Recognizing socioeconomic and cultural determinants to pain control As pediatric pain medic ine has improved drastically in developed countries and for families with good access to he alth care, the next frontier in improving access to better pediatric pain treatment is to a ddress the inequalities of pediatric pain management for unders- erved patients and familie s. If untreated pain is an unjust suff ering, on either the rights argument or the basic re quirement of the harm principle, we have reason to address disparities in access to pain co ntrol in children between high-resource and low-resource com- munities. Included among such communities are not only low-in- come countries, but also low-income neighborhoods and reg ions in middle-to-high-income countries. Just as with adults, children the world over exper ience acute and chronic pain, and yet we still lack robust epidemiological data on childhoo d and adolescent pain prevalence (Berde et al., 2012; King et al., 2011). Accurately map- p ing the global burden of any disease is the fi rst step in recognizing suff ering, and a ne cessary step toward addressing a need in some- times marginalized populations. A fairly pervasive example of this phenomenon may be seen in the failure of broad-scale eff orts to treat needle pain. Oft en state- ments refl ecting the view that pain is a part of life and children need to cope with it serve as justifi cation for failing to treat pain a ssoci- ated with needles (Taddio et al., 2009). Th e unfortunate outcome is that immunizati on rates are lowered by individuals who avoid needles and an estimated 10% of adults avoid contact with medical institutions, even when indicated, due to fear of needles (Hamilton, 1 995). As our understanding of the global burden of pediatric chronic and acute pain prevalence an d causes improves, we can more eff ec- tively target the scale-up of pain treatment regimen s in underserved areas. Th e most pressing immediate need is for pain medicines and supplie s, and improved clinical training for pain diagnosis and treatment among medical care provi ders. Implementation of pain programs require evidence-based advocacy from professional org anizations, and an appeal to the arguments from ethics and social justice presented above. Nearly 20 years ago, Walco et al. (1994, p. 543) concluded, \200\230All health professiona ls should provide care that refl ects the techno- logical growth of the fi eld. Th e assess ment and treatment of pain in children are important parts of pediatric practice, and failu re to provide adequate control of pain amounts to substandard and unethical medical practic e \200\231. Unfortunately recent data on required and optional coursework indicate that med ical school education in North America falls well short of the mark in preparing prac- titi oners to make these informed decisions (Mezei and Murinson, 2011). Th ose advocating for better access to pain control in resource- poor communities also face a perception that there are more dire needs to be met fi rst \200\224for example, malaria, childhood vaccination, clean water, or nutrition. Because a child \200\231s pain left untr eated is an CHAPTER 64 the ethics of pain control in infants and children 665 unjust suff ering, except in the cases where the pain treatment would cause more harm than the pain itself, pain treatment cannot be viewed as a luxury. It should be viewed as equall y critical, alongside the provision of preventive care, such as vaccinations, and the treat - ment of acute infections and other endemic diseases that dispropor- tionately aff ect chi ldren living in poverty. For health professionals serving children and families in poor com munities, greater eff ort may be required to advocate for coverage of good pain management and of palliative care when resources are not readily available. strong; my son does not need morphine \200\231 \200\224a provider \200\231s fundamental eth ical duty is to minimize harm and suff ering for the patient, but this can be managed with cultural sensitivity. As argued earlier in considering pragmatic appeals to non-treatment o f pain, the duty to prevent harm and the rights argument ought to outweigh any cul- tural a ppeal to allowing pain in children. Where adults may be free to martyr themselves or choose to undergo suff ering and pain for a greater good or for deeply held spiritual or cultural beliefs, they are not free to martyr their children ( Prince v Massachusetts , 1944). In p ractice, there are more sensitive and eff ective ways to navigate cul- tural beliefs in a f amily. Understanding cultural perceptions of pain can help shape care providers \200\231 co nversations with families about pain management; introducing current models of pain mechani sms and processing may counter cultural beliefs that mitigate adequate pain treatment. In t he end, awareness of cultural underpinnings for undertreatment of pain can help shape clini cal strategies but does not alter the basic moral obligation to treat a child or infant \200\231s pain. (Please see Clemente, Chapter 11, this volume.) As we expand eff orts to improve access to eff ective pain manage- ment for all families ac ross socioeconomic and political borders, we will also encounter a wider array of cultural beliefs about pain. Pain is a subjective experience imbued with social and cultural meaning , and this known variation in the experiences of pain has three sig- nifi cant ethical impl ications for practice in diverse patient popula- tions (Craig and Pillai Riddell, 2003). First, social and cultural factors may impact whether and to what degree parents pursue or have adequate access to information and resources for addressing their child \200\231s pain . Given that there is vari- ation in parents \200\231 acceptance of exposures to pain, inju ry, or risk in children (Goodman and McGrath, 1991), children from some com- munities may b e at greater risk for injury and pain, and less likely to have access to treatment. In this case, undertreatment of pediatric pain may be consonant with other socioeconomic determina nts of health care access for children from marginalized groups or com- munities and could be embraced as part of a more general eff ort to address health disparities in child health . Ethical considerations in pediatric pain research As already discussed, optimal clinical de cision-making is based on evidence. Th e more data we have on the safety and eff ectiveness of available treatments for the population to which they will be administered, the better. If, for example, we wish to understand the safety and effi cacy parameters of using a spec ifi c analgesic medica- tion for pain relief in premature neonates, ideally we would have d ata from pharmacokinetic and pharmacodynamic studies, as well as from effi cacy trials cond ucted in that population at our disposal (Anand et al., 2006). However, there are some sign ifi cant ethical and pragmatic challenges to be addressed in order to do so. Second, specifi c cultural beliefs may discourage the expression or reporting of pain as a weakness, making it more diffi cult to assess pain in a child patient. For example, one stu dy of Somali families reported a belief that adults and children, especially men and boys, are expected to be stoic when in pain and not openly express pain (Finnstrom and Soderhamn, 2006). For providers treating children from culturally diverse communities, approaching fa milies with cultural humility \200\224asking questions to help understand beliefs about a c hild \200\231s pain \200\224can help inform a respectful approach to these patients, while also being alert to the potential underreport- ing of pain. In approaches to treating chron ic pain and end of life care, it is also important to distinguish cultural beliefs and prac tices of a particular family from lack of knowledge about the nature of pain in a child or unfamiliarity with available treatments (Zalon et al., 2008). In such circumstances provide rs have an opportunity to educate parents about the biological and sensory nature of pain i n children, ultimately to help them understand when pain treat- ment is necessary for allev iating a child \200\231s physical suff ering. Th e US government enacted a series of laws seeking to improve knowledge of the safety and effi cacy of specifi c drug preparations as applied in pediatric population. Th ese include d the Food and Drug Administration Modernization Act (FDAMA) of 1997, the Best Pharmaceutic als for Children Act (BPCA) in 2002, and the Pediatric Research Equity Act (PREA) in 2003 ( Sachs et al. 2008). As a function of these initiatives, as of 4 January, 2012, there have b een 426 labeling changes, including 388 trials involving children. Although these results a re certainly encouraging there have been very few labeling changes for medications specifi cally indicated for pain. Th us, in our current state, for children under 6 months of age, there are no medications l abeled for pain relief. For children between 6 and 24 months, only ibuprofen has been appro ved for analgesia, and for those older than 2 years, the list expands to include oral aceta minophen, aspirin, meperidine, hydroco- done, tolmetin, the combination product of acetamin ophen and codeine (for age >3 years), intravenous acetaminophen, buprenor- phine, meperidin e, and fentanyl citrate; epidural chloroprocaine, lidocaine, and mepivacaine, continuous ep idural clonidine (for intractable cancer pain), and transdermal fentanyl. A handful of othe r non-steroidal anti-infl ammatory medications are approved for the treatment of arthritis and have analgesic eff ects, including celecoxib, naproxen for children over 2 years, and e todolac and oxaprozin for those over 6 years (Sachs et al., 2008; United States Food and Dr ug Administration, 2012). It should be noted that of these, aspirin is not used due to conc erns for Reye syndrome, Th ird, perceptions or beliefs among providers and other sys- temic factors may lead to dis parities in the treatment of pain for some minority families and communities. For example, a review of pain studies in adult patients in the United States demonstrated that blacks an d Hispanics are more likely to be undertreated for pain than white patients (Bonham 2001). More data are needed to understand the exact causes of such patterns of undertreatment, but a fi rst step is to be alert to patterns of discrimination and to highlight the importance of correcting such disparities in pain management training and practice by emphasizing the univer- sally experienced phenomena of pain across ethnic populations (Edwards et al., 200 5). In those cases where a parent \200\231s cultural beliefs discount a child \200\231s pain \200\224for example, \200\230in our culture it is important for a boy to be SECTION 9 special topics 666 meperidine due to concern about normeperidine induced central nervous system excitation and seizures, and codeine due to its variable metabolism. Th e issue becomes even more complicated when one invokes local standards. Consider a study of venepuncture in newborns. In Institution A, the local standard is to provide a topical anesthetic and sucrose. In Institution B, there are no standard interventions for needle pa in. A placebo controlled trial is clearly not acceptable in the former setting, but is it a cceptable in the latter? What con- stitutes \200\230local \200\231 to defi ne standards, t he institution, the immediate geographic area, the region, the country? What if the latter setting is in a less developed nation where innovation in pain medicine has been slow to em erge or almost non-existent? Th ere is no consensus on these important issues at present. Recognizing the slow progress, in 2009, the United States Food and Drug Administration conv ened a panel of experts to examine the design of analgesic trials in children, including an examination of the propriety of extrapolating safety and effi cacy data from adult studies and to recommend the best validated outcome measures for assessing pain (Berde et al., 201 2). Th e standard paradigm used to show the clinical effi cacy of analgesic medications is a placebo controlled trial. However, administration of placebos may involve additional expo sure to pain by the child participant and therefore constitutes an ethical violation as it exposes the research participant to greater than minimal risk (Shaddy and Denne, 2010). It is not acceptable for a minor research participant to experience untreated pain, even for a very brief period, as that presents increased risk over standard care. While such risk may be deemed acceptable to adults who may evaluate their plights aft er fully informed consen t, this process is not reasonable for minors, especially those who are preverbal and cannot possibly understand the risk \200\223benefi t analy- sis involved. It was concluded that w hen extrapolation from adult studies is deemed inadequate to demonstrate safety and effi ca cy in younger patients, alternative research paradigms are to be invoked that eliminate exp osure to untreated pain. When we consider pediatric pain research in the global con- text, it is important to take g reat care in determining the current \200\230standard of care \200\231 for the purposes of deciding whether a new inter- vention warrants study, or for the purposes of instituting a dequate controls in a clinical trial (Lavery et al., 2007). Th e overriding ethi- cal conce rn is to protect against exploitation of children in com- munities where the standard of ca re in pain management is very low or non-existent. For example, it would not be ethically a ppro- priate to investigate a new drug for the management of cancer pain in children in a r ural hospital where there are no available drugs for treatment of pain, and include a contr ol arm where children receive no pain treatment because no pain treatment is the cur- rent standard of care. However, if the question under investiga- tion is to test improved delive ry of an intravenous analgesic in a refugee camp setting, and what is being tested is a low -cost, tem- perature-resistant bag and line placement kit, one which would not be used in a large urban hospital in a developed country, but would be highly useful in a rural clinic in a developing country, then attention to local context is highly appropriate. In fact, fa iling to approve such a study on the grounds that the study team is not providing the highe st standard of pediatric pain treatment avail- able would deny a specially designed pain in tervention which is desperately needed in confl ict zones. For this reason, the current thi nking on the standard of care question in international research is to adhere to rigorous i nternational principles of research ethics, while allowing some appeal to local standards w here a study may be the only means of delivering a targeted, context-specifi c inter- venti on (Bhutta, 2002). Th us, research participation by minors in such a trial is ethi- cally defensible only if ( 1) there is true equipoise and thus it is not clear that the experimental conditions pose m ore risk or less benefi t than the current standard of care or (2) if the child participant stands to benefi t directly by participating in the research. Th ere is broad consensus on this issue, as affi rmed by the most recent documents of Declaration of Helsinki (World Me dical Association, 2008), the European Union Clinical Trial Directive (European Union, 2008 ), the Good Clinical Practice Guidelines of the United States FDA (United States Food and D rug Administration, 2011), the International Conference on Harmonization (International Con ference on Harmonization of Technical Requirements for Registration of Pharmaceuticals for Human Use, 2000), the National Commission for the Protection of Human Subjects of Biomedica l and Behavioral Research (United States Department of Health and Human Services, 2009), an d the Canadian Tri-Council ethical guidelines (Canadian Institutes of Health Research, Natu ral Sciences and Engineering Research Council of Canada, 2010). Conclusion \200\230Above all, do no harm. \200\231 \200\230It is a human right to have ac cess to pain management without discrimination, for people in pain to acknowledgment of the ir pain and to be informed about how it can be assessed and managed, of all people with pai n to have access to appropriate assessment and treatment of the pain by adequately trained health care professionals \200\231 (Cousins and Lynch, 2011, p. 2674). Th ese ethical princ iples form the foundation of the ethi- cal approach to pain in infants and children. Becaus e children are the most vulnerable of people and because they are at the greatest risk for deleterious eff ects of untreated pain, these issues become heightened. Whether the focus i s the provision of pain relief, inclu- sion in research, or considerations of pain in broad societal and cultural contexts, we must constantly weigh the benefi ts and risks of our ac tions. We owe it to the children under our care to rely on science, not personal bias or sp eculation, in evaluating and treat- ing pain. Failure to do so is a threat to basic ethical standards. A critical element in evaluating the potential risk of research participation by infants an d children focuses on a comparison to the \200\230standard of care \200\231. How the latte r is defi ned, however, is quite diffi cult to determine, as rarely are there published sta ndards and in only some instances are there published guidelines. Even when such guidelines exist, the degree to which there is adherence may vary dramatically. For example, in 2001 the American Academy of Pediatrics and the American Pain Society jointly issued a guide- li ne on the assessment and management of acute pain in infants, children, and adolescents (Am erican Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health a nd American Pain Society Task Force on Pain in Infants, Children, and Adolescents, 2001). T o date there is little evidence, however, that the espoused elements have been adopted as a \200\230standard of care \200\231. CHAPTER 64 the ethics of pain control in infants and children 667 American Academy of Pediatrics Committee on Drugs. (1990). Policy Statement: Naloxone dosag e and route administration for infants and children: Addendum to Emeregency Drug Doses for Infants and Children. Pediatrics , 86 , 484 \200\223485 . Case example Nancy was a 17-year-old girl with advanced leukemia. She was on the inpatient oncology unit , following a second failed bone marrow transplant with multiple complications, including i ntes- tinal graft -versus-host disease (GVHD). Patients in Nancy \200\231s sit- uation can oft en be expected to experience deep somatic pain related to the bone marrow expansion and /or sensitization to engraft ment, superfi cial somatic pain related to chemotherapy or rad iation therapy-induced oral mucositis, oral ulcers and skin lesions associated with GVHD, v isceral pain related to intesti- nal GVHD or neutropenic enterocolitis, and neuropathic pai n related to drug-induced neuropathies (Niscola, 2008). Nancy had made it clear to provider s that she would prefer comfort care to further aggressive chemotherapy regimens, unambigu- ously demonstrating understanding that she would die. Her mother, however, wanted to pursu e experimental treatments in an attempt to prolong Nancy \200\231s life, and refused to giv e parental consent for comfort care, including aggressive pain management, fearing that thi s might compromise her daughter \200\231s response to possible disease modifying agents. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health and American Pain Society Task Force on Pain in Infants, Children, and Adolescents. (2001) . Th e assessment and management of acute pain in infants, children, and adolescents. Pedia trics , 108 , 793 \200\223797 . Anand, K. J., Aranda, J. V., Berde, C. B., Buckman, S., Capparelli, E. V., Carlo, W., et al . (2006). Summary proceedings from the neonatal pain-control group. Pediatrics , 117 , S9 \200\223S22 . Bailey, J. E., Campagna, E., and Dart, R. C. (2009). Th e underrecognized toll of prescript ion opioid abuse on young children. Ann Emerg Med , 53 , 419 \200\22324 . Berde, C. B., Walco, G. A., Krane, E. J., Anand, K. J., Aranda, J. V., Craig, K. D., et al . (2012). Pediatric analgesic clinical trial designs, measures, and extrapolation: Report o f an FDA scientifi c workshop. Pediatrics , 129 (2), 354 \200\223364 . Bhutta, Z. A. (2002). Ethics in international health research: a perspective from the developing world. Bull World Health Organ , 80 , 114 \200\22320 . Bonham, V. L. (2001). Race, ethnicity, and pain treatment: striving to understand the cause s and solutions to the disparities in pain treatment. J Law Med Ethics , 29 : 52 \200\22368 . Ethical questions for consideration: the primary issue in this context was whether or not o pioid analgesics should be reduced in response to parental wishes. Secondary issues for con sidera- tion included whether the patient should be given chemother- apy, even though she m ade it clear she did not want it; including enrolment in a trial of an experimental agent. What would be the best approach for navigating the disagreement between Nancy and her mothe r? Bostick, N. A., Sade, R., Levine, M. A., and Stewart, D. Jr. (2008). Placebo use in clinica l practice: report of the American Medical Association Council on Ethical and Judicial Aff airs. J Clin Ethics , 19 , 58 \200\22361 . Bromberg, R. and Goldman, R. D. (2007). Does analgesia mask diagnosis of appendicitis among children? Can Fam Physician , 53 , 39 \200\22341 . Cahana, A. and Romagnioli, S. (2007). Not all placebos are the same: a debate on the ethics of placebo use in clinical trials versus clinical practice. J Anesth , 21 , 102 \200\2235 . Canadian Institutes of Health Research, Natural Sciences and Engineering Research Council o f Canada. (2010). Tri-Council Policy Statement: ethical conduct for research involving huma ns . Available at: <http://www. pre.ethics.gc.ca/pdf/eng/tcps2/TCPS_2_FINAL_Web.pdf> (acces sed 15 January 2012). Approach: an ethics committee consultation was sought to identify an optimal approach for t he oncology team. While Nancy was not an emancipated or mature minor by legal stand- ards, being several months shy of her eighteenth birthday, she was suffi ciently mature to have a voice in even life and death decisions with support from her mother and the medical team. Her wishes to move towards comfort care should be heard and respected. Th is would include ensuring that everything was done to help Nancy make this decision with support. Patients w ho are severely depressed and/or in severe pain can have trouble making diffi cult decision s. Th e team could ensure that she was as com- fortable as possible when making the decisio n, given adequate social support, and then try re-approaching her to make sure she understa nds the option of experimental treatment. ChildKind International. (2010). Th e ChildKind Initiative: a program to reduce pain in chi ld health facilities worldwide [Online]. Available at: <http://www.iasp-pain.org/PainSummit /ChildKind_Initiative2010.pdf> (accessed 2 January 2012). Cousins, M. J. and Lynch, M. E. (2011). Th e Declaration Montreal: access to pain managemen t is a fundamental human right. Pain , 152 , 2673 \200\22374 . Craig, K. D. and Pillai Ridd ell, R. R. (2003). Social infl uences, culture, and ethnicity. In P. J. McGrath and G. A. F inley (eds) Pediatric pain: biological and social context , pp. 159 \200\22382 . Seattle, W A : IASP Press . De Graaf, J., van Lingen, R. A., Simons, S. H., Anand, K. J., Duivenvoorden, H. J., Weisgla s-Kuperus, N., et al . (2011). Long-term eff ects of routine morphine infusion in mechanica lly ventilated neonates on children \200\231s functioning: fi ve-year follow-up of a random ized controlled trial. Pain , 152 , 1391 \200\2231397 . Outcome: the team tried the described communication approach, and Nancy \200\231s mother re mained adamant that she wanted to continue fi ghting for her daughter, not yielding on her stance regarding opioid analgesics. When the psychologist spoke to Nancy in private, she sa id that she would rather endure pain than spend her fi nal time with her mother in a state of confl ict. She decided to go along with the experimental treatment and succumbed to her illness about 8 weeks later. Dengler-Crish, C. M., Horst, S. N. and Walker, L. S. (2011). Somatic complaints in childhoo d functional abdominal pain are associated with functional gastrointestinal disorders in ad olescence and adulthood. J Pediatr Gastroenterol Nutr , 52 , 162 \200\22365 . Diekema, D. S. (2004). Parental refusals of medical treatment: the harm principle as thresh old for state intervention. Th eor Med Bioeth , 25 , 243 \200\223264 . Edwards, R. R., Moric, M., Husfeldt, B., Buvanendran, A. and Ivankovich, O. (2005). 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CHAPTER 65 Sociodemographic disparities in pediatric pain management: relationships and pre dictors Miriam O. Ezenwa and Anna Huguet Summary Th e purpose of this chapter is to present a narrative review of research studies e xamining sociodemographic predictors of dispari- ties in pain management in children and ad olescents. Findings from this review are confl icting. In the majority of the studies, soci odemo- graphic variables were not statistically signifi cant predictors of dis- parities in pain management. However, some gaps remain. For the studies in which evidence of sociodemo graphic disparities exist, it is: (1) not clear whether the statistically signifi cant soci odemographic disparities were also clinically meaningful and (2) in all of the stud- ies re viewed, the goal was to determine predictors of disparities in pain management. Future stud ies need to focus on determining the clinical meaningfulness of other fi ndings and systema tically testing explanatory models for possible sociodemographic disparities in pediatric p ain management. Adequately addressing these gaps will help to move forward the science of s ociodemographic disparities in pediatric pain management. disparities in pain research, there are important sociodemographic factors, other than race /ethnicity, that could be potential predic- tors of disparities in pain management both ind ependently and in combination. Th ese factors include age, sex, educational level, geo- gra phic location, and income level. Most of the studies reviewed in the IOM report on racial a nd ethnic disparities in health care were conducted with adults (Smedley et al., 2003). Th e pioneering work of scholars on pain experiences in children reporting inadequacy of pain control in children (Beyer et al., 1984; Eland and Anderson 1977; Schechter et al., 1986) s et the stage for more studies focus- ing on pediatric pain management, including studies fo cused on sociodemographic disparities in pediatric pain management. However, there is still limited research. In this chapter, a non-systematic review aimed to explore several sociodemographic factors (including age, sex, race/ethnicity, insur- ance status, and residential area) as potential predictors of disparities in pain management in children and adolescents is presented. Pai n management is a multidimensional and global construct encom- passing concepts such as pai n intensity, prescription for pain medi- cation, pain medication used, and satisfaction wit h pain control. For the purpose of this chapter, we defi ne pain management as receiving pa in medications or prescriptions for pain medications. Included in the review were original studies conducted in the US and Europe, in which investigators compared groups on dispariti es in pain man- agement based on the following sociodemographic factors: age, sex, race/eth nicity, health insurance status, and residential region. Th e database searched was Medline (PubMed and Ovid Medline). We identifi ed 12 studies that met our inclusion criteria and a nalyzed them using a descriptive analytic approach (see Table 65.1 ). Introduction Over two decades of research in adults with pain show evidence of racial dispa rities in pain management. Racial and ethnic minor- ity patients are more likely to receive poor pain management than Caucasians (Cintron and Morrison, 2006; Ezenwa and Fleming, 2012 ; Ezenwa et al., 2006; Meghani et al., 2012). Much research on the health disparities liter ature has focused on race/ethnicity as the explanatory factors for the health disparities i n pain management. Th is focus is underscored by the defi nition of health care dispari- ti es provided by the Institute of Medicine (IOM). Th e IOM defi ned health disparities as \200\230Racial or ethnic diff erences in the quality of health care that are not due to acc ess-related factors or clinical needs, preferences, and appropriateness of intervention \200\231 (Smedley et al., 2003, p. 3). While this defi nition is pertinent and has pro- vid ed a springboard for honing in on explanatory factors for racial Age-related factors We identifi ed six studies that examined age-related dispari- ties in p ain management. Th e fi ndings are confl icting. In three SECTION 9 special topics 670 Table 65.1 Summary of \201 ndings on sociodemographic disparities in pediatric pain manag ement Authors Design Sample Setting Major \201 ndings Statistics used Age-related factors Zuppa et al. (2005) Retrospective chart review 2348 children aged between 1-month and 16 years old hospitalized at the PICU in 2002 USA, pediatric intensive care unit (PICU) Th e utilization of the most frequently administered drugs (e.g. nalbuphine, morphine, vanc omycin, and cefotaxime) di \200 ered by age Univariate (Chi-square) analysis VanderBeek et al. (2006) Retrospective cohort study 503 patients 18 years of age or younger with a diagnosis of fractured radius or ulna USA, tertiary care children \200\231s hospital No statistical age di \200 erences were found between those who use conscious sedation and those who didn \200\231t; however, younger age of the patient was a signi \201 cant predi ctor of conscious sedation use Univariate (t-test) and multivariate statistical (logistic regression) analysis Stevens et al. (2010) Retrospective survey 847 children aged between 3 and 17 years old that receive an headache diagnosis USA, outpatient setting (including primary and secondary care) Age was not found to be related with the likelihood of being prescribed an evidence- based medication once a diagnosis is given Univariate logistic regression Boyd et al. (2006) Survey 1017 students in 5th \200\22310th grades (ages ranged from 10 to 18 years) USA, Detroit-area public school district No signi \201 cant age di \200 erences in were found in the reporting of use of medical u se of pain medications Univariate (Chi-square) analysis Ellis et al. (2002) Survey and chart review 273 children ranging in age from 10 days to 17 years who were on the inpatient unit during the 8-h study period (patients on the psychiatric and the intensive care unit were excluded ) Canada, pediatric teaching hospital Th ere was no signi \201 cant correlation between age and the amount of opioid or non-opio id analgesia administered Correlations Univariate (Chi-square) analysis Fein et al. (2010) Retrospective chart review 363 children younger than 21 years that had lumbar punctures performed in 2003 USA, children \200\231s tertiary care hospital Younger patients received pain management less often than did older patients: \227\206 16 (6.5%) of 246 neonates (0 \200\2232 months), 4 (14.3%) of 28 infants (3 \200 \22318 months), 9 (60%) of 15 preschoolers (19 \200\22359 months), and 55 (85.9%) of 64 old er children (60 months to 21 years). \227\206 7.2% of children younger than 18 months; 82% of children 19 months or older.