Original Articles
Physiologic correlates of comfort in healthy children*,**

https://doi.org/10.1053/jpmn.2003.6Get rights and content

Abstract

Pain assessment is particularly challenging when children are unable or unwilling to provide a self-report. Although clinicians frequently use vital signs as an adjunct to pain assessment, little evidence exists to support this practice. The purpose of this study was to explore the ability of selected physiologic variables (peripheral skin temperature, heart rate, skin conductance activity [SCA], respiratory rate, electromyogram [EMG] of the frontalis and right forearm muscles, and systolic and diastolic blood pressure [BP]) to detect changes in children's autonomic arousal from baseline. A one-group, repeated measures, randomized crossover design guided the study. Chosen from a convenience sample, 100 healthy children (ages 8-17 years) served as their own controls while undergoing two levels of intervention: cold pressor pain and guided imagery. Although most physiologic responses showed changes in the expected direction, EMG, SCA, and heart rate decreased slightly during cold pressor. Few significant intercorrelations were demonstrated among the physiologic variables. SCA, forehead EMG, respiratory rate, systolic and diastolic BP detected significant changes in arousal across measures. Notably, heart rate failed to detect changes for any of the measures. Results emphasize the need for caution in interpreting heart rate as an index of comfort. Further research is needed to examine the effects of clinical pain on physiologic indices and to further examine age and sex influences. To be relevant for assessment of acute established pain, physiologic variables must also be tested for their sensitivity beyond the immediate period of autonomic arousal. © 2003 by the American Society of Pain Management Nurses

Section snippets

Design and methods

A one-group, repeated measures, randomized crossover design guided this study. Chosen from a convenience sample, subjects served as their own controls while undergoing two levels of intervention: cold pressor pain and guided imagery. Measurement of physiologic and self-report variables occurred across baseline, intervention, and recovery periods for the interventions.

The University's institutional review board approved the study. Parents and children signed informed consent and assent

Sample

A convenience sample of 100 children and adolescents was recruited from posted flyers and word of mouth. Inclusion criteria specified that children were ages 8 through 17 years, English-speaking, healthy, and free of pain at the time of the study. Excluded were children with significant developmental delays, Raynaud's phenomenon or disease, attention deficit disorder, and coexisting conditions or taking medications known to affect autonomic nervous system response.

Data collection occurred in a

Results

Children who received the cold pressor test first (cold pressor group) were not demographically different from those who received imagery first (imagery group). Data examined for group differences included age, sex, ethnicity, whether a parent elected to stay in the room during data collection, worst previous pain the child could recall, room temperature at start of data collection, and parent's estimate of pain tolerance. The last 59 children in the sample were asked if they expected the water

Discussion

This study examined the ability of selected physiologic variables (peripheral skin temperature, heart rate, SCA, respiratory rate, EMG of the frontalis and right forearm muscles, and systolic and diastolic BP) to detect changes from baseline in children experiencing arousing and relaxing stimuli. When examined descriptively, physiologic responses generally reflected decreased arousal during imagery and increased arousal during cold pressor.

Exceptions were noted for forearm EMG and SCA, which

Conclusion

Physiologic responses to cold pressor and imagery were largely unaffected by age, sex, or treatment order. Responses could reasonably be expected to vary most between the imagery and cold pressor measures. Five variables were able to detect this response: SCA, forehead EMG, respiratory rate, and systolic and diastolic BP. Only two variables, forehead EMG and systolic BP, showed mean differences between the baseline and imagery periods. The relatively weak cold pressor test in this study (13° C

References (32)

  • M. van Dijk et al.

    The association between physiological and behavioral pain measures in 0- to 3-year-old infants after major surgery

    Journal of Pain and Symptom Management

    (2001)
  • L.K. Zeltzer et al.

    The cold pressor pain paradigm in children: Feasibility of an intervention model (part II)

    Pain

    (1989)
  • K.J.S. Anand

    The applied physiology of pain

  • B. Ambuel et al.

    Assessing distress in pediatric intensive care environments: The COMFORT scale

    Journal of Pediatric Psychology

    (1992)
  • K.D. Craig

    The facial display of pain

  • T.P. Culbert et al.

    Biofeedback with children and adolescents: Clinical observations and patient perspectives

    Developmental and Behavioral Pediatrics

    (1996)
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    *

    This research was funded by a grant from National Institutes of Health, National Institute for Nursing Research NINR (R15 NR04762).

    **

    1524-9042/03/0401-0000$30.00/0

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