Pain management for pediatric tonsillectomy: an integrative review through the perioperative and home experience.

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Journal for Specialists in Pediatric Nursing

REVIEW

Pain management for pediatric tonsillectomy: An integrative review through the perioperative and home experience Dekeisha Howard, Katherine Finn Davis, Eileen Phillips, Eileen Ryan, Deborah Scalford, Regina Flynn-Roth, and Elizabeth Ely Dekeisha Howard, RN, MSN, is a Nurse Manager, Cardiac Stepdown/PACU, Nemours/Alfred I. duPont Hospital for Children, Wilmington, Delaware; Katherine Finn Davis, PhD, RN, CPNP, is a Nurse Researcher; Eileen Phillips, RN, BSN, is a Clinical Level III Nurse; Eileen Ryan, RN, MSN, CRNP, is an Anesthesia Nurse Practitioner; Deborah Scalford, RN, MSN, is a Clinical Supervisor; Regina Flynn-Roth, RN, MSN, CPAN, is an Education Nurse Specialist; and Elizabeth Ely, PhD, RN, is a Nurse Researcher, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA

Search terms Pain, pain management, pediatric, postoperative pain, review, tonsillectomy. Author contact [email protected], with a copy to the Editor: [email protected] Disclosure: The authors report no actual or potential conﬂicts of interest. Elizabeth Ely serves on JSPN’s editorial board. Submissions from members of the journal’s editorial staff or editorial board receive double-blind peer review. Journal staff and editorial board members are not assigned to the review of or make decisions on manuscripts for which they are listed as authors.

Abstract Purpose. This integrative review aims to increase our understanding of current pain management care practices for children undergoing tonsillectomy. Conclusions. Synthesis of the literature resulted in four main opportunities for care providers to manage pain: preoperative education and preparation, intraoperative surgical interventions, and postoperative pharmacologic and nonpharmacologic interventions in the post anesthesia care unit and home settings. Practice Implications. Nurses have many opportunities to understand pain management practices and intervene to minimize pain experienced in pediatric outpatients undergoing tonsillectomy.

First Received December 20, 2012; Final revision received June 21, 2013; Accepted for publication June 30, 2013. doi: 10.1111/jspn.12048

The under-treatment of pediatric pain has been widely researched but continues to be a concern for healthcare professionals and patients. Tonsillectomy, with or without adenoidectomy, is a common pediatric surgery associated with a moderate to high level of pain postoperatively. As large numbers of children have this surgery annually, it is valuable to understand what pain management practices are available and supported by current evidence in the literature. Therefore, the purpose of this integrative literature review is to summarize the current evidence for pain management options and identify strategies that pediatric nurses can utilize when caring for children who have undergone tonsillectomy. Pain management strategies encompass family involvement since children undergoing Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

uncomplicated surgery are usually discharged home to the care of their parents within hours following the procedure. BACKGROUND AND SIGNIFICANCE

Tonsillectomy is one of the most common surgical procedures in the United States, with more than half a million procedures performed each year in children younger than 15 years (Baugh et al., 2011). Tonsillectomy is also associated with moderate to high complaints of pain immediately postoperatively and for the first few days following surgery (Baugh et al., 2011; Helgadóttir & Wilson, 2004; Pop, Manworren, Guzzetta, & Hynan, 2007; Warnock & Lander, 1998; Wiggins & Foster, 2007). 5

Pain Management for Pediatric Tonsillectomy: An Integrative Review Through the Perioperative and Home Experience

Children and their parents endorse that a tonsillectomy is one of the most painful “minor” surgeries of childhood. Furthermore, children have more pain after tonsillectomy as compared to other types of outpatient surgeries (Finley, McGrath, Forward, McNeill, & Fitzgerald, 1996; Kotiniemi et al., 1997). Since tonsillectomy is a very common surgery associated with moderate to severe pain, a thorough understanding of pain management best practices both pre- and post-tonsillectomy is crucial. To improve postoperative pain, nurses must recognize the importance of pain and pain management (Pop et al., 2007; Simons & Moseley, 2009). However, adequate pain control can be challenging to achieve as nurses often underestimate children’s pain after tonsillectomy. Despite advances in pain management, studies show that children’s pain is often undertreated (Helgadóttir & Wilson, 2004), and hospitalized children often receive analgesics in subtherapeutic doses and at less than optimal intervals (Wilson & Helgadóttir, 2006). Clearly, a comprehensive understanding of pain and pain management is a critical first step. SEARCH STRATEGY

An extensive search of the literature utilizing multiple terms was conducted on pain management practices in children undergoing tonsillectomy. Online databases searched included PubMed, MEDLINE, and CINAHL. The Cochrane Database of Systematic Reviews, American Academy of Pediatrics, the Association of Operating Room Nurses, and the American Society of PeriAnesthesia Nurses Internet sites were also searched for additional guidelines and evidence. To assure that this review contained the most up-to-date information, the search was limited to include only evidence published between 2005 and 2012, unless they were seminal articles. When a search using any one of the search terms yielded a high number of results, two search terms were combined to help limit the search and find the most relevant articles. Databases were searched using database-specific search term suggestions when offered. The review of literature was limited to the English language and excluded all abstracts. Relevant key words used to search the databases included the following: adenotonsillectomy, anxiety, distress, induction, pain, pain management, pain management plan, parental presence, postoperative pain, preoperative preparation, tonsil, and tonsillectomy. To ensure a complete search, each of these terms and their synonyms were entered into the search indi6

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vidually as well as in combination (where appropriate). To obtain a broader understanding regarding nonpharmacologic pain management interventions, the search was expanded to include general postoperative pediatric patients. All searches were age limited to birth to 18 years of age to capture the typical pediatric population. The literature search yielded approximately 80 articles related to preoperative, intraoperative, postoperative, and home-based pain management. Additionally, the references from each article were reviewed for supplementary articles not previously found. Articles were excluded if the population was primarily adult (>18 years old). All article abstracts were reviewed by two study authors, first to determine whether the articles met inclusion criteria (e.g., describing perioperative management of pain in children post-tonsillectomy). Ultimately, 51 articles were identified as pertinent and were included in this integrative literature review. After identifying the appropriate articles to include, the literature was evaluated using the Johns Hopkins Nursing evidence appraisal system (Newhouse, Dearholt, Poe, Puch, & White, 2007). Each article underwent an independent review by one of the authors. Any disagreements or questions in the critiques were resolved by a subset of authors reviewing the article and reaching consensus. The strength of evidence ranged from Level I (highest) to Level V (lowest). Approximately 40% of the articles were meta-analyses of randomized controlled trials (RCT) or RCTs (Level I), and the remaining articles were quasi-experimental, nonexperimental, or qualitative studies, literature reviews, or expert opinions (Levels II–V; see Table 1). INTEGRATIVE REVIEW OF THE LITERATURE Preoperative variables

Nurses have the unique opportunity to interact with patients prior to surgery, which offers the opportunity to prepare and begin to educate the child and family. Preoperative variables that have the potential to impact pain experienced by children are: the anxiety/pain link, type of preoperative education and preparation, use of preoperative medications, and parental presence for induction of anesthesia. The anxiety/pain link. Discussions of pain must address the concept that pain and anxiety are closely linked and clearly described as influencing each other (Kain, Mayes, Caldwell-Andrews, Karas, & Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

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Table 1. Summary of Articles Included in the Integrative Review Author/year Preoperative Brewer and colleagues (2006) Chundamala and colleagues (2009) Fortier, Chorney, and colleagues (2009) Kain and colleagues (2000) Kain and colleagues (2006) Kain and colleagues (2007) Klemetti and colleagues (2009) Logan and Rose (2005) Uman and colleagues (2008) Visintainer and Wolfer (1975) Intraoperative Atef and Fawaz (2008) Burton and Doree (2007)

Cushing and colleagues (2009) Engelhardt and colleagues (2003) Gemma and colleagues (2009) Grainger and Saravanappa (2008) Hollis and colleagues (1999) Mohamed and colleagues (2009) Pinder and colleagues (2011) Steward and colleagues (2011) Postoperative PACU Baugh and colleagues (2011)a Carlson (2009) Crandall and colleagues (2009) Fortier and colleagues (2010) Hadden and colleagues (2011) He and colleagues (2005) He and colleagues (2010)

Sample

LOE

Conclusion

142 children, 5–11 years old Evidence-based review of 14 studies, 1,775 parents and children 143 children, 7–17 years old 103 children, 2–8 years old

I

Preoperative preparation by child life therapists decreased postoperative anxiety measured in PACU. Parental presence was comparable to midazolam in managing anxiety for the child undergoing outpatient surgery (including tonsillectomy). Distraction techniques should be considered. Children wanted information about pain preoperatively; higher anxiety was related to higher need for information. Addition of PPIA to midazolam did not incrementally reduce child’s anxiety, but parents were more satisfied and less anxious when present for induction. Preoperative anxiety linked with more painful postoperative recovery.

241 children, 5–12 years old 262 children, 2–10 years old 116 children, 4–10 years old 65 children, 12–18 years old 28 RCTs 1,990 children 2–19 years old 84 children, 3–12 years old

III

III I III III I III

14.1% of children do not benefit from midazolam; nonresponders were younger (4.2 vs. 5.9 years), more anxious, and had higher emotionality scores at baseline. Face-to-face preparation by nurses was more effective than standard of care in decreasing pain scores in the PACU. Children who anticipate more postoperative pain experience more postoperative pain.

I

Certain nonpharmacologic interventions (distraction, hypnosis, cognitive-behavioral) for procedural pain and distress are effective. Highlights the pain/anxiety link.

I

Systematic preparation, rehearsal, and supportive care prior to stressful procedures significantly reduced distress.

40 children, 3–10 years old 9 RCTs 833 adults & children 1–64 years old 114 patients, 6–47 years old 20 children, 2–14 years old

I I

Tramadol infiltrated appears to be an effective method of analgesia. Insufficient evidence to conclude coblation is associated with less pain and bleeding.

I I

No significant pain differences between monopolar cautery and harmonic scalpel surgical techniques. Tramadol has similar analgesic effects as morphine post tonsillectomy.

60 children, 3–7 years old

I

Peritonsillar infiltration with ropivacaine did not provide major pain reduction.

13 RCTs 777 adults and children 6 RCTs 284 adults and children 150 children, 2–12 years old 2 RCTs 254 children and adults 19 RCTs 1,756 children 9 months–18 years old

I

Topical anesthetics provide similar levels of analgesia as infiltrated, but less side effects.

I

No evidence that use of local anesthetics improved postoperative pain.

I I

Preoperative dexamethasone IV combined with glossopharyngeal nerve block decreased pain post tonsillectomy. No method of tonsillectomy is superior in morbidity outcomes.

I

Single dose of IV dexamethasone reduces tonsillectomy morbidity.

Clinical practice guideline

IV

Provides evidence-based pain management guidelines for clinicians.

443 postoperative nurses

III


III

261 children, 2–12 years old 102 children, 2–17 years old 187 nurses 108 nurses

III

Nurses were aware of evidence-based postoperative pain assessment but did not consistently use in practice. Children’s tonsillectomy experience and outcome was affected by time, previous experience, age, and anxiety. Identifying and treating anxiety for parents and children can help prevent negative postoperative outcomes. Children having tonsillectomy experience significant pain.

Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

III III II

Various nonpharmacologic methods were used, but more education and use is needed. Educational intervention had positive effect on nurses’ use of nonpharmacologic methods.

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Table 1. Continued Author/year

Sample

LOE

Conclusion

Helgadóttir & Wilson, (2004)a Idvall and colleagues (2005) Kamerling and colleagues (2008) Pop and colleagues (2007) Simons and Moseley (2009) Smith and colleagues (2009) Wiggins and Foster (2007)

68 child/parent dyads 3–7 years old 6 child/parent dyads 7–18 years old Parental visitation in pediatric PACU setting 92 children, 3–8 years old 175 children, 7–12 years old 178 children, 7–12 years old 38 children, 4–18 years old

III III

Temperament affects child’s perception of pain and parent report of child’s pain behaviors. Children perceived nonpharmacologic measures as a helpful adjunct to treat pain.

V

Expedient parent visitation in PACU has beneficial effects on postoperative recovery.

III III

Patients all received adequate pain control, but dosing was individualized. Nurses’ pain assessment and management practices can be inadequate.

III

No difference in PACU length of stay between two analgesic protocols.

III

Wilson and Helgadóttir (2006)a Postoperative home Bean-Lijewski and colleagues (2007) Chambers and colleagues (2003)


III

Children were in significant pain while at home but received only half of the prescribed pain medication doses. Children received inadequate pain management both in hospital and at home.


I

51 children, 7–12 years old 107 children, 2–6 years old and their caregivers 110 children, 7–12 years old and their caregivers 6 RCTs 528 participants (397 children) 2 studies 75 and 28 children, 7–12 years old 261 children, 2–12 years old 132 children, 2–12 years old 80 children, 6–15 years oldb

III

Chambers and colleagues (1996) Fedorowicz and colleagues (2011) Finley and colleagues (2003) Fortier, Chorney, and colleagues (2009) Rony and colleagues (2010) Sutters and colleagues (2004)

Sutters and colleagues (2007) Sutters and colleagues (2010) Sutters and colleagues (2011) Sutters and colleagues (2012) Unsworth and colleagues (2007) von Baeyer and colleagues (2011) Warnock and Lander (1998) Wiggins (2009)

III I

NSAIDs (rofecoxib) reduce pain scores compared to acetaminophen with hydrocodone. The Parents’ Postoperative Pain Measure (PPPM) has strong psychometric properties when used with parents of children ages 2–12 years old. PPPM has strong psychometric properties and is related to child self-report of pain in the home setting. Lidocaine spray is more effective at reducing pain severity short-term than a placebo.

III

Further evidence to support the specificity and sensitivity of the PPPM to measure postoperative tonsillectomy pain in the home setting.

III

Despite high pain ratings, low doses of analgesics were given by parents at home.

III

Parents did not dose children according to their pain scores.

I

Children in the 2 of 3 groups with ATC dosing received significantly more analgesic medication than those in the PRN dosing group. Nurse coaching provided no additional benefit than did ATC dosing. Adequate pain control was not achieved in any of the 3 groups. Children reported having more pain than they anticipated; nonpharmacologic pain reduction methods also helpful. Scheduled dosing of acetaminophen and hydrocodone is more effective than as-needed dosing; nurse coaching did not increase compliance with scheduled dosing. A specific educational program for parents regarding pain management at home with tools such as diaries and timers leads to improved pain outcomes. Acetaminophen with hydrocodone is effective in relieving postoperative pain; parents miss scheduled doses by postoperative day 3. Providing parents with the Wong–Baker Faces pain scale to assess pain at home did not affect parental analgesic administration. Evidence for preliminary psychometric strength of the PPPM—Short Form.

I

80 children, 6–15 years oldb 113 children, 6–15 years old 193 children, 6–15 years oldc 47 children, 3–5 years old

III


I

264 children, 7–12 years old 129 children, 5–16 years old 13 children, 12–18 years old

III

I I

III I

Tonsillectomy causes substantial pain up to 7 days and if poorly managed leads to increased use of healthcare services. ATC pain medication administration did not improve pain outcomes over usual care; education and support are needed by families at home.

Note: ATC, around the clock; LOE, level of evidence; I = experimental study/randomized controlled trial (RCT) or meta-analysis of RCT; II = quasiexperimental study; III = non-experimental study, qualitative study, or meta synthesis; IV = opinion of nationally recognized experts based on research evidence or expert consensus panel (systematic review, clinical practice guideline); V = opinion of individual expert based on non-research evidence (i.e., case studies, literature reviews, organizational experience; Newhouse et al., 2007); PPIA, parental presence for induction of anesthesia; PACU, postanesthesia care unit. aThese references are also included in the postoperative home section; bThe study participants are the same; cThis study combines the

participants from Sutters and colleagues (2004, 2010).

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McClain, 2006; Uman, Chambers, McGrath, & Kisely, 2008). Further support for the anxiety/pain link preoperatively was provided when researchers documented that children ranked anticipatory anxiety about pain issues as a major concern before surgery (Fortier, Chorney, et al., 2009). One largescale pediatric study examined school-age children and concluded that children with higher preoperative anxiety had significantly higher pain scores postoperatively (Kain et al., 2006). The authors postulated that decreasing anxiety in children preoperatively may result in improved postoperative outcomes. The concept of pain as a self-fulfilling prophecy has been discussed in the pediatric literature. Adolescents with high levels of psychological distress and anxiety about their impending surgery experienced more postoperative pain (Logan & Rose, 2005). Other highly ranked areas of anticipatory anxiety in addition to pain were fear of needles, concern about waking up during surgery, and not having their parents accessible (Fortier, Chorney, et al., 2009). Preoperative education/preparation. Given the association between preoperative anxiety and pain outcomes, how can nurses best prepare children and families for their perioperative experience and potentially decrease anxiety and subsequent pain? Psychological preparation for pediatric surgical patients and their families was identified as important more than 30 years ago (Visintainer & Wolfer, 1975). Preoperative preparation can be provided by nurses or child life specialists (CLSs) who are professionals trained in child development and work with children to alleviate the anxiety that accompanies illness and hospital procedures. A study comparing preparation by CLSs and standard preoperative admission teaching by pediatric nurses suggested a collaborative approach between nursing and CLSs to improve outcomes and lessen anxiety (Brewer, Gleditsch, Syblik, Tietjens, & Vacik, 2006). When nurses or CLSs are not available, educational materials are often mailed, accessed online, or provided via phone. When this type of educational preparation is offered, children and families do not have the opportunity to interact and ask questions. Personal review of preoperative information was found to be superior to standard phone/written information in improving pain ratings (Klemetti et al., 2009). Similarly, an interactive preoperative program which included video, pamphlets, mask practice, and telephone coaching by healthcare providers resulted in less analgesic use (Kain et al., 2006). Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

Preoperative medications. Pharmacologic agents are widely used to decrease preoperative anxiety and potentially impact postoperative pain. The most commonly used anxiolytic is oral or intravenous midazolam (Kain et al., 2007). Of concern are children who experience paradoxical reactions, are allergic to midazolam, or do not have the expected response. One study documented that 14.1% of children did not respond to midazolam despite adequate serum drug levels (Kain et al., 2007). These children were younger, rated preoperatively as more anxious, and had higher emotionality scores. Children intolerant of anxiolytics are often considered candidates for alternative interventions including parental presence for induction. Parental presence for induction of anesthesia. The use and effectiveness of parental presence for induction of anesthesia (PPIA) in decreasing preoperative anxiety and potentially the associated postoperative pain is a concept recently examined in the literature. Although parents and healthcare providers might expect that parental presence extending into the operating room would be an effective intervention, a recent systematic review that included 14 studies, nine of which were RCTs, did not support PPIA as decreasing anxiety for children (Chundamala, Wright, & Kemp, 2009). However, one trial, which found PPIA to be no more effective than midazolam in decreasing children’s anxiety, found parental anxiety after separation was lower and overall satisfaction with the perioperative experience was higher (Kain et al., 2000). These authors suggest family preoperative education/ preparation programs and distraction techniques should be explored as alternative interventions that can be implemented by perioperative nurses. While there might not be direct support for PPIA in lieu of sedative medications for decreasing preoperative anxiety in children based on the existing evidence, clinical experience and support of family-centered care principles provides guidance that decisions about PPIA need to be individualized. Studies designed to ask both children and their parents about their desires and expectations regarding parental support in this setting need to be conducted. Intraoperative variables

Advances in intraoperative surgical interventions have been shown to improve outcomes around postoperative tonsillectomy pain (Cushing, Smith, Chiodo, Elmasri, & Munro-Peck, 2009). Dissection 9


and cautery are two common surgical techniques. However, Cochrane reviews report that despite a multitude of various techniques and studies, there is inadequate evidence to recommend one surgical technique to significantly decrease morbidity and pain outcomes (Burton & Doree, 2007; Pinder, Wilson, & Hilton, 2011). Although nurses do not directly provide intraoperative pain management interventions, understanding how these interventions may affect pain outcomes postoperatively is important. Intraoperatively, medications can be given intravenously, topically, or infiltrated into the peritonsillar bed to decrease pain following surgery. Intravenous tramadol provided similar analgesic effects as morphine with less side effects (Engelhardt, Steel, Johnston, & Veitch, 2003), and intravenous dexamethasone diminished postoperative pain and morbidity (Mohamed, Ibraheem, & Abdelraheem, 2009; Steward, Grisel, & Meinzen-Derr, 2011). Recent evidence, including a Cochrane review, concluded that there is no evidence that either infiltrated or topical local anesthetics to the peritonsillar bed improve postoperative pain (Gemma, Piccioni, Gioia, Beretta, & Bussi, 2009; Hollis, Burton, & Millar, 1999). However, a recent RCT showed that significant pain reduction can be achieved with the use of topical tramadol versus placebo (Atef & Fawaz, 2008). Additionally, a systematic review concluded that topical and/or infiltrated local analgesics such as ropivicaine, bupivicaine, lidocaine, and adrenaline provide a reduction in pain postoperatively; however, topical administration was preferable since similar levels of analgesia were achieved with fewer adverse effects (Grainger & Saravanappa, 2008). Therefore, the evidence supporting the effectiveness of local anesthetics is mixed. Postoperative care in the PACU

Pain management is one of the highest priorities in the postanesthesia care unit (PACU), secondary only to maintaining sufficient respiratory function. Adequate pain management in the immediate postoperative period is essential to providing comfort and insuring satisfactory oral intake to prevent dehydration and other surgical complications (Hadden, Burke, Skotcher, & Voepel-Lewis, 2011). Upon PACU admission, accurate assessment of pain, including frequency of reassessment and use of developmentally appropriate pain scales, is critical (Simons & Moseley, 2009). Children depend upon nurses and their parents for pain reduction interventions. When assessing postop10

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erative pain, self-report is the acknowledged gold standard; however, children are not always able to verbalize their pain concerns. Issues include heightened anxiety, altered sensorium making it difficult to self-report pain, and a potentially frightening environment (e.g., face masks; Fortier, Rosario, Martin, & Kain, 2010; Pop et al., 2007). As children cannot always take an active role in their pain management, it is imperative that nurses have a better understanding and knowledge of pain assessment and relief options. An integral role of nursing is the assessment, management, and education of patients and families regarding pain. However, nurses often do not assess children’s pain effectively despite reporting awareness of evidence-based pain assessment practices (Carlson, 2009). Reasons cited are: individual nurse’s clinical judgment of pain intensity, inappropriate pain management evaluation (i.e., focusing on medication dose vs. pain score), and misconceptions regarding opioid pain medicine (i.e., fear of addiction, respiratory depression; Idvall, Holm, & Runeson, 2005; Pop et al., 2007; Wiggins & Foster, 2007; Wilson & Helgadóttir, 2006). Notably, nurses attributed higher pain scores and were more likely to administer analgesics to children who were more vocal about their pain (Helgadóttir & Wilson, 2004). Pharmacologic. PACU nurses must consider the appropriate therapy needed including both pharmacologic and nonpharmacologic therapies (He et al., 2010). Pharmacologic intervention with intravenous and/or oral opioids is required to effectively treat either self-reported or nurse-assessed moderate to severe pain (Helgadóttir & Wilson, 2004). The most common intravenous opioids used are morphine and fentanyl, which have been found equally effective in terms of pain relief and length of stay even when used in combination (Smith, Newcomb, Sundberg, & Shaffer, 2009). Children need more than acetaminophen alone for adequate pain control after tonsillectomy (Wilson & Helgadóttir, 2006). How much more is a common question. One study examined five analgesic treatments—fentanyl alone, fentanyl with an oral opioid; morphine alone, morphine with an oral opioid, and use of oral opioid alone (acetaminophen with codeine or hydrocodone)—and found all participants achieved adequate pain control and there were no considerable differences in pain scores between treatment groups (Pop et al., 2007). This suggests that acetaminophen plus an opioid may provide sufficient pain relief. Non-opioid pharmacologic interventions are also available. The use of steroids can reduce nausea and Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

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vomiting, a common postsurgical occurrence and a side effect of opioids, and swelling, thereby potentially reducing the pain associated with these symptoms (Baugh et al., 2011). Medication choices, therefore, should be individualized considering all factors because there has been no ideal class of medication or dosing frequency proven to manage pain (Baugh et al., 2011). Continuing education is recommended to help nurses manage pain with appropriate, safe administration of pharmacologic agents of all types and frequent reassessments (Wilson & Helgadóttir, 2006). Nonpharmacologic. Nonpharmacologic measures to treat postoperative pain are an important adjunct therapy that nurses can initiate and control without medical orders. Common nonpharmacologic methods to assist in pain relief are for parents to be present, provide effective distraction techniques, and offer cold foods (Idvall et al., 2005). Nurses from other cultures also frequently use nonpharmacologic interventions such as preparatory information, comforting/reassurance, comfortable environment, distraction, and positioning (He, Pölkki, Vehviläinen-Julkunen, & Pietilä, 2005). Although an educational intervention had a positive effect on nurses’ use of these therapies; many barriers, such as ongoing knowledge deficit stemming from the need for ongoing education and hands-on sessions to reinforce teaching, can prohibit consistent use of these therapies (He et al., 2010). Therefore, understanding of nonpharmacologic interventions by both nurses and caregivers is an important step in pain management post-tonsillectomy. In pediatrics, the focus is on family-centered care. Traditionally, parents were not allowed into the PACU due to patient acuity, quick turnover, and possible adverse effects of anesthesia. However, through education and promotion of the practice, an increase in visitation and earlier reunion of parent and child can happen (Kamerling, Lawler, Lynch, & Schwartz, 2008). As anxiety is an influencing factor contributing to pain intensity, promoting parental presence may help decrease anxiety and consequently reduce pain (Crandall, Lammers, Senders, & Braun, 2009). Parental presence is valuable, although preparation is necessary for it to be a positive experience for both parent and child. Postoperative care at home

Recognition and management of pain following hospital discharge, often only a few hours after Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

surgery, becomes the responsibility of the parent. Thus, good communication between PACU nurses and parents regarding home pain management is crucial. To provide a tool to assist parents with this, Chambers and colleagues developed a parent postoperative pain measurement (PPPM) scale (Chambers, Reid, McGrath, & Finley, 1996). Reliability and validity of the 15-item scale has been established with a population of children ages 6–12 years (Chambers et al., 1996; Finley, Chambers, McGrath, & Walsh, 2003). More recently, the group further tested the original PPPM measure and established the use of the scale for children ages 2–6 years and their parents, again following adenotonsillectomy (Chambers, Finley, McGrath, & Walsh, 2003). The PPPM assists parents in monitoring pain-specific behavioral cues over time in the home setting and has been shown to improve pain management through increasing appropriate medication administration. Further refinement of the measure was reported to reduce the measure from 15 to 10 items thereby creating a similar zero to 10 metric as is commonly used in patient-reported pain assessment scales (von Baeyer, Chambers, & Eakins, 2011). This newer PPPM short form was tested with children ages 7–12 years using previously obtained data from 264 children and will need to be tested in younger children before replacing the PPPM for that population. Unsworth, Franck, and Choonara (2007) conducted an RCT with the parents of 88 children (72 completed the study) undergoing elective tonsillectomy to determine if parents who were taught to use a pediatric pain assessment tool (the Wong–Baker Faces scale) would regularly assess their child’s pain and provide analgesia based on that assessment. No differences were found by the group on the parental administration of pain medication. The authors concluded that the use of a self-report pain scale may not improve postoperative pain management at home. Pharmacologic. Moderate to severe posttonsillectomy pain peaks at 48 to 72 h after surgery and can last up to 2 weeks (Fortier, MacLaren, Martin, Perret-Karimi, & Kain, 2009; Wilson & Helgadóttir, 2006); therefore, parents need to have a good understanding of pain expectations and control measures. However, there are still many unknowns regarding children’s pain management at home, their pain experiences, expectations, evaluations, and what measures are the most effective in relieving pain (Sutters et al., 2004, 2007; Wiggins, 11


2009). Research does show good pain relief with acetaminophen with codeine or hydrocodone in either scheduled or as needed (PRN) doses (Sutters et al., 2007, 2012). However, the recent black box warning by the Food and Drug Administration calls this practice into question. Despite interventions to increase doses of analgesia (i.e., around-the-clock alarms), pain intensity remained the same for the first 2 days following surgery. Additionally, increased pain intensity over time and ear pain continued to be a frustration for both the parent and the child (Wiggins, 2009). A recent RCT suggests that scheduled administration of acetaminophen with hydrocodone reduced children’s pain in the first 3 days postoperatively as compared to PRN dosing. This difference was seen despite whether nurse coaching had occurred (Sutters et al., 2010). Analgesic use decreased despite continued pain severity related to fears of dependence, unrecognized pain symptoms, and belief that pain medications should be a last resort (Fortier, Chorney, et al., 2009). Limited evidence for nonsteroidal anti-inflammatory drugs (NSAIDs) exists with an RCT reporting significant improvement in pain relief with swallowing with the use of rofecoxib as compared to acetaminophen with hydrocodone (Bean-Lijewski, Kruitbosch, Hutchinson, & Browne, 2007). Education, which parents receive through the entire perioperative process, is critical for a successful recovery. Parent education should begin early in the preoperative period and be reinforced in the PACU before discharge for optimal results in treating pain and preventing complications (Warnock & Lander, 1998). Children are often under-medicated by parents at home, leading to increased unscheduled medical visits (Fortier, Chorney, et al., 2009). Sufficient doses of medication are often not administered at home indicating a need for improved teaching (Rony, Fortier, Chorney, Perret, & Kain, 2010). Recommendations include that nurses instruct parents to give their children medication for the first 48 h around the clock (Helgadóttir & Wilson, 2004). Additionally, research suggests that with careful education from perioperative nurses about pain management at home, a program including written materials on around-the-clock dosing and use of a timer, increase parental adherence to an analgesic regimen (Sutters, Savedra, & Miaskowski, 2011). The pediatric PRO-SELF© program, developed and tested by Sutters and colleagues (2011), provides support for the ongoing need to capture and maximize learning needs of parents throughout the perioperative experience with home management 12

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follow-up. Coaching, demonstrating, and discussing pain assessment, medication administration, and the use and purpose of specific pain management techniques in the moment with parents’ presence may enhance parents’ abilities to continue to use these techniques at home. Recent guidelines reinforced the expedient treatment of pain for the first few days postoperatively as most beneficial (Baugh et al., 2011). Parents provide this pain management and so need the tools to do so effectively. Nonpharmacologic. Many of the aforementioned nonpharmacologic interventions implemented in the PACU setting are also useful at home. Additionally, cognitive behavioral pain management techniques such as music, imagery, and computer/video games assist with distraction (Wiggins, 2009). Post surgery, children report the following therapies as being helpful: eating soft or cold foods (i.e., popsicles), drinking a lot, not talking too much, cold packs, comforting from their parents, distraction, relaxing/resting/sleep, and positioning (Idvall et al., 2005; Sutters et al., 2007). A Cochrane review suggests additional research is necessary to confirm if there are any effective pain relief outcomes from the use of either nonpharmacologic or pharmacologic oral rinses, mouthwashes, and sprays (Fedorowicz, Al-Muharraqi, Nasser, Al-Harthy, & Carter, 2011). CONCLUSIONS AND IMPLICATIONS

The purpose of this integrative review was to increase nurses’ understanding of current pain management care practices for children undergoing tonsillectomy. Nurses must have adequate understanding of evidence-based pain interventions and the ability to implement those interventions. Five opportunities for nurses to be knowledgeable about and intervene in pain management are: (a) adequate preoperative/postoperative education and preparation for the parent and child, (b) intraoperative techniques and pain management interventions, (c) appropriate postoperative pain assessment, (d) pharmacologic and nonpharmacologic treatment in the PACU and home setting, and (e) partnering with children and caregivers to support them through this very painful surgery. Family involvement throughout the perioperative period is critical. This integrative review suggests education and preparation are important and may impact the pain and anxiety experienced by children undergoing tonsillectomy. The concepts of anxiety and pain are interrelated and nurses should Journal for Specialists in Pediatric Nursing 19 (2014) 5–16 © 2013, Wiley Periodicals, Inc.

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acknowledge the association and individualize the child and family’s care and interventions. Knowledge of pertinent intraoperative variables can influence postoperative pain management choices. Postoperatively, pain can be managed with medications while concurrently utilizing nonpharmacologic strategies and involving parents. At home, parental education regarding appropriate medication dosing, hydration, and continued nonpharmacologic strategies is key to achieving optimal pain management. Although tonsillectomy is one of the most common and painful childhood surgeries, we have limited evidence for many of the interventions discussed here. Additional research is needed to determine the best approaches to pain management throughout the perioperative period. Research examining the interrelationships between anxiety and pain would provide nurses with helpful information to target highly anxious children to potentially affect their pain outcomes. While evidence does exist that lessening anxiety decreases selfreported pain, a causal link between anxiety and physical pain has not been substantiated. Optimal methods of preoperative preparation strategies also need to be tested. Additional research is needed regarding intraoperative and postoperative medication administration in terms of optimal combinations, route, and frequency of dosing. Parents’ understanding and adherence with optimal postoperative pharmacologic pain management at home continues to be a challenge, indicating research into this area would be very informative.

How might this information affect nursing practice?

The implications for practice are plentiful as nurses are the main contact for the patient and family throughout the perioperative experience. Nurses should fully understand and embrace pain management opportunities and patient/family education. Understanding of pain management is crucial to enhancing implementation of both pharmacologic and nonpharmacologic interventions at each opportunity (pre, intra-, postoperatively, and at home). Nurses are critical to the successful pain management post-tonsillectomy both in the hospital and at home; keeping in mind that although each child responds differently to pain, every child deserves appropriate assessment and pain relief interventions.


Every interaction with patients and families should be viewed as an opportunity to educate, explore the individual child’s pain management needs, and deliver the best possible pain control. Providing education to parents of the child’s perspective of pain management and relief efforts will prepare the family for anticipated responses and give them a toolkit of options that will work best for the management of their child’s pain. Preoperatively, the use of videos, phone preparation, and tours has shown a link to decrease in medication usage. An understanding of surgical techniques can provide a foundation to parents when educating about postoperative pain. In the postoperative recovery period, nurses’ discussion with parents about the use of the commonly used pharmacologic and nonpharmacologic techniques become important to engage them in the understanding of care necessary at home. This includes the specific use of home diaries, around-the-clock timers, rest/ distraction, cold liquids/food and/or ice packs, video games, or other nonpharmacologic interventions they find useful based on their child’s individual coping needs. With any pain management tool or intervention used at home, parent education regarding its use must be provided along with follow-up with parents via phone or electronic media to answer their home pain management questions and provide valuable guidance. Nurses are truly the key to a successful postoperative pain management outcome for children undergoing tonsillectomy. They work collaboratively with the family to have a clear understanding and help guide the child and family through the perioperative process, preparing them along the way as to what to expect in terms of pain and how to appropriately manage that pain using both pharmacologic and nonpharmacologic methods.

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