|Year : 2016 | Volume
| Issue : 2 | Page : 116-121
How common is pain in Indian school going children? A phase 1 pilot study
Vrushli Ponde, Dipal Shah, Anuya Gursale, Kiran Patel, Vishal Baldua
Holy Family Hospital and Research Centre, Mumbai, India
|Date of Web Publication||18-Jul-2016|
Holy Family Hospital and Research Centre, Hill Road, Bandra West, Mumbai - 400 052
Source of Support: None, Conflict of Interest: None
Background: There is a lack of information about the prevalence of pain among school going Indian children, and therefore, this study was conducted. A cross-sectional population survey was conducted in school children from Grades III to VI. The objective was to determine the prevalence of pain, including chronic pain. The secondary objectives were to find a correlation between chronic pain with age, gender, parental history of chronic pain and past surgical history along with the various characteristics of chronic pain. Method: Seven hundred questionnaires were distributed in schools from Grades III to VI. They were answered at home by the children along with their parents. The data thus obtained were analyzed with appropriate statistical tests. The level of significance was set at P ≤ 0.05. Results: The overall prevalence of non-chronic pain was found to be 37.6% (95% confidence interval being 34.0-41.2%). The prevalence of chronic pain was 3.90% (95% confidence interval being 2.86-4.94%). There was no statistically relevant correlation between gender, age, family history of chronic pain, or past surgical history with chronic pain. Conclusion: Our study suggests that prevalence of pain in Indian school going children is common, although the prevalence of chronic pain is far less than that estimated world-wide.
Keywords: Epidemiology, Indian, pain, school children
|How to cite this article:|
Ponde V, Shah D, Gursale A, Patel K, Baldua V. How common is pain in Indian school going children? A phase 1 pilot study. Indian J Pain 2016;30:116-21
| Introduction|| |
Chronic pain in children has a staggering prevalence of 20% world over.  There is limited information available on the prevalence of pain in general as well as chronic pain in Indian children. Hence, this study was conducted.
Pain in adults and its various treatment modalities are well-established. Pediatric pain, on the other hand, remains underdiagnosed and consequently undertreated. The primary initiative for the treatment of any type of pain in children is to explore and establish its epidemiological factor followed by its treatment as required. Few epidemiological studies have been conducted to estimate the prevalence of persistent pain in children in the past with some investigators addressing specific conditions such as a headache or abdominal pain.  The primary objective of this study was to determine the prevalence of overall pain and chronic pain, in Indian school going children. The secondary objectives were to understand the characteristics of pain such as its frequency, intensity, and duration in those who had chronic pain. We also tried to find any correlation between prevalence of chronic pain in children with age, gender, parental history of chronic pain, and past surgical history.
| Methods|| |
The Ethical Committee approval for the study was obtained. Informed consent from the parents to participate in this survey and for publication of the data was taken. This was a cross-sectional population survey conducted in school going children.
We included 700 children from the age of 6 to 12 years, studying in Class 3 to Class 6. The principals of the respective schools were contacted and the permission to conduct this survey was obtained. Each school allotted us a single point of contact. This person functioned as a connecting point between the parents or guardians and the investigating team.
A structured questionnaire was especially designed for this study and was adapted to the particular age group. This was in the form of a simple multiple choice questionnaire [Appendix 1]. The informed consent forms and questionnaire were distributed among the children. They were asked to fill it at home along with their parents or guardians. The answered questionnaires were collected by the schools and handed over to our surveying team for analysis. The questionnaire recorded the name of the participating school followed by the demographics of the child such as the age, gender, school year, date of birth, address and their emergency contact number. The initial question assessed the presence of pain. If the answer was negative, the participants were not required to answer any further questions in the survey. Those who answered in affirmative to the presence of pain were expected to complete the questionnaire. Those who answered positively to the presence of pain for 3 months or more were categorized to have chronic pain. For those with chronic pain, the various characteristics of pain were then noted and data were analyzed.
Data were analyzed using Spss software version 15 (IBM Inc. Chicago, IL, USA). Data was given as mean ± standard deviation or percentage. Prevalence and 95% confidence interval of prevalence were calculated using a normal distribution of Z-test. Chi-square test and Fisher exact probability test was applied to compare percentages. The level of Significance was taken as P ≤ 0.05. All tests were two-tailed. Our study had the power of 99% to detect the prevalence of 0.38 with α of 0.05 using Binomial proportion method with a sample size of 692 subjects.
| Results|| |
A total of 700 questionnaires were distributed to children belonging to 6-12 years of age. Of these, 8 did not return the questionnaires giving us a responder rate of 98.86% (692). The nonresponders were excluded from the study. In the remaining 692 children, 352 (50.9%) were male and 340 (49.1%) were females.
A total of 260 (37.6%) children gave a positive reply to the presence of pain while 404 (58.4%) refused it. The 28 (4.0%) children who consented to the questionnaire but gave no further response were included in the study but excluded from any further analysis. The 404 children who reported no pain were also excluded from further statistical analysis. Of these 260 children, there were 352 (50.9%) males and 240 (49.1%) females. Of the 260 children who replied positively, 27 children had pain for the last 3 months or more.
The overall reported prevalence of pain in children aged between 6 and 12 years in our study was as found to be 37.6% (95% confidence interval being 34.0-41.2%) while that of chronic pain was 3.90% (95% confidence interval being 2.86-4.94%).
For children with chronic pain following observations were made.
Of the 27 children with chronic pain, 15 male and 12 female children had the presence of pain for 3 or more months. There was no association found between the presence of chronic pain with gender (Pearson Chi-square = 1.11, df = 2, P = 0.572).
The mean age for all children with pain was 8.75 ± 1.26 years. For those with pain <3 months, the mean age was 8.81 ± 1.25 years versus 8.89 ± 1.28 years for those with chronic pain (P = 0.821, not significant). The age-wise distribution among children with chronic pain is as shown in [Table 1]. There was no correlation between chronic pain with any particular age group (Fisher's exact test 8.778, df = 12, P = 0.688).
Among those with chronic pain, leg pain was the most common. [Table 2] outlines the distribution of chronic pain at various sites. Chronic pain of severity of Grade 1 and Grade 3 was more common [Figure 1]. Six of these 27 children had continuous pain. The frequency of pain was as shown in [Table 3]. Most had pain for about 2-3 times a month.
None of the children with chronic pain had their sleep affected due to pain and slept well at night. Physical activity was the single most common factor reported to increase the pain severity while rest accounted for the most common relieving factor [Table 4]. Dull type of pain was most common followed by throbbing and pricking type [Figure 2]. Six children had their pain severe enough to affect their attendance at school and the frequency of absentees in school was as in [Table 5]. Twenty-four children actively participated in sports while 3 did not. Of the 27 kids with chronic pain, only 4 had an ongoing treatment for chronic pain.
Four of the 27 children had a history of surgery performed. There was no significant association between chronic pain and operations (Fischer exact test 3.163, df = 4, P = 0.558). Eight children had a positive family history of pain, but there was no significant association between chronic pain and family history (Fischer's exact test = 7.68, df = 4, P = 0.96).
| Discussion|| |
Because we do not know the epidemiology of pain in Indian kids, we felt that it was important to elucidate the prevalence of overall pain along with chronic pain. If the pain attributes are known and analyzed the chances of recognizing and treating it may improve.
Our community sample showed that 37.6% school going children complained of pain and 3.9% suffered from chronic pain. This is the first study which tries to provide a comprehensive picture of pain, in general, and chronic pain in particular in Indian children aged 6-12 years. The operational definition of chronic pain in our survey was taken as pain lasting for 3 or more months as defined by the International Association for the Study of Pain.
Perquin et al.  analyzed a large representative sample of school children for all pain experiences and found that 25% of the subjects reported chronic or recurrent pain of 3 months or longer. King et al.  in his systematic review found median prevalence rates of chronic pain in children to be 11-38%. In a similar study carried out by Haraldstad et al.  on 1238 Norway children aged 8-18 years, the overall prevalence was found to be 21% and with the questionnaire filled by children and adolescents to be as high as 60% which is quite higher than that found in our study. They had concluded that parents seem to be less aware regarding the presence of chronic pain in their children. This could be the probable reason for relatively less prevalence found in our study since the questionnaires were completed by the parents although the children were involved in choosing the answer. Furthermore, the difference in the prevalence rates could be due to the difference in the age group that was studied. Their study had found a positive association between age and pain while girls in age group of 16-18 years reported more pain. This higher prevalence has been attributed to menstrual problems and better education. A similar correlation between age and gender has also been found in the Dutch children aged 0-18 years as studied by Perquin et al.  and in a systematic review undertaken by King et al.  However in our study, we found no such correlation between age or gender and chronic pain.
In our study, head, abdominal pain, and back were the most common types of pain. Similar results have been observed by Perquin et al.  in children aged more than 8 years. We did not evaluate for individual site details and characteristics of overall pain. These results are not comparable since several studies have reported varying prevalence rates for individual types of pain as studied by King et al.  in the systematic review of the studies of chronic and recurrent pain such as headache (8-83%); abdominal pain (4-53%); back pain (14-24%); musculoskeletal pain (4-40%); multiple pains (4-49%); other pains (5-88%). van Dijk et al.  reported a headache to the most common pain symptom in a school survey conducted in a cohort of 495 children, this is similar to our finding.
In our study, single location pain of dull, throbbing, and pricking type predominated. Perquin et al.  had found about one-third of patients with chronic pain to have severe and frequent pain. However in our study <22.2% of the children had severe or continuous pain. Physical activity and fasting were the most common aggravating factor while rest and sleep were most common relieving factors. Sleep and interests in sports were not affected in the majority of the children with chronic pain.
The pain prevented 25% of children who experienced chronic pain from attending school, overall although it did not seem to affect the school attendance much. Eleven percent of children who experienced chronic pain from attending school lacked interest in sports.
Our study found no definite relation between chronic pain in the family and chronic pain in kids.
The perception of pain can and its reporting can be variable in children. Srouji et al.  in their review of pain assessment scales in children found that by age of 4 children are usually able to use 4-5 item pain discrimination scales and by age of 5 gain the ability to recognize the influence of pain and rate the intensity of pain and by age of 7 and 8 can begin to understand the quality of pain and also answer few pediatric pain questionnaire. The mean age group of the children in our study was 8.75 ± 1.26 years. Furthermore, the questionnaires were completed by the parents and kids together. Hence, we are safe to assume that their understanding of pain and its characteristics with its reporting in the questionnaire to be reliable.
Limitations of our study
Probably extending our study to adolescent age group could have yielded positive correlation with age and gender as found in previous studies. Since the perception of pain However, our study did not aim to study the adolescent age group. We did not study the socioeconomic background and psychological factors such as anxiety and depression in the participants and hence its effect on chronic pain in children cannot be commented on. Since this is a cross-sectional study, the changes if any occurring in the prevalence rates or nature of different kinds of pain in various age group cannot be assessed and the chances of underestimation of the disease prevalence cannot be ruled out. Hence, we recommend a wider age group with long-term follow-up and longitudinal studies for better evaluation and understanding of chronic pain in children.
| Conclusion|| |
From this study, it seems that in Indian school going children nonchronic is far more common than chronic pain with a prevalence of 37.6%. The prevalence of chronic pain is 3.9%. Larger randomized longitudinal studies could probably provide more information regarding chronic pain and its characteristics in children.
Financial support and sponsorship
Funding received from Holy Family hospital and Research Centre.
Conflicts of interest
There are no conflicts of interest.
| References|| |
Perquin CW, Hazebroek-Kampschreur AA, Hunfeld JA, Bohnen AM, van Suijlekom-Smit LW, Passchier J, et al.
Pain in children and adolescents: A common experience. Pain 2000;87:51-8.
King S, Chambers CT, Huguet A, MacNevin RC, McGrath PJ, Parker L, et al.
The epidemiology of chronic pain in children and adolescents revisited: A systematic review. Pain 2011;152:2729-38.
Haraldstad K, Sørum R, Eide H, Natvig GK, Helseth S. Pain in children and adolescents: Prevalence, impact on daily life, and parents' perception, a school survey. Scand J Caring Sci 2011;25:27-36.
van Dijk A, McGrath P, Pickett W, VanDenKerkhof EG. Pain prevalence in nine- to 13-year-old schoolchildren. Pain Res Manag 2006;11:234-40.
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[Figure 1], [Figure 2]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]