg) Gender Male Female Ethnicity White Hispanic African American Asian American Indian Other Typeof Surgery T T+A T+A+M
% (N)
% (N)
55.2% (48) 44.8% (39) Father 48.8% (42J 32.6% (28) 9.3% (8) 1.2%(I) 2.3% (2) 5.8% (5)
Mother 57.5%(501 31.0%(27) 4.6% (4) 1.2% (I) 2.3% (2) 3.4% (3)
84.8 (27.7) 28.6 (12.3)
11.5%(10) 58.6% [51) 29.9% (26)
ABBREVIATIONS: T, tonsillectomy;A, adenoidectomy;M, myringotomy.
oral intake, and the incidence of bleeding and emesis. The content validity of the interview guide was established through a review by a panel of experts in pediatrics and pain management.
Procedure The study was approved by the Hospital's Institutional Review Board, as well as by the Human Research Committee at the University of California, San Francisco. Parental consent and child assent (when age-appropriate) was obtained for all participants. The investigator approached the child and parents on the morning of surgery, at which time the demographic questionnaire was completed, baseline measures were obtained for the immediate postoperative portion of the study (see Sutters et al., 1995), and a follow-up telephone interview was scheduled with the parents. Before discharge, the patient's chart was reviewed to document the discharge pain medication orders. Parents were contacted at home, by telephone, 24 hours after discharge to evaluate the child's pain experience and management. Parents were interviewed using the 15-item interview guide.
Data Analysis Descriptive statistics were generated to summarize sample characteristics (Table 1). Student's t-tests or Chi-square analyses were performed to answer the study questions. Ap-value of <.05 was considered statistically significant.
RESULTS
Evaluation of Pain Intensity Parents were asked to rate their children's overall pain intensity and worst pain intensity for the first
PAIN MANAGEMENT OF CHILDREN AT HOME Table 2. Parent TelephoneInterview Approximately 24 hours from the time of discharge, the parent was contacted by telephone to obtain information on how the child was doing at home. Intradudion: "C-eadafternoo~aMrs. Smith. This is I am one of the nurses from Valley Children's Hospital. I am calling to see how your child is doing at home after his operation yesterday. I would like to ask you several questions." 1. Did you give your child any pain medicine since he/she came home from the hospital? (1) Yes {2) No 2. If so, what was the name/strength of the pain medicine(s) that you gave your child? 3. How much pain medicine did you give your child each time (e.g., 1 or 2 tsp., 1 or 2 chewable tabs)? 4. How many times did you give your child the pain medicine? 5. Did your child get enough relief from the pain medicine? (1) Yes (2) No (3) Unsure 6. If the answer to question number 5 is no, did you call the physician? (1) Yes (2) No (3) Notapplicoble 7. How would you rate your child's worst pain at home? (0) None (11 Mild (2) Moderate {3J Severe 8. How would you rate your child's overall pain at home? (0) None (1) Mild (2) Moderate (3) Severe 9. Did your child complain o~ear pain after his/her tonsillectomy? {1) Yes (2) No 10. How did your child sleep last night? (0) Slept well (1) Restless,interrupted sleep (3) Didn't sleep at all 11. What has your child's behavior been like since he/she came home from the hospito[? (0) Usual self (1) Unusually quiet, subdued (2) Cried occasionally, made attempt at play (3) Fussy, irritable, did not want to play (4) Cried constantly, inconsolable since surgery (5) Other 12. How is your child drinking? (0) Drinking well (1) Taking sips only, drinking small amounls (2) Not drinking at all 13. If your child is not drinking, is it because he/she says it hurts when he/she drinks? (1) Yes (2) No (3) Not applicable 14. ff your child is nat drinking, is it because he/she says he feels nauseated or sick to his stomach, or is throwing up? (1) Yes {2) No (3) Not applicable 15. Has your child had any problems with bleeding since he/she came home from the hospital? {0) No bleeding (1) Streaks of blood in mucous or drainage from mouth or nose (2) Small amount of bright red blood from mouth or nose 13) A lot of bleeding which requiredyou to bring your child back to the hospital
24 hours after discharge from the hospital, using a 4-point verbal rating scale (0 = no pain, I = mild pain, 2 = moderate pain, and 3 = severe pain). Figure 1 provides a frequency distribution of parental reports of children's overall pain intensity. Forty-three percent of the parents reported their children's overall pain intensity to be either moder-
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ate or severe for the first 24 hours after discharge from the hospital. The overall mean pain intensity was 1.39 (SD = 0.68; range 0 to 3). Children who complained of ear pain (N = 15) were found to have higher overall pain intensity scores (• = 5.5, p = .02) than children who did not have ear pain. Parents of 11 of the 15 children with ear pain reported that their child experienced moderate to severe pain. Parental reports of worst pain intensity ranged from 0 to 3, with a mean of 1.91 (SD = 0.82). As illustrated in Figure 2, 74% of the parents (62/84) reported that their child experienced moderate to severe pain at some point during the initial 24 hours at home after tonsillectomy.
Analgesic Prescription The type, dose, and administration schedule of the postdischarge pain medications were evaluated (Table 3). Acetaminophen with codeine was the most frequently ordered analgesic. However, the prescribed doses for 93.7% of the analgesics were below the dose levels recommended in the Clinical Practice Guideline on Acute Pain Management published by the Agency for Health Care Policy and Research (Acute Pain Guideline Panel, 1992). All analgesics were prescribed for use on an "as needed" basis, rather than on a routine schedule.
Analgesic Administration and Pain Relief Parents were asked to provide information regarding analgesic administration for the first 24 hours at home (i.e., medication, dose, and interval) and the adequacy of pain relief. If pain relief was reported as inadequate, parents were questioned as to whether they had contacted their physician. The analgesic most frequently administered was acetaminophen with codeine, which was consistent with the analgesic prescriptions. Children received an average of 3 doses of an analgesic within the first 24 hours after discharge home, Children with lower overall pain intensity scores received significantly fewer doses of an analgesic (i.e., 0 to 3 doses; X2 = 4.8, p = .03) than children with higher overall pain intensity scores (i.e., 4 to 7 doses). The number of episodes of vomiting did not differ for children who received between 0 and 3 doses of analgesics and those who received between 4 and 7 doses. Over one-half (56.9%) of the parents administered less than 50% of the maximum 24 hour dose ordered (see Table 4). Eight parents (9%) changed to a different drug than the one prescribed (i.e., administered a second medication and/or substi-
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SUI-rERS A N D
OVERALL PAIN INTENSITY
0 1 2 3
= = = =
MIASKOWSKI
None Mild Moderate Severe
60
50
qD r-
40
o
"6 30 rG)
.u
a.
20
Figure 1. Frequency distribution of parental reports of children's overall pain intensity (N = 841, using a verbal descriptive rating scale (0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain), for the first 24 hours after discharge from the hospital for tonsillectomy.
10
1
2
Pain I n t e n s i t y
0 1 2 3
W O R S T PAIN 6O
5O 2 e-
.= -a ,m e-
40
C) 9
m
30
C
ae.
Figure 2. Frequency distribution of parental reports of children's worst pain intensity (N = 84), using a verbal descriptive rating scale (0 = no pain, 1 = mild pain, 2 --- moderate pain, and 3 - severe pain), for the first 24 hours after discharge from the hospital for tonsillectomy.
20
10
1
2
Pain Intensity
= = = =
None Mild Moderate Severe
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Table3. PostdischargeAnalgesicPrescriptions %(N) Analgesicordered None Acetaminophenwith codeine Acetaminophenwith hydrocodone Acetaminophen Doseorderedcomparedwith recommendeddose by body weight* Belowthe recommendeddose At the recommendeddose Abovethe recommendedclose
1.2% { 1) 91.7% (77) 2.4% (2) 4.8% (4)
93.7% (74) 2.5% (2) 3.8% (3)
*Recommendeddoses usedwere: CodeineI mg/kg every 3-4 hr; Hyclrocodone0.2 mg/kg every3-4 hr; Acetaminophen10-15 mg/kg every4 hr.
tuted a less potent analgesic). Sixteen parents (19%) administered doses at or below the lower limits of the prescribed dose range, and two parents (2%) administered doses in excess of the dose ordered. Only 9% (8/84) of the parents administered analgesics at the prescribed dose and maximum frequency prescribed. Of note, three parents (3.6%) did not administer any analgesics to their child. Seventy-seven percent of the parents stated that pain relief after administration of the analgesic was adequate. Parents of 11 children (13%) reported that the analgesic(s) provided inadequate pain relief and seven parents (8%) were unsure about the amount of pain relief their child experienced. Six of the parents who reported inadequate pain relief contacted their physician to request stronger pain medication. Table4. Typeand Amountof AnalgesicAdminisl~d in He 24 HoursAfter Tonsillectomy Analgesicadministeredby parents None Acetaminophenwith codeine Acetaminophenwith hydrocodone Acetaminophen Acetaminophenwith codeine + acetaminophen Acetaminophenwith codeine+ ibupro~n Percentageof maximum24 hour doseorderedthat was actuallyadministered 0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100% >100%
3.6% (31 82.0% (69) 2.4% (2) 3.6% (3) 6.0% I5) 2.4% 12)
5.1% (4) 7.6% (6) 10.0% (8) 15.2% (12) 19.0% (15) 1.3% 11) 15.2% (12) 1.3% (1) 12.6% (10) 11.4% (9) 1.3%(1)
Oral Intake/Emesis Parents reported that 45% of the children (38/84) were drinking well. However, 50% of the children (42/84) were only taking sips of clear liquids, and 5% (4/84) were not drinking at all, despite encouragement. Based on parental reports, pain associated with drinking was responsible for inadequate oral intake for all of these children. Children with higher pain intensity ratings drank significantly less than children with lower pain intensity scores (X2 = 3.1, p = .08). In addition, 8% of parents reported that concurrent complaints of nausea and/or emesis also contributed to reduced oral intake. Nearly one-third of the children experienced one or more episodes of emesis at home during the early postoperative period.
Sleep Parents reported that 56% of the children experienced a restless sleep and that 6% of the children did not sleep at all the night after surgery. Children with higher pain intensity ratings experienced more sleep disturbances (X2 = 8.24, p = .004) than children with pain intensity ratings of 0 or 1. Only eight of the 52 children who experienced some degree of sleep disturbance on the first postoperative night, experienced mild pain or no pain at all. History of previous hospitalization or surgery did not effect the occurrence of sleep disturbances.
Behavior Children with pain intensity ratings of 2 or 3 had significantly more behavioral changes (X 2 = 10.2, p = .001) than children with pain intensity ratings of 0 or 1. Parents reported that over half of the children were unusually quiet for the 24 hours after surgery. However, children with pain intensity ratings ranging from moderate to severe (i.e., 2 to 3), showed the most prominent behavioral changes ranging from "fussy, crying on occasion, but still attempting to participate in routine activity or play" to "extremely irritable or inconsolable, and unable to engage in any form of distraction." The child's past history of previous surgery or hospitalization did not influence the reported behavioral changes.
Bleeding None of the children experienced significant episodes of bleeding within the first 24 hours after the surgery, Only two of the parents (2.4%) reported that their child had occasional streaks of blood in their saliva, that resolved spontaneously.
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DISCUSSION The results of this study, using parental reports, show that after tonsillectomy children experience moderate to severe pain that is undertreated. In addition, children with higher pain intensity scores experienced more sleep disturbances, poorer oral intake, and more behavioral changes during the first 24 hours after surgery. Parental ratings of pain intensity following tonsillectomy are consistent with previously published reports (Brodsky et al., 1993; Gedaly-Duff & Ziebarth, 1994). However, all of these studies, including our own, have relied on parental perception of their children's pain intensity. Additional research is warranted that incorporates children's self-report of pain intensity. Children's self-report ratings and parental ratings could be compared to provide a more accurate description of the pain experience after tonsillectomy. One of the major contributions of this study is an analysis of the type and amount of analgesics administered by parents. Parents gave their children significantly less analgesics than prescribed', despite pain intensity reports ranging from mild to severe. However, even if parents administered the maximum dose at the most frequent interval prescribed, adequate analgesia may not have been achieved, given that 93.7% of the doses prescribed were already subtherapeutic. Factors that may have contributed to parental undertreatment of their children's pain include: (1) parental expectations regarding the amount of pain associated with tonsillectomy; (2) fears of overdosage, overuse, and/or addiction; (3) difficulties encountered with administration of the analgesic (e.g., lack of cooperation by the child); (4) lack of knowledge about the analgesics prescribed and concerns about potential side effects (e.g., nausea); and (5) parental expectations about acceptable levels of pain or pain relief. Additional research is warranted to determine what factors influence parents decisions about administering analgesics and ways to insure optimal pain management for children recovering from surgery at home. Additional physician education is also imperative to ensure that the recommended doses of analgesics for pediatric patients are prescribed. The majority of parents reported adequate pain relief for their children after analgesic administration. However, while children may have experienced some temporary pain relief, this effect may not have been sustained in view of the relatively high overall pain intensity reports. Reluctance to contact the physician may be related to parental
expectations about pain and pain relief and parental perceptions of what constitutes an acceptable level of pain. Prescribed analgesic doses were subtherapeutic for the majority of children. In addition, these drugs were underused by the parents. Therefore, it is difficult to evaluate the efficacy of acetaminophen with codeine in the management of posttonsillectomy pain in children. However, anecdotal parental comments about the adverse effects experienced by some children (e.g., pain on swallowing the medication and gastric upset) suggest that the side effects experienced by the children after administration of acetaminophen with codeine may have deterred parents' continued usage of the analgesic. Although acetaminophen with codeine is advocated as the drug of choice, alternative analgesics with less aversive side effects may be more acceptable and efficacious. Therefore, a critical evaluation of the optimal analgesics for use after tonsillectomy in children is warranted. A small number of parents acknowledged that they were unsure if their child experienced adequate pain relief after analgesic administration. This finding suggests that some parents may not be aware of what cues to rely on in assessing their children's pain, thus impairing their ability to evaluate their children's pain experience and response to pain relief interventions. Further research could evaluate whether teaching parents to assess their children's pain using a self-report measure would influence their analgesic administration practices. Finally, children with higher pain intensity scores experienced significantly more deleterious effects (i.e., poor oral fluid intake, sleep disturbances, behavioral changes, and emesis) in the first 24 hours after surgery. The fact that children with lower pain intensity ratings experienced less deleterious effects suggests that better pain relief improves pain outcomes and recovery from surgery. A prospective trial comparing a prescribed analgesic regimen with standard parental care during the first 24 hours after surgery would provide confirmatory evidence that proactive postoperative pain control improves recovery. Children whose worst pain was of moderate to severe intensity showed the most significant sleep disturbances. These data suggest that children's worst pain may have occurred at night. Although the time of day that analgesics were administered was not evaluated, it is possible that children may not have received analgesics during the night. This finding emphasizes the significance of educating
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parents regarding the importance of around-theclock analgesic dosing during the first 24 hours after surgery, even if it means arousing the child briefly during the night to administer a dose of pain medication. Based on these findings, additional parental
instruction in home management of children's pain is warranted to address the severity of pain associated with the surgical procedure, the need for scheduled administration of analgesics at therapeutic doses, signs and symptoms of pain, and what to do if relief is inadequate.
REFERENCES Acute Pain Guideline Panel. (1992). Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guideline. AHCPR Pub. No. 92-0032. Rockville, MD: Agency for Health Care Policy and Research, Public Health Service, U.S. Department of Health and Human Services. Astfalk, W., Warth, H., & Leriche, C. (1991). Day case surgery in childhood from the parent's point of view. European Journal of Pediatric Surgery, 1(6), 323-327. Bogetz, M.S. (1989). Anesthesia for pediatric outpatient surgery. Pediatrician, 16(1-2), 45-55. Brodsky, L., Radomski, K., & Gendler, J. (1993). The effect of postoperative instructions on recovery after tonsillectomy and adenoidectomy. International Journal of Pediatric Otorhinolaryngology, 25(1-3), 133-140. Carabott, J.A., Javaheri, Z., Keilty, K., & Manger, G. (1992). Oral fluid intake in children following tonsillectomy and adenoidectomy. Pediatric Nursing, 18(2), 124-127. Eid, N.S. & Jones, V.E (1994). Bacterial tracheitis as a complication of tonsillectomy and adenoidectomy. Journal of Pediatrics, 125(3), 401-402. Ferrari, L.R. & Donlon, J.V. (1992). Metoclopramide reduces the incidence of vomiting after tonsillectomy in children. Anesthesia & Analgesia, 75(3), 351-354. Furst, S.R. & Rodarte, A. (1994). Prophylactic antiemetic treatment with ondansetron in children undergoing tonsillectomy. Anesthesiology, 81(4), 795-796. Gedaly-Duff, V. & Ziebarth, D. (1994). Mother's management of adenoid-tonsillectomy pain in 4- to 8-year-olds: A preliminary study. Pain, 57(3), 293-299. Jebeles, J.A., Reilly, J.S., Gutierrez, J.E, Bradley, E.L., & Kissin, I. (1991). The effect of pre-incisional infiltration of tonsils with bupivacaine on the pain following tonsillectomy under general anesthesia. Pain, 47(3), 305-308. Jebeles, J.A., Reilly, J.S., Gutierrez, J.F., Bradley, E.L., & Kissin, I. (1993). Tonsillectomy and adenoidectomy pain reduction by local bupivacaine infiltration in children. International Journal of Pediatric Otorhinolaryngology, 25(1-3), 149-154. Kang, J., Brodsky, L., Danziger, I., Volk, M., & Stanievich, J. (1994). Coagulation profile as a predictor for post-tonsillectomy and adenoidectomy (T + A) hemorrhage. International Journal of Pediatric Otorhinolaryngology, 28(2-3), 157-165. Kendrick, D. & Gibbin, K. (1993). An audit of the complications of pediatric tonsillectomy, adenoidectomy, and adenotonsillectomy. Clinical Otolaryngology, 18(2), 115-117.
Klausner, R.D., Tom, L.W., Schindler, ED., & Potsic, W.E (1995). Depression in children after tonsillectomy. Archives of Otolar3.ngolog3~Head and Neck SurgeD', 121(1), 105-108. Linden, B.E., Gross, C.W., Long, T.E., & Lazar, R.H. (1990). Morbidity in pediatric tonsillectomy. Laryngoscope, 100, 120124. Nardone, EL. & Schuchard, B. (1991). Parental pain perception of the same-day surgery pediatric patient. Journal of Nursing Quality Assurance, 5(3), 59-64. Pandit, U.A., Malviya, S., & Lewis, I.H. 0995). Vomiting after outpatient tonsillectomy and adenoidectomy in children: The role of nitrous oxide. Anesthesia & Analgesia, 80(2), 230-233. Roberts, C., Jayaramachandran, S., & Raine, C.H. (1992). A prospective study of factors which may predispose to postoperative tonsillar fossa haemorrhage. Clinical Otolaryngology, 17(l), 13-17. Rusy, L.M., Houck, C.S., Sullivan, L.J., Ohlms, L.A., Jones, D.T., McGill, T.J., & Berde, C.B. (1995). A double-blind evaluation of ketorolac tromethamine versus acetaminophen in pediatric tonsillectomy: Analgesia and bleeding. Anesthesia & Analgesia, 80(2), 226-229. Schloss, M.D., Tan, A.K., Schloss, B,, & Tewfik, T.L. (1994). Outpatient tonsillectomy and adenoidectomy: Complications and recommendations. International Journal of Pediatric Otorhinolaryngolog~, 30, 115-122. Schmitt, D.B. & Berman, S. (1987). Ear, nose, and throat. In C.H. Kempe, H.K. Silver, D. O'Brien, & V.A. Fulginiti (Eds.), Current pediatric diagnosis and treatment (pp. 308-340). New York: Appleton-Century-Crofts. Schofield, N.M. & White, J.B. (1989). Interrelations among children, parents, premedication, and anaesthetists in pediatric day stay surgery. British Medicine Journal, 299, 1371-1375. Shutt, E.E. (1991). Stressors perceived by parents of children experiencing ambulatory surgery. The Kansas Nurse, May, 1-2. Spicher, C.M. & Yund, C. (1989). Effects of preadmission preparation on compliance with home care instructions. Journal of Pediatric Nursing, 4(4), 255-262. Sutters, K.A., Levine, J.D., Dibble, S., Savedra, M., & Miaskowski, C. (1995). Analgesic efficacy and safety of singledose intramuscular ketorolac for postoperative pain management in children following tonsillectomy. Pain, 61, 145-153.
PPROXIMATELY 50% of all pediatric surgiA cal procedures are performed on an outpatient basis and that number is increasing (Bogetz, 1989). However, very little information is available on the early postoperative experience of children at home after discharge from an ambulatory surgery center. Areas that warrant investigation are the severity of the child's postoperative pain; the ability of parents to monitor and manage their child's pain; and the effect of pain on the child's progress towards resuming normal activities. Nearly one-third of all children in the United From the Valley Children's Hospital, Fresno, CA and the Department of Physiological Nursing, University of California, San Francisco, CA. Supported by research grants from the American Nurses Foundation; Alpha Eta and Alpha Gamma Chapters of Sigma Theta Tau International; the Graduate Student Research Award from the University of California, San Francisco, School of Nursing Century Club Funds; the Purdue Frederick Company; Novametrixs Medical Systems; and Critikon Corporation. Address reprint requests to Christine Miaskowski, RN, PhD, FAAN, Professor and Chair, Department of Physiological Nursing, University of California, Box 0610-N611Y, San Francisco, CA 94143-0610. Copyright 9 1997 by W.B. Saunders Company 0882-5963/97/1203-000653. 00/0
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States undergo tonsillectomy and/or adenoidectomy (Schmitt & Berman, 1987). This procedure is performed on an outpatient basis for the majority of pediatric patients. To date, only a limited number of studies have evaluated the postoperative pain experience of children after tonsillectomy (Brodsky, Radmoski, & Gendler, 1993; Gedaly-Duff & Ziebarth, 1994; Nardone & Schuchard, 1991; Shutt, 1991; Spicher & Yund, 1989), or ambulatory surgery in general (Astfalk, Warth, & Leriche, 1991; Nardone & Schuchard, 1991; Schofield & White, 1989). Based on the existing literature, further descriptive data on the pediatric pain experience after tonsillectomy are necessary before appropriate interventions can be determined. Therefore, the purposes of this study were to determine: (1) the intensity of the overall and worst pain experienced by children in the first 24 hours after tonsillectomy; (2) the type and amount of analgesics prescribed for home management of posttonsillectomy pain; (3) the type and amount of pain medication administered by parents in the first 24 hours postoperatively; (4) the percentage of children experiencing adequate pain relief; and (5) the effects of pain on the child's sleep pattern, behavior, and ability to consume fluids. Journal of PediatricNursing,Vol 12, No 3 (June),1997
PAIN MANAGEMENT OF CHILDRENAT HOME
UTERATUREREVIEW Much of the literature concerning morbidity after tonsillectomy in children has focused on postoperative hemorrhage (Kang, Brodsky, Danziger, Volk, & Stanievich, 1994; Kendrick & Gibbin, 1993; Roberts, Jayaramachandran, & Raine, 1992; Schloss, Tan, Schloss, & Tewfik, 1994), infection (Eid & Jones, 1994), or nausea and vomiting (Ferrari & Donlon, 1992; Furst & Rodarte, 1994; Pandit, Malviya, & Lewis, 1995; Schloss et al., 1994). However, significant unrelieved postoperative pain after tonsillectomy can result in potentially serious complications that require medical attention or warrant readmission to the hospital. Research on the management of pain and oral fluid intake in children undergoing tonsillectomy has largely addressed the efficacy of interventions executed within the perioperative period (Carabott, Javaheri, Keilty, & Manger, 1992; Jebeles, Reilly, Gutierrez, Bradley, & Kissin, 1991; 1993; Linden, Gross, Long, & Lazar, 1990; Rusy et al., 1995; Sutters, Levine, Dibble, Savedra, & Miaskowski, 1995). More recently, parental management of their children's postoperative pain and other parameters of postoperative morbidity associated with tonsillectomy, including inadequate oral intake and alterations in sleep, activity, and behavior are being evaluated subsequent to discharge from the hospital (Brodsky et al., 1993; Carabott et al., 1992; GedalyDuff & Ziebarth, 1994; Klausner, Tom, Schindler, & Potsic, 1995; Shutt, 1991). In one study (Gedaly-Duff & Ziebarth, 1994), mothers (N = 7) reported that pain associated with tonsillectomy persisted for up to 2 weeks, with the most severe pain (i.e., 5 to 9, on a 0 to 10 scale) occurring between the first 12 to 36 hours postoperatively. Pain was reported to be episodic, varying with time of day, analgesic administration, and oral intake. Mothers reported difficulties assessing their children's pain and verbalized concerns about overdosing, undermedicating, and addicting their children. Mothers administered acetaminophen or acetaminophen with codeine to their children. However, the prescribed drug, dose, and schedule of administration, as well as the actual amount of analgesic administered, was not reported. One could not determine from the data presented whether or not children were undermedicated and whether or not the undermedication was a consequence of prescription and/or administration inadequacies. In addition, the small sample size limits generalizability of the study findings. In another study (Shutt, 1991), parents (N = 10) were interviewed within 3 to 5 days after their
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child's tonsillectomy, using a semistructured interview guide with open-ended questions. The child's behavior, emotional response, and refusal to eat or drink were cited as the most frequent parental concerns during the immediate postoperative period. Although one of the major contributing factors to poor oral intake is pain, parental perceptions of their child's pain intensity were not reported. Specific information about the nature of the child's behavioral and emotional responses was not provided. In another study that investigated the effect of postoperative diet and activity instructions on recovery after tonsillectomy and adenoidectomy (Brodsky et al., 1993), parental evaluations (N = 92) of pain, activity, diet, and the use of pain medications were obtained, in addition to the incidence of postoperative hemorrhage. Parents rated pain once a day using a 0 to 3 scale (i.e., 0 = continuous, 1 = intermittent, 2 = rare, and 3 = absent). Mean pain ratings on days 3 and 7 were 0.9 (SD = 0.4) and 1.2 (SD = 0.5), respectively. Acetaminophen was the analgesic prescribed for all patients. The number of analgesic doses administered on the third and seventh postoperative days were reported as 3.3 and 2.9 respectively, suggesting a modest decline in analgesic administration over time. The amount of each dose administered and the total dose of analgesic administered during the first 24 hours after discharge home were not reported. Activity levels were reduced, with parents reporting that their children were somewhat lethargic, and tired easily with activity. Activity levels did not return to baseline normal activity by the end of the first week after surgery. Spicher and Yund (1989) evaluated the effects of a preadmission program, at the time of tonsillectomy, on the emotional state of the child and parent; on parental compliance with written home care instructions; and on the child's postoperative behaviors. A telephone interview was conducted with the parents (N = 40) 7 days after surgery to evaluate compliance with home care instructions and children's behavior. Most of the children did not receive the recommended amount of oral fluid during the first 24 hours after surgery and parents were concerned about eating difficulties and changes in activity levels. Of note, parents who attended the preparation program tended to disregard the instructions for pain control (i.e., they modified the dosage and administration schedule for acetaminophen and codeine, based on their perception of their children's need, rather than administer the analgesics on a 4-hour schedule as instructed). Measures of
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perceived pain intensity and dose and frequency of analgesic administration were not reported. In another study (Nardone & Schuchard, 1991), involving telephone interviews of parents (N = 75), parental perceptions of their children's pain after a variety of surgical procedures (e.g., tonsillectomy, adenoidectomy, myringotomy and tympanoplasty, and herniorrhaphy) were evaluated. Thirty-one percent of the parents reported that their children experienced moderate to severe pain during the postoperative period. The efficacy of the analgesic regimen was not reported for the various surgical procedures. However, five parents reported that the prescribed pain medications were inadequate in relieving either moderate or severe pain. In summary, the findings from these studies provide preliminary information about the trajectory of the postoperative pain experience and the recovery pattern of children at home after tonsillectomy. However, significant gaps exist in the literature about the intensity, quality, and pattern of pain; analgesic prescription and administration practices; as well as the influence of postoperative pain on specific outcome measures (i.e., sleep pattern, oral intake, and behavior) that influence the recovery of children after tonsillectomy.
MATERIALS AND METHODS
Sample This study is part of a larger study of 87 children admitted through ambulatory surgery for tonsillectomy that evaluated the effects of ketorolac compared with placebo on pain intensity and opioid use in the immediate postoperative period (Sutters et al., 1995). A total of 84 parents participated in the postdischarge portion of the study (i.e., three parents were unavailable at the time of the follow-up telephone call). Children were between the ages of 3 and 12 years (mean = 84.8 months; SD = 27.7). Additional descriptive data including the type of surgical procedure, weight, gender of the children, and ethnicity of the parents are reported in Table 1.
Instruments A demographic data sheet was completed by the parents preoperatively. The data collection instrument for this study was developed by the investigators based on an extensive review of the literature and consisted of a semistructured telephone interview guide (see Table 2). The interview guide consisted of 15 questions which queried the parents regarding pain intensity, the amount and type of analgesic ordered, the amount and type of analgesic administered, the effectiveness of the analgesic, the child's sleep and activity pattern, the adequacy of
Table 1. SampleDemographicsof Children and Parents
Mean(SD) Age (months) Weight (kg) Gender Male Female Ethnicity White Hispanic African American Asian American Indian Other Typeof Surgery T T+A T+A+M
% (N)
% (N)
55.2% (48) 44.8% (39) Father 48.8% (42J 32.6% (28) 9.3% (8) 1.2%(I) 2.3% (2) 5.8% (5)
Mother 57.5%(501 31.0%(27) 4.6% (4) 1.2% (I) 2.3% (2) 3.4% (3)
84.8 (27.7) 28.6 (12.3)
11.5%(10) 58.6% [51) 29.9% (26)
ABBREVIATIONS: T, tonsillectomy;A, adenoidectomy;M, myringotomy.
oral intake, and the incidence of bleeding and emesis. The content validity of the interview guide was established through a review by a panel of experts in pediatrics and pain management.
Procedure The study was approved by the Hospital's Institutional Review Board, as well as by the Human Research Committee at the University of California, San Francisco. Parental consent and child assent (when age-appropriate) was obtained for all participants. The investigator approached the child and parents on the morning of surgery, at which time the demographic questionnaire was completed, baseline measures were obtained for the immediate postoperative portion of the study (see Sutters et al., 1995), and a follow-up telephone interview was scheduled with the parents. Before discharge, the patient's chart was reviewed to document the discharge pain medication orders. Parents were contacted at home, by telephone, 24 hours after discharge to evaluate the child's pain experience and management. Parents were interviewed using the 15-item interview guide.
Data Analysis Descriptive statistics were generated to summarize sample characteristics (Table 1). Student's t-tests or Chi-square analyses were performed to answer the study questions. Ap-value of <.05 was considered statistically significant.
RESULTS
Evaluation of Pain Intensity Parents were asked to rate their children's overall pain intensity and worst pain intensity for the first
PAIN MANAGEMENT OF CHILDREN AT HOME Table 2. Parent TelephoneInterview Approximately 24 hours from the time of discharge, the parent was contacted by telephone to obtain information on how the child was doing at home. Intradudion: "C-eadafternoo~aMrs. Smith. This is I am one of the nurses from Valley Children's Hospital. I am calling to see how your child is doing at home after his operation yesterday. I would like to ask you several questions." 1. Did you give your child any pain medicine since he/she came home from the hospital? (1) Yes {2) No 2. If so, what was the name/strength of the pain medicine(s) that you gave your child? 3. How much pain medicine did you give your child each time (e.g., 1 or 2 tsp., 1 or 2 chewable tabs)? 4. How many times did you give your child the pain medicine? 5. Did your child get enough relief from the pain medicine? (1) Yes (2) No (3) Unsure 6. If the answer to question number 5 is no, did you call the physician? (1) Yes (2) No (3) Notapplicoble 7. How would you rate your child's worst pain at home? (0) None (11 Mild (2) Moderate {3J Severe 8. How would you rate your child's overall pain at home? (0) None (1) Mild (2) Moderate (3) Severe 9. Did your child complain o~ear pain after his/her tonsillectomy? {1) Yes (2) No 10. How did your child sleep last night? (0) Slept well (1) Restless,interrupted sleep (3) Didn't sleep at all 11. What has your child's behavior been like since he/she came home from the hospito[? (0) Usual self (1) Unusually quiet, subdued (2) Cried occasionally, made attempt at play (3) Fussy, irritable, did not want to play (4) Cried constantly, inconsolable since surgery (5) Other 12. How is your child drinking? (0) Drinking well (1) Taking sips only, drinking small amounls (2) Not drinking at all 13. If your child is not drinking, is it because he/she says it hurts when he/she drinks? (1) Yes (2) No (3) Not applicable 14. ff your child is nat drinking, is it because he/she says he feels nauseated or sick to his stomach, or is throwing up? (1) Yes {2) No (3) Not applicable 15. Has your child had any problems with bleeding since he/she came home from the hospital? {0) No bleeding (1) Streaks of blood in mucous or drainage from mouth or nose (2) Small amount of bright red blood from mouth or nose 13) A lot of bleeding which requiredyou to bring your child back to the hospital
24 hours after discharge from the hospital, using a 4-point verbal rating scale (0 = no pain, I = mild pain, 2 = moderate pain, and 3 = severe pain). Figure 1 provides a frequency distribution of parental reports of children's overall pain intensity. Forty-three percent of the parents reported their children's overall pain intensity to be either moder-
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ate or severe for the first 24 hours after discharge from the hospital. The overall mean pain intensity was 1.39 (SD = 0.68; range 0 to 3). Children who complained of ear pain (N = 15) were found to have higher overall pain intensity scores (• = 5.5, p = .02) than children who did not have ear pain. Parents of 11 of the 15 children with ear pain reported that their child experienced moderate to severe pain. Parental reports of worst pain intensity ranged from 0 to 3, with a mean of 1.91 (SD = 0.82). As illustrated in Figure 2, 74% of the parents (62/84) reported that their child experienced moderate to severe pain at some point during the initial 24 hours at home after tonsillectomy.
Analgesic Prescription The type, dose, and administration schedule of the postdischarge pain medications were evaluated (Table 3). Acetaminophen with codeine was the most frequently ordered analgesic. However, the prescribed doses for 93.7% of the analgesics were below the dose levels recommended in the Clinical Practice Guideline on Acute Pain Management published by the Agency for Health Care Policy and Research (Acute Pain Guideline Panel, 1992). All analgesics were prescribed for use on an "as needed" basis, rather than on a routine schedule.
Analgesic Administration and Pain Relief Parents were asked to provide information regarding analgesic administration for the first 24 hours at home (i.e., medication, dose, and interval) and the adequacy of pain relief. If pain relief was reported as inadequate, parents were questioned as to whether they had contacted their physician. The analgesic most frequently administered was acetaminophen with codeine, which was consistent with the analgesic prescriptions. Children received an average of 3 doses of an analgesic within the first 24 hours after discharge home, Children with lower overall pain intensity scores received significantly fewer doses of an analgesic (i.e., 0 to 3 doses; X2 = 4.8, p = .03) than children with higher overall pain intensity scores (i.e., 4 to 7 doses). The number of episodes of vomiting did not differ for children who received between 0 and 3 doses of analgesics and those who received between 4 and 7 doses. Over one-half (56.9%) of the parents administered less than 50% of the maximum 24 hour dose ordered (see Table 4). Eight parents (9%) changed to a different drug than the one prescribed (i.e., administered a second medication and/or substi-
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SUI-rERS A N D
OVERALL PAIN INTENSITY
0 1 2 3
= = = =
MIASKOWSKI
None Mild Moderate Severe
60
50
qD r-
40
o
"6 30 rG)
.u
a.
20
Figure 1. Frequency distribution of parental reports of children's overall pain intensity (N = 841, using a verbal descriptive rating scale (0 = no pain, 1 = mild pain, 2 = moderate pain, and 3 = severe pain), for the first 24 hours after discharge from the hospital for tonsillectomy.
10
1
2
Pain I n t e n s i t y
0 1 2 3
W O R S T PAIN 6O
5O 2 e-
.= -a ,m e-
40
C) 9
m
30
C
ae.
Figure 2. Frequency distribution of parental reports of children's worst pain intensity (N = 84), using a verbal descriptive rating scale (0 = no pain, 1 = mild pain, 2 --- moderate pain, and 3 - severe pain), for the first 24 hours after discharge from the hospital for tonsillectomy.
20
10
1
2
Pain Intensity
= = = =
None Mild Moderate Severe
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Table3. PostdischargeAnalgesicPrescriptions %(N) Analgesicordered None Acetaminophenwith codeine Acetaminophenwith hydrocodone Acetaminophen Doseorderedcomparedwith recommendeddose by body weight* Belowthe recommendeddose At the recommendeddose Abovethe recommendedclose
1.2% { 1) 91.7% (77) 2.4% (2) 4.8% (4)
93.7% (74) 2.5% (2) 3.8% (3)
*Recommendeddoses usedwere: CodeineI mg/kg every 3-4 hr; Hyclrocodone0.2 mg/kg every3-4 hr; Acetaminophen10-15 mg/kg every4 hr.
tuted a less potent analgesic). Sixteen parents (19%) administered doses at or below the lower limits of the prescribed dose range, and two parents (2%) administered doses in excess of the dose ordered. Only 9% (8/84) of the parents administered analgesics at the prescribed dose and maximum frequency prescribed. Of note, three parents (3.6%) did not administer any analgesics to their child. Seventy-seven percent of the parents stated that pain relief after administration of the analgesic was adequate. Parents of 11 children (13%) reported that the analgesic(s) provided inadequate pain relief and seven parents (8%) were unsure about the amount of pain relief their child experienced. Six of the parents who reported inadequate pain relief contacted their physician to request stronger pain medication. Table4. Typeand Amountof AnalgesicAdminisl~d in He 24 HoursAfter Tonsillectomy Analgesicadministeredby parents None Acetaminophenwith codeine Acetaminophenwith hydrocodone Acetaminophen Acetaminophenwith codeine + acetaminophen Acetaminophenwith codeine+ ibupro~n Percentageof maximum24 hour doseorderedthat was actuallyadministered 0-10% 11-20% 21-30% 31-40% 41-50% 51-60% 61-70% 71-80% 81-90% 91-100% >100%
3.6% (31 82.0% (69) 2.4% (2) 3.6% (3) 6.0% I5) 2.4% 12)
5.1% (4) 7.6% (6) 10.0% (8) 15.2% (12) 19.0% (15) 1.3% 11) 15.2% (12) 1.3% (1) 12.6% (10) 11.4% (9) 1.3%(1)
Oral Intake/Emesis Parents reported that 45% of the children (38/84) were drinking well. However, 50% of the children (42/84) were only taking sips of clear liquids, and 5% (4/84) were not drinking at all, despite encouragement. Based on parental reports, pain associated with drinking was responsible for inadequate oral intake for all of these children. Children with higher pain intensity ratings drank significantly less than children with lower pain intensity scores (X2 = 3.1, p = .08). In addition, 8% of parents reported that concurrent complaints of nausea and/or emesis also contributed to reduced oral intake. Nearly one-third of the children experienced one or more episodes of emesis at home during the early postoperative period.
Sleep Parents reported that 56% of the children experienced a restless sleep and that 6% of the children did not sleep at all the night after surgery. Children with higher pain intensity ratings experienced more sleep disturbances (X2 = 8.24, p = .004) than children with pain intensity ratings of 0 or 1. Only eight of the 52 children who experienced some degree of sleep disturbance on the first postoperative night, experienced mild pain or no pain at all. History of previous hospitalization or surgery did not effect the occurrence of sleep disturbances.
Behavior Children with pain intensity ratings of 2 or 3 had significantly more behavioral changes (X 2 = 10.2, p = .001) than children with pain intensity ratings of 0 or 1. Parents reported that over half of the children were unusually quiet for the 24 hours after surgery. However, children with pain intensity ratings ranging from moderate to severe (i.e., 2 to 3), showed the most prominent behavioral changes ranging from "fussy, crying on occasion, but still attempting to participate in routine activity or play" to "extremely irritable or inconsolable, and unable to engage in any form of distraction." The child's past history of previous surgery or hospitalization did not influence the reported behavioral changes.
Bleeding None of the children experienced significant episodes of bleeding within the first 24 hours after the surgery, Only two of the parents (2.4%) reported that their child had occasional streaks of blood in their saliva, that resolved spontaneously.
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SUI-rERS AND MIASKOWSKI
DISCUSSION The results of this study, using parental reports, show that after tonsillectomy children experience moderate to severe pain that is undertreated. In addition, children with higher pain intensity scores experienced more sleep disturbances, poorer oral intake, and more behavioral changes during the first 24 hours after surgery. Parental ratings of pain intensity following tonsillectomy are consistent with previously published reports (Brodsky et al., 1993; Gedaly-Duff & Ziebarth, 1994). However, all of these studies, including our own, have relied on parental perception of their children's pain intensity. Additional research is warranted that incorporates children's self-report of pain intensity. Children's self-report ratings and parental ratings could be compared to provide a more accurate description of the pain experience after tonsillectomy. One of the major contributions of this study is an analysis of the type and amount of analgesics administered by parents. Parents gave their children significantly less analgesics than prescribed', despite pain intensity reports ranging from mild to severe. However, even if parents administered the maximum dose at the most frequent interval prescribed, adequate analgesia may not have been achieved, given that 93.7% of the doses prescribed were already subtherapeutic. Factors that may have contributed to parental undertreatment of their children's pain include: (1) parental expectations regarding the amount of pain associated with tonsillectomy; (2) fears of overdosage, overuse, and/or addiction; (3) difficulties encountered with administration of the analgesic (e.g., lack of cooperation by the child); (4) lack of knowledge about the analgesics prescribed and concerns about potential side effects (e.g., nausea); and (5) parental expectations about acceptable levels of pain or pain relief. Additional research is warranted to determine what factors influence parents decisions about administering analgesics and ways to insure optimal pain management for children recovering from surgery at home. Additional physician education is also imperative to ensure that the recommended doses of analgesics for pediatric patients are prescribed. The majority of parents reported adequate pain relief for their children after analgesic administration. However, while children may have experienced some temporary pain relief, this effect may not have been sustained in view of the relatively high overall pain intensity reports. Reluctance to contact the physician may be related to parental
expectations about pain and pain relief and parental perceptions of what constitutes an acceptable level of pain. Prescribed analgesic doses were subtherapeutic for the majority of children. In addition, these drugs were underused by the parents. Therefore, it is difficult to evaluate the efficacy of acetaminophen with codeine in the management of posttonsillectomy pain in children. However, anecdotal parental comments about the adverse effects experienced by some children (e.g., pain on swallowing the medication and gastric upset) suggest that the side effects experienced by the children after administration of acetaminophen with codeine may have deterred parents' continued usage of the analgesic. Although acetaminophen with codeine is advocated as the drug of choice, alternative analgesics with less aversive side effects may be more acceptable and efficacious. Therefore, a critical evaluation of the optimal analgesics for use after tonsillectomy in children is warranted. A small number of parents acknowledged that they were unsure if their child experienced adequate pain relief after analgesic administration. This finding suggests that some parents may not be aware of what cues to rely on in assessing their children's pain, thus impairing their ability to evaluate their children's pain experience and response to pain relief interventions. Further research could evaluate whether teaching parents to assess their children's pain using a self-report measure would influence their analgesic administration practices. Finally, children with higher pain intensity scores experienced significantly more deleterious effects (i.e., poor oral fluid intake, sleep disturbances, behavioral changes, and emesis) in the first 24 hours after surgery. The fact that children with lower pain intensity ratings experienced less deleterious effects suggests that better pain relief improves pain outcomes and recovery from surgery. A prospective trial comparing a prescribed analgesic regimen with standard parental care during the first 24 hours after surgery would provide confirmatory evidence that proactive postoperative pain control improves recovery. Children whose worst pain was of moderate to severe intensity showed the most significant sleep disturbances. These data suggest that children's worst pain may have occurred at night. Although the time of day that analgesics were administered was not evaluated, it is possible that children may not have received analgesics during the night. This finding emphasizes the significance of educating
PAIN MANAGEMENT OF CHILDRENAT HOME
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parents regarding the importance of around-theclock analgesic dosing during the first 24 hours after surgery, even if it means arousing the child briefly during the night to administer a dose of pain medication. Based on these findings, additional parental
instruction in home management of children's pain is warranted to address the severity of pain associated with the surgical procedure, the need for scheduled administration of analgesics at therapeutic doses, signs and symptoms of pain, and what to do if relief is inadequate.
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