Assessment of Pain Intensity among Preschool-age Children during Venipuncture

Introduction

Children are not outlandish with pain; in fact, it is a part of their lives. They experience it during vaccination and venipuncture in the early days of their births and even common diseases in their childhood. Irrespective of this universality of pain, it is yet a complex and multidimensional experience that is hard to clearly define and even more troubling when trying to understand what pain is among children (Ebrahimpour, Pashaeypoor, Salisu, Cheraghi&Hosseini, 2019).

According to Becker, Navratilova, Nees, and Van Damme (2018), and the International Association of the Study of Pain [IASP] (2020), pain is much more than the conscious perception of a sensory event. It is aversive and inseparably linked to emotion as reflected in the generally accepted definition of pain as "an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage".

Emerging evidence from a recent study by Levy and Mills (2018) emphasized that pain is considered the fifth vital sign. In the same context, Pancekauskaitė and Jankauskaitė (2018) pointed out that pediatric pain and its assessment and management are challenging for health care professionals. Pediatric procedural pain is often underestimated and neglected because of various myths, beliefs, and difficulties in its evaluation and treatment. It is known that neonates and children can feel pain and that it has long-term effects that last through childhood into adulthood.

Pain is a substantial source of distress for hospitalized children, family caregivers, and healthcare providers alike. Pain in children can be produced from physical damage, disease process, invasive procedures, and other unknown factors (Amponsah et al., 2020). Several previous studies have shown that children's common source of pain comes from medical procedures and nursing, such as immunization and venipuncture (Thrane, Wanless, Cohen &Danford, 2016). Uncontrolled pain also has a direct impact on health outcomes and more than a few effects on all areas of life (Kahsay, 2017).

Venipuncture is a recurrently performed needle-related procedure, is one of the most alarming experiences and a common source of moderate to severe pain among children. Venipuncture is a devastating medical, emotional, and physical problem for both pediatric patients and their families (Walther-Larsen et al., 2017). Painful, invasive procedures are disturbing - for many children, worse than the disease itself. The seemingly endless barrage of needle sticks frightens children and tears at the heart of parents, who are unable to guard their children against them. One can assume that the prick of a needle will hurt anyone, it is quite clear that there are significant differences between children in how they respond to noxious stimuli (Karlsson, Rydstrom, Enskar&Englund, 2014).

Meentken, Beynum, Legerstee, Helbing and Utens, (2017) documented that hospitalized children undergo multiple, cyclic procedures such as venipuncture throughout their treatment course, and many describe such procedures as the most distressing part of their hospitalization.  Management of pain is a basic need and precise of all children; effective pain management requires health professionals, including pediatric nurses, is eager to try many interventions to achieve optimal results.

Bukola and Paula, (2017); El Geziry, Toble, Al Kadhi, Pervaiz, and Al Nobani, (2018) emphasized that unrelieved continuing pain may have untoward effects on children's health, functional abilities, and quality of life. Appropriately managing the pain from vein punctures is associated with shorter hospital stays and lower hospital costs. Freedom from pain is the right of children and must be considered in nursing practice. Pain-reducing methods are grouped into two categories pharmacological and non-pharmacological interventions or both (as integrative medicine). Non-pharmacological measures categorized into biophysical interventions like massage, acupuncture, and transcutaneous electrical nerve stimulation (TENS), and heat and cold therapy, behavioral-cognitive strategies such as distraction, relaxation, play, guided imagery, therapeutic touch, biofeedback, thought stopping, positive self-talk. Alotaibi, Higgins, Day and Chan, (2018) documented that the mitigation of suffering is one of the four fundamentals of nursing care. The pain must be detected before it can be alleviated, and the assessment of pain is an essential part of nurses' responsibilities.

Significance of the Study

Despite the up warding evidence on pain management and the accessibility of evidence-based clinical guidelines, pain in children is still inadequately treated. This can be attributed to a lack of knowledge among health professionals, misconceptions among children and their families, or lack of guidelines (Thrane et al., 2016).

Through empirical observations and experiences as a clinical instructor in the pediatric care units, it was noticed that many children who are scheduled for venipuncture for blood sampling are exposed to varying intensity of pain. Based on the literature review, preschool-age children were selected to participate in the current study because they are among the most affected age groups in the hospital. They have worries about the anticipation of the painful procedures, fear of bodily injury from mutilation, bodily intrusion, body image changes, disability, or even death. As well they perceive painful procedure as a punishment for misdeeds.

Effective procedural pain management is essential to ensure adherence to the increased number of painful procedures required for health maintenance in pediatric patients and to create a cooperative and trusting relationship between health care providers, children, and their families. Finally, most pain can be either prevented, treated, or at least reduced using inexpensive techniques. Despite this, most children in our hospitals do not receive adequate treatment. Thus; the aim of the current study was to assess pain intensity among preschool children during venipuncture.  Ultimately, the results of the current study might generate attention and motivation and evidence-base for further researches in the field of pediatric pain as well as providing guidance and recommendations that should be reflected in pediatric nursing education and practice.

Aim of the Study

The aim of the current study was to assess pain intensity among preschool children during venipuncture

Research question: -

• What is the level of pain intensity among preschool-age children during venipuncture?
• What are the factors affecting the level of pain intensity among preschool-age children during venipuncture?

Research design: -

A descriptive research design was utilized to achieve the aim of the current study. Descriptive research seeks to provide an accurate description of observations of phenomena (Grove & Gray, 2018). This design helps describe a situation or an event in knowing the level of pain intensity among preschool-age children during venipuncture.

Sample: -

The study sample consisted of all available preschool-age children undergoing venipuncture procedures over six months (the total number was 60 children) who admitted to the pediatric medical unit at Minia University Hospital for Obstetrics and Pediatrics (MUHOP).

Inclusion criteria:

• Children aged 3-6 years.
• Children exposing to peripheral venipuncture (blood sampling) without interventions to decrease pain during puncture.

Setting: -

The current study was conducted in the pediatric medical unit on the fourth floor at Minia University Hospital for Obstetric and Pediatric (MUHOP).

Data Collection Tools:

The following three tools were used to collect the required data: -

Tool I: A structured interview questionnaire in the Arabic language was designed by the researcher after reviewing the related literature and consists of 19 questions. It divided into two parts:

Part 1: - Personal and social characteristics of children as age, gender, rank, place of residence, mothers' age, and occupation.

Part 2: - It involved 13 questions, five questions related to the child's medical history, such as diagnosis, history of previous hospitalization, causes, and the number of prior hospitalization admissions. Also, it comprised five questions about past painful experiences that the child exposed to it. The mothers of children have answered these questions as previous painful events, factors that increase the child's pain, factors that decrease the child's pain, and the sites of the past pain. This part included three questions related to the venipuncture site, such as the site of venipuncture, numbers of vein penetration, and the place where the venipuncture took place.

Tool II: - Wong-Baker Faces Pain Rating Scale, developed by Wong and Baker (1983). It was a self-report pain scale to assess pain intensity in children aged 3 to 7 years. Each child was asked to choose the face that best described the intensity of the pain being experienced. Each face was rated by number to determine the intensity of pain, which (0-10) coding as the following: (Face 0 = No hurt, Face 2 = Hurts a little bit, Face 4 = Hurts a little more, Face 6 = Hurts, even more, Face 8 = Hurt whole lot and Face 10 = Hurts worst). These faces were assigned scores from 0 to 10, with a higher score indicating a higher severity of pain. According to a study in the Kingdom of Saudi Arabia, conducted by Alalo, Ahmad, and El Sayed (2016) to identify pain intensity after an ice pack application prior to venipuncture among 50 school-age children that modify the scoring system of Wong-Baker Faces Pain Rating Scale to become score 0 referred to no pain, score two referred to mild pain, score 4-6 referred to moderate pain and score 8-10 referred to sever pain. Apart from being acceptable and straightforward, this scale had a high test-retest reliability and content validity. The scale had high reliability with a Cronbach's alpha coefficient of 0.70, as tested by Drendel, Kelly, and Ali (2011). The scale is available online without copyright restrictions.

Tool III: - The Children's Hospital of Eastern Ontario Pain Scale (CHEOPS): Developed by McGrath et al. (1985). The scale can be used to monitor the effectiveness of interventions for reducing pain and discomfort. A behavioral observation scale will be used to rate a child's intensity of pain on six verbal and motor behaviors. Each behavior was assigned a value according to the following criteria, 0 (behavior that is the antithesis of pain), 1 (behavior that not indicative of pain, but not the antithesis of pain), two behavior indicating mild to moderate pain), and 3 (behavior indicative of severe pain). The total score for the tool ranges from 4-13; a score higher than 4 indicates pain.  Concerning the reliability of the scale, Suraseranivongse et al. (2001) tested the scale reliability and it was 0.80, which was considered acceptable. CHEOPS is available online without copyright restrictions.

Validity:

The content validity of the data collection tool (1) was examined by three experts who were affiliated to the Faculty of Nursing, Minia, and Assuit University at the Pediatric Nursing Department. The tool was examined for content coverage, clarity, relevance, applicability, wording. Based on experts` comments and recommendations, minor modifications had been made, such as rephrasing and rearrangements of some sentences.

Pilot Study: -                   

The pilot study was conducted on six children who met the inclusion criteria to investigate and ensure the feasibility, objectivity, applicability, clarity, and adequacy, and to determine possible problems in the methodological approach or tools. The results of the pilot study were used to test the proposed statistical and data analysis methods. The tools were completed without difficulty. Children who participated in the pilot study were included in the total sample of the current study.

Ethical Considerations:

Written approval was obtained from the Research Ethics Committee at the Faculty of Nursing, Minia University. Written permission was granted from the director of MUHOP and the chairpersons of the pediatric medical units after explaining the aim and nature of the study. The written informed consent was obtained from the mothers of children after a complete description of the study's aim and nature to gain their acceptance and cooperation. Children and their mothers were informed that contribution to the study was voluntary. The researcher also informed the mothers and preschool children about their rights to withdraw from the study at any time without giving any cause and without any effect on the care of their children. Confidentiality was secured for each mother and her child, where they assured that the study was harmless, and all the gathered data used for the research purpose only.

Procedure

Before the venipuncture procedure: -

The researcher gave the mothers and their children a clear and simple explanation of the aim and the content of the sheet; reassuring them that the procedure is safe, and invited them to participate and written informed consent was obtained from mothers. The researcher interviewed the children and their mothers individually to collect data related to the characteristics of children who met the inclusion criteria using (tool 1) the interview took place in the beside area of the medical unit where venipuncture for blood samples taken. After explaining the purpose and during the interview the researcher explained the first pain assessment scales (Wong-Baker Faces Pain Rating Scale) and the second pain scale (CHEOPS) taught each child about how to use the scale. The time for the interview took about 30-35 minutes for each child. The procedure was discussed with the responsible nurse to gain her cooperation and to save time and effort

During venipuncture: -

Only a usual venipuncture done by the assigned nurse based on physician written order. During the venipuncture procedure, the researcher assessed and documented the child's pain intensity using the behavioral observation scale (CHEOPS). Immediately after the venipuncture, each child was asked to choose the face that describes his intensity of pain based on Wong-Baker Faces Pain Rating Scale. Data collection was conducted over 6 months extending from March 2019 till August 2019.

Statistical Analysis

The collected data was coded, categorized, tabulated, and analyzed using the Statistical Package for Social Science (SPSS 20.0). Descriptive statistics in the form of frequencies, percentages for the qualitative variables, mean and standard deviation for the quantitative variables was used. Chi square was used to test the association between two Qualitative variables. Spearman's rank correlation was used to assess the interrelationships among the quantitative variables. Graphs were done for data visualization using Microsoft Excel. The P - value of ≤ 0.05 indicates a significant result while, P value of > 0.05 indicates a non-significant result.

Results:

Table (1): Percentage Distribution of the Studied Children According to Their Personal and Social Data (n=60).

Table (1) presented the personal data pertinent to children and their mothers who participated in the current study. More than one-third (36.6%) of children's age ranged from 5<6 years, and their mean age was 4.6 ± .9 years. Besides, 43.3% of them ranked as the second child, 60% were male, and 40% were female.  The highest percentage (70%) of the mothers was not read and write, and 85.0% of them were housewives.

Table (2): Percentage Distribution of the Studied Children According to Their Medical History (N=60).

Table (2) pointed out that 36.7% of the studied children diagnosed with diarrhea, vomiting, and dehydration, followed by diabetes (20%). The majority (80%) of the studies children had acute health problems. More than half (55%) of children had previous hospital admissions, and 51.5% were admitted to the hospital for the first time. The mean of prior hospital admission was 1.5 ± .6 times, and 81.8 % from children admitted at the hospital for an emergency health problem.

Table (3): Percentage Distribution of the Studied Children According to Their Previous Painful Experience (n=60).

# More than one answer was responded

Table (3) revealed that all (100%) of the studied children had previous painful experiences, and 80% of them suffered from abdominal pain. The majority of children (91.7%) went to sleep and rest as home measures to relieve their pain, and 41.7% of them felt comfort in a semi-sitting position. The mother's presence and playing with other children were the main things that reduced pain in the hospital, as replied by 100% and 55% respectively of the studied children.

Figure (1): Percentage Distribution of Venipuncture Site among the Studied Children (n=60)

Figure (1) demonstrated that 66.7% of children had venipuncture in the dorsal hand veins whereas 33.3% had venipuncture in the forearm veins.

Figure (2): Pain Intensity during Venipuncture among the Studied Children According to Wong-Baker Faces Pain Rating Scale (n=60)

Figure (2) showed that the highest percentage (60%) of the children suffering from severe pain intensity during the venipuncture while 40%. of them suffering from moderate pain intensity during the venipuncture according to Wong-Baker Faces Pain Rating Scale.

Table (4): Children's Hospital of Eastern Ontario Pain Scale among the Studied Children during Venipuncture (n=60).

Table (4) demonstrated that 50% of the studied children reacted by moaning during venipuncture. Seventy percent of them showed face grimacing. Concerning the verbal items of CHEOPS, 58.3% of the studied children complained about pain, and about other things. In relation to torso items of CHEOPS, 43.3% of children watched restrained. It was found that 43.3% of children their touch was restricted during venipuncture. Relating to the legs element of CHEOPS 40% of the studied preschool-age children their legs showed kneeling.

Table (5): Total Mean Score of Faces Pain Rating Scale and CHEOPS during Venipuncture among the Studied Children (n=60).

Table (5) evident that the total mean score ± SD of the faces pain rating scale among children during venipuncture was 7.2 ± 2.2 while The total mean score ± SD of CHEOPS among children was 12.2 ± .75.

Table (6): Correlational Matrix between Children's Age and the Total Mean Scores of CHEOPS, Wong-Baker Faces Pain Rating Scale during Venipuncture (n=60).

*Statistically significant differences

Table (6) illustrated that there were statistically significant negative correlations between children's age and the total mean score of the CHEOPS and Face Pain Rating Scale during venipuncture (r=-.490, P=<.0001 & r=-.30, P=<0.05 respectively), and the other personal data of the studied children has no effect of their intensity of pain during the venipuncture procedure.