Australasian Emergency Nursing Journal (2012) 15, 133147

Available online at www.sciencedirect.com

journal homepage: www.elsevier.com/locate/aenj

RESEARCH PAPER

Improving pain management of abdominal pain in

children presenting to the paediatric emergency
department: A prepost interventional study
Suzanne Williams, MNSc (NP), BN (Hons), Grad Cert Paed Crit Care, Grad Cert Paed,
Chld & Yth Hlth Nrsing, RN, NP, B. Health Sc (Nursing) a,
Kerri Holzhauser, RN, BHealth Sc (Nrsg) b,c
Donna Bonney, RN, BN, MN, Grad Cert Emerg d
Elizabeth Burmeister, MSc (Biostatistics), BN, DipNurs b
Yuri Gilhotra, MBBS, FACEM a
Randall Oliver, RN, BN a
Kerry Gordon, RN, NP, MNSc (NP), BN (Hons) a
a

Mater Childrens Hospital Emergency Department, Brisbane, Australia

Princess Alexandra Hospital, Brisbane, Australia
c
Grifth University Research Centre for Clinical and Community Practice Innovation, Brisbane, Australia
d
Mater Health Services, Brisbane, Australia
b

Received 6 September 2011; received in revised form 18 April 2012; accepted 18 April 2012

KEYWORDS
Abdominal pain;
Child;
Paediatric;
Pain management;
Analgesia;
Pain assessment;
Emergency
department

Summary
Background: In 2007, the Mater Childrens Hospital Emergency Department participated in the
Emergency Care Pain Management Initiative funded by the National Health and Medical Research
Council National Institute of Clinical Studies (NHMRC NICS). The ndings of this NHMRC NICS
research across eleven paediatric emergency departments highlighted decits in pain management of abdominal pain. Specically pain assessment, timeliness of analgesia, and pain
management guidelines were found to be lacking.
Methods: In response to the NICS report local practice was reviewed and a pilot research project
undertaken to develop a clinical guideline for the pain management of abdominal pain in children presenting to the emergency department. The guideline was developed by an expert panel
and trialled using a pre and post intervention design.

Corresponding author at: Mater Childrens Hospital Emergency Department, Raymond Terrace, South Brisbane 4001, Brisbane,
Australia. Tel.: +61 07 3163 6337; fax: +61 07 3163 8744.
E-mail address: Suzanne.williams@mater.org.au (S. Williams).

1574-6267/$ see front matter 2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.aenj.2012.04.003

134

S. Williams et al.
Results: The results demonstrated improved compliance to assessment and documentation of
pain scores and assimilation of the best practice principles recommended in the guideline.
Conclusions: This project raised local awareness in the pain management of abdominal
pain and provides baseline information for future improvement. The guideline has been trialled in the clinical setting of paediatric emergency and has the potential to improve pain
management practices in children presenting to the emergency department with abdominal
pain.
2012 College of Emergency Nursing Australasia Ltd. Published by Elsevier Ltd. All rights
reserved.

What is known
The literature suggests that pain management
of abdominal pain in children presenting to the
emergency department is poorly managed. Early
administration of analgesia does not mask signs of an
acute abdomen. However this is not well understood
and presents a signicant barrier to appropriate pain
management of children presenting to the emergency department. Furthermore time to analgesia
in this patient group is often delayed and falls outside the NICS NHMRC recommendation of analgesia
within 30 min of triage.
What this paper adds
This paper describes the introduction of an evidence based guideline to support pain management
of abdominal pain in children. The guideline was
trialled using a prepost interventional study. Clinical ndings demonstrated an improvement in pain
assessment and documentation and improved knowledge of nursing and medical staff in regard to pain
management. This research provides a basis for
future improvement in pain management practices.

Introduction
Abdominal pain is one of the most common symptoms reported in the paediatric population presenting
to the emergency department (ED).1 However, children
with abdominal pain do not routinely receive timely or
appropriate analgesia in this setting.1 Childrens pain is
often inadequately treated affecting the childs ability
to cope and causing feelings of helplessness, fear and
anxiety.2
In 2007 the Mater Childrens Hospital Emergency Department (MCH ED) participated in the Emergency Care Pain
Management Initiative funded by the National Health and
Medical Research Council National Institute of Clinical
Studies (NHMRC NICS). This initiative included a retrospective chart audit to investigate pain management
of abdominal pain, migraine and fractured femur.3 Ten
major paediatric Australian and New Zealand departments,
members of the Paediatric Research in Emergency Departments International Collaborative (PREDICT), participated
in the audit.4 The ndings across the paediatric peer group
revealed only 62% of children with abdominal pain received

analgesia in the emergency department (ED).3 The median

time to analgesia (from arrival in ED) for the abdominal pain
cohort was 1.71 hours at MCHED compared to 1.20 hours
across the peer group.3 A sub-analysis of the data extracted
for the NICS study identied that of the 20 patients included
in the audit at MCHED, only 15% (n = 3) received analgesia within 30 min of triage in line with the national target
recommended by NICS.3,5 Other common decits were identied in the general standard of practice across the health
services in comparison to the current pain management
recommendations by the NHMRC. Areas of particular note
included documentation of pain assessment, time to analgesia, reporting systems to monitor pain performance and
feedback to staff, pain management guidelines and other
barriers such as time, knowledge, resources and pre-existing
misconceptions amongst doctors and nurses.3 In summary
the ndings and recommendations of the NICS Collaborative Pilot Study correlate with the Royal Australasian College
of Physicians Guideline Statement on paediatric pain management that clinical practice does not consistently reect
evidence-based practice.2
In light of the NICS report, current local practice was
reviewed in 2008 prompting a search for industry guidelines. The absence of current paediatric guidelines provided
a driver amongst staff at the MCH ED to develop an evidencebased guideline to facilitate the appropriate management
of pain in children presenting to the Emergency Department (ED) with abdominal pain. A pilot research project was
developed based on the ndings of the NICS study. Primary
goals included early administration of appropriate analgesia and timely, objective pain assessment. Approval for the
project was granted by the Mater Human Research and Ethics
Committee and funding provided by a Queensland Health
Nursing and Midwifery Novice Research Grant. This project
culminated in the development of evidence based guideline
and best practice principles for the management of pain
in children presenting to the emergency department with
abdominal pain. This guideline has been successfully trialled
and implemented locally and is available for use by nursing
and medical staff in the ED.

Review of the literature

A review of the literature was undertaken in March 2008
with the assistance of an experienced librarian. A broad
search was performed to determine if there was an existing
guideline addressing the pain management aspect of caring for children with abdominal pain in emergency. Studies
that were included in the systematic review adhered to the
following inclusion criteria:

Pain management of children with abdominal pain

The study focused on pain management of abdominal
pain
The setting of the study was the emergency department
Study participants were children aged 018 years
The study was available in English
An initial search for existing clinical guidelines was
conducted and included the National Clearinghouse, the
National Health and Medical Research Council, Royal Childrens Melbourne Clinical Practice guidelines, New South
Wales Health Clinical Practice Guidelines, National Institute of Clinical Evidence (UK), Therapeutic Guidelines Inc.,
Medline Plus, Up to Date, Joanna Briggs Institute, Cochrane
Library, Australian and New Zealand College of Anaesthetists
and Faculty of Pain Medicine and Queensland Health Clinical Guidelines. The search did not reveal any existing
guidelines which specically addressed pain management of
children with abdominal pain presenting to the emergency
department.
A comprehensive search strategy was subsequently
designed using the following Medical Subject Headings (MeSH) with explosion of key words: abdomen,
acute/diagnosis; acute/drug therapy; abdominal pain AND
acute; child or adolescent; analgesia OR analgesic agent;
and emergency/medicine/nursing/hospital.
Limiters narrowed the search to children 018 years
and studies available in English. This search was initiated in Cinahl, Medline plus and Embase and yielded 114
papers. Abstracts of included studies were retrieved and
assessed for eligibility according to the inclusion criteria.
The titles of these papers were assessed independently by
two researchers. Scrutiny of the research abstracts determined which studies related to children, described the
emergency department setting and focused on the pain management of abdominal pain. This selection process yielded
30 papers which were read independently by two reviewers. If the paper met the inclusion criteria or if eligibility
was unclear, the full text of the article was retrieved.
Of these 30 papers twenty were excluded because on
closer inspection they were found to be editorials, commentaries, were not set in the emergency department
and/or referred to adult patients. The nal ten papers
were critically reviewed by three independent reviewers
utilising a data extraction sheet and scoring process.6,7
Review items included abstract and title, introduction and
aims, theoretical framework, method and data, sampling,
data analysis, ethics and bias, results, transferability or
generalisability, implications and usefulness. Each item
attracted a possible highest score of 4, with a maximum
total of 40 points. Based on the numeric score a ranking was applied from very poor to very good. All papers
eligible for selection scored greater than 25 points or a
ranking of fair to very good. This literature provided the
foundation upon which the guideline and algorithm was
developed.
A search of the literature was repeated in June, 2010 at
the time of data analysis to determine if any other relevant
studies had been published since development of the algorithm. A single study was found which supported the ndings
of the initial systematic review however did not add any new
information. This study has been included in the supporting
references.

135

Summary of the literature

Review of the literature did not yield specic paediatric
guidelines for pain management of abdominal pain in children presenting to emergency. Much of the research reects
an adult focus of current evidence with few clinical trials
examining paediatric practice.
Abdominal pain is one of the most common symptoms
triggering paediatric presentation to emergency.1 Goldman, Narula, Klein-Kremer and Rogovik report as few
as 9% of children presenting to emergency with acute
abdominal pain receive opioid analgesia despite subsequently requiring abdominal surgery as a result of their
presentation.1 Goldman, Crum, Bromberg, Rogovik and
Langer report only 50% of children with a high clinical
index for appendicitis received analgesia. Only a minority of these children received opioids.8 Myths such as
children do not feel or remember pain and treating
pain masks underlying symptoms continue to inuence
clinical decisions in regard to paediatric pain management.
Clinicians sometimes withhold analgesia from paediatric
patients with acute abdominal pain due to concerns that
pain medication could mask or alter physical signs and
symptoms, making diagnosis more difcult.818 Furthermore, if opioids are prescribed for abdominal pain in
children it is frequently at a sub-clinical dose.1 Such practices continue in contradiction to current evidence.15,818
Administering morphine in an appropriate dose to children
with abdominal pain results in a signicant reduction of
their pain without any signicant difference in diagnostic
accuracy.13,816
A number of barriers to administration of analgesia in
the emergency department are commonly identied in the
literature. These include tradition, culture, experience of
the clinician, lack of knowledge in regard to effect of
analgesia, fear of addiction and absence of clinical guidelines and leadership.15 Other inuences in pain management
include attitudes and practices of senior clinicians. Goldman
et al. reported that some ED physicians withheld analgesia in deference to the paediatric surgeons disapproval of
the administration of analgesia to children with abdominal
pain.8
The literature describes specic strategies to address
barriers to appropriate pain management.15 Use of
an age appropriate pain assessment tool facilitates
accurate assessment and documentation of paediatric
pain.4 Initiation of pain assessment and management at
triage by nurses was commonly identied as a key to
early and effective pain management in the emergency
department.1,8 This strategy is further enhanced by the
use of protocols supporting nurse initiated analgesia.
Documentation of pain scores during clinical assessment
of children improves pain management.1,8 Appropriate
analgesia is more likely to be administered if there
is a protocol or guideline to support use, especially
in the case of opioids.5,8 Staff education and support is recommended to develop pain assessment skills
and effective prescribing practices.1,5 Evidence based
pain management guidelines and pain assessment tools
are not routinely implemented in paediatric emergency
practice.2

136

Methods
In response to the NICS report current local practice was
reviewed in 2008 and a pilot research project undertaken
to develop and introduce a clinical guideline for the pain
management of abdominal pain in children presenting to the
emergency department.

Hypotheses and specic aims of the study

Introduction of a guideline for pain management of abdominal pain in children presenting to the emergency department
will:
1. Improve documentation of pain score on assessment of
pain at triage
2. Increase the proportion of children with abdominal pain
receiving analgesia within 30 min by 20% to a minimum of
35% in comparison to the NICS pilot study result of 15%.
3. Improve the knowledge of nursing and medical staff in
regard to pain management
4. Assist in identifying barriers to pain management

Setting
Mater Childrens Paediatric Emergency Department is a tertiary referral centre currently treating more than 47,000
presentations of children aged 016 years per annum. The
MCH ED services the Brisbane South population 24 h per day
for acutely ill or injured children. As one of two tertiary
Paediatric Emergency Services in Queensland and as the Paediatric Trauma Centre for Brisbane South, the department
receives transfers from regional hospitals and northern New
South Wales.
Of 39,000 presentations at MCHED in 2007, approximately
2.2% were diagnosed with abdominal pain, which equates to
approximately 72 presentations per month.

Study design
The study used a pre-test post-test intervention design.
The intervention consisted of the development and introduction of an evidence-based paediatric pain management
guideline. A staff survey on attitudes to pain management
informed development of the guideline and provided a base
line upon which to measure changes in attitudes after the
guideline had been introduced. Retrospective pre and post
chart audits using the NICS audit tool enabled comparison of
practice before and after introduction of the guideline.

Development of the guideline

A systematic review of the literature, NICS data and survey
results informed initial development of a draft guideline.
The guideline focuses on analgesia to manage abdominal
pain and does not include adjuncts to abdominal pain management such as antacids, anti-emetics, antispasmodics and
aperients. An expert panel was convened to review the draft
and further develop the guideline. The panel included two

S. Williams et al.
paediatric emergency specialists, a clinical nurse consultant, two nurse educators, a senior paediatric pharmacist, a
representative of the National Institute of Clinical Studies, a
senior research adviser and a nurse practitioner. One of the
nurse educators is afliated with a tertiary paediatric acute
care facility in Brisbane, and, the remaining clinicians are
afliated with Mater Childrens Hospital. The senior research
advisor is afliated with a tertiary adult health care facility in Brisbane. The opinions of panel members associated
with ofcial government agencies represent their views and
not necessarily those of the agency of which they are afliated. Development of the guideline was completed within
six months from July to December, 2008 and reviewed in
August 2011.

Staff survey
A staff survey was administered before and after the introduction of the guideline. Participation in the survey was
voluntary and anonymous and offered to medical and nursing
staff. The purpose of the survey was to examine attitudes
and barriers to pain management of abdominal pain and
inform development of the guideline and subsequent education sessions. The survey was adapted from a pain survey
previously developed for paediatric nurses by Manworren
and approved by the Mater HREC.19 Content validity established by the expert panel by a review of current questions
for language and relevance to the Australian setting and
the objectives of the project. The survey was piloted on
a small number of paediatric nurses of varying levels of
experience. Internal reliability was established using KuderRichardson co-efcient (KR-20), a co-efcient alpha formula
used specically for dichotomous variables.20 The KR-20 was
calculated based on 64 responses and reliability was 0.90.
To maintain condentiality, surveys were placed in each
staff mailbox with a letter of explanation and a sealed
depository provided in a staff area. Surveys were collected
from the depository after two weeks. Results from the survey
were used to inform the education strategy and development of the paediatric pain management guideline. The
survey was re-administered one month after the guideline
trial was completed to measure changes in knowledge and
attitudes in the wake of the education sessions and implementation of the guideline.

Population, sample size and data collection

For the purpose of the retrospective chart audits, the population included all paediatric presentations (aged two to
sixteen years) with a diagnosis of abdominal pain. As in the
NICS study the Emergency Department Information system
(EDIS) was used to identify this population which included
the following ICD10 codes: R10.0 abdominal pelvic pain;
R10.1 pain localised upper abdomen; R10.2 pelvic and
perineal pain; R10.3 pain localised to other parts of
abdomen; R10.4 other and unspecied abdominal pain;
R30.9 pain micturition unspecied; R30.0 pain associated with micturition.
Sample size for the chart audits was calculated using pilot
data from the NICS pain initiative audit. Approximately 15%
of the NICS population (MCHED cohort) received analgesia

Pain management of children with abdominal pain

within the national target timeframe of 30 min. The MCH ED
study aimed to increase the proportion of children receiving
analgesia within 30 min by at least 2035% following implementation of abdominal pain management guidelines. The
sample size calculated to detect an increase by 2035% was
80 in both pre and post intervention groups assuming a baseline percentage of 15%, type I error of 0.05 (95% condence
interval) and power of 85%. The sample was selected based
on presentations with the nominated EDIS codes over two
months and randomised for the purpose of the pre and post
interventional audits. Retrospective data was collected in
the two months before and after trial of the guideline. Data
collection was based on the method developed in the NICS
study and facilitated with a modication of the NHMRC NICS
pain initiative data collection tool.18

Introduction of the guideline

Introduction of the guideline was achieved through a variety
of media including email, electronic noticeboard, education
sessions with PowerPoint presentations and poster displays
in work areas. The education session presented a synopsis of
the research project, summary of the ndings from the NICS
NHMRC pilot study, education regarding pain management
principles and general discussion time to explore staff perceptions in relation to pain management. It also provided an
opportunity to discuss misconceptions identied in the survey. A trial of the guideline commenced for 6-month period
from March 2009.

Data analysis
Data was collected using an access database and statistical
analysis performed using STATA: Data Analysis and Statistical
Software. Differences before and after implementation of
the abdominal pain management guidelines were analysed
using non parametric tests for continuous data including pain
scores and time to analgesia. Chi-squared test and relative
risk were used to analyse the dichotomous outcome of difference in the proportions of children receiving analgesia by
30 min before and after the intervention. Demographic data
analysis used t-tests.

Ethical considerations
The project was approved by the Mater Health Services
Human Research and Ethics Committee (HREC). Charts were
randomised using patient record numbers. The data collection was de-identied with allocation of sample numbers
180 to each record. A code sheet to enable data checking
was created to link the coded data to the identied data.
This was stored in a secure location accessible by the data
collection team separate to the raw data.

137
Table 1 Diagnosis of patients ICD-10 codes pre and post
intervention audit.
ICD-10

Name

Pre, n (%)

Post, n (%)

R10.0
R10.1

Abdominal pelvic pain

Pain localised upper
abdomen
Pelvic and perineal
pain
Pain localised to
other parts of the
abdomen
Pain micturition
unspecied

13 (16.1)
14 (17.5)

9 (11.3)
17 (21.3)

R10.2
R10.3

R30.9

1 (1.3)
52(65)

48(60)

5 (6.3)

Total

80

80

No signicant difference, p = 0.304 (chi square).

Demographics
The mean age of patients was 8.9625 (SD 4.064) prior to
intervention and 8.425 (SD 3.897) after the intervention.
There was no statistical difference p = 0.39 (t-test). The gender of the sample was 53.8% pre-test male and 42.5% post
test with no statistical difference between the two time
points difference p = 0.154 (chi square).
The majority of diagnoses were pain localised to other
parts of abdomen R10.3 (n = 48 pre and 52 post). Other diagnoses include R10.0 abdominal pelvic pain; R10.1 pain
localised upper abdomen; R10.2 pelvic and perineal pain;
and R30.9 pain micturition unspecied (Table 1).
Data reported in the following tables includes documentation of pain score, reassessment of pain score, time to
analgesia and percentage of patients receiving analgesia
within 30 min. The time to analgesia specically reports time
from triage to receiving analgesia if there was no analgesia
given at home or in the ambulance.

Documentation of pain score

The pain score predominately used at MCHED is the Alder
Hey Triage Pain score observational pain scoring tool. This
tool has been validated for use in children presenting to
emergency.21 Staff are introduced and educated in the use
of this pain score during orientation to the department
(Table 2).
Pain score at triage refers to documentation of an Alder
Hey Triage Pain Score in the triage assessment by the triage
nurse at the time of triage.21 A signicant difference was
found in pain score documentation pre and post intervention
(Table 3).

Table 2

Pain score at triage.

Was the pain score documented?

Results
The following tables describe age, gender, diagnosis of the
population in both pre and post test samples. There was no
signicant difference found in any of these variables.

1 (1.3)

Yes
Pre
Post

25
38

No
31.25
47.50

55
42

Signicant difference, p = 0.035 (chi square).

68.75
52.50

138
Table 3

S. Williams et al.

Survey

Reassessment of pain score.

Was the pain score reassessed?

Yes
Pre
Post

6
9

No
7.4
11.25

20
21

25.0
26.25

No signicant difference, p = 0.56 (chi square).

Table 4 Time to analgesia (no analgesia given prior to

presentation).

Mean
Median
Interquartile range
Range

Pre (min), n = 80

Post (min), n = 79

18.8
10.5
8, 49
0154

29.9
12.0
6, 48
0236

No signicant difference, p = 0.57.

Reassessment of pain score refers to documentation of an

Alder Hey Triage Pain Score in the patient observation chart
after the rst documented pain score or administration of
analgesia whilst in the emergency department.21

Time to analgesia from triage

Time to analgesia was dened as number of minutes elapsed
from time of triage to administration of any analgesia by any
route. Children who received analgesia pre hospital at home
or on route were excluded. There was an improvement in
both pre (92.5 min) and post (91 min) test medians in comparison to the NICS data with a median of 103 min.3 However
there was no signicant improvement in time to analgesia
between the pre and post intervention data (Table 4).

Analgesia within 30 min of triage

There was a small increase in the post intervention data by
2.4% of children receiving analgesia within 30 min of triage.
The pre-intervention baseline data was improved by 37.8% in
comparison to the NICs data.3 Children who received analgesia prior to triage (at home or in the ambulance) were
excluded (Table 5).

Guideline
This guideline describes pain management recommendations for children presenting to emergency with abdominal
pain and includes evidence based best practice principles
and an algorithm guiding choice of analgesia based on pain
score (Fig. 1).
Table 5 Percentage of children receiving analgesia within
30 min of registration.
NICS audit
Pre audit, n = 28
Post audit, n = 27

15%
64.3%
66.7%

Of the seventy surveys that were delivered to participants

37 surveys (52.8%) were returned pre intervention and 27
(38.5%) surveys post intervention. The pre-survey omitted to
collect designation of the participant. The post survey was
completed by seventeen nurses, one doctor and nine undesignated participants. The data collected from the pre-survey
was analysed to inform the education strategy by focusing
on identied knowledge decits.
Overall survey results demonstrated a signicant
improvement in the number of correct answers for the
majority of questions as demonstrated in Table 6 . Each survey was marked and out of a score of 36, scores ranged from
a minimum of 7 to a maximum of 18, median score of 13 (IQR
11, 14) in the pre-test and a minimum of 17 to a maximum
of 33, median score of 29 (IQR 26, 30) in the post-test. Using
MannWhitney Test for two independent samples there was
statistical signicant difference of p = 0.000.

Limitations
There were several limitations to this study. During the time
the trial was implemented there was a large turnover of
nursing and medical staff, which was challenging in regard
to initiation to the guideline. Education sessions were well
attended by approximately 85% of nursing staff and poorly
attended by medical staff possibly due to the times the sessions were held. The education sessions were not continued
throughout the trial; however the guideline was included
in training at triage workshops attended by nursing staff.
Recently the guideline has also been added to the orientation package for new nursing staff, which, it is anticipated
will enhance uptake. All staff (nursing and medical) were
sent regular information emails throughout the course of
the trial with the guideline attached to promote use. The
department electronic notice board was also used to promote the guideline.
When collecting data it was observed that 0 was rarely
used to indicate no pain. In this situation the triage nurse
more commonly describes the child as happy and playing
or pain free. These observations were not treated as a
pain score within the data collection for both pre and post
data collection. Recording of a 0 pain score is necessary
to provide a baseline observation upon which to measure
clinical progression and this nding will be integrated into
future pain score training.
Compliance to survey participation was 52.8% pre audit,
however only 38.6% of surveys were returned post audit.
Due to an error on the survey form participants were not
differentiated as medical or nursing in the pre audit survey,
approximately 70% of the post audit surveys were completed
by nursing staff.
Development of the guideline was facilitated by an
expert panel of paediatric health experts; however children and parents were not represented. All but one member
of the expert panel were from Mater Childrens Hospital as
invitations for external recruitment to the expert panel had
limited success. The content of the guideline addresses analgesia however does not include adjuncts such as antacids,
antispasmodics, antiemetics or aperients. Inclusion of these

Pain management of children with abdominal pain

Figure 1

Guideline for pain management of abdominal pain in children.

139

140
Table 6

S. Williams et al.
Survey results.
% Correct
post, n = 27

p value (chi square)

Question

Correct
response

% Correct
pre, n = 37

1. Observable changes in vital

signs must be relied upon to
verify a childs/adolescents
statement that he has severe
pain.
2. Because of an
underdeveloped neurological
system, children under
2 years of age have
decreased pain sensitivity
and limited memory of
painful experiences
3. If the infant/child/
adolescent can be distracted
from his pain this usually
means that he is not
experiencing a high level of
pain.
4. Infants/children/
adolescents may sleep in
spite of severe pain.
5. Comparable stimuli in
different people produce the
same intensity of pain
6. Non-drug interventions (e.g.
heat, music, imagery, etc.)
are very effective for
mildmoderate pain control,
but are rarely helpful for
more severe pain.
7. Children who will require
repeated painful procedures
(e.g. venepuncture), should
receive maximum treatment
for the pain and anxiety of
the rst procedure to
minimise the development of
anticipatory anxiety before
subsequent procedures.
8. Respiratory depression
rarely occurs in
children/adolescents who
receive opioids
9. Paracetamol 650 mg PO is
approximately equal in
analgesic effect to codeine
32 mg PO.
10. The World Health
Organization (WHO) pain
ladder suggests using single
analgesic agents rather than
combining classes of drugs
(i.e. Combining an opioid
with a non-steroidal agent).
11. The usual duration of
analgesia of morphine IV is
45 h.

False

10.8

88.9

78.1%

0.000

False

8.1

92.6

84.5%

0.000

False

21.6

74.1

52.5%

0.000

True

35.1

81.5

46.4%

0.000

False

96.3

96.3%

0.000

False

67.6

33.3

34.3%

0.007

True

13.5

92.6

83.1%

0.000

True

78.4

25.9

52.5%

0.000

True

91.9

7.4

84.5%

0.000

False

19.4

96.2

76.8%

0.000

False

18.9

85.2

66.3%

0.000

Improvement

Pain management of children with abdominal pain

141

Table 6 (Continued)
% Correct
pre, n = 37

% Correct
post, n = 27

p value (chi square)

Question

Correct
response

12. Parents should not be

present during painful
procedures.
13. Adolescents with a history
of substance abuse should
not be given opioids for pain
because they are at high risk
from repeated addiction.
14. Beyond a certain dosage of
morphine increases in
dosage will NOT provide
increased pain relief.
15. Young infants, less than
6 months of age, cannot
tolerate opioids for pain
relief.
16. The child/adolescent with
pain should be encouraged
to endure as much pain as
possible before resorting to a
pain relief measure.
17. Children, less than 8 years,
cannot reliably report pain
intensity and therefore, the
nurse should rely on the
parents assessment of the
childs pain intensity.
18. Based on ones religious
beliefs a child/adolescent
may think that pain and
suffering is necessary
19. Anxiolytics, sedatives, and
barbiturates are appropriate
medications for the relief of
pain during painful
procedures
20. After the initial
recommended dose of opioid
analgesic, subsequent doses
should be adjusted in
accordance with the
individual patients
response.
21. The child/adolescent
should be advised to use
non-drug techniques alone
rather than concurrently
with pain medications.
22. Giving children/
adolescents a placebo is
often a useful test to
determine if the pain is real.
23. In order to be effective,
heat and cold should be
applied directly to the
painful area.

False

False

2.7

False

35.1

False

10.8

False

False

16.2

84.6

68.4%

0.000

True

32.4

73.1

40.7%

0.001

False

27.0

59.3

32.3%

0.010

True

13.5

96.3

82.8%

0.000

False

5.4

92.6

87.2%

0.000

False

False

21.3

96.3

Improvement
96.3%

0.000

97.3%

0.000

70.4

35.3%

0.005

92.6

81.8%

0.000

100

100

100

70.4

100%

100%

49.1%

0.000

0.000

0.000

142

S. Williams et al.
Table 6 (Continued)
Improvement

p value (chi square)

100

100%

0.000

Correct
response

24. Analgesia cannot be

administered to children
with suspected appendicitis
before review by the surgical
team.
25. Oral analgesia can be given
to children with suspected
appendicitis at any time.
26. Analgesia should be
offered in the order of
weakest drug to strongest
drug and titrated until pain
has been treated.
27. Pain is more likely to be
effectively managed in the
paediatric patient if a pain
score is utilised

False

True

32.4

85.2

53.1%

0.000

False

13.5

77.8

64.3%

0.000

True

89.2

7.4

81.8%

0.000

Multiple choice
i. The recommended route
of administration of opioid
analgesics to children with
brief, severe pain of sudden
onset, e.g. trauma or
postoperative pain, is:
a. Intravenous
b. Intramuscular
c. Subcutaneous
d. Oral
e. Rectal
f. I dont know
ii. Which of the following IV
doses of morphine
administered would be
equivalent to 15 mg of oral
morphine?
a. Morphine 3 mg IV
b. Morphine 5 mg IV
c. Morphine 10 mg IV
d. Morphine 15 mg IV
iii. Analgesics for
post-operative pain should
initially be given:
a. Around the clock on a
xed schedule
b. Only when the
child/adolescent asks for the
medication
c. Only when the nurse
determines that the
child/adolescent has
moderate or greater
discomfort
iv. Analgesia for chronic pain
should be given:

% Correct
pre, n = 37

% Correct
post, n = 27

Question

Correct
response

% Correct
pre, n = 37

% Correct
post, n = 27

97.2

100

43.8

Improvement

p value (chi square)

2.8%

0.383

52.2

8.4%

0.537

94.4

92.6

1.8%

0.765

81.1

74.1

7.0%

0.503

Pain management of children with abdominal pain

143

Table 6 (Continued)
Multiple choice
a. Around the clock on a
xed schedule
b. Only when the
child/adolescent asks for the
medication only when the
nurse determines that the
child/adolescent has
moderate or greater
discomfort
v. The most likely
explanation for why a
child/adolescent with pain
would request increased
doses or pain medication is:
a. The child/adolescent is
experiencing increased pain
b. The child/adolescent is
experiencing increased
anxiety or depression
c. The child/adolescent is
requesting more staff
attention
d. The child/adolescents
requests are related to
addiction
vi. The most accurate judge
of the intensity of the
childs/adolescents pain is:
a. The treating physician
b. The childs/adolescents
primary nurse
c. The child/adolescent
d. The pharmacist
e. The childs/adolescents
parent
vii. Which of the following
describes the best approach
for cultural considerations in
caring for child/adolescent
pain?
a. Because of the diverse
and mixed cultures in
Australia, there are no
longer cultural inuences on
the pain experience.
b. Nurses should use
knowledge that has dened
clearly the inuence of pain
on
c. Children/Adolescents
should be individually
assessed to determine
cultural inuences on pain.

Correct
response

% Correct
pre, n = 37

100

% Correct
post, n = 27

100

Improvement

p value (chi square)

86.5

96.0

9.5%

0.214

96.2

96.2%

0.000

144

S. Williams et al.
Table 6 (Continued)

Multiple choice
viii. What do you think is the
percentage of patients who
over report the amount of
pain they have? Circle the
correct answer (correct
answer is underlined)
0 or 10% 20% 30% 40%
50% 60% 70% 80% 90%
100%
ix. Narcotic/opioid addiction
is dened as psychological
dependence accompanied by
overwhelming concern with
obtaining and using narcotics
for psychic effect, not for
medical reasons. It may
occur with or without the
physiological changes of
tolerance to analgesia and
physical dependence
(withdrawal). Using this
denition, how likely is it
that opioid addiction will
occur as a result if treating
pain with opioid analgesics?
Circle the correct answer.
<1% 5% 25% 50% 75%
100%

Correct
response

% Correct
pre, n = 37

54.1

78.4

adjuncts was discussed at length by the research team and

omitted as a more thorough assessment is required prior
to prescription of these medications. Distraction has been
included as an adjunct to analgesia but training in distraction was not provided to nursing or medical staff.

Discussion
Development of this guideline has been driven by the goal
to reduce pain experienced by children presenting to the
emergency department. This is signicant for a number
of reasons. Inappropriate management of pain can lead
to increased levels of pain experienced by children during
subsequent treatments as anxiety; distress, anger and emotional turmoil contribute to heightened pain perception.22
Painful experiences in hospital during childhood signicantly
impact on the childs future health behaviours manifesting
in doctor phobias and avoidance of medical experiences and
settings and contributing to poor health outcomes.2,2226
This guideline represents the rst step in improving pain
management of abdominal pain in children presenting to
emergency. Paediatric abdominal pain presentations span
a broad range of illnesses which arise from both medical and surgical aetiology. Consequently, approach to pain
management requires a range of analgesia which will treat

Improvement

p value (chi square)

40.7

13.4%

0.293

96.3

17.9%

0.042

% Correct
post, n = 27

the acuity of the pain. This is evident in the algorithm, which

reects the World Health Organisation (WHO) pain ladder
approach, matching pain score to analgesia.27 The algorithm
focuses on pharmacological pain management in conjunction with distraction and does not address the use of other
non-pharmacological adjuncts.
The algorithm is underpinned by the six best practice
principles presented in the guideline which translate current evidence into practice. Key to these principles is pre
and post pain documentation and initiation of analgesia at
triage, practices which have been show to improve pain
management.8,9 The recommended medications listed in the
algorithm do not include non-steroidal anti-inammatory
medication because these medications are contra-indicated
for abdominal pain.9 It should also be noted that the use
of codeine has not been advocated in the guideline as efcacy is variable between individuals, with possibly 50% of
children falling within this category.9 Distraction therapy
is recommended as a non-pharmacological intervention as
an adjunctive to all pharmacological therapies as it has
been found to reduce the stress and pain experienced
by the paediatric patient especially in regard to painful
procedures.2326 The effectiveness of distraction in isolation
or as an adjunct to pharmacological measures during any
potentially painful procedures is extensively documented in
the literature.2326,2831

Pain management of children with abdominal pain

The primary aims of the study were to:
- improve documentation of pre and post analgesia pain
score on assessment of pain at triage
- increase the proportion of children with abdominal pain
receiving analgesia within 30 min by 20% to a minimum of
35% in comparison to the NICS pilot study result of 15%.
- improve the knowledge of nursing and medical staff in
regard to pain management
- identify barriers to pain management
Three of the four study aims were achieved. The ndings revealed a signicant improvement in pain assessment
and documentation of pain score at triage. It is unclear if
this improvement can be attributed to the introduction of
the guideline or to the education sessions. Improvement in
staff knowledge was demonstrated in 27 of the 36 pain survey questions despite staff turnover. Several barriers to pain
management were identied in the survey results including inadequate understanding of the use of distraction in
paediatric pain management. The proportion of children
receiving analgesia within 30 min of triage was not increased
by 20% after the guideline was introduced. However, when
the pre-test data was collected the proportion of children
receiving analgesia within 30 min of triage was measured
at 64.3%, an improvement on the NICS baseline of 49.7%.
The post-test improved marginally to 66.7% demonstrating
no statistical signicance despite introduction of the guideline. The driver for the signicant improvement between
the NICS and pre-test time to analgesia could be attributed
to increased clinician awareness through dissemination and
discussion of the NICS results prior to commencement of this
study.
The pre audit survey informed both the development
of the guideline and preparatory education sessions. The
post intervention survey results demonstrate assimilation
of many of the best practice principles recommended in
the guideline. Improvement in staff knowledge was demonstrated in 27 of the 36 questions despite staff turnover. This
improvement was supported by education sessions and exposure and access to the guideline during the implementation
phase. One of the drivers motivating development of the
guideline was the practice of some clinicians of withholding analgesia prior to surgical review in children with acute
abdominal pain. Subsequently the following statement was
presented in the survey: Analgesia cannot be administered
to children with suspected appendicitis before review by
the surgical team. In the pre intervention survey no participants responded correctly to this statement; whereas in the
post survey 100% of participants accurately identied this
statement to be false. Other signicant areas of improvement included acknowledgement that analgesia was more
likely to be consistently administered if a pain scoring system was utilised, that children age two years and under do
not have reduced memory or sensitivity to pain and that
doses of opioid can be titrated according to the individuals
response.
There were several positive albeit incidental ndings of
this research which included 100% documentation of pre and
post analgesia pain score by ambulance ofcers exemplifying best practice. Compliance to weighing children at triage
was 100%. Weight is an essential measurement used for

145
calculation of drugs when managing the paediatric patient
and children are mandatorily (where practical) weighed
when triaged in the department. Thus the incidental audit
provided evidence of consistent clinical practice.

Recommendations
Several target areas for improvement were identied in this
study. These include the use of distraction, post analgesia
pain assessment and documentation and time to analgesia
from triage. The identication of these barriers is valuable in providing impetus to change and improve practice.
Distraction was not well understood as an adjunctive to
pharmacological analgesia especially in the presence of
severe pain.
Formalised training in distraction techniques may
improve its use as an adjunct to pharmacological analgesia. Delays in timely analgesia prompt a closer review of the
underlying practical processes, particularly at triage. This
nding provides a baseline on which to develop strategies
such as nurse initiated narcotic analgesia at triage and pain
management education. Whilst initial pain scores were well
documented, ongoing pain assessment documentation was
extremely poor. Further education and audit may promote
this practice. Practice may also be improved by the addition of a pain score column to all clinical documentation
sheets. Currently this prompt is only provided on the initial
emergency assessment documentation.
Continued adherence of the guideline will require ongoing support, education and audit. To achieve this goal the
guideline has also been included in the nursing staff orientation manual and triage training and is located in poster
form at triage to support continuing education and use of
the algorithm. Ongoing education and engagement of both
medical and nursing staff may address the barriers to timely
pain management including attitudes to pain management,
lack of knowledge and resources. Future data collection
focusing on audits of time to analgesia, pre and post pain
assessment documentation and adherence to the guideline in regard to prescription of analgesia, may provide a
feedback mechanism which will potentially improve clinical
practice. Development of a parent/carer pain management
educational handout may further support pain management
by engaging the family in the process.
Systematic review of the literature revealed a paucity of
evidence regarding pain management of abdominal pain in
children presenting to the emergency department. Future
directions may include continuing audit of time to analgesia
from triage to measure compliance to the guideline recommendations. Compliance to specic medication in relation
to pain score was not assessed in this study, but could provide insight into pain management practices in the future.
Multi-centre trials utilising clinical guidelines may assist
in progressing and developing paediatric pain management
practices in the emergency department.

Conclusion
This evidence based guideline has been trialled in the clinical setting of paediatric emergency. The results of a post
guideline implementation retrospective audit and survey

146
have demonstrated improved compliance to documentation
of pain scores and assimilation of the guideline best practice principles. This project raised local awareness of pain
management of abdominal pain and provides a baseline for
future improvements. Introduction of the guideline at other
sites has the potential to support consistent pain managment practice and improve pain management for children
presenting to the emergency department with abdominal
pain.

S. Williams et al.

5.

6.

7.

Provenance and conict of interest

8.

Author Kerri Holzhauser is an Associate Editor of the Australasian Emergency Nursing Journal but had no role in the
peer-review or editorial decision-making of the paper whatsoever. No competing interests were declared for all other
authors. This paper was not commissioned.

Funding
This project was supported by a novice nursing and midwifery research grant from Queensland Health.

9.

10.

11.

Acknowledgements
12.

The authors would like to acknowledge Dr Grant Stone

and the staff of the Mater Childrens Hospital Emergency
Department for their advice, support and contribution. The
literature review would not have been possible without
the expertise and enthusiasm of Kathy Hibberd, librarian
from the University of Queensland. Dr Geoff Spurling kindly
assisted with statistical design.
We would also like to thank the following members of the
expert panel for review and development of the guideline:
Dr Rob Pitt, Staff Paediatrician, Nambour Hospital, Sharon
Bluett, Nurse Educator Mater Childrens Hospital, Brisbane,
Melissa Prince, Clinical Nurse Consultant, Mater Childrens
Hospital, Brisbane, Lorelle Maylon, Nurse Educator, Royal
Childrens Hospital, Brisbane, Scott Bennetts, Assistant
Director, Effective Practice Program, National Institute of
Clinical Studies, National Health & Medical Research Council, David M Pache, Senior Clinical Pharmacist Mater Health
Services, Conjoint Lecturer School of Pharmacy, UQ.

13.

14.

15.

16.

17.
18.

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