Introduction

Pain, defined as the sensory perception of subjective discomfort experienced by all human beings, is a common reason for consultation and its management has become a parameter of quality of care. Surgical pain is traumatic and causes stress in any individual. However, in children, the magnitude of pain is even greater due to their lack of verbal and cognitive skills to communicate their pain (1).

Assessing the magnitude of pain in pediatrics is not easy, and in very young children, it represents a real diagnostic challenge. Patient-physician communication can be limited and depends largely on the subjective perception of parents and caregivers, who are the ones who know the child best and can report changes in the patient that are indicative of pain (2,3).

Several attitudinal barriers have been identified that hinder adequate pain management, both among healthcare professionals and the general population (4-6).

A study by Kaminsky et al. identified significant differences in the perception of postoperative pain by children and their caregivers, which led to errors in analgesic management. Currently, the number of outpatient surgeries has increased significantly, and parents are responsible for recognizing and managing their children’s pain after hospital discharge (7).

Studies report that 35 % to 60 % of children undergoing various surgical procedures experience moderate to severe pain despite receiving analgesics in the postoperative period (8-11).

The most important goal of postoperative analgesia is pain relief. Pain control after surgery promotes proper feeding, rest, and mobility for the child. On the other hand, poor management can produce negative short-and long-term effects and increase morbidity and mortality. For this reason, it is important to have standardized scales and properly established therapeutic protocols that take into account the uniqueness of each patient (7,12-14).

Pain perception is a complex phenomenon to study. Factors such as anxiety, lack of familiarity with the procedure, and myths and beliefs that exist in the family environment play an important role. The importance of identifying these factors lies in developing individualized analgesic management plans tailored to each patient, type of intervention, and available resources (15-17).

As we witness the emergence of new and promising technologies such as artificial intelligence and virtual reality, research on the harmful impact of acute and/or chronic pain and its prevention remains a challenge for pediatric care (18).

Little is known in Latin America about such a central and determining topic in the quality of care for children and adolescents. Therefore, a study was designed to provide new information for clinical practice in pain management in patients undergoing outpatient surgical procedures.

Materials and methods

An analytical, descriptive, and cross-sectional study was conducted in a Pediatrics and Neonatology Department in the Autonomous City of Buenos Aires, Argentina. The service includes a pediatric inpatient ward, a pediatric intensive care unit, a long-term progressive care unit, and a day hospital. The latter has 5 beds for the admission of patients scheduled for short-stay surgeries (same-day surgery and discharge).

Caregivers of healthy children aged 1 to 15 years old who were admitted to the day hospital for their first scheduled surgery were included. Patients with underlying conditions that significantly affected their health, as well as those who had previously undergone a surgical procedure, were excluded from the study. The primary study variables correspond to the caregivers responses to the three questionnaires, while the secondary variables relate to the characterization of the population and type of surgery.

Each participant completed three validated questionnaires designed to assess preoperative pain perception, beliefs about analgesic medication, and postoperative pain perception. Participation was voluntary, and confidentiality was maintained at all times.

The first survey included questions from two instruments: the Parental Pain Expression Perceptions (PPEP) and the Medication Attitude Questionnaire (MAQ). This survey was administered before the surgical procedure. A second survey was developed based on the Parental Postoperative Pain Measure (PPPM) and was completed by telephone within 48 hours after hospital discharge.

The PPEP, developed by Dr. Zisk Rony, assesses parents’ knowledge and attitudes regarding children´s pain expression. It consists of 9 items rated on a 7-point Likert scale, where higher scores indicate greater misinformation among parents about pain (1).

The MAQ assesses parents’ attitudes toward the use of analgesic medications to treat children ‘s pain. It consists of 9 items exploring beliefs and knowledge related to analgesia (1).

The PPPM is an instrument used to measure the presence of postoperative pain. It has been validated in Spanish and has shown good reliability and validity for children aged 2 to 12 years. This scale helps identify behavioral changes in children that may indicate poor pain control.

Questionnaire comprehension was tested through a pilot study involving 25 caregivers who were not part of the main study.

Statistical analysis was performed using SPSS software, version 25. Variables were described using absolute and relative frequencies. All statistical tests were conducted with a 95 % confidence level and a significance level (α) of 0.05.

The study was approved by the Center for Basic and Applied Biomedical Studies and Development at Universidad Maimónides.

Results

A total of 146 caregivers met the inclusion criteria at the time of admission to the short-stay surgical center. Data for the study variables were obtained through the three questionnaires.

Follow-up was conducted by telephone 48 hours after hospital discharge, using the Spanish version of the PPPM. Of the 146 participants from the initial phase, 127 caregivers were successfully contacted. The loss of 19 participants (13 % of the initial sample) was due to unsuccessful contact attempts after three phone calls.

The average age of the patients was 6.95 years old, with a standard deviation of 3.81 and a range from 1 to 15 years old. Most of the patients were accompanied by their mothers, who were mainly either in a domestic partnership or married.

After gathering the population’s general characteristics, the PPEP and MAQ questionnaires were administered.

Responses to the PPEP questionnaire - Parents’ perceptions of pain expression. Table II shows the caregivers’ responses. It can be seen that 88.7 % of caregivers agreed that children always tell their parents when they are in pain, 84.2 % reported that children always express pain by complaining, and 82.6 % stated that children in pain have difficulty falling asleep. 62.3 % disagreed that children do not feel pain when they are calm. While 77.4 % disagreed that children experience less pain than adults, nearly a third of participants believed that children exaggerate pain, and 37.7 % said they complain of pain to receive care.

Responses to the MAQ questionnaire - Attitudes toward medication. Table III shows caregivers’ responses regarding the use of pain medication.

The most frequent surgical procedure was the resection of cysts or tumors (30.8 %), followed by tonsillectomy (26 %) and hernioplasty (18.5 %). Less frequent procedures included urological surgeries such as posthioplasty (13.7 %), orchidopexy (6.2 %), and frenulotomy (5.5 %).

Finally, 48 hours after hospital discharge, the last questionnaire, the PPPM, was administered via telephone. The results are summarized in Table IV, indicating that 67. 7% of caregivers reported increased crying, and 86.6 % denied that the children refused to eat.

Discussion

Pain, as well defined in the literature, is an unpleasant sensory and emotional experience related to damage to tissue integrity that activates various hormonal mechanisms. Surgery is a clear cause of pain (13,21,22).

A study was carried out to analyze caregivers’ perceptions of their interpretation of their children’s pain and their knowledge of commonly used medications. This study also assessed the children’s postoperative experience. In our sample, the patients were predominantly male (67.8 %), the main age group was children under 4 years old (16.4 %), and the caregiver who answered the questionnaire was primarily the child’s mother, similar to the results found in Kaminsky’s study, where the participants were predominantly male with a mean age of 6 years (7).

The PPEP questionnaire assessed parents’ perceptions of pain. We found that most caregivers believe that children express pain by crying, always let others know when they are in pain, and do so immediately. To a lesser extent, caregivers believe that a quiet child, such as a child who plays, is not in pain. These results contrast with those found in Dr. Zisk’s initial study, as parents reported that children do not always express pain immediately or by crying to their caregiver. In contrast, her study considered that a quiet or nonplaying child may be experiencing pain (1). Similar results were obtained by Desalegn et al. in Ethiopia, where 78 % of parents agreed that children express their pain by crying, and 76.6 % stated that children who play do not feel pain (23,24).

The MAQ questionnaire revealed a lack of knowledge among parents and caregivers about analgesic medication. 53.4 % were unaware of the medications’ adverse effects, 54.1 % were unaware of whether analgesic use predisposes to addiction, and 43.8 % were unaware of whether pain medication use predisposes children to substance abuse in adulthood. Furthermore, 69.9% of parents stated that the lowest possible dose of medication should be administered due to the risk of adverse effects, 68.5 % believed that analgesic medication should only be administered when the child is in pain, and 50.7 % maintained that pain medication serves to teach children to take medication responsibly. Similar results were reported in the Desalegn studies, where 21.7 % of parents had adequate knowledge about pain and only 17.3 % reported a positive attitude toward analgesic use. Parents who participated in this last study considered that the least amount of analgesics possible should be administered to avoid adverse effects and addictions (23,24).

Our results differ from those found in a Finnish study by Haamen et al., in which, while 69 % of parents surveyed expressed concern about the adverse effects of medication, 84 % stated that the prescribed medications are safe and effective (25).

The results obtained from the first two questionnaires are comparable to those found in a study carried out by Yu and Kim in Korea, where, in a sample of 124 children undergoing tonsillectomy, 87.9 % of parents perceived that their children communicate when they are in pain, while 60.5 % expressed concern about the adverse effects of medications (26).

Finally, the results gathered from the last questionnaire revealed that patients avoided touching or moving the surgical area and sought greater proximity to their caregivers during the postoperative period. Similarly, it was found that appetite was not affected postoperatively and that although they cried more than usual, the children retained their energy. These results are similar to those of the Chambers group, who reported that 59.3% of children avoided touching the painful area, 52.3 % played less than usual, and 50.9% had less energy than usual. Our results showed a higher proportion of parents who reported that their children sought their closeness more than usual
(61.4 % vs. 22.2 %) (27).

Although it is a small sample size in a single healthcare center, this research can represent a starting point for healthcare teams to work on raising awareness about the timely detection and adequate characterization of pain, as well as promoting the appropriate use of analgesics, especially in the postoperative context. The importance of conducting these research studies is to have more tools that allow us to transmit quality information to caregivers and thus achieve collaboration between the medical team and caregivers that facilitates ensuring that the postoperative period is not an event that negatively impacts the patient and their community.

Based on the results of this study, we are developing a comprehensive pain management program in the day hospital. The strategies selected for training healthcare personnel include the incorporation of pain assessment cards and workshops on the rational use of analgesic medication in children. Regarding caregiver awareness in pain assessment and management, informative talks for parents and audiovisual resources tailored to the type of surgery, age, and condition of the patient are provided (This information has been posted on the institution’s social media and websites for home consultation with any questions, and a telephone line has been set up for rapid response).

Conclusion

Parents’ and caregivers’ perceptions of pain and knowledge regarding postoperative analgesic management are limited. Lack of accurate information may pose a risk to patient recovery.

Long-term studies are needed to more accurately assess changes in caregivers’ perceptions of pain and analgesic use, as well as medical staff adherence to prescriptions.

Conflict of interest

None.

Funding

None.

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