Clinical Use of Baxter Animated Retching Faces (BARF) Scale in Children

Pediatric research in the management of nausea has been limited by the absence of a reliable
method to quantify the intensity of this subjective symptom. In adults, the visual analog
scale (VAS) is an accurate tool, but this has not been shown to be reliable in young
children. By default the most common objective outcome measure used in pediatric studies has
been the incidence and number of emetic episodes. This measure, however, correlates poorly
with the somatic subjective symptom of nausea.

Apfel et al have shown that 30-40% of adult patients undergoing surgery have post discharge
nausea and / or vomiting while 12% have vomiting. These data on nausea in adults were based
on a visual analog scale for nausea. There are no data on the incidence of postoperative
nausea in children since the severity of symptoms are difficult to measure as younger
children are known to be unable to use the VAS reliably.

Recently a pictorial scale for measuring nausea, the Baxter Animated Retching Faces (BARF)
scale, has been developed and shown to have construct, content and convergent validity as an
instrument to measure nausea in children. The clinical usefulness of this scale in
determining the incidence of postoperative and post-discharge nausea in children has yet to
be determined including the lowest age where it can be used reliably, the score associated
with a patient's perception of a need for treatment, the minimum change in the scores of
clinical relevance and the test-retest reliability when nausea is rated as not having
changed.

Inclusion Criteria:

1. Age > 3 years but below 18 years

2. Elective surgery

3. American Society of Anesthesiologists physical status 1-3 (Free from major concurrent
disorders)

4. Free from nausea and / or vomiting in the previous 24 hours

5. Cognitive, visual, hearing and communicative ability to use the VAS as shown by the
ability to complete a seriation task in which children pick the biggest of 6 cut out
shapes, then the smallest, and the biggest remaining until no shapes remain (Beyer et
al: J Pediatr Nurs 1992; 7: 335-46)

Exclusion Criteria:

1. Developmental delay

2. Blindness

3. Impaired cognitive or communicative abilities including inability to rate the
intensity of symptoms and failure to complete the seriation task

4. Surgical procedures which may result in diminished hearing or vision in the immediate
postoperative period

5. Nausea and /or vomiting within 24 hours prior to the procedure

6. Inability to understand English,

7. Patient or parental refusal to participate

8. Pregnant females