A cognitive-behavioral approach to pain associated with pediatric chronic diseases

Understanding the benefits of horticultural therapy on paediatric patient's well-being during hospitalisation

Purpose

The aim of this study is to undertake a systemic literature review (SLR) of horticultural therapy and to explore whether its inclusion in a healthcare programme can enhance hospitalised children's well-being.

Design/methodology/approach

An empirical study was developed using a mixed methods approach to monitor stakeholders' perceptions of horticultural therapy. Specifically, hospitalised children (N = 31) and their families (N = 21), as well as medical and nursing staff (N = 3), were engaged in the empirical study. Qualitative and quantitative surveys were developed, involving two paediatric units in an Italian hospital.

Findings

The authors’ findings show a significant improvement of children's mood and psycho-physical well-being following horticultural therapy. The authors found positive effects of interactive horticultural therapy on hospitalised paediatric patients and their parents. Parents perceived a positive influence on their mood and found the therapy very beneficial for their children. Qualitative analyses of children's and parents' comments (and related rankings) revealed the helpful support role of horticultural therapy in dealing with the hospitalisation period. There is a very limited number of studies that have inspected co-therapy implementation in paediatric hospitals, and to the best of the authors' knowledge, no study has yet examined the effect of horticultural therapy in such a context. The practice of horticultural therapy with children in health settings has been documented in some Italian hospitals, but its effectiveness has not yet been well established in the literature.

Originality/value

The authors’ findings could provide useful insights to clinicians, health managers and directors in creating and sustaining a successful group co-therapy programme under the managed healthcare system.

Effectiveness of integrative modalities for pain and anxiety in children and adolescents with cancer: a systematic review

Throughout the trajectory of the cancer experience, children and adolescents will likely face pain and anxiety in a variety of circumstances. Integrative therapies may be used either alone or as an adjunct to standard analgesics. Children are often very receptive to integrative therapies such as music, art, guided imagery, massage, therapeutic play, distraction, and other modalities. The effect of integrative modalities on pain and anxiety in children with cancer has not been systematically examined across the entire cancer experience. An in-depth search of PubMed, CINAHL, MedLine, PsychInfo, and Web of Science, integrative medicine journals, and the reference lists of review articles using the search terms pain, anxiety, pediatric, child*, oncology, cancer, neoplasm, complementary, integrative, nonconventional, and unconventional yielded 164 articles. Of these, 25 warranted full-text review. Cohen's d calculations show medium (d = 0.70) to extremely large (8.57) effect sizes indicating that integrative interventions may be very effective for pain and anxiety in children undergoing cancer treatment. Integrative modalities warrant further study with larger sample sizes to better determine their effectiveness in this population.

The interpretation of Rome III criteria and method of assessment affect the irritable bowel syndrome classification of children

BACKGROUND

Paediatric classification of irritable bowel syndrome (IBS) is complicated by the potential discrepancy between parent and child report and by the interpretation of pain-stool relations in the Rome III classification system.

AIM

To compare IBS classification by diary and by child and parent respondents.

METHODS

Children (ages 7-10 years, n = 90) with recurrent abdominal pain and their parents completed IBS symptom questionnaires and 2-week pain and stool diaries. Diaries were coded with two algorithms, one defining stool changes individually and one defining changes normatively. Proportions of dichotomous classifications (IBS vs. not IBS) between pairs of classification methods/respondents were evaluated using Chi-squared tests (χ²) to determine whether coding methods were significantly related, the degree of inclusiveness, and whether differences in classification were randomly distributed.

RESULTS

Individual and normative diary classifications were congruent in 62% of cases, but the individual method classified more children with IBS, 53% vs. 18%. Parent and child questionnaire reports were not correlated. The normative diary classifications and parent questionnaire were the most congruent pair of methods (76% of cases).

CONCLUSIONS

Poor congruence among methods suggests that Rome III IBS criteria need better specification, and efforts to improve parent-child agreement are necessary.

Pain symptoms and stooling patterns do not drive diagnostic costs for children with functional abdominal pain and irritable bowel syndrome in primary or tertiary care

OBJECTIVE

The objectives of this study were to (1) compare the cost of medical evaluation for children with functional abdominal pain or irritable bowel syndrome brought to a pediatric gastroenterologist versus children who remained in the care of their pediatrician, (2) compare symptom characteristics for the children in primary versus tertiary care, and (3) examine if symptom characteristics predicted the cost of medical evaluation.

METHODS

Eighty-nine children aged 7 to 10 years with functional abdominal pain or irritable bowel syndrome seen by a gastroenterologist (n = 46) or seen only by a pediatrician (n = 43) completed daily pain and stool diaries for 2 weeks. Mothers provided retrospective reports of their children's symptoms in the previous year. Cost of medical evaluation was calculated via chart review of diagnostic tests and application of prices as if the patients were self-pay.

RESULTS

Child-reported diary data reflected no significant group differences with respect to pain, interference with activities, or stool characteristics. In contrast, mothers of children evaluated by a gastroenterologist viewed their children as having higher maximum pain intensity in the previous year. Excluding endoscopy costs, cost of medical evaluation was fivefold higher for children evaluated by a gastroenterologist, with higher cost across blood work, stool studies, breath testing, and diagnostic imaging. Symptom characteristics did not predict cost of care for either group.

CONCLUSIONS

Despite the lack of difference in symptom characteristics between children in primary and tertiary care, a notable differential in cost of evaluation exists in accordance with level of care. Symptom characteristics do not seem to drive diagnostic evaluation in either primary or tertiary care. Given the lack of differences in child-reported symptoms and the maternal perspective that children evaluated by a gastroenterologist had more severe pain, we speculate that parent perception of child symptoms may be a primary factor in seeking tertiary care.

Increased gastrointestinal permeability and gut inflammation in children with functional abdominal pain and irritable bowel syndrome

OBJECTIVES

To determine gastrointestinal (GI) permeability and fecal calprotectin concentration in children 7 to 10 years of age with functional abdominal pain and irritable bowel syndrome (FAP/IBS) versus control subjects and ascertain potential relationships with pain symptoms and stooling.

STUDY DESIGN

GI permeability and fecal calprotectin concentration were measured. Children kept a 2-week diary of pain episodes and stooling pattern.

RESULTS

Proximal GI permeability was greater in the FAP/IBS group (n = 93) compared with control subjects (n = 52) (0.59 +/- 0.50 vs 0.36 +/- 0.26, respectively; mean +/- SD; P < .001) as was colonic permeability (1.01 +/- 0.67 vs 0.81 +/- 0.43, respectively; P < .05). Gastric and small intestinal permeability were similar. Fecal calprotectin concentration was greater in children with FAP/IBS compared with control children (65.5 +/- 75.4 microg/g stool vs 43.2 +/- 39.4, respectively; P < .01). Fecal calprotectin concentration correlated with pain interference with activities (P = .01, r(2) = 0.36). There was no correlation between GI permeability and pain related symptoms. Neither permeability nor fecal calprotectin correlated with stool form.

CONCLUSIONS

Children with FAP/IBS have evidence of increased GI permeability and low-grade GI inflammation, with the latter relating to the degree to which pain interferes with activities.

Characteristics of pain and stooling in children with recurrent abdominal pain

OBJECTIVE

To collect symptom data longitudinally from children with recurrent abdominal pain (RAP) and control (asymptomatic) children.

PATIENTS AND METHODS

Children with RAP (n = 77) and controls (n = 33) 7 to 10 years of age completed daily diaries for 2 weeks tracking pain frequency and severity, how often the pain interfered with activities, and stooling pattern.

RESULTS

RAP children reported a greater number of pain episodes and greater pain severity than control children. Pain commonly was reported to be in the periumbilical area and occurred evenly across the day in both groups. However, the pain interfered with activity more often in the RAP group. There was a positive relationship between pain and interference with activities. Both groups reported stool changes, but there were no differences between groups in stool character (eg, hard, mushy). For both groups, the presence of watery stool was related positively to pain. Of children with RAP, 65% could be categorized as having irritable bowel syndrome, whereas 35% were classifiable as having functional abdominal pain according to the pediatric Rome II criteria.

CONCLUSIONS

To the best of our knowledge, this is the first longitudinal report of symptoms in children with RAP compared with controls. These data demonstrate that there is considerable overlap between children with RAP and control children on a number of items commonly obtained in the history (eg, pain location, timing, stooling pattern). Most children with RAP could be characterized as having irritable bowel syndrome. The relationship between pain reports and interference with activities substantiates the need to deal specifically with the abdominal pain to decrease disability. The relationship between pain and watery stools requires further study.

A pilot and feasibility study of virtual reality as a distraction for children with cancer

OBJECTIVE

To pilot and test the feasibility of a novel technology to reduce anxiety and pain associated with an invasive medical procedure in children with cancer.

METHOD

Children with cancer (ages 7-19) whose treatment protocols required access of their subcutaneous venous port device (port access) were randomly assigned to a virtual reality distraction intervention, a non-virtual reality distraction, or treatment as usual without a distraction. The researchers obtained assessments of the child's pain and anxiety from the parent, child, and unblinded nurses. Pulse rate was monitored throughout the procedure, and behavioral indices of distress were recorded, as observed by the researchers.

RESULTS

Reductions in pain and anxiety were found for children who used the virtual reality distraction in comparison with the no distraction condition as evidenced by lower pulse rate and reports of pain by nurses. No significant differences were found for the non-virtual reality condition versus the no distraction condition on pulse rate.

CONCLUSIONS

These findings suggest that virtual reality may be a useful tool for distraction during painful medical procedures, but further studies are needed to test potential efficacy and feasibility during other, more distressing medical procedures with larger sample sizes.

Use of virtual reality as a distractor for painful procedures in a patient with pediatric cancer: a case study

Virtual reality (VR) has been demonstrated as an effective tool to help people overcome a variety of anxiety disorders. In this case study, the use of VR as a distractor to alleviate pain and anxiety associated with an invasive medical procedure for a pediatric cancer patient was explored. An A-B-C-A design during four consecutive medical appointments in an outpatient oncology clinic compared no distraction (A), non-VR distraction on a computer screen (B), and VR distraction with a head set (C). Behavioral observations of distress by the researcher and reports of pain and anxiety by the patient, parent, and nurse were taken before and during the procedure. The child's pulse was monitored throughout the procedure. The findings from this case study suggest benefit from using VR distraction, as indicated by lower pain and anxiety ratings, reduced pulse, and fewer observed behavioral indices of distress. The need for larger scale studies and application of VR with younger children is discussed in the context of confirming effectiveness of this technique and providing more generalizable information about efficacy.

A pain workshop: an approach to eliciting the views of young people with chronic pain

Chronic pain is complex and there is still much to discover about the burden that it places on children and their families. The aim of this study was to explore the way in which the experience of chronic pain impacts on the lives of young people. Through the use of a pain workshop that involved a series of guided activities and a focus group, young people were able to share their experiences with each other and the facilitators/researchers. Data were analysed using a theoretical coding technique supported by Atlas.ti. Five key interlinked themes emerged from the data and each theme is expressed in the words of the young people themselves: 'no one's pain's the same', 'getting on with it', 'it's hard 'cos...', 'keeping with the dream', and 'it depends ... some are OK'. The young people did experience significant disruption in their lives as a result of their pain. Pain was experienced as if it was both a separate entity as well as an intrinsic part of them and, to a degree, blighted their future. Based on the experiences shared by the young people, professionals need to develop insight and strategies into the challenges young people with chronic pain face on a daily basis.

The effects of interactive music therapy on hospitalized children with cancer: a pilot study

BACKGROUND

The use of music therapy with children in health settings has been documented, but its effectiveness has not yet been well established. This pilot study is a preliminary exploration of the effectiveness of interactive music therapy in reducing anxiety and increasing the comfort of hospitalized children with cancer.

METHODS

Pre- and post-music therapy measures were obtained from children (N = 65) and parents. The measures consisted of children's ratings of mood using schematic faces, parental ratings of the child's play performance, and satisfaction questionnaires completed by parents, children and staff.

RESULTS

There was a significant improvement in children's ratings of their feelings from pre- to post-music therapy. Parents perceived an improved play performance after music therapy in pre-schoolers and adolescents but not in school-aged children. Qualitative analyses of children's and parents' comments suggested a positive impact of music therapy on the child's well-being.

CONCLUSIONS

These preliminary findings are encouraging and suggest beneficial effects of interactive music therapy with hospitalized pediatric hematology/oncology patients. In future studies replicating these findings should be conducted in a randomized control trial.