Pain management in children as perceived by the nursing team

Larissa de Oliveira Ulisses^I; Lorena Fernanda Nascimento Santos^II; Cristina Nunes Vitor de Araújo^III; Elenilda Farias de Oliveira^IV; Climene Laura de Camargo^V

^I Nurse. Master´s student in Nrusing. Emergency care unit Adroaldo Albergaria. Salvador, Bahia, Brazil. E-mail: lariulisses@gmail.com
^II Nurse. Specialist Neonatology. Master in Nursing from the Federal University of Bahia. Emergency care unit. Salvador, Bahia, Brazil. E-mail: lorenafnasc@yahoo.com.br
^III Nurse. Specialist Neonatology. Master´s in Nursing from the Federal University of Bahia. Ph.D. student in Nursing. Salvador, Bahia, Brazil. E-mail: cristinavitor22@yahoo.com.br
^IV Nurse. Masters in Pathology. Ph.D. in Nursing by the Federal University of Bahia. Professor at the Adventist College of Bahia. Municipal Health Department. Salvador, Bahia, Brazil. E-mail: didafarias@yahoo.com.br
^V Nurse. Post-Doctorate by the Université Rene Descartes-Sorbonne. Associate Professor Federal University of Nursing School of Bahia. Salvador, Bahia, Brazil. E-mail: climenecamargo@hotmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2017.15379

ABSTRACT

Objective: to describe pain management in children by the nursing team. Methodology: this qualitative study in a pediatric unit of a university hospital in Salvador, Bahia, was conducted in 2012, after approval by the research ethics committee (Opinion No. 79/11). Three nurses, two technicians and two nursing auxiliaries participated in the study. Semi-structured interviews were carried out and analyzed using content analysis, from which three categories emerged: identifying pain in the hospitalized child; pain assessment instruments; preventing and treating pain. Results: findings included pharmacological interventions prioritized over non-pharmacological interventions; insufficient and ineffective interventions; failure to use appropriate instruments; and parental non-participation in this scenario. Conclusion: the team needed more in-depth scientific training in pain management, beyond reproduction of the biomedical drug treatment model.

Keywords: Nursing team; pediatric nursing; ache; management of pain.

INTRODUCTION

In the hospital context, many children are submitted to painful procedures, requiring the preparation of the nursing team for the prevention, evaluation, and treatment of pain. In order, professionals need a clear perception of whose their work object to perform these functions, assessing in what context this child is inserted, their relationship with family members, their inner and outer world and their unique way of being a child that lives the pain in the period of hospitalization¹.

The complaint of pain is often underestimated, mainly because it is a phenomenon of difficult measurement. This is caused by the difficulty children have in characterizing the pain or by not being able to verbalize what they are feeling. This fact is generally strengthened by the lack of preparation of the team to identify the signs of pain and the non-use of evaluation instruments.

The adequate management of pain should be a priority in the therapeutic planning of pediatric patients since it impairs their recovery and, when treated in a preventive or as early as possible, it is easier to manipulate than when it is already established or intense². A study conducted in Londrina, Paraná, on the perception of nursing regarding the evaluation and management of pain in pediatrics revealed a lack of knowledge and awareness about pain, noting that this evaluation does not occur at all times of vital signs measurement or when to do so, it occurs incorrectly³. This finding corroborates the research on nurses' perception regarding the use of an instrument for pain assessment in preterm infants in Rio Grande do Sul, Brazil, highlighting the scientific ignorance of nurses about the new technologies used in pain management in the newborn⁴, which contributes to worsening child care during the painful experience.

A Canadian study found that children followed up at 32 pediatric hospital units experienced an average of 6.3 painful procedures per day, with only a quarter of pain management interventions specifically linked to painful action⁵.

In this context, every nursing professional who takes care of children should ensure that they have access and fast relief of pain and stress in the most efficient and safe way possible. To make this process viable, they need to be prepared to deal with this multifactorial phenomenon. Thus, the objective of this study was to know the pain management in children by nursing workers.

THEORETICAL REFERENCE

Pain is a subjective phenomenon that undergoes influences of physiological and psychological variables, being a unique experience for each individual ⁶. The intensity of pain stimuli may be influenced by cultural aspects as well as by the perception of the observer, and it is important to be aware of individual and family beliefs and values during pain assessment⁷.

The younger the age, the lower the definition and location of pain. Neonates and infants do not verbalize the pain they feel. Their identification occurs through behavioral changes such as vigorous and inconsolable crying, facial expressions, chin tremor, muscle twitching, agitation, restlessness, irritation, body expressions such as uncomfortable position, movement of arms and legs, and physiological changes, such as tachycardia, alteration of vital signs, and saturation fall^8,9.

To collaborate in this process, the evaluation of pain must be done through scales and instruments that favor interaction and communication among nursing professionals, who begin to see and perceive the evolution of pain in each patient and to verify the response therapy. Once identified, interventions can be implemented so the pain is minimized, establishing a comfortable environment for the patient⁹.

Thus, the knowledge and the use of pain identification scales can contribute to a better intervention in painful situations and to systematized evaluations aiming at better management of pain, but few services use these instruments. During the choice of these instruments, the clinical conditions of the child, age, gender, socio-cultural aspects and cognitive development should be considered. The assessment provides the basis for the diagnosis, selection of treatments and evaluation of treatment efficacy for pediatric patients with acute, recurrent and chronic pain. Extensive research has resulted in the availability of a range of valid, reliable, and recommended tools to assess children's pain ⁹.

A systematic review on the quality of existing practice guidelines on pain management in children has led to the recommendation that pain assessment in children aged 0 to 18 years old should be self-reported as a gold standard whenever possible and for children who do not verbalize, behavioral measures should be used to assess pain, where such assessment should be documented before, during and after painful procedures and evaluated with the same frequency of other vital signs^9,10.

Valid and reliable pain assessment instruments are available for children of all ages and levels of development¹¹. The scales that measure the intensity of pain are insufficient to evaluate it, making it necessary to associate with other valid and reliable instruments that assess the impact of pain on children's quality of life (sleep, activities, social, school)⁹.

The first step in evaluating pain is to build a history of pain. The second step is to assess the child's pain using a pain assessment instrument appropriate for their cognitive development. The third step is to evaluate the effectiveness of pain relief interventions. Pain should be evaluated regularly to detect the presence of pain and to evaluate the effectiveness of treatments^9,12.

METHODOLOGY

This is a qualitative, descriptive study carried out in a pediatric ward of a university hospital in the city of Salvador, Bahia. This is a clipping of the graduate course in child health presented for the coordination of multi-professional hospital residency in health.

The study participants were nurses working in the pediatrics sector of the hospital with experience in the area of more than one year, with three nurses - two specialists in pediatrics, two nursing technicians, and two nursing assistants. The average experience of child health care varied in nine years among nurses; in three years, among the nursing technicians; and in twenty-two and a half years, among nursing assistants. In the unit, the staff is predominantly female, reflecting still a profession built with the social imaginary in the hospital environment and the specialty not being a place for men, because it is a space intended for women because they have the role of caregivers, a historical charge to which nursing is directly linked¹³.

This study was submitted and approved by the Ethics Committee of the institution, according to the opinion nº 79/11, dated November 08, 2011. A free and informed consent form was elaborated, in which the criteria established in the Resolution 196/1996 of the National Health Council were respected.

The semi-structured interview technique was used. The interviews were conducted during the work period of these professionals in January 2012. They were held at previously scheduled times, preserving the privacy of professionals and avoiding interruptions. For better use of the information, the narratives were recorded with the permission of the participants and transcribed for later systematization and analysis. To ensure the confidentiality of the information, the interviewees had their names identified by the following codes E1, E2, E3, and so on.

The data were systematized using the Thematic Content Analysis method proposed by Lawrence Bardin¹⁵, following the phases of pre-analysis, material exploration, treatment, inference and interpretation of the results obtained.

Based on the systematization process, the empirical material was grouped by similarities and differences, allowing the emergence of three thematic categories: Identification of pain in the hospitalized child; Pain assessment instruments; Prevention and treatment of pain.

RESULTS AND DISCUSSION

The results of the research reveal that pain management in children by nursing workers is carried out in stages involving the identification of pain, the use of instruments, their prevention, and their treatment, as illustrated in the following categories.

Identification of pain in hospitalized child

For proper management, the nursing team understands the need to identify the child's pain. They refer to perception through crying, speech, features, and movement restrictions.

Pain identification requires skills and knowledge to the professional. Responsibility for pain relief and child comfort requires an accurate assessment of the physiological, emotional, behavioral, and environmental aspects that cause pain in the patient⁹. Participants differentiated pain identification between age groups, associating behavioral aspects of the babies, such as crying and facial mimicry, and verbal reporting of children older than two years old.

The identification of pain in neonates and infants uses the behavioral and physiological parameters¹², such changes are in other age groups, which also begin to express through self-reporting⁹.

The most studied behavioral responses to pain are a motor response, facial mimicry, crying, and sleep and wake patterns¹⁶. This finding corroborates another study that identified crying as the best parameter for identification of pain in the newborn by the nursing team¹⁷. According to another study, crying analysis is an important aspect of proper pain management. Therefore, to be able to identify this specific form of communication by the health professional, it is necessary to know the characteristics of the crying of pain, as well as carefully observe the behavior of the child and this will certainly bring information for the correct and ready care to the child with pain to the caregiver⁸.

Although less frequent than crying, changes in facial expression and movement of children were other forms of pain identification by the participants, as they say:

The cognitive level, as well as the clinical condition of the child9, has to be considered to correctly identify pain in the child. Due to its subjective nature, it is up to the nurse to consider the genuineness of the pain complaint, which interferes with the care given to this complaint, since it is directly proportional to the professionals' knowledge, attitudes, and beliefs, acting as a compass in the management of pain¹⁸. However, when evaluating pain in the child, the professional should attend to the erroneous beliefs, internalizing the idea that the pain intensity is lower than in an adult, or that they will not remember the pain experience².

The identification of pain through self-reporting should consider the social context in which the child is inserted, the motivations and expectations of the child. In this sense, parents are important partners in this evaluation. Among the participants, none associated the parents' collaboration in the identification of pain. From a literature review, it was found that the participation of parents and family in the hospitalization of the child strengthens the psychosocial development, resulting in the greater adaptation of the child, consequently leaving the child more comfortable to expose their needs¹⁷.

The presence of the parents is fundamental in the evaluation of pain since the children learn with their parents how to interpret a symptom, to express discomfort and to respond to illness, injury or pain, which was confirmed in their study on the management of pain in pediatrics by the nursing team¹⁶. Even in the recognition of crying, behavior frequently cited as a form of pain identification, the mother or the caregiver intuitively learns to identify and differentiate it from other symptoms, making the importance of this partnership evident.

Incorrect identification of pain can lead the child to inadequate treatment, affecting morbidity, mortality, as well as higher hospital costs. In this study, no pain assessment scale was described as a pain identification method.

Although assessing and measuring pain are not easy tasks, these procedures should become routine for nurses and other nursing workers, who should record this information in the child's record so appropriate pain relief arrangements can be implemented⁹. It is necessary to make a judgment based on the analysis to identify pain in the child, associating the physiological and behavioral responses, which should not be interpreted individually, but in an integral way^9,11.

In a study about the perceptions of the nursing team regarding pain in neonatology, professionals associated pain with painful procedures, not identified in this study⁴. Because it is a subjective experience, it is not possible to prove the presence of pain, but it is possible to confirm the existence of signs associated with a painful condition^9,10.

Also in this context, the association of behavioral and physiological aspects makes pain assessment more complete, since only physiological changes, for example, changes in oxygen saturation, blood pressure, they are not specific for pain identification, and may be associated with other symptoms⁹. Only one research subject associated with his discourse the physiological and behavioral changes to identify the pain, which makes the other evaluations incomplete and fragile as to the accuracy of his data.

In these reports of this category, it is observed the absence and importance of the nursing care systematization, which would allow the identification of pain in a correct and standardized way, as well as defining the roles of women in pain management. This assistance is understood as a methodology used to organize, systematize the work based on the principles of the scientific method¹⁹. In addition, inadequate pain control is often related to the lack of criteria and methods of assessment and recording^4,11. Pain characteristics such as location, quality, intensity, onset, duration, worsening or improvement factors, associated factors, duration and magnitude of the relief obtained must be well known and recorded.

Pain assessment instruments

Not all members of the nursing team reported knowing and using the pain assessment instruments during its management.

For the pain to be assessed objectively and clearly, ensuring uniformity in this analysis, pain assessment scales were created according to the degree of development and clinical conditions of the child. These scales assist health professionals in assessing painful stimuli using isolated or associated physiological and behavioral parameters, helping to determine the need for specific intervention. These multidimensional instruments facilitate the interaction among health team members to observe and perceive the evolution of the pain in each patient and verify the response to the therapy implemented¹¹.

Among the participants of the research, two of them reported knowing at least one evaluation scale, strengthening the results found in another research about knowledge and perception of the nursing team in relation to pain in hospitalized children, in which 67% of the nurses knew more than three scales, while the nursing technicians only know the scales in 22% of them²¹.

The scale of faces was the most cited among the participants and the numerical was the second more mentioned, according to the following statements:

The lack of knowledge about the instruments of identification, reflecting the absence of a standardized assessment of pain, causes losses in the management of pain to the child. This lack of professional knowledge about this theme restricts the therapeutic actions performed for pain relief^21,22.

As for the time of experience in pediatrics, it was verified that most of the participants who had more than nine years of service did not know any instrument of evaluation of the pain. Professional experience, theoretical knowledge and the recognition of patient pain are controversial factors, presenting different results in several studies²³.

None of the research subjects used the scales in their clinical practice of pain assessment, based on behavioral aspects, a result also found in a study about the knowledge nurses in the neonatal intensive care unit have about pain in the newborn²². Thus, it is important the differentiated view with multidimensional perception of the pain experience being sensitive to the suffering of the other, being present, knowing to listen, touching, relating, requiring approximation, in the perspective of perceiving the subjective aspects of the pain, in which they react physically and emotionally to the suffering that pain brings them¹¹.

Pain Prevention and Treatment

Os sujeitos da pesquisa demonstraram prevenir a dor na criança de forma variada, através da redução da mobilidade, proteção da região dolosa e uso de medicamentos.

The research subjects demonstrated to prevent pain in the child in a varied way, through the reduction of mobility, protection of the malicious region and use of medicines.

Prevention is the best way to combat pain. It does not cause harm to the child's health, providing a qualified and humanized care, and should be a priority during child care, minimizing the number of painful or stressful procedures²⁴.

Regarding the use of drugs, it was seen the reproduction of the biomedical model inserted in the assistance provided, with the prioritization of the medicalization of the body over non-drug practices in the prevention and treatment of pain. It is noticed the need to modify the interventions performed for pain management through a continuous education, actions based on scientific evidence, protocols for prevention and treatment of pain²⁵ without necessarily being linked to drug therapies because the best way to guarantee the right of the child when not feeling pain is with prevention actions.

The treatment of pain involves both pharmacological measures and those that do not involve drug treatment, so-called non-pharmacological treatment¹¹. When questioned about the treatment for the complaint of pain, some participants reported performing the drug intervention in the first instance, as stated below:

In these reports, the routine of the nursing professionals as followers of the prescription for intervention in the pain complaint is observed. There was no characterization of the medication used, whether it is a non-steroid or opioid analgesic, which indicates the absence of a relationship between the pain intensity and the pharmacological treatment adopted, showing that the nursing team performs what is prescribed without evaluation of the clinical picture.

A study carried out with the aim of identifying the prevalence and intensity of pain, as well as its evaluation and drug treatment in hospitalized pediatric patients concluded that 43% of pediatric pain is underused with inadequate use of analgesic drugs²⁶.

Non-pharmacological interventions were considered by most of the research subjects as a complement to drug therapy as evident in the following statements:

Medication administration is the basis for pain relief, but because pain is more than a sensory experience, other non-pharmacological methods are an important part of pediatric patient care. In this scenario, the use of recreational resources to minimize the discomfort resulting from the child's hospitalization process is evident, since it allows the extravasation of feelings such as anger and hostility²⁶.

Other non-pharmacological practices have also been highlighted.

Among the non-pharmacological interventions reported by the participants, there was the use of thermotherapy, comfort massage and positioning results also found in a study on non-pharmacological interventions in pain control in neonates, which showed that these interventions were performed by an indiscriminate form of pain intensity²⁸.

Although most participants describe non-pharmacological measures as important and sometimes even superior activities to the use of drugs, the predominance of drug therapy as a more effective action is evident, because when asked which of the therapies considered more effective, five subjects reported it was drug treatment.

The overvaluation of drug therapy restricts the non-pharmacological activities used by nursing workers since in their activities they have described few and repeated interventions when the literature already offers a range of non-drug options for the treatment of pain in children²⁴.

Demonstrating the efficacy of non-pharmacological measures, a systematic review using the Cochrane method showed a meta-analysis involving 28 studies, a 20.65% reduction in pain attributed to non-pharmacological interventions, such as distraction, hypnosis, and anticipatory information²⁹.

Pain in children must be adequately identified, evaluated and, above all, treated, which is still a very difficult task for the multi-professional health team. In this way, it evokes the need for women workers to appropriate the use of instruments that guide the management of pain in children since they have a particular way of perceiving and demonstrating this experience²⁹.

CONCLUSION

Pain management should be one of the priorities during hospitalization in pediatrics since pain is a frequent complaint and can cause physical and psychological harm to the child's health. The evaluation of pain, without adequate protocols and/or instruments for the age, restricted the assistance, as well as the incipient knowledge of the professionals reinforces the permanence of this picture.

This article allowed understanding how the pain management in the child is given by nursing professionals, perceiving the perpetuation of the biomedical model. Prior pharmacological interventions were shown to the detriment of non-pharmacological ones, limited knowledge among the participants, insufficient interventions and little resolution, not using the appropriate instruments, besides the parental participation in this scenario. Such practices hinder to identify the child's needs in the context of pain.

In this way, we understand the need to strengthen nursing practices based on scientific knowledge, prioritizing preventive therapy, inferring in this process the partnership of the health institution through the systematization of nursing assistance in favor of patient safety. Finally, guaranteeing the right of the child not to feel pain when there are ways to avoid it is needed.

we identified the need to expand the field of study to other wards, specialized units in pain, other health services; and increase the number of participants as a limitation of the research.

REFERENCES

1. Persegona KR, Zagonel IPS. A relação intersubjetiva entre o enfermeiro e a criança com dor na fase pós-operatória no ato de cuidar. Esc Anna Nery. 2008 [Access on 2017 Oct 14]; 12:430-6. Available from: http://www.eean.ufrj.br/revista_enf/20083/artigo%204.pdf .

2. Silva LDG, Tacla MTGM, Rossetto EG. Manejo da dor pós- -operatória na visão dos pais da criança hospitalizada. Esc Anna Nery. 2010 (Internet), [Access on 2017 Oct 14]; 14:519-26. Available from http://www.scielo.br/pdf/ean/v14n3/v14n3a13.pdf .

3. Blasi DG, Candido LK, Tacla TGM, Ferrari RAP.Assessment and management of pain in child: perception of the nursing team. Semina cienc. biol. saude. 2015 (Internet), [Access on 2017 Oct 14]; 36(1,supl):301-10. Available from: http://www.uel.br/revistas/uel/index.php/seminabio/article/view/18491/16956 . Doi: 10.5433/1679-0367.2014v35n2p301.

4. Monfrim XM, Saraiva LA, Moraes CL. Scale of pain evaluation: perception of nurses in a neonatal intensive care unit. Rev. enferm. UFSM. 2015 (Internet), [Access on 2017 Oct 14]; 5(1):12-22. Available from: https://periodicos.ufsm.br/index.php/reufsm/article/view/15049/pdf . Doi: 10.5902/2179769215049.

5. Stevens BJ, Abbott LK, Yamada J, et al., CIHR Team in Children's Pain. Epidemiology and management of painful procedures in children in Canadian hospitals. CMAJ. 2011 (Internet), [Access on 2017 Oct 14]; 183(7):E403–E410pmid:21464171. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3080557/pdf/183e403.pdf . Doi: 10.1503/cmaj.101341.

6. Tacla MTGM, Lima RAG. Aspectos culturais do cuidado à criança com dor: vivência de enfermeiras pediatras. Cienc. Cuid. Saude. 2012 (Internet), [Access on 2017 Oct 14]; 11:71-7. Available from: http://www.periodicos.uem.br/ojs/index.php/CiencCuidSaude/article/view/17054/pdf . Doi: 10.4025/cienccuidsaude.v10i5.17054.

7. LaFond CM, Van Hulle Vincent C, Oosterhouse K, Wilkie DJ. Nurses' Beliefs Regarding Pain in Critically Ill Children: A Mixed- -Methods Study. Journal of pediatric nursing. 2016 (Internet), [Access on 2017 Oct 14]; 31(6):691-700. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124392/pdf/nihms810632.pdf . Doi:10.1016/j.pedn.2016.08.002.

8. Rodrigues JB, Souza DSB, Werneck AL. Identificação e avaliação da percepção dos profissionais de enfermagem em relação a dor/ desconforto do recém-nascido. Arq cienc saúde. 2016 (Internet), [Access on 2017 Oct 14]; 23:27-31. Available from: http://www.cienciasdasaude.famerp.br/index.php/racs/article/view/108/173 . Doi: 10.17696/2318-3691.23.1.2016.108.

9. Manworren RC, Stinson J. Seminars in Pediatric Neurology Pediatric Pain Measurement, Assessment and Evaluation. Seminars in pediatric neurology. 2016 (Internet), [Access on 2017 Oct 14]; 23(3):189-200. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5261830/pdf/nihms831892.pdf . Doi: 10.1016/j. spen.2016.10.001.

10.Lee GY, Yamada J, Kyololo O, Shorkey A, Stevens B. Pediatric clinical practice guidelines for acute procedural pain: a systematic review. Pediatrics. 2014 (Internet), [Access on 2017 Oct 17]; 133(3):500-15. Available from: http://pediatrics.aappublications.org/content/pediatrics/133/3/500.full.pdf . Doi: 10.1542/ peds.2013-2744. Epub 2014 Feb 2.

11.Santos JP, Maranhão DG. Cuidado de Enfermagem e manejo da dor em crianças hospitalizadas: pesquisa bibliográfica. Rev Soc Bras Enferm Ped. 2016 (Internet), [Access on 2017 Nov 14]; 16:44-50. Available from: https://sobep.org.br/revista/images/ stories/pdf-revista/vol16-n1/vol_16_n_1-artigo-de-revisao-2.pdf

12.Rodrigues JB, Souza DSB, Werneck AL. Identificação e avaliação da percepção dos profissionais de enfermagem em relação a dor/desconforto do recém-nascido. Arq Ciênc Saúde. 2016 (Internet), [Access on 2017 Nov 14]; 23:27-31. Available from: http://www.cienciasdasaude.famerp.br/index.php/racs/article/view/108/173 . Doi: 10.17696/2318-3691.23.1.2016.108

13.Souza LL, Araújo DB, Silva DS, Bêrredo VCM. Representações de gênero na prática de enfermagem na perspectiva de estudantes. Ciências & Cognição. 2014 (Internet), [Access on 2017 Nov 14]; 19(2):218-32. Available from: http://www.cienciasecognicao.org/revista/index.php/cec/article/view/908/pdf_13

14.Ministério da Saúde (Br).l Diretrizes e Normas regulamentadoras de pesquisa envolvendo seres humanos: Resolução 196/96 do Conselho Nacional de Saúde. Rio de Janeiro: Ministério da Saúde/ Fundação Oswaldo Cruz, 1996.

15.Bardin, L. Análise de conteúdo. São Paulo: Edições 70, 2011.

16.Guinsburg R, Arias MCC. A linguagem da dor no recém-nascido. Documento Científico do Departamento de Neonatologia Sociedade Brasileira de Pediatria. São Paulo, 2010 (Internet), [Access on 2017 Oct 14]; Available from: http://www.sbp.com.br/pdfs/doc_linguagem-da-dor-out2010.pdf

17.Brassolatt MM, Veríssimo MLaÓR. A presença dos pais e a promoção do desenvolvimento da criança hospitalizada: análise da literatura. Rev Soc Bras Enfer Ped. 2013 (Internet), [Access on 2017 Nov 14]; 13:37-45. Available from: http://www.sobep.org.br/revista/component/zine/article/167-a-presena-dos-pais-e-a-promoo-do-desenvolvimento-da-criana-hospitalizada-anlise-da-literatura.html

18.LaFond CM, Van Hulle Vincent C, Oosterhouse K, Wilkie DJ. Nurses' Beliefs Regarding Pain in Critically Ill Children: A Mixed- -Methods Study. Journal of pediatric nursing, 2016 (Internet), [Access on 2017 Nov 14]; 31(6):691-700. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5124392/pdf/nihms810632.pdf Doi:10.1016/j.pedn.2016.08.002.

19.Monteiro AR, Schreiber G, Sade PMC. O papel do enfermeiro frente ao manejo da dor em adultos. Revista Eletrônica da Faculdade Evangélica do Paraná, Curitiba, 2011 (Internet), [Access on 2017 Nov 14]; 1:2-11. Available from: http://www.fepar.edu.br/revistaeletronica/index.php/revfepar/article/view/21/34

20.Nicolau CM, Modesto K, Nunes P, Araújo K, Amaral H, Falcão MC. Avaliação da dor no recém-nascido prematuro: parâmetros fisiológicos versus comportamentais. Arquivos Brasileiros de Ciências da Saúde, 2008 (Internet), [Access on 2017 Nov 14]; 33: 146- 50. Available from: http://files.bvs.br/upload/S/1983-2451/2008/v33n3/a146-150.pdf

21.Oliveira Júnior AR, Paula WKAS, Guerra MCGC. Dor no recém- -nascido: estudo transversal sobre assistência de enfermagem em unidades neonatais. Revista enfermagem UFPE Online. 2011 (Internet), [Access on 2017 Nov 14]; 11(1):125-32. Available from: http://www.ufpe.br/revistaenfermagem/inde x.php/revista/article/view/1428/pdf_618

22.SilvaGM, Figueiredo MGS, Kameo SY, Oliveira FM, Dantas SA. Intensive care nurses knowledge on pain in preterm newborns. Rev iberoam educ invest Enferm (Internet), 2015 [Access on: 2017 Nov 14]; 5(1):47-55. Available from: http://www.enfermeria21.com/revistas/aladefe/articulo/150/

23.Kanai KY, Fidelis WMV. Conhecimento e percepção da equipe de enfermagem em relação à dor na criança internada. Revista Dor (Internet), 2010 [Access on 2017 Nov 12]; 11:20-7. Available from: http://files.bvs.br/upload/S/1806-0013/2010/v11n1/a1495.pdf

24.Motta GCP, Cunha MLC. Prevention and non-pharmacological management of pain in newborns. Rev bras enferm. (Internet), 2015; 68(1): 131-5. Available from: http://www.lume.ufrgs.br/bitstream/handle/10183/117307/000966524.pdf?sequence=1 . Access on 2018 Jan 14. Doi: 10.1590/0034-7167.2015680118p.

25.Khoza SLT, Tjale AA. Knowledge, attitudes and practices of neonatal staff concerning neonatal pain management. Curationis, (Internet), 2014 [Access on 2017 Nov 14]; 37(2):E1-9. Available from: http://curationis.org.za/index.php/curationis/article/viewFile/1246/1468>Doi:10.4102/curationis.v37i2.1246

26.Taylor EM, Boyer K, Campbell FA. Pain in hospitalized children: A prospective cross-sectional survey of pain prevalence, intensity, assessment and management in a Canadian pediatric teaching hospital. Pain Research &Management, 2008; 13:25-32.

27.Monteiro ACM, Rodrigues BMRD, Pacheco STA, Pimenta LS. A atuação do enfermeiro junto à criança com câncer: cuidados paliativos. Rev Enferm UERJ, (Internet), 2014 [Access on 2017 Feb 21]; 22:778-83. Available from: http://www.facenf.uerj.br/v22n6/v22n6a09.pdf

28.Batalha LMC. Intervenções não farmacológicas no controlo da dor em cuidados intensivos neonatais. Rev Enferm Referência, 2010; III(2):73-80.

29.Uman LS, Chambers CT, McGrath PJ, Kisely S. A systematic review of randomized controlled trials examining psychological interventions for needlerelated procedural pain and distress in children and adolescents: An abbreviated Cochrane Review. Journal of Pediatric Psychology, 2008; 3:842-54.