Send letter to journal:
Re: In Support of observational Pain Tools for Emergency Medicine Triage in Children

PLEASE NOTE THIS IS A RESUBMISSION FOR PRINTING PURPOSES WITH THE NECESSARY PERMISSIONS AS REQUESTED EMERMED/2008/069971 - Notify Author Re: Deficiencies

We read with interest this article by Shavit et al comparing the Alder Hey Triage Pain Score with a subjective scoring tool. The finding of a discrepancy in scoring between the tools, with the AHTPS scoring lower, is entirely consistent with the similar finding we reported in our paper (archdischild.2004;89;625-630). The conclusion drawn by the authors that this indicates that observational scoring should not be recommended is not justified. The findings may reflect the fact that the observational tool is not fully refined and the weighting for the different elements needs further research and development.

In the Shavit study pain scores were lower at triage assessment than in the waiting room. It was suggested that the reason for this was that Triage was a more reassuring environment. The inference made from this is that pain scoring is significantly influenced by anxiety. However, while this is likely, a subjective tool would be more affected by anxiety than an observational tool (AHTPS) and indeed the difference between the scores in the different settings reflected this. In order to eliminate as much of the anxiety element as possible subjective tools were initially developed in the situation of recurrent or procedural pain on the basis that there is an opportunity to explain the scoring tool prior to the painful event. This is not the case with children presenting at the ED with acute pain, which is why we do not think this type of scoring is appropriate for the ED setting where children in pain cannot be expected to consider and accurately interpret a new task. In addition there are some children who deny pain on subjective tools because of fear. This is why we still maintain that subjective scoring is inappropriate for A&E Triage. We also believe that it is possible that our tool underestimates pain and that it requires further research and refinement especially to re examine the parameters of the tool and their relative values to see how it can be improved. This area should be further explored before such methods are rejected. The need for a valid pain scoring tool is to indicate the appropriate level of analgesia to be prescribed. We acknowledge that the area of pain assessment is very complex and are committed to providing the best pain management to all children and would welcome interest, from others, in work to further refine the AHTPS. "The Corresponding Author has the right to grant on behalf of all authors and does grant on behalf of all authors, an exclusive licence (or non exclusive for government employees) on a worldwide basis to the BMJ Publishing Group Ltd and its Licensees to permit this article (if accepted) to be published in EMJ editions and any other BMJPGL products to exploit all subsidiary rights, as set out in our licence(http://emj.bmjjournals.com/ifora/licence.dtl)."

Competing Interest Please list Competing Interests if they exist, if not please include the

Send letter to journal:
Re: In Support of Observational Pain Tools for Emergency Medicine Triage in Children

We read with interest this article by Shavit et al comparing the Alder Hey Triage Pain Score with a subjective scoring tool. The finding of a discrepancy in scoring between the tools, with the AHTPS scoring lower, is entirely consistent with the similar finding we reported in our paper (Archdischild.2004;89;625-630). The conclusion drawn by the authors that this indicates that observational scoring should not be recommended is not justified. The findings may reflect the fact that the observational tool is not fully refined and the weighting for the different elements needs further research and development.