Amy L. Drendel

Objectives: Compare child and parent text message reporting of pain outcomes following emergency department (ED) discharge. Methods: Children 8 to 17 years, discharged from the ED with long-bone fracture, whose parent was enrolled in the multicenter study to report their child's pain and function outcomes (R01HD091302) were enrolled in this single-center study between April 2021 and February 2022. Both respondents reported pain-related dysfunction (scale: 0 to 10), maximum pain (scale: 0 to 10), and medication dissatisfaction (scale: 1 to 4) for 7 days by text message. Average differences in outcomes between respondents were tested using a paired t-test and mixed models. Text response rate was evaluated. Results: Overall, 80 child-parent dyads were included, and 80% of children texted reports on at least 1 day, 74% for ≥3 days, and 45% for all 7 days. Parents’ overall response rate was 91% for at least 1 day, 80% for ≥3 days, and 44% for all 7 days. Compared to parents, child reports were not different for the child's dysfunction score (difference = 0.21 points, 95% CI: −0.03, 0.44; P-value = 0.086) but were higher for child's maximum pain score (0.31 points, 95% CI: 0.09, 0.52; P-value = 0.006) and dissatisfaction score (0.22, 95% CI: 0.15, 0.30; P-value = <0.001). Discussion: Children ages 8 to 17 years can report at-home pain experiences by text message at rates comparable to their parents. Children report significantly higher pain severity and dissatisfaction with pain medications, but dysfunction was similar compared to parent's report. Children and their parents can text message their at-home acute pain experiences after ED discharge.

Background: Procedural sedation is routinely provided for children in the emergency care setting. However, there are still significant gaps in knowledge regarding the optimal provision of sedation for children who are undergoing painful and/or distressing procedures. We aimed to develop a prioritised research agenda that identifies key questions for paediatric procedural sedation in the emergency care setting that will guide future research and optimise care for children. Methods: We used a modified Delphi approach to achieve consensus among a multidisciplinary and geographically diverse expert advisory group. An initial list of 42 research questions was identified, with successive rounds of questionnaires conducted until there was a convergence of opinion or a point of diminishing returns was reached. The list was iteratively refined each round by advisory group members who ranked research questions and were given the opportunity to provide suggestions for potential additional questions and provide feedback regarding questions considered. Results: 54 advisory group members participated in the modified Delphi approach. Over the course of two rounds, we identified 10 research questions as the highest priority for future investigation. These questions included topics addressing short- and long-term outcomes related to inadequate assessment and provision of sedation, patient-centered and family-centered outcomes, validity and reliability of clinically important outcome measures, most effective sedative regimens for children undergoing painful procedures, most effective sedative regimens for children undergoing non-painful procedures, most effective sedatives for minimal sedation/anxiolysis, effectiveness of novel sedation approaches, eliminating health disparities, clinician education and competency and the use of simulation to improve sedation outcomes. Conclusions: The 10 research questions identified as highest priority can inform future work by researchers, funders, policymakers and other key decision makers who aim to meaningfully advance the provision of procedural sedation for children cared for in the emergency care setting.

Introduction: Individual genetic variation may influence clinical effects for pain medications. Effects of CYP2C9, CYP3A4, and CYP2D6 polymorphisms on clinical effectiveness and safety for ibuprofen and oxycodone were studied. Objective: Primary objectives were to AU2 evaluate if allelic variations would affect clinical effectiveness and adverse events (AEs) occurrence. Methods: This pragmatic prospective, observational cohort included children aged 4 to 16 years who were seen in a pediatric emergency department with an acute fracture and prescribed ibuprofen or oxycodone for at-home pain management. Saliva samples were obtained for genotyping of allelic variants, and daily telephone follow-up was conducted for 3 days. Pain was measured using the Faces Pain Scale-Revised. Results: We included 210 children (n = 140 ibuprofen and n = 70 oxycodone); mean age was 11.1 (±SD 3.5) years, 33.8% were female. Median pain reduction on day 1 was similar between groups [ibuprofen 4 (IQR 2,4) and oxycodone 4 (IQR 2,6), P = 0.69]. Over the 3 days, the oxycodone group experienced more AE than the ibuprofen group (78.3% vs 53.2%, P < 0.001). Those with a CYP2C9*2 reduced function allele experienced less adverse events with ibuprofen compared with those with a normal functioning allele CYP2C9*1 (P = 0.003). Neither CYP3A4 variants nor CYP2D6 phenotype classification affected clinical effect or AE. Conclusion: Although pain relief was similar, children receiving oxycodone experienced more AE, overall, than those receiving ibuprofen. For children receiving ibuprofen or oxycodone, pain relief was not affected by genetic variations in CYP2C9 or CYP3A4/CYP2D6, respectively. For children receiving ibuprofen, the presence of CYP2C9*2 was associated with less adverse events.

Introduction: After discharge from the emergency department (ED), pain management challenges parents, who have been shown to undertreat their children’s pain. Our goal was to evaluate the effectiveness of a five-minute instructional video for parents on pain treatment in the home setting to address common misconceptions about home pediatric pain management. Methods: We conducted a randomized, single-blinded clinical trial of parents of children ages 1-18 years who presented with a painful condition, were evaluated, and were discharged home from a large, tertiary care pediatric ED. Parents were randomized to a pain management intervention video or an injury prevention control video. The primary outcome was the proportion of parents that gave their child pain medication at home after discharge. These data were recorded in a home pain diary and analyzed using the chi square test to determine significant difference. Parents’ knowledge about components of at-home pain treatment were tested before, immediately following, and two days after intervention. We used McNemar’s test statistic to compare incorrect pretest/correct post-test answers between intervention and control groups. Results: A total of 100 parents were enrolled: 59 parents watched the pain education video, and 41 the control video. Overall, 75% of parents completed follow-up, providing information about home medication use. Significantly more parents provided pain medication to their children after watching the educational video: 96% vs 80% (difference 16%; 95% CI 7.8-31.3%). Significantly more parents had correct pain treatment knowledge immediately following the educational video about pain scores (P = 0.04); the positive effects of analgesics (P <0.01); and pain medication misconceptions (P = 0.02). Most differences in knowledge remained two days after the video intervention. Conclusion: The five-minute educational video about home pain treatment viewed by parents in the ED prior to discharge significantly increased the proportion of children receiving pain medication at home as well as parents’ knowledge about at-home pain management.

Objective: This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS). Methods: A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure. Results: A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen’s κ, agreement for SPS and FPS-R was ‘fair’ for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and ‘poor’ for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had ‘fair’ agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed ‘poor’ agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R. Conclusion: The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

Introduction: Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018–2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019–2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. Methods: Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months–18 years old, emergency severity index score 2–5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. Results: We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. Conclusions: This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

In 2008, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) published a consensus statement that recognized the dearth of research surrounding the topic of children’s satisfaction with acute pain management. This review of published literature will summarize what is known about the topic of children’s satisfaction with pain management, identify current gaps in the knowledge, and provide direction for future research in this critical area. Including children in the decision-making process as soon as they are developmentally able is a concept that is the fundamental basis for seeking assent and more active roles within healthcare decisions for children. It is the responsibility of adults to provide them with increasing opportunities for self-evaluation and more independent management of their healthcare, encouraging the development of children into adults. As clinicians and researchers, it is our prerogative to support the maturation of children by building effective methods to communicate their satisfaction with acute pain treatment and healthcare. Children’s satisfaction with acute pain management is not well studied and further research is needed for the development of inclusive, developmentally appropriate measures of satisfaction for our pediatric patients.

Objective: To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. Design: A retrospective cohort study of pediatric ED visits in 2015. Setting: Four pediatric EDs. Subjects: Children aged four to 18 years with a long-bone fracture discharged from the ED. Methods: A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. Results: There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12–18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. Conclusions: For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.