Acute pain management and control among children with sickle cell anemia attending the Sickle Cell Clinic - Mulago Hospital

Abstract

Background: Sickle cell disease is the most common hemoglobinopathy worldwide with the greatest burden of the disease occurring in sub-Saharan Africa. Pain is the hallmark of Sickle Cell Anemia. Despite the fact that pain is the most common reason for hospital visit, studies on pain assessment and treatment are scarce. Those available have documented that children with Sickle Cell Anaemia often suffer both under treatment and over treatment of their pain in hospital. The Sickle Cell Clinic Day Care Centre is an innovation for treating children with SCA with acute pain and no medical complications as outpatients. Although Day Care Clinic based management of acute painful episodes has been in existence for years, adequate information on treatment outcomes and associated factors that could be used to improve acute pain management for children with SCA is not available in Sickle Cell Clinic at Mulago Hospital. Objectives: This study aimed to evaluate pain management, describe the treatment outcomes and associated factors among children with sickle cell disease who present with acute pain at the Sickle Cell Clinic. Methods: A prospective cohort study with qualitative and quantitative components was done at the Mulago hospital Sickle Cell Clinic. Children with SCA aged 6 months to 12 years old with an acute painful episode were enrolled. History, examination and pain severity was scored using age appropriate pain assessment tools. Children were re assessed at discharge from the Day Care Centre and followed up at 72 hours to determine the treatment outcomes. Key informant interviews and focused group discussions with health workers at the clinic were conducted. Data was entered into Epi data version 3.1, exported to and analysed using STATA version 12.0. The proportion of children with adequate and inadequate pain control was done using descriptive statistics. The factors associated with the outcomes by logistic regression. Qualitative data was analyzed manually using the content thematic approach. Results: A total of 317 children of ages between 6 months and 12 years were enrolled with mean age of 6(±3.4) years. At discharge from the day care clinic 65.6% of children had inadequate pain control and 34.4% were adequately controlled. After 72 hours, 270(85.4%) had adequate pain control and 46(14.6%) inadequate pain control. The factors that were significantly associated with inadequate pain control both at discharge from day care and at 72 hours were having lower limb pain OR=11.9, 95%CI: (0.8-17.5), p=0.020, having shortness of breath OR=5. 95%CI: (1.4-18.7), p =0.05 and receiving an under dose of morphine OR=9.1, 95%CI: (1.8-44.9), p=0.007.Inconsistent drug supply, inadequate pain assessment, attitude of health workers and lack of knowledge on pain treatment guidelines were also associated with sub optimal pain management. Conclusion: Two thirds of children receive suboptimal pain management from the DCC. The significantly associated factors being under dose of morphine, lower limb pain, and shortness of breath, inconsistent supply of drugs, inadequate training and assessment of pain, health worker attitude and lack of knowledge of pain treatment guidelines. Training in pain assessment and treatment should be done for all health workers involved in care of children with sickle cell anemia.