This topical review presents the current challenges in defining chronic pain in infants, summarizes evidence from animal and human infant studies regarding the biological processes necessary for chronic pain signaling, and presents observational/experiential evidence from clinical experts. A literature search of four databases (CINAHL, EMBASE, PsycINFO, and MEDLINE) was conducted, along with hand searches of reference lists. Evidence from animal studies suggest that important neurophysiological mechanisms, such as the availability of key neurotransmitters needed for maintenance of chronic pain, may be immature or absent in the developing neonate. In some cases, human infants may be significantly less likely to develop chronic pain. However, evidence also points to altered pain perception, such as allodynia and hyperalgesia, with significant injury. Moreover, clinicians and parents in pediatric intensive care settings describe groups of infants with altered behavioral responses to repeated or prolonged painful stimuli, yet agreement on a working definition of chronic pain in infancy remains elusive. While our understanding of infant chronic pain is still in the rudimentary stages, a promising avenue for the future assessment of chronic pain in infancy would be to develop a clinical tool that uses both neurophysiological approaches and clinical perceptions already presented in the literature.
To conduct a systematic review of the interrelationships between children's coping responses, children's coping outcomes, and parent variables during needle-related procedures. A systematic literature search was conducted. It was required that the study examined a painful needle-related procedure in children from 3 to 12 years of age, and included a children's coping response, a children's coping outcome, and a parent variable. In all, 6,081 articles were retrieved to review against inclusion criteria. Twenty studies were included. Parent coping-promoting behaviors and distress-promoting behaviors enacted in combination are the most consistent predictors of optimal children's coping responses, and less optimal children's coping outcomes, respectively. Additional key findings are presented. Children's coping with needle-related procedures is a complex process involving a variety of different dimensions that interact in unison. Parents play an important role in this process. Future researchers are encouraged to disentangle coping responses from coping outcomes when exploring this dynamic process.
The aim of this study was to examine the concurrent and predictive relations between healthy toddlers' pain behavior and cardiac indicators (ie, heart rate [HR] and respiratory sinus arrhythmia [RSA]) during routine vaccinations. Caregiver–infant dyads were part of a longitudinal cohort observed during their 12- and 18-month vaccinations. Behavioral and cardiac data were simultaneously collected for 1-minute preneedle and 3-minutes postneedle. Videotapes were coded for pain behaviors (FLACC; Merkel et al., 1997), and cardiac data were analyzed (HR, RSA) during sequential 30-second epochs. Four separate cross-lagged path models were estimated using data from the 12- (n = 147) and 18-month (n = 122) vaccinations. Across 12- and 18-month vaccinations, predictive within-measure relations were consistent for FLACC, HR, and RSA, reflecting good stability of these pain indicators. Behavioral indicators predicted subsequent HR and RSA within the immediate postneedle period. Both baseline behavior and HR/RSA predicted future pain scores. Concurrent residual relations between behavioral and cardiac indicators were inconsistent across time and indicators. Results suggest that behavioral and cardiac indicators reflect unique aspects of the nociceptive response. As such, multimodal assessment tools should be used and contextualized by child age, cardiac indicator, baseline behavior/physiology, and pain phase.
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Highlights NFCS and MBPS coding systems were examined using Confirmatory Factor Analysis. A revised 3-item NFCS maintained good psychometric properties of 7-item version. Redefinition of MBPS with cry as a sole indicator was suggested. The revised scales increase efficiency of coding based on improved psychometrics.
AbstractDiverse behavioural cues have been proposed to be useful cues in infant pain assessment, but there is a paucity of evidence based on formal psychometric evaluation to establish their validity for this purpose. We aimed to examine two widely-used coding systems, the Neonatal Facial Coding System (NFCS) and the Modified Behaviour Pain Scale (MBPS), by examining their factor structures with confirmatory factor analysis using a large archival dataset. The results indicated that an item-reduced NFCS scale with three items produced a one-factor pain model that maintained the good psychometric properties of the 7-item scale. In addition, it was found that MBPS also has challenging internal consistency, with items that are both weakly correlated and highly redundant. One-item of the MBPS may be able to capture the construct of pain equally well or potentially improve its psychometric properties. Redefinition of MBPS with cry as a sole indicator was suggested. This analysis provides two new iterations of the NFCS and MBPS that improve construct validity and internal consistency. These shorter versions also improve the feasibility of both measures and increase their potential for clinical use as less time is required for their administration.Perspective: This article presents new iterations of the NFCS and MBPS scales. These revised measures improve the internal consistency of the measures, feasibility of use of the tools in research settings and the efficiency of the coding process. The revised tools could also improve the feasibility of coding within clinical settings.
Distress regulation can be defined as one's ability to modulate emotions and behaviors in order to recover from distressing events and return to homeostasis (Kopp, 1989; Thompson, 2011). The dynamic and complex nature of distress regulation has been highlighted in infancy and toddlerhood and involves sequencing expressed emotion, regulatory strategies, and biology (Ekas, Braungart-Rieker, & Messinger, 2018). Toddlerhood is a critical developmental phase to examine the multidimensional nature of distress regulation because it encompasses the transition from passive caregiver-directed regulation to more active and purposeful self-regulation (Kopp, 1989). Also, many abilities and important systems that are involved in the experience and expression of emotions are established in toddlerhood, leading to some of the greatest developmental changes in emotion regulation and emotion regulation skills (Ekas et al., 2018; Kahle, Miller, Helm, & Hastings, 2018). Most empirical work on the underlying physiological components of distress regulation in toddlerhood highlights the maturation of the autonomic nervous system as fundamental in
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