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    Picture Scale Created to Assess Children’s Nausea

    By Jennifer Huddleston, staff writer    

    Researchers have developed an animated rating scale, the Baxter Animated Retching Face Scale (called BARF), in an attempt to measure nausea in children.

    “I have always felt that we do not measure nausea properly in children, as compared to what we do in adults,” said Mehernoor F. Watcha, M.D., the study’s co-author and an attending anesthesiologist at Texas Children’s Hospital in Houston, Texas. “So the aim was to try to create an easy-to-use scale that we could use to measure nausea in these patients.”[1]

    The visual analog scale for measuring nausea in adult patients is not as effective in patients younger than 9 years of age, so oftentimes the occurrence of vomiting is the most common outcome used to measure nausea in children’s studies, despite the fact that it does not often correlate with nausea symptoms.[2]

    “Nausea and vomiting are two different experiences and one of the reasons we felt it was important to develop this scale,” said Amy L. Baxter, M.D., principal investigator of the study and director of emergency research at Children’s Health Care of Atlanta in Georgia. “Everyone who has ever been nauseated knows that you can feel sick for days without vomiting, and sometimes throwing up relieves nausea and improves subsequent nutrition. Most research has used emesis as the proxy outcome measure, which may miss the point.”[3]

    A three-phase study was used to create the BARF scale, which was conceived by Baxter.[4] During the first phase, 30 children identified nausea-associated features in pictures of cartoon faces. Then a Web-based data collection computer program was developed to render the identified nausea-associated features into 140 animated faces that seamlessly morph from neutral (no nausea) to maximum nausea (retching).[5]

    During the third phase, 15 experienced nurses completed 80 trials of the program, during which they were asked to select which animated picture they felt best represented 20 percent, 40 percent, 60 percent or 80 percent of maximum nausea. The pictures most frequently selected were then used to fill the six-face BARF scale, with a neutral face as zero and a retching face as the 100 percent anchor.[6]

    Watcha said he hopes that the development of a tool like the BARF scale will positively change pediatric anesthesiology in much the same way that the discovery of pediatric pain measurement tools has changed the practice.

    “There is no question that once we developed a tool for measuring pain in children, the approach and management changed dramatically,” Watcha said. “I hope this tool similarly changes the landscape with regard to pediatric nausea. Time will tell, but if you can measure it, then there will be another tool to use in the recovery room or elsewhere because now we really rely on the parent looking at the child’s face or an experienced nurse who looks at the child and says this child has got nausea.”[7]

    Baxter said that a study of parents and children “found zero correlation between parents’ knowledge of how much nausea bothered their children compared to the kids’ self-report. Parents were very accurate about needle procedures, though; we think nausea is just harder for an observer to assess.”[8]

    Peter J. Davis, M.D, anesthesiologist-in-chief at Children’s Hospital of Pittsburgh and professor of anesthesia and pediatrics at the University of Pittsburgh Medical Center in Pennsylvania, said he sees the value in a scale like BARF.

    “It is very difficult to reliably quantify nausea in children,” he said, adding that “young children cannot readily describe nausea.”[9]

    Davis, a member of Anesthesiology News’ editorial advisory board, also emphasized the need for future studies.

    “Any kind of scale like this one must have two fixed points,” said Davis. “And although this one is supposed to be measuring nausea, the highest point on the scale is vomiting. In addition, nobody knows how reliable this scale is, so reliability will have to be the focus of future studies.”[10]

    The scale is currently being validated in oncology and postoperative patients and those treated in emergency departments.[11]


    [1] Vlessides, Michael. “Picture Scale for Pediatric Nausea Is Worth a Thousand Words.” Anesthesiology News , Volume 34:12. December 2008.
    [2] Watcha, Mehernoor F., et al. “Development of a Pictorial Animated Rating Face (Barf) Scale for Measuring Nausea in Children.” ASA Abstract A1385. Oct. 21, 2008. 
    [3] Vlessides, Michael. “Picture Scale for Pediatric Nausea Is Worth a Thousand Words.” Anesthesiology News , Volume 34:12. December 2008.
    [4]  Ibid.
    [5] Watcha, Mehernoor F., et al. “Development of a Pictorial Animated Rating Face (Barf) Scale for Measuring Nausea in Children.” ASA Abstract A1385. Oct. 21, 2008. 
    [6]  Ibid
    [7] Vlessides, Michael. “Picture Scale for Pediatric Nausea Is Worth a Thousand Words.” Anesthesiology News , Volume 34:12. December 2008.
    [8]  Ibid.
    [9]  Ibid.
    [10]  Ibid.
    [11]  Ibid.



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