Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline

Exploring experiences and needs among children with cancer undergoing peripherally inserted central catheter insertion: A qualitative study

Objective

This study aimed to explore the experiences of children with cancer undergoing peripherally inserted central catheter (PICC) insertion.

Methods

This study employed a descriptive qualitative approach. A total of 20 children undergoing PICC insertion were enrolled through purposive sampling. Semi-structured interviews, supplemented by draw-and-tell techniques, were conducted to collect data. Thematic analysis method was employed to analyze the interview data.

Results

Four themes and 11 subthemes were identified regarding the experience of peripherally inserted central catheter insertion in pediatric cancer patients, including (1) uncertainty (unknown procedure and lack of confidence); (2) high sensitivity (vulnerable to environmental influences and care what others think); (3) psychophysical changes (stress response, physical discomfort, disruption of daily routines, and accepted with pleasure); and (4) multidimensional needs (information, comfort, and self-actualization needs).

Conclusions

The findings underscore the importance of gaining a deeper understanding of the symptoms and needs of pediatric cancer patients undergoing PICC insertion. By appreciating and honoring children's voices, we can effectively cater to their distinct worries and guarantee they get the care and consideration they merit.

Effectiveness of Technology-Based Intervention in Symptom Management in Pediatric Oncology Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Technology-based interventions are increasingly integrated to improve symptom management of pediatric oncology patients. However, evidence for their effectiveness remains low across various studies characterized by different methodologies and patient populations. This study aimed to synthesize and analyze the effectiveness of technology-based intervention in symptom management in pediatric oncology patients.

METHODS

Six databases (PubMed, Web of Science, Cochrane Library, Ovid MEDLINE, CINAHL, and Scopus) were searched from January 1, 2014, to January 1, 2024. The methodological quality of the included studies was assessed using the Cochrane and JBI checklists. The PRISMA guidelines for systematic reporting were followed in this study. The search protocol has been registered with the PROSPERO International Prospective Register of Systematic Reviews (CRD42024516320).

RESULTS

Thirteen studies with 624 pediatric oncology patients were analyzed. Significant differences were found between intervention and control groups in pain (Hedge's g = -0.695, 95% CI: -0.994 to -0.396, p < 0.001), fear (Hedge's g = -0.737, 95% CI: -1.01 to -0.464, p < 0.001), anxiety, and nausea and vomiting (Hedge's g = -0.573, 95% CI: -0.912 to -0.235, p < 0.001).

CONCLUSION

The findings indicate that VR, iPad, humanoid robots, and Pain Squad reduce pain in pediatric oncology. VR, biofeedback-based VR, and iPads also alleviate fear, while all three plus humanoid robots mitigate anxiety. VR, interactive mobile apps, tablet games, text reminders, and iPads effectively decrease nausea and vomiting. More research is needed to evaluate the long-term effects of these interventions.

Hidradenitis Suppurativa in Children

Hidradenitis suppurativa (HS) in children can be especially challenging to treat due to a lack of pediatric-specific data and guidelines. Management strategies for this special population are often extrapolated from the adult HS literature. Many treatments, including topical agents, oral antibiotics, hormonal agents, biologics, and procedures, often utilized for adults, may also be implemented in children; however, certain age-specific considerations should be noted. Early identification and treatment of HS may help reduce the development of irreversible tissue damage and mitigate potentially devastating impacts on mental health and physical functioning.

Evidence-based practice of hypnosis in dentistry: Narrative summary of reviews and meta-analysis

The purpose of this article is to provide a concise summary of the scientific literature in the form of a narrative review to highlight areas where the use of clinical hypnosis is supported by scientific evidence in dentistry. A literature review was carried out to identify relevant peer-reviewed articles on PubMed, written in French or in English, with time limitation from 2000 to May 2023, and updated in December 2024. Articles had to be systematic reviews or meta-analysis linked with the management of dental anxiety and acute dental pain, as well as chronic orofacial pain. Twelve articles were selected for analysis, with 8 on dental anxiety, 3 on temporomandibular disorders, and 1 on burning mouth syndrome. Several literature reviews and meta-analyses published on the subject support the use of hypnosis in several clinical contexts, including local anesthesia, dental extraction and dental anxiety in adults and children. Evidence is also presented to improve the condition of patients suffering from pain associated with temporomandibular disorders. However, the literature remains somewhat fragmented because of the diversity of hypnosis techniques applied, and the different dental procedures or conditions explored. Hypnosis can have a considerable impact in the management of dental anxiety and acute dental pain. It also seems promising for the management of orofacial pain, but further research would be necessary. This research highlights that the available evidence is sufficient to encourage the integration of evidence-based hypnosis training to improve the management of acute stress and pain in dental practice.

Topical analgesia during needle-related procedures in children: a clinical practice guideline

During intensive and long-lasting treatments, short-term or emergency care, children often undergo minor needle-related procedures (ie, venepuncture, venous cannulation and puncture of central venous access ports). The use of topical analgesia topical analgesia before these procedures can reduce needle-related pain. There is, however, uncertainty about the type of local anaesthetic (ie, eutectic mixture of topical analgesia (EMLA) or tetracaine-containing creams (eg, Rapydan) that should be used.Therefore, a clinical practice guideline (CPG) was developed to establish a comprehensive, evidence-based overview and provide recommendations for clinical practice.A comprehensive multidisciplinary panel was assembled, comprising 16 professionals and patient representatives in the Netherlands. A systematic literature review was performed, and after dual appraisal of all articles, results were extracted and meta-analyses were performed. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess, extract and summarise the evidence. An in-person meeting was held to discuss the evidence, complete an evidence-to-decision framework and formulate recommendations.In total, ten randomised controlled trials comprising 1808 children formed the evidence base for the recommendations. We recommend the use of EMLA in children who need to undergo a minor needle-related procedure, with minimal application duration of 60 min (strong recommendation, very low-quality evidence). We suggest the use of tetracaine-containing creams only when rapid cannulation/puncture (ie, within 30-60 min) is required (weak recommendation, very low-quality evidence).In this CPG, we provide recommendations regarding the choice of local anaesthetic for needle-induced pain during minor procedures in children. With these recommendations, we aim to reduce procedural pain and thereby contribute to improving care for children.

The Effectiveness of Nonpharmacological Interventions to Reduce Procedural Pain of Pediatric Oncology Patients: A Systematic Review and Meta-analysis

BACKGROUND

Relieving procedural pain in pediatric oncology is an important facilitator of the cancer treatment process.

OBJECTIVE

To synthesize the effect of nonpharmacological interventions on reducing the procedural pain of pediatric oncology patients in randomized controlled trials.

METHODS

A meta-analysis and systematic review for randomized controlled trials. The PROSPERO has registered the meta-analytic approach used in this review. For studies published in English from the earliest record to May 2023, comprehensive and systematic literature searches were carried out using PubMed, Web of Science, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Science Direct, Springer Link, Scopus, EMBASE, Ovid, ELSEVIER, ProQuest and the CENTRAL, and Taylor & Francis. Two researchers used the Cochrane Collaboration method to assess the risk of bias in the included studies.

RESULTS

Four hundred ninety-four participants in 7 trials met the eligibility requirements. The primary findings showed no evidence of a significant publishing bias. This study revealed that nonpharmacological therapies significantly reduced procedural pain. Virtual reality techniques outperform nondigital distraction techniques in subgroup analysis of intervention types when it comes to lowering procedural pain in pediatric oncology patients.

CONCLUSION

In pediatric oncology, nonpharmacological therapies significantly and positively reduce procedural pain. No adverse events were reported in the included studies. Nonpharmacological therapies can be utilized by pediatric oncology nurses to mitigate procedural pain associated with needles.

IMPLICATIONS FOR PRACTICE

The findings of this study will contribute to the application of effective nonpharmacological interventions by clinical nurses and will provide guidance for the planning of further research.

The Effect of Virtual Reality Distraction and Fatigue Training on Anxiety and Fatigue Levels in Children with Cancer: A Randomized Controlled Study

OBJECTIVES

This randomized controlled trial evaluated the effect of virtual reality (VR) distraction and fatigue training on anxiety and fatigue in children with cancer.

METHODS

The sample of this parallel design randomized controlled trial consisted of 41 children aged 7 to 16 who were receiving chemotherapy treatment in the pediatric hematology and oncology wards of a university hospital. Data was collected with the Child Anxiety Scale-State, Child Fatigue Scale-24-Hours, and Visual Fatigue Scale in both groups before and during the first three days of chemotherapy treatment. All children admitted to the clinic during chemotherapy received fatigue education. On the first, second, and third days of chemotherapy treatment, children in the study group underwent a 15-minute VR distraction intervention following stratified randomization. Repeated measures analysis of variance was used to compare scale scores by group, time, and group-time interaction.

RESULTS

Of the patients, 63.4% were male, and 39% had neuroblastoma. There was no difference between the groups in terms of diagnosis, age, duration of diagnosis, chemotherapy, or hemoglobin levels. A statistically significant difference was found between the mean scores of the anxiety and fatigue scores in the intervention and control groups in terms of group, time, and group-time interaction.

CONCLUSION

Applying VR distraction on the first, second, and third days of chemotherapy treatment was found to be useful in lowering anxiety and fatigue levels in addition to fatigue training.

IMPLICATIONS FOR NURSING PRACTICE

Virtual reality distraction is an effective method for reducing anxiety and fatigue in this population.

The use of immersive virtual reality for managing physical and psychological distress in children and adolescents with cancer undergoing chemotherapy via implanted vascular access device needle insertion: A systematic review

PURPOSE

Children and adolescents undergoing cancer treatment often endure distressing procedures, leading to pain and anxiety. Immersive virtual reality (VR) is a novel distraction technique for distress management, but research in pediatric oncology remains limited. This systematic review aims to assess the effectiveness of IVR intervention utilizing advanced head-mounted displays, in alleviating physical and psychological distress among Children and Adolescents diagnosed with malignancies undergoing chemotherapy treatment via Implantable Venous Access Device/Port (IVAD/P) (P) needle insertion. Additionally, the study evaluates the usability and acceptability of the IVR intervention among healthcare professionals, patients, and their parents.

METHOD

A thorough database search (PubMed, Medline, Embase, CINHAL, and APA Psycinfo) identified seven relevant quantitative studies published until April 2024.

RESULTS

In five studies, VR significantly reduced physical distress, especially pain, though the other two showed positive trends without statistical significance. For psychological distress, two studies reported significantly lower levels in the VR group, while three showed promising but statistically insignificant results. Children and adolescents, as well as healthcare professionals, found VR user-friendly and expressed willingness to use it again.

CONCLUSIONS

The review suggests that immersive VR has significant potential as a distraction method for children and adolescents undergoing CMT via IVAD/P. It shows promise in reducing physical and psychological distress and is well-received by patients and healthcare professionals.

International expert opinion on the considerations for combining vosoritide and limb surgery: a modified delphi study

BACKGROUND

Achondroplasia is the most common form of skeletal disorder with disproportionate short stature. Vosoritide is the first disease-specific, precision pharmacotherapy to increase growth velocity in children with achondroplasia. Limb surgery is a standard approach to increase height and arm span, improve proportionality and functionality, as well as correcting deformities. The aim of this study was to gain expert opinion on the combined use of vosoritide and limb surgery in children and adolescents with achondroplasia.

METHODS

An international expert panel of 17 clinicians and orthopaedic surgeons was convened, and a modified Delphi process undertaken. The panel reviewed 120 statements for wording, removed any unnecessary statements, and added any that they felt were missing. There were 26 statements identified as facts that were not included in subsequent rounds of voting. A total of 97 statements were rated on a ten-point scale where 1 was 'Completely disagree' and 10 'Completely agree'. A score of ≥ 7 was identified as agreement, and ≤ 4 as disagreement. All experts who scored a statement ≤ 4 were invited to provide comments.

RESULTS

There was 100% agreement with several statements including, "Achieve a target height, arm span or upper limb length to improve daily activities" (mean level of agreement [LoA] 9.47, range 8-10), the "Involvement of a multidisciplinary team in a specialist centre to follow up the patient" (mean LoA 9.67, range 7-10), "Planning a treatment strategy based on age and pubertal stage" (mean LoA 9.60, range 8-10), and "Identification of short- and long-term goals, based on individualised treatment planning" (mean LoA 9.27, range 7-10), among others. The sequence of a combined approach and potential impact on the physes caused disagreement, largely due to a lack of available data.

CONCLUSIONS

It is clear from the range of responses that this modified Delphi process is only the beginning of new considerations, now that a medical therapy for achondroplasia is available. Until data on a combined treatment approach are available, sharing expert opinion is a vital way of providing support and guidance to the clinical community.

Non-pharmacological interventions to reduce procedural needle pain in children (6-12 years): A systematic review

PROBLEM

Children of different age groups frequently undergo painful procedures involving needles, which can be a source of significant discomfort. Regrettably, this aspect of care often receives insufficient attention from healthcare professionals. The existing literature proposes several methodologies for managing procedural pain, with nonpharmacological techniques being particularly promising. These techniques should be adapted to the patient's age, but literature predominantly emphasizes their use with infants. Thus, it is necessary to evaluate their effectiveness in diverse age groups. Consequently, the purpose of this systematic review is to identify non-pharmacological interventions used to prevent needle-related procedural pain in children (age group 6-12 years).

ELIGIBILITY CRITERIA

Primary studies in English language on non-pharmacological interventions in children aged 6-12 years undergoing needle-related procedures found on PubMed, CINAHL and Embase.

SAMPLE

A total of 18 studies were included.

RESULTS

The results indicate the potential application of various non-pharmacological techniques, with distraction methods standing out. These techniques include activities like utilizing cards, watching cartoons, employing virtual reality and playing video games.

CONCLUSIONS

Children's procedural pain represents a significant challenge in treatment plans. Literature offers several approaches, including nonpharmacologic methods, to control this problem. Prioritizing procedural pain management is critical both at clinical and organizational levels to improve the quality of pediatric care.

IMPLICATIONS

These findings offer different options to support clinical practice, holding the potential to enhance the quality of patient care.

Supporting parent capacity to manage pain in young children with cancer at home: Co-design and usability testing of the PainCaRe app

Young children receiving outpatient cancer care are vulnerable to undermanaged pain. App-based solutions that provide pain treatment advice to parents in real-time and in all environments may improve access to quality pain care. We used a parent co-design approach involving iterative rounds of user testing and software modification to develop a usable Pain Caregiver Resource (PainCaRe) real-time pediatric cancer pain management app. Parents of children (2-11 years) with cancer completed three standardized modules using a PainCaRe prototype. App usability and acceptability were evaluated using the validated System Usability Scale and a thematic analysis of app testing sessions and interviews. Iterative testing sessions were conducted until data saturation. Interview themes were synthesized into action items that guided revisions to PainCaRe and additional testing rounds were conducted as necessary. Twenty-two parents participated in three testing cycles. Overall, parents described PainCaRe as an acceptable and potentially clinically useful pain management tool. Mean system usability scores were in the acceptable scale range during each testing cycle. Usability issues identified and resolved included those related to software malfunction, complicated app navigation logic, lack of clarity on pain assessment questions, and the need for pain management advice specifically tailored to child developmental stage. Using co-design methods, the PainCaRe cancer pain management app was successfully refined for its acceptability and utility to parents. Next steps will include a PainCaRe pilot study before evaluating the impact of the app on younger children's pain outcomes in a randomized controlled trial.

The effect of a pushing technique with normal saline on peripheral intravenous catheter placement success in paediatric haematology and oncology: A randomized controlled trial

PURPOSE

The aim of the present study is to determine the effect of the pushing technique with saline on the success of peripheral IV catheter placement in a paediatric haematology and oncology sample.

METHODS

The randomized controlled trial was conducted among 60 paediatric haematology and oncology patients aged between 0 and 17. The participants were randomly assigned to two peripheral intravenous catheter placement groups (intervention group, n:30, control group, n:30). Each patient was evaluated with the Difficult Intravenous Access (DIVA) score before being included in the study. Each patient was assessed using the Personal Information Form for Children and Catheter Registration Form.

RESULTS

The average age of the children was 86.4 months (SD = 60.0); 36.7% were female. The pushing technique with saline significantly increased the success of placing a peripheral IV catheter on the first attempt in the intervention group compared to the control group (F = 42.391, p = 0.000). The number of attempts during peripheral IV catheter placement significantly decreased in the intervention group compared with the control group (t = -5.676, p = 0.000). Complications were less in the intervention group compared with the control group (χ2 = 24.438, p = 0.000). The procedure time was significantly shorter in the intervention group compared with the control group (t = -4.026, p = 0.000).

CONCLUSION

The pushing technique with saline is an effective method to increase the first attempt success rate, decrease the number of attempts, reduce the procedure time, and reduce the complications during peripheral intravenous catheter placement procedures in paediatric haematology and oncology patients with difficult intravenous access.

TRIAL REGISTRATION

This study was registered at ClinicalTrials.gov (NCT05685290 & date of first recruitment: January 3, 2023) https://clinicaltrials.gov/ct2/show/NCT05685290.

The effectiveness of non-pharmacological interventions on reducing pain in patients undergoing bone marrow aspiration and biopsy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients often consider bone marrow aspiration and biopsy to be one of the most painful medical procedures. The effectiveness of non-pharmacological interventions to reduce pain during bone marrow aspiration and biopsy remains unclear.

AIM

To synthesize existing evidence regarding the effectiveness of non-pharmacological interventions in mitigating procedural pain among patients undergoing bone marrow aspiration and biopsy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Six electronic databases, including PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Library and Web of Science were searched from inception to July 15, 2023. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 2.0. Meta-analysis was conducted using STATA 16. The certainty of the evidence was assessed by the GRADE approach.

RESULTS

This meta-analysis included 18 studies derived from 17 articles involving a total of 1017 participants. The pooled results revealed statistically significant pain reduction effects using distraction (SMD: -.845, 95% CI: -1.344 to -.346, p < .001), powered bone marrow biopsy system (SMD: -.266, 95% CI: -.529 to -.003, p = .048), and acupoint stimulation (SMD: -1.016, 95% CI: -1.995 to -.037, p = .042) among patients undergoing bone marrow aspiration and biopsy. However, the pooled results on hypnosis (SMD: -1.228, 95% CI: -4.091 to 1.515, p = .368) showed no significant impact on pain reduction. Additionally, the pooled results for distraction did not demonstrate a significant effect on operative anxiety (MD: -2.942, 95% CI: -7.650 to 1.767, p = .221).

CONCLUSIONS

Distraction, powered bone marrow biopsy system and acupoint stimulation are effective in reducing pain among patients undergoing bone marrow aspiration and biopsy.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

RELEVANCE TO CLINICAL PRACTICE

This meta-analysis highlights the effectiveness of distraction, powered bone marrow biopsy system and acupoint stimulation for reducing pain in patients undergoing bone marrow biopsy. Healthcare professionals should consider integrating these interventions into pain management practices for these patients.

REGISTRATION

(PROSPERO): CRD42023422854.

Duress and Distress Versus a Neurocognitive Mess: The Challenges of Procedural Sedation in Pediatric B-ALL

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice.

Pain monitoring app leads to less pain in children with cancer at home: Results of a randomized controlled trial

BACKGROUND

The authors developed a pain monitoring app offering educational information, and real-time health care professional feedback on clinically significant pain (>4 numeric rating scale [NRS]-11) for children with cancer to reduce pain at home.

METHODS

This monocenter, nonblinded randomized controlled trial enrolled Dutch children (0-18 years old) receiving cancer treatment (≥3 months after diagnosis, ≥2 months treatment remaining). Children were randomly assigned to use the app or receive usual care (two parallel groups). We assessed whether use of the app yielded less clinically significant pain (aim 1) and whether it affected pain severity, duration, interference, pain management strategies, and parental emotional well-being (aim 2). The app was also evaluated by families (aim 3).

RESULTS

A total of 94 children were randomized to use the app (15 drop-outs), and 90 were to receive care as usual (11 drop-outs). The app group (n = 79, mean age: 7.5 [5.1] years, 48% girls, 63% hemato-oncology diagnosis) reported significantly less clinically significant pain compared to usual care (n = 79, mean age: 7.5 [5.4] years, 52% girls, 65% hemato-oncology diagnosis) (odds ratio [OR], 0.38; 95% confidence interval [CI], 0.198-0.734]) (aim 1), as well as significantly lower pain severity (β = -0.27; 95% CI, -0.407 to -0.142). No differences were found for duration, interference, or management strategies. Parents in the app group reported significantly less distress compared to usual care (β = -0.84; 95% CI, -1.61 to -0.03]) (aim 2). Families generally evaluated the app positively (aim 3).

CONCLUSIONS

Use of the app resulted in less clinically significant pain at home. The exact working mechanisms of the app should be further elucidated.

Pain in pediatric oncology-A Swedish nationwide follow-up study among nurses and physicians

To examine nurses' and physicians' assessments of pain in children with cancer, and to identify the methods in use to diagnose, evaluate, and treat pain. In addition, to examine whether/how the healthcare professionals' assessment and management of pain has changed compared to 1995 and identify the needs for training. The study has a descriptive and comparative design. 363 nurses and physicians working with children with cancer in Sweden were invited to participate in April 2017. Participants answered an updated version of a questionnaire used in 1995 by Ljungman et al. focusing on the healthcare professionals' experience of pain among their patients, their pain treatment strategies, and need for training. 120 nurses and 65 physicians participated. Fifty percent of nurses and 55% of physicians answered that moderate-to-severe pain was experienced often or very often by children with cancer. Methods recommended in international guidelines to diagnose, evaluate, and treat pain were generally followed. Compared with findings from 1995 by Ljungman et al., nurses, and physicians assessed that moderate-to-severe pain was seen more often. The greatest need for training was reported for pharmacology, different routes for administration of opioids, treatment with nitrous oxide, and nonpharmacological interventions. Nurses and physicians assessed that moderate-to-severe pain is often present in children with cancer. More time to treat pain in the department and training in certain areas seem to be needed to improve pain management.

The effect of a biofeedback-based virtual reality game on pain, fear and anxiety levels during port catheter needle insertion in pediatric oncology patients: A randomized controlled study

PURPOSE

It is essential to control pain, fear, and anxiety related to medical procedures to improve the well-being of the child and family trying to cope with the disease process. This study investigated the impact of the biofeedback-based virtual reality game (BioVirtualPed) on pain, fear, and anxiety levels during port needle insertion in pediatric oncology patients (POPs).

METHODS

This randomized controlled study was conducted at a hospital between August and December 2023 involving 62 POPs aged 6-12 and their mothers. The intervention group wore a virtual reality headset and a respiratory sensor during the procedure. Data were collected using the Descriptive Information Form, Wong-Baker Pain Assessment Scale, Child Fear Scale, Children's State Anxiety, Satisfaction Scoring-Visual Analog Scale, and ADXL354 Sensor. Statistical analysis was performed using IBM SPSS for Windows Version 24.0.

RESULTS

The intervention group showed lower mean pain scores than the control group (p < 0.001). There was no difference in pre-procedure fear and anxiety scores between groups (p > 0.05 and p > 0.05, respectively). Post-procedure fear and anxiety scores were lower in the intervention group (p < 0.001 and p < 0.001, respectively). The intervention group's mean respiratory rates were lower (p < 0.001), and their satisfaction scores were higher (p < 0.001). Agreements between POPs and mothers on pain, fear, and anxiety scores were good and excellent across groups (p < 0.001).

CONCLUSIONS

The BioVirtualPed reduced procedure-related pain, anxiety, and fear, increased care satisfaction, and had a positive effect on the mean respiratory rate, hence it shows promising results, but these findings need further comfirmation.

Goldfish or aquatic turtle? Impact of two animal assisted interventions on children's pain, anxiety, and fear during IV catheterization: A randomized controlled trial

PURPOSE

This study aimed to determine the effect of goldfish and aquatic turtle nursing interventions on children's pain, anxiety, and fear during IV catheter insertion.

DESIGN AND METHODS

The randomized controlled trial included 98 children (control group = 32, goldfish group = 33, aquatic turtle group = 33) aged 5-6 years, attending outpatient clinic for blood sampling and catheterisation procedures. Pain was measured using the Wong Baker Facial Pain Scale, anxiety was measured using the Child Anxiety Scale-State, and child fear was measured using the Child Fear Scale, before, during, and after catheterization.

RESULTS

When analyzing the pain, anxiety, and fear findings, no statistical difference was found between the scores of the mother, child, and researcher before the procedure. During the catheterization procedure, the pain, anxiety, and fear scores of the children in the fish and turtle groups increased statistically less than those in the control group. When analyzing the post-procedure findings, the pain, anxiety, and fear scores of the control group were similar to those before the procedure. In the fish and turtle groups, anxiety and fear scores were statistically the lowest (p < 0.05).

CONCLUSION

It can be concluded that animal-assisted practices reduce anxiety and fear during and after the catheterization procedures while diverting attention from pain.

PRACTICE IMPLICATIONS

Goldfish or aquatic turtle intervention improve children's attitudes toward pain, anxiety, and fear during IV catheter insertion. Pediatric nurses could consider incorporating, such as the animal assisted intervention, into their clinical practice to reduce the pain, anxiety, and fear experienced by children during medical/nursing procedures.

The effect of virtual reality on pain, fear and emotional appearance during blood draw in pediatric patients at the hematology-oncology outpatient clinic: A randomized controlled study

OBJECTIVE

Invasive attempts can be very painful and stressful for pediatric patients. Virtual Reality (VR) can be used to distract patients undergoing such procedures in pediatric hematology oncology patients.

METHODS

A parallel trial design approach was adopted for this randomized controlled trial, guided by the CONSORT checklist. The study sample (n = 69) was divided into a VR group (n = 34) and a control group (n = 35) using stratified randomization. For the blood draw attempt, no distraction method was applied to the control group, while the children in the VR group were distracted from the procedure with the Epic Roller Coasters VR application. The primary variable assessed was pain, while secondary variables were fear and emotional appearance. The scores of emotional appearance, fear, and pain were compared with a Mann-Whitney U Test.

RESULTS

The pre-procedure emotional appearance score was 11.3 ± 4.3 in the VR group and 11.0 ± 5.0 in the control group, and the post-procedure score was 6.5 ± 3.3 in the VR group and 11.8 ± 5.3 in the control group, indicating a difference in emotional appearance after the procedure. VR group had lower negative emotional appearance, lower pain, and lower fear scores after procedure compared to the control group.

CONCLUSION

VR can be considered an effective approach to reducing the negative emotional appearance and for relieving pain and fear in children aged 4-12 years undergoing blood draw procedures in pediatric hematology and oncology outpatient unit (ClinicalTrials.gov: NCT05675358).

Parent and clinician perceptions and recommendations on a pediatric cancer pain management app: A qualitative co-design study

Pain is one of the most prevalent and burdensome pediatric cancer symptoms for young children and their families. A significant proportion of pain episodes are experienced in environments where management options are limited, including at home. Digital innovations such as apps may have positive impacts on pain outcomes for young children in these environments. Our overall aim is to co-design such an app and the objective of this study was to explore the perceptions of children's parents about app utility, needed system features, and challenges. We recruited parents of young children with cancer and multidisciplinary pediatric oncology clinicians from two pediatric cancer care centers to participate in audio-recorded, semi-structured, co-design interviews. We conducted interviews structured around technology acceptance and family caregiving theories until data saturation was reached. Audio-recordings were then transcribed, coded, and analyzed using thematic analysis. Forty-two participants took part in the process. Participants endorsed the concept of an app as a useful, safe, and convenient way to engage caregivers in managing their young child's pain. Overall, the app was valued as a means to provide real-time, multimodal informational and procedural pain support to parents, while also reducing the emotional burden of pain care. Recommendations for intervention design included accessibility-focused features, comprehensive symptom tracking, and embedded scientific- and clinically-sound symptom assessments and management advice. Predicted challenges to app use included the workload burden it may place on parents and clinicians. The insights gathered will inform the design principles of our future childhood cancer pain digital research.

Developing rights-based standards for children having tests, treatments, examinations and interventions: using a collaborative, multi-phased, multi-method and multi-stakeholder approach to build consensus

Children continue to experience harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. The international ISupport collaboration aimed to develop standards to outline and explain good procedural practice and the rights of children within the context of a clinical procedure. The rights-based standards for children undergoing tests, treatments, investigations, examinations and interventions were developed using an iterative, multi-phased, multi-method and multi-stakeholder consensus building approach. This consensus approach used a range of online and face to face methods across three phases to ensure ongoing engagement with multiple stakeholders. The views and perspectives of 203 children and young people, 78 parents and 418 multi-disciplinary professionals gathered over a two year period (2020-2022) informed the development of international rights-based standards for the care of children having tests, treatments, examinations and interventions. The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.    Conclusion: This is the first study of its kind which outlines international rights-based procedural care standards from multi-stakeholder perspectives. The standards offer health professionals and educators clear evidence-based tools to support discussions and practice changes to challenge prevailing assumptions about holding or restraining children and instead encourage a focus on the interests and rights of the child. What is Known: • Children continue to experience short and long-term harm when undergoing clinical procedures despite increased evidence of the need to improve the provision of child-centred care. • Professionals report uncertainty and tensions in applying evidence-based practice to children's procedural care. What is New: • This is the first study of its kind which has developed international rights-based procedural care standards from multi-stakeholder perspectives. • The standards are the first to reach international multi-stakeholder consensus on definitions of supportive and restraining holds.

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

Physicians' Knowledge, Attitudes, and Perception Toward Pediatric Palliative Care in Saudi Arabia: A National Exploratory Survey

BACKGROUND

Pediatric palliative care (PPC) helps maintain the quality of life for both children and their families. It has been identified as an important goal within the global health agenda. In Saudi Arabia, the discipline remains in its infancy, as illustrated by the absence of PPC programs in academic and health care institutions.

AIM

The aim was to conduct a pilot study assessing physicians' knowledge, attitudes, and perceptions toward PPC.

METHOD

Data were gathered through a self-administered questionnaire sent to physicians working in Saudi Arabia.

RESULTS

One hundred twelve completed the survey (male 54.2%, n = 50). A total of 40.8% (n = 42) had 20 years or more of experience, 42.9% (n = 48) were from the hematology-oncology specialty, and 68.5% (n = 74) received no training in PPC. Half suggested that children should be informed of their condition but mostly when reaching 12 or 15 years of age. Various physicians reported that the most appropriate time to discuss a transition to palliative care goals is when diagnosing an incurable condition or when despite all efforts, a condition continues to progress and death is expected.

CONCLUSION

Multiple gaps were identified. PPC basic concepts should be included in the formal medical curriculum (e.g., pain management, communication, and ethical considerations at the end of life). There is also a significant need to develop further both primary and specialized palliative care.

A whole new world of healing: exploring medical hypnotherapy for pediatric patients : A review

This narrative review aims to unravel the potential of medical hypnotherapy for the treatment of children with a variety of diseases and symptoms. Going beyond its history and assumed neurophysiology, the chances of success for hypnotherapy will be outlined per pediatric speciality, accentuated by clinical research and experiences. Future implications and recommendations are given on extracting the positive effects of medical hypnotherapy for all pediatricians.    Conclusion: Medical hypnotherapy is an effective treatment for children with specified conditions such as abdominal pain or headache. Studies suggest effectiveness for other pediatric disciplines, from the first line up to third line of care. In a time in which health is defined as 'a state of complete physical, mental and social well-being', hypnotherapy stays an underrated treatment option for children. It is a unique mind-body treatment, which true potential still needs to be unraveled. What is Known: • Mind-body health techniques become a more relevant and accepted part of treatment in pediatric patients. • Medical hypnotherapy is an effective treatment for children with specified conditions such as functional abdominal pain. What is New: • Studies suggest the effectiveness of hypnotherapy in a high variety of pediatric symptoms and disease. • Hypnotherapy is a unique mind-body treatment which potential goes far beyond its current utilization.

Procedural anxiety among children and adolescents with cystic fibrosis and their parents

BACKGROUND

Procedural anxiety involves acute distress around medical procedures and may lead to avoidance or resistance behaviors that interfere with effective cystic fibrosis (CF) care and health outcomes. While individuals with CF commonly endure uncomfortable and/or distressing medical procedures, procedural anxiety among children and adolescents with CF has received little research attention. This study investigated the prevalence and correlates of procedural anxiety among individuals with CF aged 6-18 and their parents.

METHOD

Eighty-nine parents of children with CF completed surveys examining child procedural anxiety, anxiety, and health behaviors (including treatment adherence); and parent vicarious procedural anxiety.

RESULTS

Seventy-five percent of participants rated at least one CF-related procedure as "extremely" anxiety-inducing for their child. Parental vicarious procedural anxiety was reported in 80.9% of participants. Procedural anxiety significantly correlated with child anxiety, treatment-resistive behaviors, and parent-vicarious procedural anxiety. Procedural anxiety was associated with younger age and frequency of distressing procedures, but not with forced expiratory volume in 1 s, body mass index, hospitalizations, or exposure to general anesthesia.

CONCLUSION

Procedural anxiety is common among children, adolescents, and caregivers, and is associated with child anxiety and treatment resistance, emphasizing the importance of screening and interventions for procedural anxiety as part of routine CF care from early childhood. Implications for screening and intervention are discussed.

Digital health tools for pain monitoring in pediatric oncology: a scoping review and qualitative assessment of barriers and facilitators of implementation

PURPOSE

We aimed to systematically identify and characterize existing digital health tools for pain monitoring in children with cancer, and to assess common barriers and facilitators of implementation.

METHODS

A comprehensive literature search (PubMed, Cochrane, Embase, and PsycINFO) was carried out to identify published research on mobile apps and wearable devices focusing on acute and/or chronic pain in children (0-18 years) with cancer (all diagnoses) during active treatment. Tools had to at least include a monitoring feature for one or more pain characteristic(s) (e.g., presence, severity, perceived cause interference with daily life). Project leaders of identified tools were invited for an interview on barriers and facilitators.

RESULTS

Of 121 potential publications, 33 met inclusion criteria, describing 14 tools. Two methods of delivery were used: apps (n=13), and a wearable wristband (n=1). Most publications focused on feasibility and acceptability. Results of interviews with project leaders (100% response rate), reveal that most barriers to implementation were identified in the organizational context (47% of barriers), with financial resources and insufficient time available mentioned most often. Most factors that facilitated implementation related to end users (56% of facilitators), with end-user cooperation and end-user satisfaction mentioned most often.

CONCLUSIONS

Existing digital tools for pain in children with cancer were mostly apps directed at pain severity monitoring and little is still known about their effectiveness. Paying attention to common barriers and facilitators, especially taking into account realistic funding expectations and involving end users during early stages of new projects, might prevent evidence based interventions from ending up unused.

Immersive and Non-Immersive Virtual Reality for Pain and Anxiety Management in Pediatric Patients with Hematological or Solid Cancer: A Systematic Review

Invasive and painful procedures, which often induce feelings of anxiety, are necessary components of pediatric cancer treatment, and adequate pain and anxiety management during these treatments is of pivotal importance. In this context, it is widely recognized that a holistic approach, including pharmacological and non-pharmacological modalities, such as distraction techniques, should be the standard of care. Recent evidence suggested the use of virtual reality (VR) as an effective non-pharmacological intervention in pediatrics. Therefore, this systematic review aims to analyze previously published studies on the effectiveness of VR for the management of pain and/or anxiety in children and adolescents with hematological or solid cancer. Medline, SCOPUS, Web of Science, ProQuest, CINAHL, and The Cochrane Central Register of Controlled Trials were used to search for relevant studies in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist. Randomized controlled trial, crossover trial, cluster randomized trial, and quasi-experimental studies were included. Thirteen studies, published between 1999 and 2022, that fulfilled the inclusion criteria were included. Regarding the primary outcomes measured, pain was considered in five studies, anxiety in three studies, and the remaining five studies analyzed the effectiveness of VR for both pain and anxiety reduction. Our findings suggested a beneficial effect of VR during painful vascular access procedures. Limited data are available on the reduction of anxiety in children with cancer.

Supportive interventions for childhood cancer: An umbrella review of randomized evidence

Therapeutic advancements have improved pediatric cancer prognosis, shifting the interest towards the management of psychosocial burden and treatment-related morbidity. To critically appraise the available evidence, we conducted an umbrella review of meta-analyses of randomized controlled trials on supportive interventions for childhood cancer. Thirty-four publications (92 meta-analyses, 1 network, 14,521 participants) were included. The most concrete data showed a reduction in procedure-related pain and distress through hypnosis. Moreover, exercise improved the functional mobility of the patients. Regarding pharmacological interventions, most of the meta-analyses pertained to the treatment of nausea/vomiting (ondansetron was effective) and infections/febrile neutropenia [granulocyte-(macrophage) colony-stimulating factors showed benefits]. Substantial heterogeneity was detected in 31 associations. Conclusively, supportive interventions for pediatric cancer are being thoroughly evaluated. However, most of the studies are small and of moderate quality, highlighting the need for more randomized evidence in order to increase precision in improving the quality of life of patients, survivors and their families.

The Effect of Robot-Led Distraction during Needle Procedures on Pain-Related Memory Bias in Children with Chronic Diseases: A Pilot and Feasibility Study

The current study evaluated the feasibility and preliminary clinical impact of robot-led distraction during needle procedures in children with chronic diseases on pain-related memories. Participants were 22 children (8−12 years old) diagnosed with a chronic disease (e.g., chronic immune deficiency) and undergoing a needle procedure as part of their routine treatment. Children were randomized to the experimental group (i.e., robot-led distraction) or control group (i.e., usual care). For feasibility, we evaluated study- and needle-procedure-related characteristics, intervention fidelity and acceptability, and nurse perceptions of the intervention. Primary clinical outcomes included children’s memory bias for pain intensity and pain-related fear (1 week later). Results indicated that intervention components were >90% successful. Overall, the robot-led distraction intervention was perceived highly acceptable by the children, while nurse perceptions were mixed, indicating several challenges regarding the intervention. Preliminary between-group analyses indicated a medium effect size on memory bias for pain intensity (Hedges’ g = 0.70), but only a very small effect size on memory bias for pain-related fear (Hedges’ g = 0.09), in favor of the robot-led distraction intervention. To summarize, while feasible, certain challenges remain to clinically implement robot-led distraction during needle procedures. Further development of the intervention while accounting for individual child preferences is recommended.

Feasibility of a VR Intervention to Decrease Anxiety in Children with Tumors Undergoing CVC Dressing

Virtual reality (VR) represents a promising digital intervention for managing distress and anxiety in children with tumors undergoing painful medical procedures. In an experimental cross-over study, we administered a VR intervention consisting of relaxing games during central venous catheter (CVC) dressing. The VR sessions were compared with no-VR during CVC medication. We used the distress thermometer and RCMAS-2 scale to assess distress and anxiety levels. We also explored the satisfaction level in patients and families. We enrolled 22 children. The distress levels after medication were lower in the VR group than in those without VR (VR: median 2; IQR 0-2; no-VR: median 4; IQR: 3-5). No variation in anxiety levels was detected by VR intervention. Satisfaction for using VR was very high in children and their families although a total of 12% of children were disappointed by the effect of VR. Most healthcare workers felt that VR would be useful in routine clinical practice. A VR intervention is highly acceptable, may be efficacious in decreasing distress in children with cancer undergoing painful procedures, but it is less likely that it has a measurable impact on anxiety. Evidence from larger studies is needed to assess VR translation into the clinical workflow.

The Perceptions of Children and Adolescents with Cancer Regarding Nurses' Communication Behaviors during Needle Procedures

Background: Communicating with children and adolescents with cancer during a needle procedure can prove challenging for healthcare professionals. Objective: Our aim was to explore the perceptions of children and adolescents with cancer regarding communication with nurses during needle procedures. Method: Thus was a qualitative phenomenological study. Data were gathered through seven in-depth interviews with a convenience sample of children and adolescents with cancer. Data were analyzed using a grounded theory approach to identify themes in the participants' narratives. Results: The analysis revealed three themes describing participants' experience: (1) nurses need to explain clearly what they are going to do while also allowing children to express their emotions without feeling coerced; (2) nurses need to be honest and approachable and relate to children as active participants in the treatment process; and (3) it is distressing to hear other children who are undergoing a needle procedure cry out in pain. Further application of the constant comparison method yielded a core theme: (4) the pressures faced by oncology nurses lead them to focus on the technical side of procedures at the expense of their young patients' communication needs. Conclusions: We suggest that hospital managers need to ensure that oncology nurses have sufficient training in communication skills and are confident in their ability to respect and respond to the communication preferences and needs of patients.

Quality Assessment of Cancer Pain Clinical Practice Guidelines

Introduction

Several clinical practice guidelines (CPGs) for cancer pain have been published; however, the quality of these guidelines has not been evaluated so far. The purpose of this study was to evaluate the quality of CPGs for cancer pain and identify gaps limiting knowledge.

Methods

We systematically searched seven databases and 12 websites from their inception to July 20, 2021, to include CPGs related to cancer pain. We used the validated Appraisal of Guidelines for Research and Evaluation Instrument II (AGREE II) and Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist to assess the methodology and reporting quality of eligible CPGs. The overall agreement among reviewers with the intraclass correlation coefficient (ICC) was calculated. The development methods of CPGs, strength of recommendations, and levels of evidence were determined.

Results

Eighteen CPGs published from 1996 to 2021 were included. The overall consistency of the reviewers in each domain was acceptable (ICC from 0.76 to 0.95). According to the AGREE II assessment, only four CPGs were determined to be recommended without modifications. For reporting quality, the average reporting rates for all seven domains of CPGs was 57.46%, with the highest domain in domain 3 (evidence, 68.89%) and the lowest domain in domain 5 (review and quality assurance, 33.3%).

Conclusion

The methodological quality of cancer pain CPGs fluctuated widely, and the complete reporting rate in some areas is very low. Researchers need to make greater efforts to provide high-quality guidelines in this field to clinical decision-making.

The Symptom Experience in Pediatric Cancer: Current Conceptualizations and Future Directions

PURPOSE OF REVIEW

We aimed to review the recent research on the childhood cancer symptom experience pertaining to socioeconomic factors, biology and genetics, growth and development, family psychosocial dynamics, and social and treating environments to begin to formulate recommendations for a personalized approach to symptom management.

RECENT FINDINGS

Cancer symptoms are common and distressing in children and negatively impact child and family quality of life. Many interacting factors influence children's cancer symptoms experiences, including the assessment and management of such symptoms. This paper highlights several gaps in the research related to the cancer symptom experience including routine symptom assessment, the impact of socioeconomic, biological, and genetic factors on symptoms, and the establishment of effective symptom management partnerships with families. Based on our findings, we provide recommendations related to that research which is ready to be implemented into clinical practice and areas for needed future efforts.

Effects of Distraction on Reducing Pain During Invasive Procedures in Children with Cancer: A Systematic Review and Meta-Analysis

BACKGROUND

Distraction is a known behavioral intervention that is widely used for pain management in the pediatric population. However, there is a shortage of reviews reporting the efficacy of distraction for procedural pain reduction in pediatric oncology settings.

AIM

To determine the current evidence on the effects of distraction on procedural pain in children with cancer.

DESIGN

This systematic review and meta-analysis was undertaken according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines SETTINGS: Six different databases from 1990 to June 2019.

METHOD

A literature search was conducted to identify the effects of distraction on procedural pain reduction in children with cancer. A meta-analysis was undertaken along with applying a mixed effect model to quantify the standardized mean difference in the 95% confidence interval (CI) as the overall effects.

RESULTS

Ten randomized controlled trials were included. Distraction during an invasive procedure had a large effect on pain intensity (-0.92, 95% CI -1.48 to -0.36, p = .001) and on needle insertion as well (-1.12, 95% CI -1.52 to -0.72, p = .000), but only a moderate effect on lumbar puncture procedures (-0.57, 95% CI -1.02 to -0.12, p = .012). Uncertain effects on pain relief showed up in a virtual reality (VR) distraction (-0.93, 95% CI -2.63 to 0.76, p = .28) and during active distraction (-0.72, 95% CI -1.48 to 0.03, p = .06).

CONCLUSIONS

Distraction is an efficacious intervention to reduce procedural pain during needle insertion or lumbar puncture procedures in children with cancer. However, the efficacy of active distraction and VR remain uncertain. Future research should focus on specific comparisons of different forms of distractions with larger sample sizes.

Reducing pain in children with cancer at home: a feasibility study of the KLIK pain monitor app

PURPOSE

This study assessed adherence to, feasibility of, and barriers and facilitators of implementation of an app developed to monitor and follow-up with pain in children with cancer at home.

METHODS

Children (8-18 years) receiving cancer treatment (all diagnoses) or their parents (of children aged 0-7 years) used the KLIK Pain Monitor app for 3 weeks. Pain was assessed twice daily using an 11-point numeric rating scale (NRS-11) (ranging from 0 to 10). Healthcare professionals (HCP's) from the hospital's Pediatric Pain Service were instructed to follow-up with clinically significant pain scores (≥ 4) within 120 min (scores 4-6) or 30 min (scores 7-10). Adherence, feasibility, and implementation outcomes were assessed using questionnaires, app log data, and interviews.

RESULTS

Twenty-seven children (M age = 7.3 years, 51.8% male) and six HCP's participated. Sixty-three percent (N = 17) of families used the app on a daily basis during three weeks, and 18.5% (N = 5) reported pain scores twice daily during that time (family adherence). Twelve out of 27 children (44.4%) reported a clinically significant pain score at least once. In 70% (14/20) of clinically significant pain scores, HCP's followed-up with families within the set timeframe (HCP adherence). Outcomes reveal feasibility for the majority of app functions (i.e., positive evaluation by ≥ 70% families/HCP's), and non-feasible aspects could be resolved. Identified barriers and facilitators were used to improve future implementation efforts.

CONCLUSION

Use of the KLIK Pain Monitor app seems feasible. Future research will determine its effectiveness in reducing pain in children with cancer at home.

A Person-Centered Approach to Symptom Assessment and Management for Children and Adolescents Receiving Cancer Treatment

OBJECTIVES

Discuss the clinical assessment and management of symptoms for children and adolescents receiving treatment for cancer with attention to a person-centered approach to care.

DATA SOURCES

Review of currently published literature and guidelines pertaining to symptom assessment and management for children and adolescents receiving treatment for cancer.

CONCLUSION

Symptoms such as pain, nausea, and fatigue are commonly reported by children and adolescents receiving cancer treatment and are associated with greater symptom burden. Symptom assessment should be tailored to the child or adolescent and include the child's or adolescent's preference for reporting symptoms and attention to the symptoms that are of greatest priority. Evidence-based guidelines for the management of symptoms, including pain and nausea, are available to guide symptom management interventions and should be tailored to provide person-centered care.

IMPLICATIONS FOR NURSING PRACTICE

Nurses can lead efforts through clinical practice and research initiatives to advance person-centered symptom care for children and adolescents with cancer on a global level. Priorities for future work to advance person-centered symptom assessment and management include (1) identification of best practices for symptom assessment, (2) attention to social determinants of health and their subsequent influence on symptom outcomes, (3) compilation of evidence for management of less commonly reported symptoms, and (4) implementation of published clinical guidelines for symptom management in practice settings.

Identifying clinical practice guidelines for symptom control in pediatric oncology

BACKGROUND

Children with cancer commonly experience distressing symptoms such as pain, fatigue and nausea. Improvements in patient outcomes have been associated with implementation of clinical practice guideline-consistent care across several domains. The objective of this study was to develop a process to identify symptom management clinical practice guidelines (CPGs) applicable to children and adolescents receiving cancer treatments.

METHODS

We focused on identifying CPGs to manage 15 symptoms. The process defined three Tiers of CPGs based upon applicability to pediatric cancer patients and ease of identification: Tier 1: endorsed by the Children's Oncology Group; Tier 2: housed in the Emergency Care Research Institute repository, or developed by the American Society of Clinical Oncology or National Institute for Health and Care Excellence; and Tier 3: identified by systematic review. We first searched for CPGs published 2015-2020 and identified Tiers 1 or 2 CPGs. If unavailable or scope was too narrow, we proceeded to Tier 3. If CPGs were not identified, we repeated these steps for CPGs published 2010-2014.

RESULTS

There were six Tier 1 and 13 Tier 2 CPGs published 2015-2020 across the 15 symptoms. Four symptoms required progression to Tier 3 because CPGs were absent (anger) or because scope was too narrow (pain, anorexia/excessive hunger and diarrhea). The systematic review identified three CPGs for pain and none for the other three symptoms. In total, CPGs were identified for 14 of 15 symptoms. None were identified for anger.

CONCLUSION

We created a process to identify supportive care CPGs for pediatric cancer symptom management and were able to identify CPGs that addressed 14 of 15 symptoms. Future work should focus on evaluating implementation techniques for these CPGs and determining the impact of these CPGs on provider and patient outcomes.

Improving symptom control and reducing toxicities for pediatric patients with hematological malignancies

The continuing improvement in pediatric cancer survival over time is largely attributable to the availability of intensive therapies. Increasing attention has been focused on addressing the physical and psychosocial impacts of cancer and cancer treatments. Evidence from adult oncology suggests that routine symptom screening and feedback to health care providers can improve patient-clinician communication, reduce distress, and improve quality of life and may even increase survival. Many questions remain regarding implementation of routine symptom screening in pediatric cancer care, including the best symptom assessment instrument and the reporter type and feasibility of integration with electronic health records (EHRs). Nonsymptom adverse events are also important, for both routine clinical care and adverse event reporting for patients enrolled in clinical trials. However, traditional mechanisms for reporting adverse events lead to substantial inaccuracies and are labor intensive. An automated approach for abstraction from EHRs is a potential mechanism for improving accuracy and reducing workload. Finally, identification of symptom and nonsymptom toxicities must be paired with prophylactic and therapeutic strategies. These strategies should be based on clinical practice guidelines that synthesize evidence and use multiprofessional, multidisciplinary expertise to place this evidence in clinical context and create recommendations. How best to implement clinical practice guidelines remains a challenge, but EHR order sets and alerts may be useful. In summary, although survival is excellent for pediatric patients receiving cancer therapies, more focus is needed on identification of symptoms and nonsymptom toxicities and their management. The EHR may be useful for promoting better supportive care through these mechanisms.

The effect of virtual reality on pain, fear, and anxiety during access of a port with huber needle in pediatric hematology-oncology patients: Randomized controlled trial

PURPOSE

Port needle insertions are painful and distressing for Pediatric Hematology-Oncology patients. Virtual Reality (VR) can be used during needle-related procedures in these patients. This study aimed to investigate the effect of VR distraction during access to the venous port with a Huber needle in reducing needle-related pain, fear, and anxiety of children and adolescents with cancer.

METHODS

This randomized controlled study used a parallel trial design guided by the CONSORT checklist. The sample of children (n = 42) was allocated to the VR group (n = 21) and the control group (n = 21). Port needle-related pain was assessed using the Wong-Baker Faces Pain Rating Scale after the procedure. Before and after the port needle insertion procedure, anxiety and fear assessed using self- and parent-report using the Children's Anxiety Meter and Child Fear Scale. The primary outcome was the patient-reported pain scores after the procedure and fear and anxiety scores before and after the procedure. Pain, anxiety, and fear scores of the two groups and within groups were analyzed and also Spearman correlation analysis was used.

RESULTS

Self-reported pain scores of patients in the VR and control group were 2.4 ± 1.8 and 5.3 ± 1.8, respectively. This study found a statistically significant difference between groups in pain scores (p < .001). A statistically significant difference was found between groups according to the self- and parent-reported fear and anxiety scores after the procedure. Self-reported fear scores in the VR and control group were 0.8 ± 0.9, 2.0 ± 1.0, self-reported anxiety scores were 2.9 ± 2.0, 5.4 ± 2.0, respectively (p < .001).

CONCLUSION

Virtual reality is an effective distraction method in reducing port needle-related pain, fear, and anxiety in Pediatric Hematology-Oncology patients. ClinicalTrials.gov NCT04093154.