Children's memory for pain: overview and implications for practice

Pain assessment in children undergoing venipuncture: the Wong-Baker faces scale versus skin conductance fluctuations

The aim of this study was to evaluate the efficacy of the subjective Wong–Baker faces pain rating scale (WBFS) and of the objective skin conductance fluctuation (SCF) test in assessing pain in children undergoing venipuncture. One-hundred and fifty children (aged 5–16 years) entered the study. All underwent venipuncture at the antecubital fossa to collect blood specimens for routine testing in the same environmental conditions. After venipuncture, the children indicated their pain intensity using the WBFS, whereas the number of SCFs was recorded before, during and after venipuncture. So, pain level was measured in each child with WBFS and SCF. We found that the level of WBFS-assessed pain was lower in all children, particularly those above 8 years of age, than SCF-assessed pain (p < 0.0001). Moreover, the number of SCFs was significantly higher during venipuncture than before or after venipuncture (p < 0.0001). At multivariate regression analysis, age and previous experience of venipuncture influenced the WBFS (β = −1.81, p < 0.001, and β = −0.86, p < 0.001, respectively) but not SCFs. In conclusion, although both procedures can be useful for research and clinical practice, our findings show that WBFS was affected by age and previous venipuncture, whereas SCF produced uniform data. If verified in other studies, our results should be taken into account when using these tools to evaluate pain in children.

A model for pain behavior in individuals with intellectual and developmental disabilities

The dearth of information on the pain experience of individuals with intellectual and developmental disabilities (IDD) calls for a more comprehensive understanding of pain in this population. The Non-Communicating Adults Pain Checklist (NCAPC) is an 18-item behavioral scale that was recently found to be reliable, valid, sensitive and clinically feasible to assess pain levels in adults with IDD. The aim of the present article is to propose and examine a pain model for adults with IDD. The procedure involved videotaping 228 participants (mean age: 38.7 years) before and during an influenza vaccination. The pain model was constructed using previously collected data, by means of confirmatory factor analysis of the sum scores, using the half split procedure. The model was tested on a randomized group of participants (N=89) for generalization. The constructed model seems to reflect two categories of pain responses: a basic response consisting of physiological measures and body reaction, and an advanced response consisting of vocal and emotional reactions, as well as facial and protective expressions. The model presented excellent Goodness of Fit Index (0.99) and an acceptable RMSEA value (0.061). We conclude that the current article presents a first-of-its-kind model of pain behavior in adults with IDD.

Building a computer program to support children, parents, and distraction during healthcare procedures

This secondary data analysis used data mining methods to develop predictive models of child risk for distress during a healthcare procedure. Data used came from a study that predicted factors associated with children's responses to an intravenous catheter insertion while parents provided distraction coaching. From the 255 items used in the primary study, 44 predictive items were identified through automatic feature selection and used to build support vector machine regression models. Models were validated using multiple cross-validation tests and by comparing variables identified as explanatory in the traditional versus support vector machine regression. Rule-based approaches were applied to the model outputs to identify overall risk for distress. A decision tree was then applied to evidence-based instructions for tailoring distraction to characteristics and preferences of the parent and child. The resulting decision support computer application, titled Children, Parents and Distraction, is being used in research. Future use will support practitioners in deciding the level and type of distraction intervention needed by a child undergoing a healthcare procedure.

Pain is not over when the needle ends: a review and preliminary model of acute pain memory development in childhood

SUMMARY Over the past several decades, the field of pediatric pain has made impressive advances in our understanding of the pain experience of the developing child, as well as the devastating impact of inadequately managed pain early in life. It is now well recognized that, from infancy, children are capable of developing implicit memories of pain that can influence their subsequent reactions to pain. The present review provides a synthesis of selected studies that made a significant impact on this field of inquiry, with particular emphasis on recent clinical and laboratory-based experimental research examining children’s explicit autobiographical memories for acute pain. Research has begun to move towards improving the precision with which children at risk for developing negatively estimated pain memories can be identified, given the adverse influence these memories can have on subsequent pain experiences. As such, several fear- and anxiety-related child and parent variables implicated in this process are discussed, and avenues for future research and clinical intervention are identified throughout. Finally, a preliminary empirically and theoretically derived model of acute pain memory development in childhood is presented to parsimoniously summarize the evidence accumulated to date and guide future investigation in this area.

Multimethod assessment of children's distress during noninvasive outpatient medical procedures: child and parent attitudes and factors

The present study assessed behavioral distress during noninvasive outpatient procedures in children ages 4-10 years using a multimethod approach. Factors hypothesized to exacerbate children's distress included parents' and children's attitudes toward healthcare, children's knowledge of medical settings, and parental anxiety. A total of 53 parent-child dyads were recruited from outpatient clinics, with procedural distress assessed via child report, parent report, and direct observation. Some differences emerged depending on the method used to gauge distress. Children's healthcare attitudes and knowledge were associated with observed and child-reported distress, but parent's personal anxiety was associated only with their own perceptions of children's procedural distress. Parents' attitudes toward healthcare were associated with their anxiety but not with children's behavioral distress or healthcare attitudes. Findings are discussed in terms of more consistent findings regarding children's healthcare knowledge and attitudes versus the potential need for additional research on more divergent findings regarding parents' anxiety and healthcare attitudes.

Comfort First: an evaluation of a procedural pain management programme for children with cancer

BACKGROUND

The Comfort First Program (CFP) provides children and their caregivers with early procedural pain management intervention to reduce procedural pain and distress. This study evaluated whether the CFP was meeting its goals and effectively implementing the Royal Australasian College of Physicians paediatric pain management guidelines.

METHODS

The study was conducted as a single-site cross-sectional audit. One hundred and thirty-five patients (mean age 7.7 years) receiving treatment at the Royal Children's Hospital, Melbourne, Children's Cancer Centre Day Oncology Unit were observed. Procedural aspects related to the treatment room, carer and staff behaviour, child distress and use of pharmacologic and nonpharmacologic interventions were recorded using an audit tool developed for the study.

RESULTS

The procedure room was regularly quiet and prepared before the child entered. Median procedure duration was 8 min. Median procedure wait time was 54 min. At least one carer was typically present during procedures. Comfort First (CF) clinicians were more likely to be present in procedures with a significantly distressed child. Carers, nurses and CF clinicians generally displayed comfort-promoting behaviour. Topical anaesthetic was regularly utilised. Nonpharmacologic supports were frequently used, particularly distraction. Patients under 8 years of age were significantly more likely to receive nonpharmacologic supports and have a carer and CF clinician present. Age was a significant predictor of distress, with higher distress rates in younger children.

CONCLUSIONS

The CFP was found to be effectively implementing procedural pain guidelines. Regular audit is recommended to ensure adherence to pain management standards.

Pain assessment for children: overcoming challenges and optimizing care

There is growing evidence that children have short- and long-term physical, physiological, and psychological effects due to untreated acute pain. Because the majority of children who seek care in an emergency department present with pain or experience pain during the evaluation and treatment in the emergency department, optimal assessment and treatment of pain are paramount for this population. This review will highlight the many complexities of the assessment of pain for the pediatric patient. In addition, a variety of factors that affect the self-report of pain in children will be identified. Optimizing the utility of a pain assessment remains a challenge for the health care provider in the emergency setting. The common goal of a decreased experience of pain for children through improved analgesic administration remains.

Needle and dread: Is it just a little poke? A call for implementation of evidence-based policies for the management of needle pain in clinical settings

The present commentary calls for the implementation of evidence-based policies to manage paediatric needle pain in clinical settings. While there have been fundamental advances in the treatment of needle pain over the past three decades, relevant techniques are often not used in clinical practice. Evidence indicates that needle procedures do hurt, are frequently cited as the most painful experience by children and a subset of children are terrified of them. Pain and distress from needle procedures can and must be addressed because needle procedures are frequently performed on both healthy (eg, immunizations) and ill (eg, bone marrow aspirations, lumbar punctures) children. An essential step in translating research knowledge into practice is the creation of evidence-based policies. Policy statements regarding the management of needle pain must be incorporated at the hospital, clinic and individual office levels to reduce the amount of pain and distress children suffer from needle procedures. Specific suggestions for policies to be incorporated in clinical settings are provided.

Infant Distress

Infants’ inability to articulate their pain and distress and the diverse range of behavioral responses evoked by painful stimuli may partially explain the challenges associated with the treatment of pain in neonates and infants. To assist nurses in distinguishing nonspecific distress responses from specific pain responses, a concept analysis using Wilson’s method was preformed. An evaluation of published, peer reviewed literature referencing distress in neonates and infants was conducted to extract meaningful information related to distress. This article examines the essential features, antecedents, and consequences of infant distress to generate an evidence-based definition that has relevance for neonatal and pediatric research and clinical practice.

Epidemiology and management of painful procedures in children in Canadian hospitals

BACKGROUND

Children being cared for in hospital undergo multiple painful procedures daily. However, little is known about the frequency of these procedures and associated interventions to manage the pain. We undertook this study to determine, for children in Canadian hospitals, the frequency of painful procedures, the types of pain management interventions associated with painful procedures and the influence of the type of hospital unit on procedural pain management.

METHODS

We reviewed medical charts for infants and children up to 18 years of age who had been admitted to 32 inpatient units at eight Canadian pediatric hospitals between October 2007 and April 2008. We recorded all of the painful procedures performed and the pain management interventions that had been implemented in the 24-hour period preceding data collection. We performed descriptive and comparative (analysis of variance, χ(2)) analyses.

RESULTS

Of the 3822 children included in the study, 2987 (78.2%) had undergone at least one painful procedure in the 24-hour period preceding data collection, for a total of 18 929 painful procedures (mean 6.3 per child who had any painful procedure). For 2334 (78.1%) of the 2987 children who had a painful procedure, a pain management intervention in the previous 24 hours was documented in the chart: 1980 (84.8%) had a pharmacologic intervention, 609 (26.1%) a physical intervention, 584 (25.0%) a psychologic intervention and 753 (32.3%) a combination of interventions. However, for only 844 (28.3%) of the 2987 children was one or more pain management interventions administered and documented specifically for a painful procedure. Pediatric intensive care units reported the highest proportion of painful procedures and analgesics administered.

INTERPRETATION

For less than one-third of painful procedures was there documentation of one or more specific pain management interventions. Strategies for implementing changes in pain management must be tailored to the type of hospital unit.

The analgesic properties of intraoral sucrose: an integrative review

The treatment of pain is an essential component of the clinical and ethical care of infants. Despite evidence-based practice consensus statements recommending that infants receive analgesia during minor painful procedures, numerous studies have shown that procedural pain remains poorly managed in this population. Oral sucrose administration has been associated with calming effects and reductions in observed pain behaviors with preterm and term infants aged up to 1 year. The objective of this integrative review is to synthesize findings from published randomized controlled trials evaluating the efficacy and safety of oral sucrose as a preprocedural intervention for mild to moderate procedural pain in infants. Overall, studies indicate that oral sucrose is an effective, safe, convenient, and immediate-acting analgesic for reducing crying time and significantly decreases biobehavioral pain response following painful procedures with infants.

Unresolved pain in children: a relational ethics perspective

It is considered the right of children to have their pain managed effectively. Yet, despite extensive research findings, policy guidelines and practice standard recommendations for the optimal management of paediatric pain, clinical practices remain inadequate. Empirical evidence definitively shows that unrelieved pain in children has only harmful consequences, with no benefits. Contributing factors identified in this undermanaged pain include the significant role of nurses. Nursing attitudes and beliefs about children's pain experiences, the relationships nurses share with children who are suffering, and knowledge deficits in pain management practices are all shown to impact unresolved pain in children. In this article, a relational ethics perspective is used to explore the need for nurses to engage in authentic relationships with children who are experiencing pain, and to use evidence-based practices to manage that pain in order for this indefensible suffering of children to end.

Children's experiences of procedural pain management in conjunction with trauma wound dressings

AIM

This paper is a report of the experiences of children (5-10 years) of procedural pain when they underwent a trauma wound care session.

BACKGROUND

Procedural pain in conjunction with trauma wound care often induces anxiety and distress in children. Children need to alleviate pain and avoid the development of fear in conjunction with examinations and treatments. The nurse could help children to reach this goal by using the comfort theory, which describes holistic nursing in four contexts: physical, psychospiritual, environmental and sociocultural. Few studies have focused on children's experiences of comforting activities in conjunction with trauma wound dressings.

METHODS

This study was conducted between May 2008 and January 2010. Thirty-nine participants aged 5-10 were consecutively included in this study. The wound care session was standardized for all the participants, and semi-structured qualitative interviews with open-ended questions were conducted with all the children in conjunction with the procedure. All the interviews were transcribed verbatim and analysed with qualitative content analysis.

FINDINGS

Four themes were identified: clinical competence, distraction, participation and security. The children were helped to reach comforting activities to enhance pain management.

CONCLUSION

Children require more than just analgesics in wound care. They also need to experience security and participation in this context. When children feel clinical competence in wound care, they trust the nurse to carry out the wound dressing and instead can focus on the distraction that increases their positive outcomes.

Factors explaining children's responses to intravenous needle insertions

BACKGROUND

Previous research shows that numerous child, parent, and procedural variables affect children's distress responses to procedures. Cognitive-behavioral interventions such as distraction are effective in reducing pain and distress for many children undergoing these procedures.

OBJECTIVES

The purpose of this report was to examine child, parent, and procedural variables that explain child distress during a scheduled intravenous insertion when parents are distraction coaches for their children.

METHODS

A total of 542 children, between 4 and 10 years of age, and their parents participated. Child age, gender, diagnosis, and ethnicity were measured by questions developed for this study. Standardized instruments were used to measure child experience with procedures, temperament, ability to attend, anxiety, coping style, and pain sensitivity. Questions were developed to measure parent variables, including ethnicity, gender, previous experiences, and expectations, and procedural variables, including use of topical anesthetics and difficulty of procedure. Standardized instruments were used to measure parenting style and parent anxiety, whereas a new instrument was developed to measure parent performance of distraction. Children's distress responses were measured with the Observation Scale of Behavioral Distress-Revised (behavioral), salivary cortisol (biological), Oucher Pain Scale (self-report), and parent report of child distress (parent report). Regression methods were used for data analyses.

RESULTS

Variables explaining behavioral, child-report and parent-report measures include child age, typical coping response, and parent expectation of distress (p < .01). Level of parents' distraction coaching explained a significant portion of behavioral, biological, and parent-report distress measures (p < .05). Child impulsivity and special assistance at school also significantly explained child self-report of pain (p < .05). Additional variables explaining cortisol response were child's distress in the morning before clinic, diagnoses of attention deficit hyperactivity disorder or anxiety disorder, and timing of preparation for the clinic visit.

DISCUSSION

The findings can be used to identify children at risk for high distress during procedures. This is the first study to find a relationship between child behavioral distress and level of parent distraction coaching.

Procedural pain management for children receiving physiotherapy

PURPOSE

This article provides an overview of literature relevant to the prevention and relief of pain and distress during physiotherapy procedures, with guidance for physiotherapists treating children.

SUMMARY OF KEY POINTS

Physiotherapists are generally well trained in assessing and managing pain as a symptom of injury or disease, but there is a need to improve the identification and management of pain produced by physiotherapy procedures such as stretching and splinting. In contrast to physiotherapy, other health care disciplines, such as dentistry, nursing, paediatrics, emergency medicine, and paediatric psychology, produce extensive literature on painful procedures. Procedural pain in children is particularly important because it can lead to later fear and avoidance of necessary medical care.

RECOMMENDATIONS

We emphasize the need for physiotherapists to recognize procedural pain and fear in the course of treatment using verbal, nonverbal, and contextual cues. We present many methods that physiotherapists can use to prevent or relieve procedural pain and fear in paediatric patients and provide an example of a simple, integrated plan for prevention and relief of distress induced by painful procedures.

Impact of Parent-Provided Distraction on Child Responses to an IV Insertion

This study evaluates the impact of parent-provided distraction on children's responses (behavioral, physiological, parent, and self-report) during an IV insertion. Participants were 542 children, 4 to 10 years old, randomized to an experimental group that received a parent distraction coaching intervention or to routine care. Experimental group children had significantly less cortisol responsivity (p = .026). Children that received the highest level of distraction coaching had the lowest distress on behavioral, parent report, and cortisol measures. When parents provide a higher frequency and quality of distraction, children have lower distress responses on most measures.

Music Therapy to Reduce Pain and Anxiety in Children With Cancer Undergoing Lumbar Puncture: A Randomized Clinical Trial

A nonpharmacological method can be an alternative or complement to analgesics.The aim of this study was to evaluate if music medicine influences pain and anxiety in children undergoing lumbar punctures. A randomized clinical trial was used in 40 children (aged 7-12 years) with leukemia, followed by interviews in 20 of these participants. The participants were randomly assigned to a music group (n = 20) or control group (n = 20). The primary outcome was pain scores and the secondary was heart rate, blood pressure, respiratory rate, and oxygen saturation measured before, during, and after the procedure. Anxiety scores were measured before and after the procedure. Interviews with open-ended questions were conducted in conjunction with the completed procedures. The results showed lower pain scores and heart and respiratory rates in the music group during and after the lumbar puncture. The anxiety scores were lower in the music group both before and after the procedure. The findings from the interviews confirmed the quantity results through descriptions of a positive experience by the children, including less pain and fear.

Pain in children with cerebral palsy: implications for pediatric physical therapy

PURPOSE

This literature review explores pain assessment tools and psychosocial pain management methods that are pertinent to physical therapy (PT) for children with cerebral palsy (CP).

SUMMARY OF KEY POINTS

Children with CP experience considerable pain that affects quality of life and cooperation during healthcare procedures. Physical therapist-led research on interventions to address pain in this population is limited, despite evidence for the prevalence of pain during PT interventions, and the preponderance of research supporting the use of psychosocial pain management during other healthcare-related pain-inducing procedures.

STATEMENT OF CONCLUSIONS AND RECOMMENDATIONS FOR PHYSICAL THERAPY PRACTICE

Research completed primarily by non-physical therapist healthcare professionals delineate assessment tools and psychosocial pain management techniques that hold promise for evaluating and reducing pain that occurs during PT procedures for children with CP.

Anxiety influences children's memory for procedural pain

OBJECTIVE

To examine the effects of temperament and trait anxiety on memory for pain.

METHODS

Three dimensions of temperament, as well as trait anxiety, were assessed in 36 children (five to 12 years of age) undergoing dental procedures; after the procedure, the children provided pain ratings. Following a six- to eight-week delay, the children reported how much pain they remembered.

RESULTS

Most children (85%) accurately recalled their pain. Temperament had no significant effect, but trait-anxious children showed a greater likelihood of recalling more pain than they initially reported, suggesting that they may negatively distort recollections of painful experiences.

CONCLUSIONS

When treating children, in particular trait-anxious children, clinicians should consider what children remember as part of pain management intervention.

Concurrent muscle hurt and perceived exertion of children during resistance exercise

PURPOSE

Rating of muscle hurt (RMH) and RPE were concurrently measured for 10- to 14-yr-old females (n = 50) and males (n = 50) performing unilateral biceps curl (BC) and knee extension (KE) isotonic exercise.

METHODS

BC and KE exercises were counterbalanced within subjects. Three counterbalanced, 10 repetition sets (30%, 50%, and 70% one repetition maximum (1-RM)) were performed for both exercises. RMH and RPE were obtained for active muscles using the Children's OMNI-Hurt Scale and the Children's OMNI-Resistance Exercise Scale of Perceived Exertion, respectively.

RESULTS

For both females and males, RMH ranged across sets from 1.5 to 6.0 during BC and 3.2 to 6.7 during KE. RPE ranged from 3.4 to 8.3 during BC and 5.0 to 8.9 during KE. Ratings expressed as percent scores were lower (P < 0.01) for RMH than for RPE at the 30%, 50%, and 70% 1-RM during BC and KE for females and males. Regression coefficients for weight lifted as a function of RMH ranged from r = 0.67 to r = 0.87 (P < 0.01) for BC and KE. Correlations between RMH and RPE ranged from r = 0.19 to r = 0.82 across sets for both genders.

CONCLUSIONS

Female and male children can concurrently and differentially rate their perceived intensity of muscle hurt and exertion during upper and lower body resistance exercise using numerical category metrics (i.e., OMNI scales) having construct-specific pictorial and verbal descriptors.

Reducing immunization discomfort in 4- to 6-year-old children: a randomized clinical trial

OBJECTIVE

The goal was to test a multifaceted distraction method designed to reduce injection-associated pain in school-aged children.

METHODS

A clinical trial evaluated 41 children, 4 to 6 years of age, who were given 3 standard prekindergarten immunizations; 21 were assigned randomly to an office routine control group, whereas 20 received a multifaceted, discomfort-reducing intervention. The intervention added verbal suggestions of diminished sensation and a visual focusing activity to the use of ethyl chloride, an established pain-reducing measure. The distraction materials used for the intervention consisted of topical ethyl chloride spray, an improvised, plastic, multipronged arm gripper, and a vibrating instrument descending on the contralateral arm, which provided the focusing task and visual distraction.

RESULTS

According to patient and parent Faces Pain Scale-Revised scores and nonblinded, video-taped observations scored according to the face-legs-activity-crying-consolability method, the intervention group showed highly significant reductions in pain and discomfort, compared with the control group (patient self-report, P < .0013; parent report, P < .0002; observation score, P < .0001).

CONCLUSION

This multifaceted distraction intervention reduced significantly the pain and discomfort of childhood immunizations in children 4 to 6 years of age.

Cortisol response to inoculation in 4-year-old children

This study examined whether there was a cortisol response to inoculation or if pre-inoculation levels were already elevated due to an anticipatory response to going to the doctors' office. For 4-year-old children, a base saliva sample was obtained in the home on a non-stress day, and a pre-inoculation saliva sample was obtained in the doctors' office prior to the stress. Doctors' office pre-inoculation cortisol was higher than home-based cortisol, suggesting the occurrence of an anticipatory cortisol response to the impending stress. Post-inoculation cortisol levels (+20 min) were comparable to home-based cortisol, indicating that there was no cortisol response to the inoculation itself. While there was no mean increase in cortisol, individual differences in cortisol response existed. Cortisol increases were related to important aspects of child behavioral functioning, including internalizing and externalizing behavior ratings.

Improving the assessment of pediatric chronic pain: harnessing the potential of electronic diaries

Current methods for evaluating chronic pain in children suffer from methodological problems. Real-time data capture approaches using electronic diaries have been proposed as a new standard for pain measurement. However, there is limited information available regarding the development, feasibility and validity of these approaches in children. The present paper reviews problems with current measures; rationale for developing real-time data capture approaches using electronic diaries; mechanics of developing electronic pain diaries; current evidence regarding their usability, feasibility and validity; and discusses future directions for research in this area.

A modified version of the non-communicating children pain checklist-revised, adapted to adults with intellectual and developmental disabilities: sensitivity to pain and internal consistency

Despite enhanced interest in manifestations of pain in adults with intellectual and developmental disabilities (IDD), the characteristics of pain behavior in this group have seldom been examined. The aim of the present study was to provide a sensitive pain behavior scale for adults with IDD. The participants, 228 adults (mean age, 38.7 years) with different levels of IDD, were videotaped before and during an influenza vaccination and scored using the Non-Communicating Children's Pain Checklist-Revised (NCCPC-R). Observed pain behaviors not captured by the NCCPC-R, was also registered. Sensitivity to pain of all 27 items was examined by Signed Rank test, internal consistency by Cronbach's alpha, and sensitivity to change of the total scale by Standardized Response Mean (SRM). Thirteen items were excluded from the original NCCPC-R scale; 4 new items were added, making a modified scale of 18 items. This scale, named the Non-Communicating Adults Pain Checklist-Revised (NCAPC), was rescored and examined for psychometric properties in a random sample (N = 89). Sensitivity to pain of all items (P < .05) and high internal consistency (alpha = 0.773) were demonstrated. Large sensitivity to pain at all levels of IDD was shown (SRM, 1.20 to 2.07). Better psychometric properties were demonstrated for NCAPC than NCCPC-R in the target population.

PERSPECTIVE

This article presents initial psychometric properties of a new measure, the NCAPC, evaluating pain behavior in adults with IDD. This measure could help clinicians to better capture pain expressions in this population and contribute to better pain management for this group of patients.

Cultural perspectives on pain management

Bedouin women tend to remain quiet and expressionless while giving birth despite reporting high levels of pain and fear (Harrison 1991). Culture undoubtedly influences pain perception and expression but there are dangers in making assumptions about particular groups. This article explores the underlying research and the complex clinical picture highlighting the need for cultural awareness--but ultimately we must care for the individual person in pain.

Needle pain in children: contextual factors

Pediatric pain experiences result from a complex interplay of genetic, experiential, and developmental factors. These elements, as they relate to needle-stick procedures and other relevant painful phenomena, are explored in this article so that the context of possible interventions may be more fully appreciated. Clinical implications are discussed incorporating ethical perspectives.

Effectiveness of sedation using nitrous oxide compared with enteral midazolam for botulinum toxin A injections in children

This randomized, double-blind, placebo-controlled study compared the efficacy of inhaled nitrous oxide (N(2)O) with enteral midazolam for sedation of children with cerebral palsy (CP) undergoing botulinum toxin A (BoNT-A) injections. Fifty children (29 males, 21 females; mean age 8y 2mo [SD 4y 5mo]; range 1-16y) were randomized to sedation with N(2)O (n=25) or midazolam (n=25). Groups were similar in type of CP (diplegia, 11; triplegia, three; quadriplegia, 16; hemiplegia, 16; other, three) and Gross Motor Function Classification System level (Level I, 4; II, 24; III, 4; IV, 13; V, 5). Both groups were equally sedated at time of injection (p=0.661), but those in the midazolam group were more sedated at time of discharge (p<0.001). N(2)O was more effective in reducing pain compared with midazolam as measured using the Face, Legs, Activity, Cry, Consolability (FLACC) scale (p=0.010), parental estimate of pain (p=0.009), and nursing estimate of pain (p=0.007). Parents in the N(2)O group rated it better than prior sedation with midazolam for BoNT-A injections (p=0.031). Physicians and nurses reported no difference in ease of procedure between the groups. One child in the midazolam group and eight in the N(2)O group had adverse effects, all of which resolved promptly. N(2)O appears to be an effective means of sedation for children undergoing outpatient BoNT-A injections.

Pain therapy in children and adolescents

INTRODUCTION

In children, acute pain occurs predominantly during infectious illnesses or after surgery. Chronic pain, especially headache and abdominal pain, is becoming increasingly common among children and adolescents.

METHODS

Selective literature review, also including evidence-based guidelines and recommendations.

RESULTS

Simple self-reporting and behavioral pain scales are easy to use to assess the intensity of acute pain. To evaluate chronic pain, on the other hand, more complicated, multi-dimensional instruments are necessary (e.g., semi-structured interviews). The most commonly used analgesics are ibuprofen and paracetamol (acetaminophen). When paracetamol is used, its narrow therapeutic window should be kept in mind. Perioperative pain should be treated with balanced analgesia involving a combination of non-pharmacological treatment strategies, non-opioid drugs, opioids, and regional anesthesia. Chronic pain in children can only be treated successfully over the long term with multidisciplinary team intervention based on this biopsychosocial model.

DISCUSSION

Pain not only causes children momentary suffering but also threatens to impair their normal development. Therefore, every effort should be made to prevent pain and to treat it effectively once it arises.

Evaluation of a Brief Parent Intervention Teaching Coping-Promoting Behavior for the Infant Immunization Context

This study was designed to investigate whether a brief intervention encouraging parental coping-promoting talk within the treatment room would have beneficial effects on infant pain responses to an immunization injection. Infant-parent dyads were recruited from a 6-month immunization clinic and randomized to an intervention group ( n = 25) or standard care control group ( n = 25). Parents in the intervention group received an information sheet describing adult verbalizations associated with better pain outcomes for infants. The immunization procedure was videotaped. Parents in the intervention condition made significantly more coping-promoting statements than parents in the control condition. Infants in the control condition cried significantly longer than infants in the intervention condition. Coping-promoting and distress-promoting statements did not differ in terms of affective quality. Infants whose parents had rated them as more difficult in temperament cried longer following the injection. Teaching parents to engage in coping-promoting behaviors within the infant treatment room is an effective, low-cost intervention.

Pain behaviour and distress in children during two sequential dental visits: comparing a computerised anaesthesia delivery system and a traditional syringe

OBJECTIVE

To compare the pain and distress response of children receiving a local anesthesia injection using a computerised device (Wand) or a traditional syringe over two consecutive treatment sessions and to study whether the response to the two injection techniques was different for high or low dentally anxious children.

DESIGN

Randomised controlled trial.

SETTING

Secondary dental care practice specialised in treating children.

SUBJECTS AND METHODS

Children were selected and randomly allocated to the Wand or traditional injection condition. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-ds). Based on video recordings of the injections, for each 15 seconds, the occurrence of five pain related behaviours was registered and a score was given on the Venham distress scale. Children rated their pain after each injection.

INTERVENTION

Over two consecutive treatment sessions one group received two local anaesthesia injections with the traditional syringe and the other group received two injections with the Wand.

OUTCOME MEASURES

The mean number of pain related behaviours, the mean distress scores and the self-reported pain scores were compared. Based on the CFSS-ds subjects were split into highly and low dentally anxious children.

RESULTS

One hundred and forty-seven subjects participated in the study: aged 4-11 years, 71 girls. Based on the behaviour displayed during the local anaesthesia injection and the self-reported pain after the injection, no difference could be found between an injection with the traditional syringe or the Wand over the first or second treatment session. However, on the first treatment session, highly anxious children reported more pain (p = 0.001), displayed more pain related behaviour (p = 0.002) and more distress (p <0.001) than low anxious children in reaction to the local anaesthesia injection.

CONCLUSION

No clear difference in the response of referred children could be found between an injection with the Wand or the traditional syringe. Level of dental anxiety was found to be an important factor in the response of children to a local anaesthesia injection.

Needle-free powder lidocaine delivery system provides rapid effective analgesia for venipuncture or cannulation pain in children: randomized, double-blind Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial

OBJECTIVE

The Comparison of Venipuncture and Venous Cannulation Pain After Fast-Onset Needle-Free Powder Lidocaine or Placebo Treatment trial was a randomized, single-dose, double-blind, phase 3 study investigating whether a needle-free powder lidocaine delivery system (a sterile, prefilled, disposable system that delivers lidocaine powder into the epidermis) produces effective local analgesia within 1 to 3 minutes for venipuncture and peripheral venous cannulation procedures in children.

METHODS

Pediatric patients (3-18 years of age) were randomly assigned to treatment with the needle-free powder lidocaine delivery system (0.5 mg of lidocaine and 21 +/- 1 bar of pressure; n = 292) or a sham placebo system (n = 287) at the antecubital fossa or the back of the hand 1 to 3 minutes before venipuncture or cannulation. All patients rated the administration comfort of the needle-free systems and the pain of the subsequent venous access procedures with the Wong-Baker Faces Pain Rating Scale (from 0 to 5). Patients 8 to 18 years of age also provided self-reports with a visual analog scale, and parents provided observational visual analog scale scores for their child's venous access pain. Safety also was assessed.

RESULTS

Immediately after administration, mean Wong-Baker Faces scale scores were 0.54 and 0.24 in the active system and sham placebo system groups, respectively. After venipuncture or cannulation, mean Wong-Baker Faces scale scores were 1.77 +/- 0.09 and 2.10 +/- 0.09 and mean visual analog scale scores were 22.62 +/- 1.80 mm and 31.97 +/- 1.82 mm in the active system and sham placebo system groups, respectively. Parents' assessments of their child's procedural pain were also lower in the active system group (21.35 +/- 1.43 vs 28.67 +/- 1.66). Treatment-related adverse events were generally mild and resolved without sequelae. Erythema and petechiae were more frequent in the active system group.

CONCLUSIONS

The needle-free powder lidocaine delivery system was well tolerated and produced significant analgesia within 1 to 3 minutes.

Children's self-reported pain at the dentist

The aim of the present study is to get an insight into the pain report of children over two sequential dental visits. Furthermore, it was studied whether age, previous dental experience, level of dental anxiety and injection site were of influence on the self-reported pain of children during the first and second treatment session. One hundred and forty-seven children (4-11 years old) were included in the study. After receiving a local anesthesia injection prior to their dental treatment, they were asked how much pain they had felt. The level of dental anxiety was measured once by the parental version of the Dental Subscale of the Children's Fear Survey Schedule. Young children with a low level of dental anxiety show a sensitized reaction trend for self-reported pain over two sequential dental visits. Young children with a high level of dental anxiety reported the most pain on the first treatment session. For the older children, the children having previous dental experience gave the highest pain ratings on the first treatment session. Furthermore, for both young and older children the amount of pain reported for the second injection was best predicted by the amount of pain reported for the first injection, whereby higher scores the first time predict higher scores the second time. In conclusion, the memory of previous experience with dentistry and earlier treatment sessions seems of great influence on the behaviour and the experience of children during subsequent treatment sessions.

Using memory restructuring strategy to enhance dental behaviour

AIMS

This study sought to 'restructure' memory of dental treatment to help children develop positive memories and cooperate more fully with the dentist at future visits.

DESIGN

The design compared 'usual care' plus an intervention designed to positively restructure memory with 'usual care' plus a control for 45 children, ages 6-9 years, who were in need of two restorative treatment visits. The intervention occurred at the second visit immediately before the dental treatment and focused on restructuring the child's memory of the first treatment visit. Children were asked to recall how much fear and pain they experienced during the first dental treatment.

RESULTS

The child's behaviour improved from the first dental treatment visit to the second in the intervention group but not in the control condition. When compared to the controls, those in the intervention group changed their memory of the fear they experienced at the first treatment and their memory of experienced pain.

CONCLUSIONS

Restructuring memory may be effective in reducing fear for future treatment, and is easily adaptable to clinical practice in other healthcare situations.

Does providing props during preparation help children to remember a novel event?

We investigated the conditions under which preparatory information presented 1 day before a novel event influenced 6-year-olds' recall 1 week later. Children were assigned to one of six experimental conditions. Three conditions involved preparatory information that described the event accurately but differed according to the presence and type of props (verbal, real props, and toy props). In two conditions, which also differed according to whether verbal information was supplemented with real props, half of the preparatory information described the event accurately, whereas the other half was thematically similar to, but inconsistent with, the event (misleading verbal and misleading props). Compared with the attentional control condition, all forms of preparation that described the event accurately increased correct recall. Preparation that included props improved photograph recognition. When half of the accurate information was replaced by misleading information, the positive benefit on recall was reduced, and when misleading props accompanied the misleading information, errors increased. The potential underlying mechanisms and implications for pediatric settings are discussed.

Is elective surgery traumatic for children and their parents?

AIM

The emotional consequences of elective surgery to children and to their parents have not been sufficiently studied. The aim of the present study was to prospectively assess the prevalence and severity of post-traumatic, anxiety and depressive symptoms in this population.

METHODS

Forty children and adolescents consecutively admitted for elective surgery in a general hospital participated in the study. Their parents were also assessed. The assessments were made on the day of admission and surgery, and 1 and 6 months after the surgery.

RESULTS

Minor post-traumatic symptoms of the children were noted at the first and second assessments, decreasing significantly at the 6-month assessment. Further, the prevalence of children with elevated post-traumatic symptoms decreased significantly between the first and second assessments. Parents scored highest for anxiety and depression at the first assessment. Their symptoms, however, decreased significantly within 1 month. A significant decrease between the first and second assessments was also noted in the prevalence of parents with elevated anxiety symptoms. At the 1- and 6-month follow-up assessments, there was a significant correlation between the children's symptoms and their parents'.

CONCLUSION

Mild post-traumatic symptoms may accompany paediatric elective surgery and persist for at least 1 month. Parents may also manifest anxiety and depressive symptoms, which may diminish earlier, that is, immediately after the surgery or within 1 month.

Painful procedures in children with cancer: comparison of moderate sedation and general anesthesia for lumbar puncture and bone marrow aspiration

BACKGROUND

The study was conducted to compare moderate sedation (MS) with general anesthesia (GA) in the management of frequently performed lumbar puncture or bone marrow aspiration (BMA) during the treatment of childhood cancer.

PROCEDURE

The MS (14 patients for 30 procedures) was managed by non-anesthesiologists (combined nitrous oxide-midazolam +/- non-pharmacological techniques). The GA was managed by anesthesiologists (17 patients for 30 procedures). A neutral observer recorded side effects, use of sedative antagonists, recovery time, oncologist's evaluation, procedure behaviors check list (PBCL); subjective perceptions during the procedure with a questionnaire administered to children (>6 years) and their parents; drugs costs and professional resources. P-values <0.05 were considered significant.

RESULTS

We had two inadequate sedations in MS (6.6%) versus 0 in GA. We had no significant differences in side effects (7.10% MS vs. 8.6% in GA), use of antagonists (2.90% GA vs. 0 MS), PBCL, oncologist evaluation and questionnaire data or drugs costs. We observed significant differences in recovery times (MS, mean 43 +/- SD min vs. GA, mean 117 +/- SD min) and professional resources costs. The effects of non-pharmacological techniques on anxiety were perceived very positively by both children and parents (on 0-4 scale, mean scores 3.57 for the children; 3.53 for the parents).

CONCLUSIONS

Our study suggests that MS compared favorably to GA with respect to both safety and efficacy. When performed by non-anesthesiologists, MS may be associated with better compliance and cost-effectiveness as it relies on the contribution of non-pharmacological techniques.