Behaviors, other factors affect parents' interpretation of ear pain in young children

Parents of preverbal children with acute otitis media (AOM) look at their child’s observable behaviors to determine their pain level. Although no specific symptom dictates parental assessment of pain, ear tugging and fussiness appear to be the symptoms that most influence parental perception of pain. However, interpretation of these behaviors is influenced by other factors, like socioeconomic status, according to a study published in the Journal of Pain.

Although preverbal children make up the majority of children with AOM, it has been unclear how parents decide whether a child has ear pain and which symptoms affect their assessment of pain, said researchers. Information about which symptoms have high levels of association with ear pain would help clinicians focus their history taking.

The researchers studied how parents of preverbal children determine the level of ear pain. They created 7 case scenarios of a 1-year-old child with a variety of symptoms typically associated with AOM and 1 case scenario describing an asymptomatic child. The symptoms included ear tugging, fussiness, fever, eating less, trouble sleeping, and playing less.

The study included 69 parents who had young children with a history of AOM and who presented for a well or sick visit at an ambulatory clinic. Parents were asked to rate the child’s pain level for each case scenario. Most of the parents were black, had public health insurance, and did not have a college degree.

Cases with more symptoms were assigned higher pain scores by parents. Cases with 4 symptoms were assigned higher pain scores than cases with 3 symptoms. The case with the asymptomatic child was assigned the lowest pain scores.

A univariate analysis found that each of the symptoms appeared to be linked with increased pain levels. A multivariate analysis showed that fussiness and ear tugging were most associated with pain, whereas eating less and playing less were the least associated with perceived pain level.

Parents with higher levels of education and those with private insurance tended to report slightly higher levels of pain (P=.007 and P=.001, respectively). Race did not appear to significantly influence pain level.

The findings indicate that not only did a child’s symptoms influence parental perception of pain but other factors, such as maternal education and type of insurance, also influenced parents’ perception. This is not surprising, according to the investigators, because pain is a subjective construct and more apt to be influenced by biological, psychological, and social factors.

“In a clinical setting, we feel that asking parents about specific observable behaviors, such as ear tugging and fussiness, would nicely complement a general question about ear pain. This would ensure that clinicians are aware of the specific symptoms present and at the same time fully understand and address parental concerns about their child’s condition,” researchers said.

Limitations of the study included a small sample size and a homogeneous study population. Also, parents’ responses to cases regarding a hypothetical child may differ from their responses to their own child.

Shaikh N, Kearney DH, Colborn DK, et al. How do parents of preverbal children with acute otitis media determine how much ear pain their child is having? J Pain. 2010;11(12):1291-1294.