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BACKGROUND: Thoracotomy is one of the surgical procedures most burdened by chronic post-operative pain. There is poor evidence regarding the possibility that even in pediatric patients, thoracotomy can be followed by post-operative pain. The primary objective of this analysis is to identify associations with home pain therapy, pain intensity, and possible protective factors acting on chronic pain in this population. METHODS: A retrospective cross-sectional study was conducted at Ospedale Pediatrico Bambino Gesù IRCCS. The study included pediatric patients undergoing thoracotomy. For statistical analyses, a logistic model and a zero-inflated strategy were implemented to explore associations and predict factors related to home-based analgesic therapy and pain intensity. RESULTS: Gender and age were identified as significant factors in the assignment of home therapy, with males having over seven times the risk compared to females (OR = 7.06, 95% CI = [2.11, 29.7]). At the last measurement, pain intensity was positively associated with age and the number of pain events during the week. CONCLUSIONS: The study highlights significant factors influencing post-thoracotomy pain management in pediatric patients. These findings underscore the importance of tailored pain management strategies that consider gender and age to improve post-operative care and outcomes in pediatric thoracotomy patients.

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Aim: Despite the growing evidence supporting the use of peripheral nerve stimulation (PNS) for cancer pain in adults, it is underutilized in the pediatric oncology population.Method: We describe the use of temporary, percutaneous PNS for pain management in pediatric patients suffering from cancer related pain.Results: Two adolescent patients underwent an ultrasound-guided suprascapular nerve PNS placement utilizing the percutaneous 60-day therapy system. Both patients reported approximately 60% pain relief during the therapy, as well as up to 90 days post lead removal.Conclusion: PNS may play a crucial role in the pediatric oncology population. Further studies are warranted to investigate the efficacy and safety of PNS for various cancer-related pain conditions in pediatric populations.

Peripheral nerve stimulator is a device that uses electrical impulses to stimulate the nerves that send pain signals to the brains. This device may be useful in treating pain in cancer patients. We highlight two pediatric cancer patients that had pain relief using a specific type of peripheral nerve stimulator that is removed after 60 days. It is thought that pain relief is sustained even after removing the stimulator by altering the pain signals to the brain. This treatment may serve an important role in treating pediatric cancer pain.

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BACKGROUND: Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture. OBJECTIVE: The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures. METHODS: This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children's Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention. RESULTS: Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain. CONCLUSIONS: VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR's success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population. TRIAL REGISTRATION: ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901.

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The COVID-19 pandemic prompted a rapid shift from in-person to virtually-delivered care. Many youth with chronic pain have the ability to access care virtually; however, little is known about the efficacy of pain care for youth with chronic pain delivered virtually when compared to in-person. Such evidence is essential to guide youth in making decisions about their care, but also to inform what options health professionals present to youth. The purpose of this systematic review and meta-analysis was to examine the efficacy of interventions that are delivered in-person versus virtually for youth with chronic pain. Five databases (i.e., CINAHL, EMBASE, MEDLINE, APA PsycINFO, and Web of Science) were searched in October 2022 to identify randomized controlled trials that compare single/multimodal interventions for pediatric chronic pain delivered in-person versus virtually. A total 3638 unique studies were identified through database and other searching, two of which satisfied established criteria for inclusion in this review. Both studies compared psychological interventions delivered virtually versus in-person for youth with chronic pain and showed comparable efficacy across modalities. The planned meta-analyses could not be conducted due to different outcomes within each study that could not be combined. This systematic review highlights a critical gap in the evidence regarding the efficacy of virtually delivered interventions for youth with chronic pain. This evidence is necessary to inform treatment decisions for youth, and further research is required to develop the evidence to inform clinical interventions, especially as virtual treatments continue to be offered.

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Pain science education (PSE) can be used as part of treatment and prevention for chronic pain in children. We assessed the effectiveness of PSE on knowledge, beliefs, attitudes, and behaviors in children and the people that care for children. We set a minimum criterion for education to address pain biology knowledge. We included studies aimed at both treatment and prevention of chronic pain. We conducted searches using 5 databases. We assessed the risk of bias using the Cochrane Risk of Bias 2 tool. Data were pooled using a random-effects meta-analysis or assessed using a narrative synthesis. The certainty of evidence was assessed using the Grading of Recommendations, Assessment, Development and Evaluation. We screened 14,505 records and included 7 studies involving 351 caregivers and 1,285 children. Four studies were included in meta-analyses. We found low-certainty evidence that PSE has a large beneficial effect on caregiver knowledge and beliefs compared with alternative education (standardized mean difference = 1.14 [95% confidence interval: .88-1.42]; I2 = 0%). We found no difference in functional disability in children with chronic pain after PSE (Functional Disability Inventory score mean difference = .73 [95% confidence interval: -.81 to 2.27; I = 0%]). Narrative syntheses showed low-certainty evidence for improved knowledge and beliefs in children with preventative and treatment effects. Overall, we found few studies, and along with high risk of bias, this significantly contributed to the low certainty of findings. The effect of learning pain science for both preventative and treatment effects in children, carers, and the child/carer dyad remains mostly unknown. This review was prospectively registered with The international Prospective register of systematic reviews (CRD42022344382) on July 22, 2022. PERSPECTIVE: This review examines the effect of PSE on pain-related knowledge, beliefs, attitudes, and behaviors in children and the people that care for children (0-18). The findings contribute to knowledge about pain treatments and health promotion for caregivers and their children with and without chronic pain.

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Chronic pain is a leading cause of morbidity among children and adolescents affecting 35% of the global population. Pediatric chronic pain management requires integrative health methods spanning physical and psychological subsystems through various mind-body interventions. Yoga therapy is one such method, known for its ability to improve the quality of life both physically and psychologically in chronic pain conditions. However, maintaining the clinical outcomes of personalized yoga therapy sessions at-home is challenging due to fear of movement, lack of motivation, and boredom. Virtual Reality (VR) has the potential to bridge the gap between the clinic and home by motivating engagement and mitigating pain-related anxiety or fear of movement. We developed a multi-modal algorithmic architecture for fusing real-time 3D human body pose estimation models with custom developed inverse kinematics models of physical movement to render biomechanically informed 6-DoF whole-body avatars capable of embodying an individual's real-time yoga poses within the VR environment. Experiments conducted among control participants demonstrated superior movement tracking accuracy over existing commercial off-the-shelf avatar tracking solutions, leading to successful embodiment and engagement. These findings demonstrate the feasibility of rendering virtual avatar movements that embody complex physical poses such as those encountered in yoga therapy. The impact of this work moves the field one step closer to an interactive system to facilitate at-home individual or group yoga therapy for children with chronic pain conditions.

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BACKGROUND: This study aimed to validate a Composite Pain Index (CPI) as a single pain outcome measure for sickle cell disease (SCD) across the lifespan from 8 years of age. PROCEDURE: This prospective, cross-sectional study included 55 participants with SCD who completed the PAINReportIt tool and Adolescent Pediatric Pain Tool (APPT) in random order during outpatient visits to derive respective CPI scores for comparison. RESULTS: Of the 55 participants with SCD, 46 (84%) had HgbSS, eight (15%) HgbSC, and one (2%) HgbSß0+. The mean age of all participants was 17.5 ± 2.6 years, and 28 (51%) were female, 52 (95%) were Black, 42 (98%) were non-Hispanic, and 39 (71%) had a ninth grade or higher education. Correlation analyses between the APPT and PAINReportIt revealed positive associations for the number of pain sites (r = .57, p < .001), pain intensity (r = .46, p < .001), pain quality (r = .74, p < .001), and pain pattern (r = .34, p = .01). Patients' mean CPI scores derived from the PAINReportIt was slightly higher than the APPT; 34.2 (SD = 14.7) and 30.0 (SD = 19.0), respectively. Regression analyses showed that the APPT CPI significantly predicted the PAINReportIt CPI (B = .497, t(53) = 6.051, p < .001). This finding holds true even when accounting for the order of measurement or patient's age. CONCLUSION: The initial validation of CPI as a single pain outcome measure represents a significant advancement in pain assessment for SCD. Further validation is warranted for the CPI as a measure is for both clinicians and researchers to enable longitudinal pain assessment from age 8 years across the lifespan as children age into adult care.

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Pain experiences are common during childhood (eg, "everyday" pain, vaccine injections) and are powerful opportunities for children to learn about pain and injury. These experiences likely inform fundamental and life-long beliefs about pain. There is scant research investigating the sociocultural contexts in which children learn about pain and injury. One unexplored context is the shared reading of picture books (eg, between parents/caregivers and children). In this study, we investigated whether shared reading of picture books that included depictions of pain and/or injury prompted parent/caregiver-child interactions. If interactions were observed, we explored what those interactions entailed. Twenty parents/caregivers (8 men, 12 women) and their children (n = 27; 10 boys, 17 girls) were recruited from libraries in South Australia. Parent/caregiver-child families chose from 8 books (7 fiction, 1 nonfiction) with varying amounts of pain/injury-related content. Shared reading interactions were video recorded, transcribed, and analyzed alongside analysis of the picture books using reflexive thematic analysis. Pain/injury-related interactions were observed between parents/caregivers and children during shared reading of picture books. Qualitative analyses generated 1 main theme and 3 subthemes. Findings identified that shared reading presented an opportunity for children's understanding of pain and injury to be socialized through discussion of characters' experiences. This included teaching children about pain and injury, as well as promoting empathy and emotional attunement toward characters who were depicted as being in pain. Finally, parents/caregivers often responded with observable/expressed amusement if pain/injury was depicted in a light-hearted or unrealistic way. Overall, shared reading of picture books presents an untapped opportunity to socialize children about pain and injury. PERSPECTIVE: Shared reading of picture books that have depictions of pain and/or injury can prompt parent/caregiver-child interactions about pain and injury. These interactions present critical opportunities that can be harnessed to promote children's learning of adaptive pain-related concepts and behaviors during a critical developmental period.

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Quantitative sensory testing (QST) refers to a group of noninvasive psychophysical tests that examine responses to a range of calibrated mechanical and thermal stimuli. Quantitative sensory testing has been used extensively in adult pain research and has more recently been applied to pediatric pain research. The aims of this scoping review were to map the current state of the field, to identify gaps in the literature, and to inform directions for future research. Comprehensive searches were run in 5 databases. Titles, abstracts, and full texts were screened by 2 reviewers. Data related to the study aims were extracted and analyzed descriptively. A total of 16,894 unique studies were identified, of which 505 were screened for eligibility. After a full-text review, 301 studies were retained for analysis. Date of publication ranged from 1966 to 2023. However, the majority of studies (61%) were published within the last decade. Studies included participants across the developmental trajectory (ie, early childhood to adolescence) and most often included a combination of school-age children and adolescents (49%). Approximately 23% of studies were conducted in healthy samples. Most studies (71%) used only one QST modality. Only 14% of studies reported using a standardized QST protocol. Quantitative sensory testing in pediatric populations is an emerging and rapidly growing area of pain research. Future work is needed using comprehensive, standardized QST protocols to harness the full potential that this procedure can offer to our understanding of pediatric pain.

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Objective: Pain's causes in children with severe cognitive impairment may be challenging to diagnose. This study aimed to investigate if there is a relationship between pain causes and the age of children. Methods: We conducted a multicenter retrospective study in three Italian Pediatric Units. Eligible subjects were patients from 1 to 18 years with severe neurological impairment. We collected data regarding diagnoses, pain causes and medical or surgical procedures. The timing of pain episodes was categorized into age-related periods: infants and toddlers (0-24 months), preschool children (3-5 years), schoolchildren (6-12 years), and adolescents (13-17 years). Results: Eighty children with severe neurological impairment were enrolled. The mean age was 11 years (±5.8). Gastroenterological pain was most common in the first years of life (p = 0.004), while orthopaedic and tooth pain was the most typical in schoolchildren and adolescents (p = 0.001 and p = 0.02). Concerning surgical procedures, PEG placement and gastric fundoplication were significantly more common in the first 5 years of age (p = 0.03), and heart surgery was typical of infants (p = 0.04). Orthopaedic surgery was more commonly reported in older children and adolescents (p < 0.001). Conclusions: Some causes of pain are more frequent in children with severe neurological impairment in defined age-related periods. Specific age-related pain frequencies may help physicians in the diagnostic approach.

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BACKGROUND: Knowledge mobilization (KM) is essential to close the longstanding evidence to practice gap in pediatric pain management. Engaging various partners (i.e., those with expertise in a given topic area) in KM is best practice; however, little is known about how different partners engage and collaborate on KM activities. This mixed-methods study aimed to understand what different KM partner groups (i.e., health professionals, researchers, and patient/caregiver partners) perceive as supporting KM activities within pediatric pain management. METHODS: This study used a convergent mixed-methods design. Ten partners from each of the three groups participated in interviews informed by the Consolidated Framework for Implementation Research, where they discussed what impacted KM activities within pediatric pain. Participants then rated and ranked select factors discussed in the interview. Transcripts were analyzed within each group using reflexive thematic analysis. Group-specific themes were then triangulated to identify convergence and divergence among groups. A matrix analysis was then conducted to generate meta-themes to describe overarching concepts. Quantitative data were analyzed using descriptive statistics. RESULTS: Unique themes were developed within each partner group and further analysis generated four meta-themes: (1) team dynamics; (2) role of leadership; (3) policy influence; (4) social influence. There was full agreement among groups on the meaning of team dynamics. While there was partial agreement on the role of leadership, groups differed on who they described as taking on leadership positions. There was also partial agreement on policy influence, where health professionals and researchers described different institutions as being responsible for providing funding support. Finally, there was partial agreement on social influence, where the role of networks was seen as serving distinct purposes to support KM. Quantitative analyses indicated that partner groups shared similar priorities (e.g., team relationships, communication quality) when it came to supporting KM in pediatric pain. CONCLUSIONS: While partners share many needs in common, there is also nuance in how they wish to be engaged in KM activities as well as the contexts in which they work. Strategies must be introduced to address these nuances to promote effective engagement in KM to increase the impact of evidence in pediatric pain.

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OBJECTIVE: Socio-culturally defined identity factors present significant and often understudied influences on the experience, management, and treatment of chronic pain. For instance, there exist societal narratives about how males and females are expected to experience and express pain. Such gender roles may impact youth and caregiver openness to individual multidisciplinary treatments for pediatric headache. METHODS: In this cross-sectional study, participants (N = 1087 youth/caregiver dyads, Mage = 14.5 years, 71% female, 97% cisgender, 77% White) completed a series of questionnaires, including Openness to Headache Treatment (OHT), upon presenting for initial multidisciplinary evaluation of chronic headache. Pearson correlations, independent samples t-tests and hierarchical regressions were used to analyze potential gender differences in youth and caregiver openness, as well as its relationships with pain-related and psychological factors. RESULTS: Overall, female youth and their caregivers were more open to headache treatment, broadly and for individual interventions, when compared to male counterparts. Caregiver distress related to their child's headaches (i.e., fear and avoidance) was significantly correlated with openness in female youth and their caregivers, but not males. CONCLUSION: Gendered patterns in healthcare decision-making in youth and caregivers provide insight on individual, societal, and systemic gender bias.

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INTRODUCTION: In low- and middle- income countries like Rwanda, children are most likely to suffer from painful and life-limiting conditions due to various factors predominant in these settings. Adequate pre-licensure pain management training can improve pain relief nursing practices. Educators and nurses in practice have a responsibility to teach the soon-to- be nurses for holistic competent nursing care of children, emphasizing the importance of and addressing child's suffering, yet inconsistencies were reported in what was taught regarding pediatric pain management from a theoretical perspective by nurse educators as compared to their counterparts in clinical settings in Rwanda. DESIGN: This study applied a qualitative approach using group discussions based on nominal group technique (NGT) to develop and validate a conceptual framework supporting the capacity enhancement of nurse educators and preceptors facilitating students' learning about pediatric pain management in Rwanda. METHODS: NGT meetings were conducted with academic nurses (n = 8), nurse clinicians (n = 4), and nursing students (n = 2) during a 2-day workshop to identify strategies, discuss the relevance of each strategy and to agree on key concepts of a framework for improving the ability of nurse educators and preceptors to teach PPM to nursing students. After four weeks another round of NGT meetings were done with nursing faculty (n = 6), academic nurse leaders (n = 3), nurse preceptors (n = 2), clinical nurse leaders (n = 2), a nurse leader from a regulatory body (n = 1), and nursing student (n = 1) to validate the developed framework. FINDINGS: Four main strategies corresponding to the key concepts were mapped in a framework. Participants had a consensual agreement on the importance of the developed framework, they confirmed its completeness and practicality. In addition, participants found that the developed framework is logical, and confirmed that it is applicable for its purpose. CONCLUSION: The developed framework presents an opportunity to respond to the gaps in nursing pain education in the context of limited resources settings such as Rwanda. It can also be applied in nursing practice and nursing research, aligning with the need of improving the quality of care of suffering children. Furthermore, the framework can be adapted and utilized to meet the needs of healthcare professionals other than nurses. CLINICAL RELEVANCE: Strategies are suggested to improve the ability of nurse educators and preceptors in clinical settings to facilitate the acquisition of pediatric pain management competencies by the next generation of nurses. Future Rwandan nurses could then use the competencies acquired to provide optimal health care to children with pain in the best way possible during their practices.

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OBJECTIVE: Theory of mind (ToM) is the ability to understand the thoughts, feelings, and mental states of others and is critical for effective social and psychological functioning. ToM deficits have been associated with various psychological disorders and identified in adult pain populations. For youth with chronic pain, ToM deficits may underlie the biological, psychological, and social factors that contribute to their experience of pain, but this remains poorly understood. METHODS: This topical review explored the extant literature in the areas of ToM and chronic pain, particularly for pediatric populations, with respect to biological, psychological, and social elements of the biopsychosocial model of pain. RESULTS: ToM deficits may be present alongside previously identified biological, psychological, and social correlates of pediatric pain, as a vulnerability, mechanism, and/or consequence. Biologically, ToM deficits may relate to cortisol abnormalities and neurobiological substrates of pain processing. Psychologically, ToM deficits may stem from pain-focused cognitions, thus impacting relationships and fueling impairment. Socially, chronic pain may preclude normative development of ToM abilities through social withdrawal, thereby exacerbating the experience of pain. CONCLUSION: Taken together, ToM deficits may be associated with increased risk for the development and/or maintenance of pediatric chronic pain, and pediatric chronic pain may similarly confer risk for ToM deficits. Future research should investigate the nature of ToM abilities in youth with chronic pain to test these hypotheses and ultimately inform ToM-focused and pain-based interventions, as this ability has been demonstrated to be modifiable.

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Spinal fusion surgery is one of the most common major surgical procedures in youth. Adolescent idiopathic scoliosis (AIS) is the most frequent reason for corrective spinal fusion. AIS (∼25%-47% of cases) and spinal fusion surgeries are associated with pain, including the development of new onset chronic pain for up to 15% of youth. This research used photovoice approaches to explore the journeys of youth from before, during, and after spinal fusion surgery, to demonstrate their experiences both of and beyond pain. Twenty participants were recruited from a previous study conducted by the senior author's lab. Participants captured photos/videos in their daily life (Phase 1); collected previously taken photos/videos from before/during/after their surgery (Phase 2); and participated in individual interviews to reflexively discuss the meaning behind photos/videos (Phase 3). Before interviews, a questionnaire was administered to assess pain characteristics. Nineteen girls/women with scoliosis and one boy/man with kyphosis (12-19 years old, Mage = 16 years) participated; they identified as white (80%), other (15%), and Southeast Asian (5%). The researchers used a reflexive thematic analysis approach, which generated five themes: (1) body aesthetic versus machine; (2) expectations and anticipation of surgery/outcomes; (3) desire of normalcy and freedom; (4) navigating a hoped-for positive surgery experience; and (5) the journey sculpts identity formation and sense of self. Findings support youth advocacy, underscoring the need to validate youth concerns and inform healthcare professionals of the importance of individualized care. Youth perspectives highlighted opportunities for optimizing surgery/healthcare experiences and the psychosocial impacts of scoliosis on body image and appearance.

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Pain is a distinctive burden in atopic dermatitis and recognized as an important and highly prevalent symptom. It is unknown if the presence of atopic disease may sensitize children to adverse pain profiles in the long term. We aimed to assess the impact of early-life atopic dermatitis-like symptoms on pain at 10 years of age. We used data from 1302 and 874 participants of the Generation XXI birth cohort evaluated at 6 and 15 months, respectively, and 10 years. Atopy-like symptoms since birth, including atopic dermatitis, were collected at ages 6 and 15 months by interviewing parents. Pain history in the last 3 months at age 10 was collected from parents and children using structured questionnaires. We computed relative risks (RR) and respective 95% confidence intervals of pain features at age 10 according to each atopic-like symptom at 6 and 15 months. Children whose parents reported atopic dermatitis-like symptoms at 6 months and at 15 months had higher risk of reporting any pain (RR 1.75 [1.15-2.66]) and multisite pain, respectively (RR 1.67 [1.18-2.37]) at 10 years of age.  Conclusion: Atopic dermatitis symptoms in early life were associated with a higher risk of pain at age 10, suggesting that potential for sensitization during the first decade of life and highlighting the importance of improving the health care of children with atopic dermatitis is worth investigating. What is Known: • Atopic disorders have been associated with many non-atopic comorbidities, including chronic pain. • Pain and atopic dermatitis share common inflammatory pathways. Inflammation, injury to the skin from scratching, fissures, and intolerance to irritants related to atopic dermatitis can cause pain. What is New: • Atopic dermatitis in early life is linked to an increased likelihood of experiencing pain at the age of 10, which suggests that exploring the potential for sensitization is a worthwhile area of investigation. • Our proof-of-concept study highlights the potential benefit of studying management targets and improving itching and relieving skin pain as quickly as possible, avoiding potential long-term consequences of the sensitization process.

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Classically, neuropathic pain is described as a pain caused by a lesion or disease of the somatosensory system. However, one must note that the presence of somatosensory pathology alone does not guarantee a progression to neuropathic pain. This is due, in part, to the fact that neuropathic pain is a notoriously complex disease process, involving sensitization of both the central and peripheral nervous systems. Its causes are also numerous and varied, including trauma, the compression of a nerve, autoimmune disorders, diabetes, and infections. Due to the various manifestations, causes, and symptoms of neuropathic pain, the treatment of this disease process has proved challenging for generations of physicians. This section aims to elaborate on newly proposed mechanisms for pharmacological and targeted therapies, such as neurostimulation, which aim to reduce the negative somatosensory effects of neuropathic pain.

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Children with autism spectrum disorder (ASD) experience social interaction and communication challenges and often display repetitive, restricted patterns of behavior, activities, and interests. The concept of pain is regarded as one of the most complex human stressors due to its subjective and personal nature and the influences of multiple internal and external factors. Due to the complexity of this disorder, it remains concerning how children with ASD communicate their pain and how observers (i.e., parents, carers, and health care practitioners) respond to these children's pain communication. This scoping review aimed to identify how children with ASD communicate or express their pain. Ten studies met the inclusion criteria for further data extraction. Through reflexive thematic analysis, two main themes were identified: verbal and nonverbal responses used by children with ASD to communicate their pain that could influence pain assessment and management strategies. This review highlighted that children with ASD utilized various verbal and nonverbal methods to communicate their pain experiences and that these methods differed compared to children without disabilities. Furthermore, this review emphasizes the importance of holistic pain assessment strategies as well as additional pictorial support for children with ASD. This review recommends that future research should focus on understanding how the inclusion of different stakeholders in pain assessment for children with ASD, can contribute to holistic pain assessment.

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It is often a challenge for a child to communicate their pain, and their possibilities to do so should be strengthened in healthcare settings. Digital self-assessment provides a potential solution for person-centered care in pain management and promotes child participation when a child is ill. A child's perception of pain assessment differs when it is assessed using digital or analog formats. As we move into the digital era, there is an urgent need to validate digital pain assessment tools, including the newly developed electronic Faces Thermometer Scale (eFTS). This study protocol describes three studies with the overall aim to evaluate psychometric properties of the eFTS for assessing pain in children 8-17 years of age. A multi-site project design combining quantitative and qualitative methods will be used for three observational studies. Study 1: 100 Swedish-speaking children will report the level of anticipated pain from vignettes describing painful situations in four levels of pain and a think-aloud method will be used for data collection. Data will be analyzed with phenomenography as well as descriptive and comparative statistics. Study 2: 600 children aged 8-17 years at pediatric and dental settings in Sweden, Denmark, Iceland, and USA will be included. Children will assess their pain intensity due to medical or dental procedures, surgery, or acute pain using three different pain Scales for each time point; the eFTS, the Faces Pain Scale Revised, and the Coloured Analogue Scale. Descriptive and comparative statistics will be used, with subanalysis taking cultural context into consideration. Study 3: A subgroup of 20 children out of these 600 children will be purposely included in an interview to describe experiences of grading their own pain using the eFTS. Qualitative data will be analyzed with content analysis. Our pilot studies showed high level of adherence to the study procedure and rendered only a small revision of background questionnaires. Preliminary analysis indicated that the instruments are adequate to be used by children and that the analysis plan is feasible. A digital pain assessment tool contributes to an increase in pain assessment in pediatric care. The Medical Research Council framework for complex interventions in healthcare supports a thorough development of a new scale. By evaluating psychometric properties in several settings by both qualitative and quantitative methods, the eFTS will become a well-validated tool to strengthen the child's voice within healthcare.

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Previous studies have shown the benefit and safety of pediatric acupuncture, but it is often rejected by patients and their caregivers due to the perception of needling pain associated with acupuncture. A retrospective cohort study of 230 unique patients (1380 sessions) aged 8 to 21 underwent Kiiko Matsumoto Style acupuncture in an outpatient pain clinic. Patients completed a post-acupuncture survey, including the Faces Pain Scale-Revised and Likert-like scales about overall satisfaction, relaxation, and anxiolysis. Univariate analyses were conducted on all outcomes of interest. The mean needling pain score was 1.3 out of 10 with 57.7% of patients reporting no needling pain during their first acupuncture session. The mean score for overall satisfaction was 8.4 out of 10, relaxation was 8.2 out of 10, and anxiety reduction was 7.7 out of 10. The overall satisfaction, relaxation, and anxiolytic effect of acupuncture was increased in patients with more sessions (p = 0.003, 0.022, 0.004, respectively). There was no change in needling pain scores in patients with an increased number of acupuncture sessions (p = 0.776). Patients experience minimal needling pain during acupuncture needling and are highly satisfied with acupuncture. Those with more treatment sessions report feeling increased satisfaction and relaxation.