The measurement properties of pediatric observational pain scales: A systematic review of reviews

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Abstract

Background

Valid observational pain scales are needed to assess pain and ensure sufficient treatment of pain in children that lack the verbal ability to self-report pain. Published reviews attempt to synthesize results from primary studies validating these scales and based on the findings recommendations may be given, for example which pain scales are the most appropriate for use in different pediatric populations.

Objectives

The aims of this review were to describe how systematic reviews have evaluated and recommended observational pain scales for use in children aged 0–18 years and appraise the evidence underlying these recommendations.

Design

Systematic review of reviews.

Data sources

The Cochrane Library, PubMed/MEDLINE, CINAHL, Web of Science, and PsychINFO were searched from inception to September 2016. Reference lists and gray literature were searched for additional studies.

Review methods

Study selection and data extraction were performed by two reviewers independently with a disagreement procedure in place. Methodological quality or study validity was measured using the Assessment of Multiple Systematic Reviews checklist and risk of bias or internal validity was measured using the Risk of Bias in Systematic Reviews tool. The review protocol was registered with PROSPERO: registration number CRD42016035264.

Results

Twelve reviews met the inclusion criteria. Together; they included 65 different observational pain scales for use in children, of which 28 were recommended at least once. Face, Legs, Activity, Cry, Consolability/revised version of Face, Legs, Activity, Cry, Consolability, COMFORT/COMFORT behavioral scale and Children’s Hospital of Eastern Ontario Pain Scale were evaluated and recommended most frequently. Few of the included reviews assessed the methodological quality of the studies included in the review. The narrative analysis consisted mostly of a reiteration of the results from the primary studies. In general, more recent reviews showed a lower risk of bias than older ones.

Conclusions

Included reviews exhibited low quality of evidence; thus, their recommendations regarding pain scales for use in clinical practice or research with children that lack the verbal ability to self-report pain should be interpreted with caution.

Section snippets

What is already known about the topic?

  • The implementation and use of structured pain scales are considered the foundation for effective management of pain

  • Children that lack the verbal or cognitive ability to self-report pain are at increased risk for suffering untreated pain and a large number of observational scales to assess pain in these children have been published over the last 30 years

What this paper adds

  • There is no clear consensus regarding which scales to use; although the Face, Legs, Activity, Cry, Consolability/revised version of Face, Legs, Activity, Cry, Consolability, COMFORT/COMFORT behavioral scale and Children’s Hospital of Eastern Ontario Pain Scale were recommended most frequently, 28 of the 65 evaluated scales were recommended at least once

  • These recommendations should be interpreted with caution due to the high or uncertain risk of bias and corresponding low evidence in the reviews

Design

This systematic review was conducted according to PRISMA guidelines (Liberati et al., 2009) and the review protocol has been registered with PROSPERO, registration number CRD42016035264.

Data sources and search strategy

The Cochrane Library, PubMed/MEDLINE, CINAHL, Web of Science, and PsychINFO were searched from inception to November 2015 and the search updated last in September 2016. No language or time limitations were applied. Search terms described the population (children from birth to 18 years of age), type of study

Identification and selection of reviews

All articles identified through database and complementary searches (n = 1739) were imported to EndNote. After duplicates (n = 105) were removed, 1532 articles were excluded based on title and abstract, and 102 full texts were retrieved and screened. Following the predefined eligibility criteria, 13 full texts describing 12 systematic reviews (Bai and Jiang, 2015, Bennett et al., 2009, Crellin et al., 2007, Crellin et al., 2015, Dorfman et al., 2014, Duhn and Medves, 2004, Ely et al., 2012,

Discussion

Together, the 12 reviews evaluated 65 different observational pain scales and 28 of these were recommended at least once. The FLACC/rFLACC, COMFORT/COMFORT behavioral scale and CHEOPS were recommended most frequently. Few of these reviews assessed the methodological quality of the included studies. None attempted a meta-analysis of data regarding measurement properties, and the narrative analysis was limited and consisted mostly of a reiteration of the results of the studies included in them.

Conclusions

The recommendations regarding observational pain scales for use in clinical practice or research with children vary widely across published reviews, have low evidence, and should be interpreted with caution.

There may be several reasons for these disappointing results. One is the state of the science, including the lack of a common terminology and understanding of measurement properties; few published methods to assess the methodological quality of validation studies and measurement properties

Conflicts of interest

None declared.

Acknowledgements

The authors would like to express their gratitude to the clinical health librarians at the university library of the Karolinska Institutet for their help in developing the search strategy, and to Liana Albuquerque da Silva and Ana Claudia Vieira for help in screening articles written in Portuguese. RDA is a trainee member of Pain in Child Health (PICH), a strategic research training initiative of the Canadian Institutes of Health Research.

This research did not receive any specific grant from

References (55)

  • M. Van Dijk et al.

    The reliability and validity of the COMFORT scale as a postoperative pain instrument in 0 to 3-year-old infants

    Pain

    (2000)
  • C.L. von Baeyer et al.

    Systematic review of observational (behavioral) measures of pain for children and adolescents aged 3 to 18 years

    Pain

    (2007)
  • P. Whiting et al.

    ROBIS: A new tool to assess risk of bias in systematic reviews was developed

    J. Clin. Epidemiol.

    (2016)
  • B. Ambuel et al.

    Assessing distress in pediatric intensive care environments: the COMFORT scale

    J. Pediatr. Psychol.

    (1992)
  • M. Bennett et al.

    The Recognition and Assessment of Acute Pain in Children. Update of Full Guideline

    (2009)
  • B.U. Burda et al.

    Limitations of a measurement tool to assess systematic reviews (AMSTAR) and suggestions for improvement

    Syst. Rev.

    (2016)
  • J.M. Chorney et al.

    Behavioural measures of pain

  • L.L. Cohen et al.

    Introduction to special issue: evidence-based assessment in pediatric psychology

    J. Pediatr. Psychol.

    (2008)
  • M. Connelly et al.

    Predictors of postoperative pain trajectories in adolescent idiopathic scoliosis

    Spine (Phila Pa 1976)

    (2014)
  • H. Cooper

    Research Synthesis and Meta-analysis: A Step by Step Approach

    (2010)
  • D. Crellin et al.

    Analysis of the validation of existing behavioral pain and distress scales for use in the procedural setting

    Paediatr. Anaesth.

    (2007)
  • D.J. Crellin et al.

    Systematic Review of the FLACC scale for assessing pain in infants and children: is it reliable, valid, and feasible for use?

    Pain

    (2015)
  • A.L. Drendel et al.

    Pain assessment for children: overcoming challenges and optimizing care

    Pediatr. Emerg. Care

    (2011)
  • L.J. Duhn et al.

    A systematic integrative review of infant pain assessment tools

    Adv. Neonatal Care

    (2004)
  • C.M. Faggion

    Critical appraisal of AMSTAR: challenges, limitations, and potential solutions from the perspective of an assessor

    BMC Med. Res. Methodol.

    (2015)
  • L.S. Franck et al.

    Putting pain assessment into practice: why is it so painful?

    Pain Res. Manag.

    (2009)
  • J.P.T. Higgins et al.

    Cochrane Handbook for Systematic Reviews of Interventions [eBook]. Vol. 5.1.0 [updated 2011]

    (March 2011)
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