Parents' Assessment of Earache Pain in Children May Be Unreliable

From Medscape Medical News

Laurie Barclay, MD

January 3, 2011 — Parents' assessment of earache pain in preverbal children with presumed acute otitis media (AOM) might be unreliable, according to the results of a study reported in the December 2010 issue of the Journal of Pain.

"In preverbal children, who constitute the majority of children with AOM, it is not clear how parents determine whether their child is having otalgia," write Nader Shaikh, MD, MPH, from the Division of General Academic Pediatrics, University of Pittsburgh School of Medicine in Pennsylvania, and colleagues. "Specifically, it is unclear which of the symptoms of AOM impacts parental pain assessment the most. Information regarding specific symptoms with high levels of association with otalgia can help clinicians focus their history taking."

The study goal was to assess how parents of preverbal children decide if their child is experiencing otalgia. The investigators wrote 8 case scenarios describing a 1-year-old child with AOM using various combinations of 6 observable behaviors: fussiness, ear tugging, eating less, fever, difficulty sleeping, and reduced play.

Using a visual analog scale, 69 parents of children with a history of AOM who attended an ambulatory clinic for well or sick visits were asked to score the pain level for each constructed case. Although each of the 6 observable behaviors was significantly associated with increased pain scores (P < .0001), ear tugging and fussiness had the greatest effect on the parents' pain ratings.

Factors associated with higher reported pain levels were higher level of parental education (P = .007) and private insurance (P = .001).

"Parents of preverbal children with acute otitis media use observable behaviors to determine their child's pain level," the study authors write. "Interpretation of symptoms, however, appears to be influenced by socioeconomic status. Thus, we question the utility of using a 1-item parental pain scale in clinical trials that include preverbal children."

Limitations of this study include the relatively small sample size and the homogeneous study population. The investigators also note that parents' responses to scenarios about a hypothetical child could have differed from their real-life responses to their own child.

"In the most recent guidelines on the measurement of pain in pediatric clinical trials, all pain measures recommended were multi-item scales: Use of global single-item scales for the measurement of pain in preverbal children was not endorsed," the study authors conclude. "In a clinical setting, we feel that asking parents about specific observable behaviors, such as ear tugging and fussiness, would nicely complement a general question about ear pain. This would ensure that clinicians are aware of the specific symptoms present and at the same time fully understand and address parental concerns about their child's condition."

The National Center for Research Resources supported this study. Two of the study authors are employees of Novartis Oncology.

J Pain. 2010;11:1291-1294. Abstract