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

The effect of retrieval-induced forgetting for pain-related memories on child pain-related outcomes: A randomized experimental study

BACKGROUND

Children's inability to forget the negative aspects of a painful event is associated with more anticipatory anxiety at an upcoming pain task and lower pain thresholds; however, the impact of forgetting on children's pain outcomes has not been examined. Retrieval-Induced Forgetting (RIF) was experimentally induced to investigate whether children would (1) forget more negative details of a previous painful autobiographic event and; (2) report better pain-related outcomes for an unrelated pain task (i.e., cold pressor task; CPT). Additionally, it was investigated whether the success of RIF was dependent on child characteristics known to influence children's memories for pain (i.e., attention bias to pain, attention switching ability and pain catastrophizing).

METHODS

Healthy school children (N = 128; 9-16 years old) recalled and rehearsed memory details of two painful autobiographical events, while only children in the randomized RIF group rehearsed positive details. All children underwent two CPTs (before and after RIF) and reported pain-related outcomes. Two weeks later, children recalled CPT pain and reported on future pain expectancies.

RESULTS

Children in the RIF group remembered less negative details of their past autobiographical pain events, but also reported a greater reduction in pain-related fear from the CPT 2 compared to their ratings for CPT 1, than children in the control group. They furthermore expected less pain-related fear 2 weeks later for a future pain task.

DISCUSSION

Findings suggest that RIF is a promising avenue in pediatric pain management that could be harnessed to foster more positive memories and better future pain experiences.

SIGNIFICANCE STATEMENT

Retrieval-induced forgetting (RIF) makes children forget negative details of a past autobiographical pain experience, decreases experienced pain-related fear for experimental pain and lowers future pain-related fear expectancies. Results show a promising role for RIF- based memory interventions in the context of paediatric pain care.

Parental narrative style moderates the relation between pain-related attention and memory biases in youth with chronic pain

ABSTRACT

Negatively biased pain memories robustly predict maladaptive pain outcomes in children. Both attention bias to pain and parental narrative style have been linked with the development of these negative biases, with previous studies indicating that how parents talk to their child about the pain might buffer the influence of children's attention bias to pain on the development of such negatively biased pain memories. This study investigated the moderating role of parental narrative style in the relation between pain-related attention and memory biases in a pediatric chronic pain sample who underwent a cold pressor task. Participants were 85 youth-parent dyads who reminisced about youth's painful event. Eye-tracking technology was used to assess youth's attention bias to pain information, whereas youth's pain-related memories were elicited 1 month later through telephone interview. Results indicated that a parental narrative style using less repetitive yes-no questions, more emotion words, and less fear words buffered the influence of high levels of youth's attention bias to pain in the development of negatively biased pain memories. Opposite effects were observed for youth with low levels of attention bias to pain. Current findings corroborate earlier results on parental reminiscing in the context of pain (memories) but stress the importance of matching narrative style with child characteristics, such as child attention bias to pain, in the development of negatively biased pain memories. Future avenues for parent-child reminiscing and clinical implications for pediatric chronic pain are discussed.

Pain memory in children: a systematic review and meta-analysis with a meta-regression

ABSTRACT

The aim of this systematic review and meta-analysis was to analyze the accuracy of memory of pain and the variables that may influence it in children with acute, experimental, and chronic pain. We conducted a search in electronic databases from inception to February 11, 2022. Twelve observational studies and 3 randomized controlled studies were included in the study. The main outcome measure was the accuracy of the memory of the pain intensity (experienced/recalled). To compare the outcomes reported by the studies, we calculated the standardized mean difference (SMD) over time for the continuous variables. The overall meta-analysis showed a small effect size in favor of an overestimation of experienced pain intensity (SMD = 0.28). Subanalyzing per pain context, there was a small effect size in favor of overestimation in the clinical context (SMD = 0.33), but there was no evidence of any change in the accuracy of memory of pain in the experimental context (SMD = 0.07). The mean age of the participants and the proportion of girls significantly predicted the accuracy of the memory of pain. The period since the experienced pain measurement, the intensity of expected and recalled fear, trait anxiety, and anxiety sensitivity did not significantly predict the accuracy of the memory of pain. Children showed an overestimation in pain memory between the experienced and recalled intensity of acute pain, especially in a clinical context. Furthermore, only gender and age were predictors of the accuracy of pain memory. These results highlight the relevance of pain memory to medical practice and future research.

Exploring Relations Between Unique Patient Characteristics and Virtual Reality Immersion Level on Anxiety and Pain in Patients Undergoing Venipuncture: Secondary Analysis of a Randomized Control Trial

BACKGROUND

Virtual reality (VR) is a well-researched digital intervention that has been used for managing acute pain and anxiety in pediatric patients undergoing various medical procedures. This study focuses on investigating the role of unique patient characteristics and VR immersion level on the effectiveness of VR for managing pediatric pain and anxiety during venipuncture.

OBJECTIVE

The purpose of this study is to determine how specific patient characteristics and level of immersion during a VR intervention impact anxiety and pain levels for pediatric patients undergoing venipuncture procedures.

METHODS

This study is a secondary data analysis of 2 combined, previously published randomized control trials on 252 pediatric patients aged 10-21 years observed at Children's Hospital Los Angeles from April 12, 2017, to July 24, 2019. One randomized clinical trial was conducted in 3 clinical environments examining peripheral intravenous catheter placement (radiology and an infusion center) and blood draw (phlebotomy). Conditional process analysis was used to conduct moderation and mediation analyses to assess the impact of immersion level during the VR intervention.

RESULTS

Significant moderation was found between the level of immersion and anxiety sensitivity when predicting postprocedural anxiety (P=.01). Patients exhibiting the highest anxiety sensitivity within the standard of care yielded a 1.9 (95% CI 0.9-2.8; P<.001)-point elevation in postprocedural anxiety relative to individuals with high immersion levels. No other significant factors were found to mediate or moderate the effect of immersion on either postprocedural anxiety or pain.

CONCLUSIONS

VR is most effective for patients with higher anxiety sensitivity who report feeling highly immersed. Age, location of the procedure, and gender of the patient were not found to significantly impact VR's success in managing levels of postprocedural pain or anxiety, suggesting that immersive VR may be a beneficial intervention for a broad pediatric population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04268901; https://clinicaltrials.gov/study/NCT04268901.

Healthcare Professionals' Perspectives on Improving Family-Centred Pain Care in a Tertiary Pediatric Centre

BACKGROUND

Despite being a core component of family-centered and compassionate care, children's pain is often undertreated in Canadian hospitals. Nurses' and other healthcare professionals' (HCPs) ability to understand and respond to a child and their family's pain care needs is integral to improving this care in a family-centered manner.

PURPOSE

To understand nurses' and other HCPs' perceptions of child and family needs to make care more collaborative and patient- and family-centered.

METHODS

Eighteen participants were recruited and represented the specialties of nursing (n = 8), psychology (n = 1), child life services (n = 2), medicine/surgery (n = 3), and administration/leadership (n = 4); 3 of the administrators had a nursing background. Transcripts were analysed using a semantic, inductive approach with two coders using a codebook to ensure reliability.

RESULTS

Participants felt that pain care was important, but that it needs to take greater priority in the hospital. In our analysis, we identified four core needs that nurses and other HCPs have to provide better pain care: 1. Better acknowledgement of child and family experiences; 2. Better visual and written knowledge translation tools for patients and families; 3. Better provision of verbal pain education to children and families by nurses and other HCPs; and 4. Help for patients and families to advocate for better pain care when they feel their needs are not being met.

CONCLUSIONS

Nurses and other HCPs value patient- and family-centered pain care, and wish to empower families to advocate for it when it is sub-optimal.

Atopic dermatitis in early life and pain at 10 years of age: An exploratory study

Pain is a distinctive burden in atopic dermatitis and recognized as an important and highly prevalent symptom. It is unknown if the presence of atopic disease may sensitize children to adverse pain profiles in the long term. We aimed to assess the impact of early-life atopic dermatitis-like symptoms on pain at 10 years of age. We used data from 1302 and 874 participants of the Generation XXI birth cohort evaluated at 6 and 15 months, respectively, and 10 years. Atopy-like symptoms since birth, including atopic dermatitis, were collected at ages 6 and 15 months by interviewing parents. Pain history in the last 3 months at age 10 was collected from parents and children using structured questionnaires. We computed relative risks (RR) and respective 95% confidence intervals of pain features at age 10 according to each atopic-like symptom at 6 and 15 months. Children whose parents reported atopic dermatitis-like symptoms at 6 months and at 15 months had higher risk of reporting any pain (RR 1.75 [1.15-2.66]) and multisite pain, respectively (RR 1.67 [1.18-2.37]) at 10 years of age.  Conclusion: Atopic dermatitis symptoms in early life were associated with a higher risk of pain at age 10, suggesting that potential for sensitization during the first decade of life and highlighting the importance of improving the health care of children with atopic dermatitis is worth investigating. What is Known: • Atopic disorders have been associated with many non-atopic comorbidities, including chronic pain. • Pain and atopic dermatitis share common inflammatory pathways. Inflammation, injury to the skin from scratching, fissures, and intolerance to irritants related to atopic dermatitis can cause pain. What is New: • Atopic dermatitis in early life is linked to an increased likelihood of experiencing pain at the age of 10, which suggests that exploring the potential for sensitization is a worthwhile area of investigation. • Our proof-of-concept study highlights the potential benefit of studying management targets and improving itching and relieving skin pain as quickly as possible, avoiding potential long-term consequences of the sensitization process.

Pain experiences of marginalized children in the emergency department: A scoping review protocol

INTRODUCTION

Pain affects all children, and in hospitals across North America, this pain is often undertreated. Children who visit the emergency department (ED) experience similar undertreatment, and they will often experience a painful procedure as part of their diagnostic journey. Further, children and their caregivers who experience social injustices through marginalization are more likely to experience healthcare disparities in their pain management. Still, most of our knowledge about children's pain management comes from research focused on well-educated, white children and caregivers from a middle- or upper-class background. The aim of this scoping review is to identify, map, and describe existing research on (a) how aspects of marginalization are documented in randomized controlled trials related to children's pain and (b) to understand the pain treatment and experiences of marginalized children and their caregivers in the ED setting.

METHODS AND ANALYSIS

The review will follow Joanna Briggs Institute methodology for scoping reviews using the Participant, Concept, Context (PCC) framework and key terms related to children, youth, pain, ED, and aspects of marginalization. We will search Medline, Embase, PsychInfo, CINAHL, Web of Science, Cochrane Library Trials, iPortal, and Native Health Database for articles published in the last 10 years to identify records that meet our inclusion criteria. We will screen articles in a two-step process using two reviewers during the abstract and full-text screening stages. Data will be extracted using Covidence for data management and we will use a narrative approach to synthesize the data.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. Findings will be disseminated in academic manuscripts, at academic conferences, and with partners and knowledge users including funders of pain research and healthcare professionals. Results of this scoping review will inform subsequent quantitative and qualitative studies regarding pain experiences and treatment of marginalized children in the ED.

The infant-doctor relationship: an examination of infants' distress reactions in the presence of a doctor

Fear of doctors is a common source of distress among infants; however, the underlying sources of this distress are unknown. To investigate the doctor-infant relationship, the behaviors of 61 healthy infants (176-617 days old) were observed in a simulated examination room. Their behaviors and electrocardiograms were recorded. Two groups of infants were analyzed: those who cried and those who did not. When an experimenter dressed in the doctor's attire entered the room, all 9 infants who were crying (14.8% of all infants) stopped crying, all infants gazed at the experimenter, and their mean heart rate (HR) decreased. After the auscultation started, 29.5% of all infants cried, and the HRs of infants who cried were higher than those of infants who did not cry. During the auscultation, 80.0% of infants who cried averted from the experimenter, while 34.4% of infants who did not cry. Within 5 s of gazing at the stethoscope, the number of infants who cried increased from 3 to 12, and their mean HR also increased. Our findings suggest that the fear of doctors is not due to the appearance of doctors but rather to specific actions performed by doctors, such as auscultation. Infants may regard a doctor's appearance as a source of interest. Furthermore, a stethoscope is a possible trigger for infants' crying. These behavioral observations suggest the potential for patient-centered care for infants.

Exploring the needs of children and caregivers to inform design of an artificial intelligence-enhanced social robot in the pediatric emergency department

Background & Objective

Socially assistive robots (SARs) are a promising tool to manage children's pain and distress related to medical procedures, but current options lack autonomous adaptability. The aim of this study was to understand children's and caregivers' perceptions surrounding the use of an artificial intelligence (AI)-enhanced SAR to provide personalized procedural support to children during intravenous insertion (IVI) to inform the design of such a system following a user-centric approach.

Methods

This study presents a descriptive qualitative needs assessment of children and caregivers. Data were collected via semi-structured individual interviews and focus groups. Participants were recruited from two Canadian pediatric emergency departments (EDs) between April 2021 and January 2022.

Results

Eleven caregivers and 19 children completed 27 individual interviews and one focus group. Three main themes were identified: A. Experience in the clinical setting, B. Acceptance of and concerns surrounding SARs, and C. Features that support child engagement with SARs. Most participants expressed comfort with robot technology, however, concerns were raised about sharing personal information, photographing/videotaping, and the possibility of technical failure. Suggestions for feature enhancements included increasing movement to engage a child's attention and tailoring language to developmental age. To enhance the overall ED experience, participants also identified a role for the SAR in the waiting room.

Conclusion

Artificial intelligence-enhanced SARs were perceived by children and caregivers as a promising tool for distraction during IVIs and to enhance the overall ED experience. Insights collected will be used to inform the design of an AI-enhanced SAR.

The Effect of Virtual Reality on Pain Experienced by School-Age Children During Venipuncture: A Randomized Controlled Study

Objective: The use of virtual reality (VR) as a non-pharmacologic method may enable children to tolerate invasive procedures in a hospital setting easily and feel less pain. This study aimed at determining the effect of using a VR headset during venipuncture on pain level, heart rate (HR), and oxygen saturation values in children aged 7-12 years old. Materials and Methods: This was a randomized controlled experimental study. This study included 102 children (experimental group: 52; control group: 50) who visited a pediatric outpatient clinic of a university hospital in Turkey between May 2018 and May 2019. Data were collected using the Child and Family Information Form, State Anxiety Inventory for Children, Faces Pain Scale-Revised (FPS-R). Before venipuncture, state anxiety and pain scores of the children were evaluated. The children in the experimental group wore VR headsets during venipuncture. The children in the control group underwent standard venipuncture procedure. Pain scores were evaluated again in both groups after the venipuncture. Before, during, and after the venipuncture, pulse and oxygen saturation values were measured. Results: It was determined that post-procedure pain score was 1.46 ± 1.49 in the experimental group and 4.44 ± 2.26 in the control group. Post-venipuncture pain mean scores were significantly lower in the experimental group than those of the children in the control group (Z = -6.574; P = 0.001). Secondary outcomes: The mean HR during the procedure was significantly lower in the experimental group (99.27 ± 18.34/min) than in the control group (108.20 ± 21.42/min) (P = 0.026; t = -2.265). There was no statistically significant difference between the before and after the procedure difference of oxygen saturation values (Experimental group: -0.15 ± 1.54; Control Group: 0.04 ± 0.93) between groups (Z = -0.023; P = 0.982). Conclusion: It was determined that post-venipuncture pain mean scores were significantly lower in the experimental group than in the control group. VR is effective to reduce the pain of children during venipuncture. VR headsets may be recognized as effective instruments to reduce the pain level of children in hospital settings. (Clinicaltrials.gov: NCT04950478).

Time to complain about pain: Children's self-reported procedural pain in a randomised control trial of Hall and conventional stainless steel crown techniques

BACKGROUND

Children's pain in dentistry has undesirable short- and long-term consequences; therefore, less invasive treatments merit consideration.

AIM

To investigate procedural pain scores for two treatments for carious primary molars in New Zealand primary care.

DESIGN

This study was a split-mouth randomised control trial, with secondary outcome analysis. Children (4-8 years) with proximal carious lesions on matched primary molars had one tooth treated with the Hall technique (HT) and one treated with a conventional stainless steel crown (CT); treatment type and order of treatment were randomly allocated (allocation concealment). The Wong-Baker self-report pain scale measured pretreatment dental pain, procedural pain at each treatment and post-operative pain.

RESULTS

Data were analysed for 103 children: 49 children had the HT first and 54 children had the CT first. Procedural pain scores did not differ by treatment type, with 71.8% and 76.7% of children reporting low pain for the HT and the CT, respectively. Fewer children reported low procedural pain for the second treatment than the first (p = .047). Most children reported low procedural pain for both treatments (58.3%), although 41.7% experienced moderate-high procedural pain with at least one treatment.

CONCLUSIONS

The HT caused pain for as many children as the CT. There is an opportunity for better dental pain management in this setting.

A Randomized Controlled Trial of a Parent-Led Memory-Reframing Intervention to Reduce Distress and Pain Associated with Vaccine Injections in Young Children

Children remember their memories of pain long after the painful experience is over. Those memories predict higher levels of future pain intensity. Young children's memories can be reframed to be less distressing. Parents and the way they reminisce about past events with their children play a key role in the formation of pain memories. A novel parent-led memory-reframing intervention changed children's memories of post-surgical pain to be less distressing. The intervention efficacy in the context of vaccine injections is unclear. This registered randomized controlled trial (NCT05217563) aimed to fill this gap. Seventy-four children aged 4.49 years (SD = 1.05) and scheduled to obtain two COVID-19 vaccine injections and one of their parents were randomized to receive: (1) standard care; (2) standard care and memory-reframing information; and (3) standard care and memory-reframing information with verbal instructions. Children reported their pain after vaccine injections. One week after the first vaccination, children reported memory of pain. Parents reported their use of memory-reframing strategies and intervention feasibility and acceptability. The intervention did not result in significant differences in children's recalled or future pain. Parents rated the intervention as acceptable and feasible.

Prevalence of Temporomandibular Disorders Based on a Shortened Symptom Questionnaire of the Diagnostic Criteria for Temporomandibular Disorders and Its Screening Reliability for Children and Adolescents Aged 7-14 Years

The prevalence and adequacy of diagnostic approaches for temporomandibular disorders (TMD) in children and adolescents are still matters of debate. This study aimed to determine the prevalence of TMD and oral habits in children and adolescents aged 7-14 years and evaluate the consistency between self-reported TMD symptoms and clinical findings using a shortened Axis I of Diagnostic Criteria for TMD (DC/TMD). Children (aged 7-10) and adolescents (aged 11-14) of both sexes were invited to participate in this study (n = 1468). Descriptive statistics for all observed variables and Mann-Whitney U-Tests for the clinical examination were performed. A total of 239 subjects participated in the study (response rate 16.3%). The self-reported prevalence of TMD was found to be 18.8%. The most frequently reported oral habit was nail biting (37.7%), followed by clenching (32.2%) and grinding (25.5%). Self-reported headache increased with age, while clenching and grinding decreased. Based on the answers to the DC/TMD Symptom Questionnaire, subgroups of asymptomatic and symptomatic participants (n = 59; 24.7%) were established and randomly selected for the clinical examination (f = 30). The shortened Symptom Questionnaire showed a sensitivity of 0.556 and a specificity of 0.719 for pain during the clinical examination. Although the Symptom Questionnaire exhibited high specificity (0.933), its sensitivity (0.286) for temporomandibular joint sounds was low. Disc displacement with reduction (10.2%) and myalgia (6.8%) were the most common diagnoses. In conclusion, the self-reported prevalence of TMD in children and adolescents in this study was comparable to that reported in the literature for adults. However, the accuracy of the shortened Symptom Questionnaire as a screening tool for TMD-related pain and jaw sounds in children and adolescents was found to be low.

Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy Diagnostic Criteria for Acute Needle Pain

Needle procedures are among the most common causes of pain and distress for individuals seeking health care. While needle pain is especially problematic for children needle pain and associated fear also has significant impact on adults and can lead to avoidance of appropriate medical care. Currently there is not a standard definition of needle pain. A taxonomy, or classification system, for acute needle pain would aid research efforts and enhance clinical care. To meet this need, the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks public-private partnership with the U.S. Food and Drug Administration, the American Pain Society, and the American Academy of Pain Medicine formed the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks-American Pain Society-American Academy of Pain Medicine Pain Taxonomy initiative. One of the goals of this initiative was to develop taxonomies for acute pain disorders, including needle pain. To accomplish this, a working group of experts in needle pain was convened. Based on available literature and expert opinion, the working group used a 5-dimenional structure (diagnostic criteria, common features, modulating factors, impact and/or functional consequences, and putative mechanisms) to develop an acute pain taxonomy that is specific needle pain. As part of this, a set of 4 diagnostic criteria, with 2 modifiers to account for the influence of needle associated fear, are proposed to define the types of acute needle pain. PERSPECTIVE: This article presents a taxonomy for acute needle pain. This taxonomy could help to standardize definitions of acute pain in clinical studies of patients undergoing needle procedures.

Interventions to Reduce Pediatric Anxiety During Orthopaedic Cast Room Procedures: A Systematic and Critical Analysis Review

BACKGROUND

Cast room procedures can be a source of considerable distress for pediatric patients. High levels of anxiety can make it difficult to perform procedures effectively and may negatively affect the doctor-patient relationship. We sought to evaluate available interventions to reduce anxiety in pediatric patients undergoing orthopaedic cast room procedures.

METHODS

Following the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols guidelines, we performed a systematic review to answer our study question (PROSPERO registration of the study protocol: CRD42022333001, May 28, 2022). PubMed, EBSCO host, MEDLINE, Cochrane, and Google Scholar electronic databases were used to identify all studies evaluating interventions to reduce pediatric anxiety during orthopaedic cast room procedures between January 1, 1975, and June 1, 2022. The quality of included studies was assessed using the Jadad scale.

RESULTS

Our initial search yielded 1,490 publications, which were then screened for appropriate studies that aligned with the purpose of our review. Fourteen studies comprising 8 prospective cohort and 6 randomized controlled trials were included. The total sample size of included studies consisted of 1,158 patients with participant age ranging from 1 to 21 years. The interventions investigated included noise reduction headphones, musical therapy, inclusion of a certified child life specialist, casting shears, virtual reality, Bedside Entertainment and Relaxation Theater (BERT), children's and instructional videos, and video games. Most of the included interventions were effective at reducing anxiety during cast room procedures. However, there was variation in anxiety reduction across cast room procedure and treatment modality.

CONCLUSION

The use of physical or technology-based distraction tools can play an important interventional role in improving patient satisfaction during cast room procedures. The majority were inexpensive, readily applicable to the clinical setting, and of negligible risk to the patient.

LEVEL OF EVIDENCE

Level II. See Instructions for Authors for a complete description of levels of evidence.

Hyperkalemia in a Hemolyzed Sample in Pediatric Patients: Repeat or Do Not Repeat?

OBJECTIVE

The aim of the study is to analyze whether repeat testing is necessary in healthy children presenting to a pediatric emergency department (ED) who are found to have hyperkalemia on a hemolyzed specimen.

METHODS

A 5-year retrospective analysis of pediatric ED patients found to have elevated potassium values on laboratory testing of a sample reported to be hemolyzed. All patients aged 0 to 17 years who had an elevated potassium level after an intravenous draw resulted from a serum sample that was reported as hemolyzed during an ED visit were included in the study.

RESULTS

One hundred eighty-seven patients with some degree of both hemolysis and hyperkalemia were included in the final analysis. The median age was 1.9 years of age. The most common race among all patients was White, followed by African American, and Asian. One hundred forty-five children had repeat sampling for hemolyzed hyperkalemia, 142 children, 97.9% (95% confidence interval, 95.6%-100%) had a normal potassium on repeat and 3 children, 2.1% (95% confidence interval, 0.0%-4.4%) had true hyperkalemia. The frequency of true hyperkalemia in our study population was 2% (3/145). All 3 of these patients had underlying conditions that would appropriately have raised clinician suspicion for hyperkalemia.

CONCLUSIONS

It may be unnecessary to obtain repeat samples to confirm normal potassium in a hemolyzed sample with normal blood urea nitrogen and creatinine.

Effect of a Virtual Reality Environment Using a Domed Ceiling Screen on Procedural Pain During Intravenous Placement in Young Children: A Randomized Clinical Trial

Importance

Distraction using virtual reality (VR) has been found to provide a clinically significant reduction in the experience of pain during various painful procedures. Commercially available VR systems usually require the user to wear a head-mounted display helmet, which can be challenging for young children, and whether VR can reduce pain during intravenous (IV) placement in young children is currently unknown.

Objective

To determine whether a VR environment using a novel domed ceiling screen reduces distress among children over the course of IV placement compared with standard care in a pediatric emergency department.

Design, Setting, and Participants

This randomized clinical trial was conducted from June 3, 2020, to February 8, 2021, at an urban tertiary academic children's hospital. Included were children aged 6 months to 4 years undergoing IV placement in the pediatric emergency department.

Intervention

Children in the intervention group lay on a bed to experience a VR animation using a domed ceiling screen during the IV placement procedure, which was performed as usual. Children in the control group also lay on a bed during the procedure but did not view a VR animation.

Main Outcomes and Measures

The primary outcome was pain scores measured using the Face, Legs, Activity, Cry, and Consolability (FLACC) scale at 4 time points during IV placement: immediately after the child lay down on the bed (T1), the moment the tourniquet was applied (T2), the moment a sterile alcohol swab was applied (T3), and the moment the needle penetrated the skin (T4).

Results

Of the 88 children included in the final analysis, 44 received VR distraction (median [IQR] age, 24.0 [14.5-44.0] months; 27 boys [61.4%]), and 44 received standard care (median [IQR] age, 23.0 [15.0-40.0] months; 26 boys [59.1%]). The median [IQR] FLACC scores at T4 were 6.0 (1.8-7.5) in the intervention group and 7.0 (5.5-7.8) in the control group. The ordinal logistic regression model showed that children in the VR intervention group vs the control group had a lower probability of higher FLACC scores (odds ratio, 0.53; 95% CI, 0.28-0.99; P = .046).

Conclusions and Relevance

The findings of this trial indicate that displaying VR using a domed ceiling screen may be an effective distraction method that reduces distress in young children undergoing IV placement.

Trial Registration

isrctn.org Identifier: KCT0005122.

Sedation Practices for Lumbar Punctures in Patients With Acute Lymphoblastic Leukemia: A Multicenter Retrospective Study Using Pediatric Health Information Systems

BACKGROUND

Sedation is often used to reduce pain and anxiety in pediatric patients with acute lymphoblastic leukemia (ALL) undergoing lumbar punctures (LPs). There is a potential for long-term effects on neurocognition with repeat sedative exposures in young children. The purpose of this study is to determine the practice habits regarding sedation for LPs in pediatric patients with ALL among multiple institutions.

METHODS

This is a retrospective study of 48 hospitals in the Pediatric Health Information Systems (PHIS) between October 2015 and December 2019. Children 1 to 18 years old with ALL who received intrathecal chemotherapy in an outpatient setting were included. We analyzed the prevalence of anesthesia usage and the types of anesthetics used.

RESULTS

Of the 16,785 encounters with documented use of anesthetic medications, intravenous and inhaled anesthetics were used in 16,486 (98.2%) and local anesthetics alone in 299 (1.8%). The most commonly used medications used for sedation were propofol (n=13,279; 79.1%), midazolam (n=4228; 25.2%), inhaled fluranes (n=3169; 18.9%), and ketamine (n=2100; 12.5%).

CONCLUSION

The majority of children's hospitals in the United States use intravenous and inhaled anesthetics for routine therapeutic LPs in pediatric patients with ALL. Propofol is one of the most common medications used for sedation.

Reframe the pain: Divided attention and positive memory reframing to reduce needle pain and distress in children-A feasibility randomized controlled trial

BACKGROUND

Negative experiences of needle procedures in childhood can lead to medical avoidance and vaccine hesitancy into adulthood. We evaluated the feasibility of two new interventions provided by clinical nurses to reduce the negative impact of vaccinations: divided attention (DA) and positive memory reframing (PMR).

METHODS

Children (8-12 years) were randomized into four groups: usual care (UC), DA, PMR or combined (DA + PMR). To evaluate feasibility, we undertook in-depth analysis of video-recorded interventions, nurse experiences (phone interviews) and child/parent memory recall of interventions (phone interviews at 2 weeks post-vaccination). Key clinical outcomes included child and parent ratings of needle-related pain intensity and fear assessed at baseline, immediately post-vaccination and 2 weeks post-vaccination (recalled).

RESULTS

A total of 54 child-parent dyads were screened, with 41 included (10/group, except PMR [n = 11]). The interventions were not always completed as intended: 10%-22% of participants received complete interventions and two had adverse events related to protocol breach. Preliminary within-group analyses showed no effects on child/parent pain ratings. However, children in DA + PMR had reduced recalled fear (p = 0.008), and PMR (p = 0.025) and DA + PMR (p = 0.003) had reduced fear of future needles. Parent ratings of child fear were also reduced immediately post-vaccination for UC (p = 0.035) and PMR (p = 0.035).

CONCLUSIONS

The interventions were feasible, although enhanced nurse training is required to improve fidelity. Preliminary clinical results appear promising, particularly for reducing needle-related fear.

PROTOCOL REGISTRATION

Protocol number ACTRN12618000687291 at ANZCTR.org.au SIGNIFICANCE: Two new nurse-led interventions to reduce negative impacts of vaccinations in children, divided attention and positive memory reframing, were feasible and may reduce needle-related fear. Nurses were able to deliver the interventions in various environments including non-clinical settings (schools). These interventions have potential to facilitate broader dissemination of vaccinations for children in a manner that minimizes distress.

Efficacy of topical lidocaine-prilocaine (EMLA®) for management of infant pain during pneumococcal vaccination: A randomized controlled trial

Few studies have evaluated whether topical anesthetic cream reduces pain during pneumococcal vaccination. This is crucial, since effective pain management should be evidence-based. Previous studies have shown that topical lidocaine-prilocaine (EMLA®) reduces vaccination-related pain, measured using pain-rating instruments and observation of crying time. This intervention study aimed to compare the efficacy of topical lidocaine-prilocaine cream with that of the standard of care on the expression of pain during the first pneumococcal vaccination administered at age 3 months under the Swedish national vaccination program. A randomized controlled trial included 72 infants receiving their first pneumococcal vaccination (Prevenar 13®). The study showed that topical lidocaine-prilocaine before pneumococcal vaccination significantly reduced infants' expression of pain according to the Face, Legs, Activity, Cry, Consolability (FLACC) score (P = .006) and increased latency to cry (P = .001). There were no statistically significant differences in the total crying time (P = .146) between the groups. Topical lidocaine-prilocaine cream reduced pain expression and increased latency to cry in infants receiving their first pneumococcal vaccine. Systematic efforts are needed to successfully implement the use of topical anesthetic cream and other effective non-pharmacological pain-relieving strategies during infant vaccination procedures.

The Effect of a Pain Educational Video Upon Child Pain-Related Memory and the Moderating Role of Parental Pain- and Non-Pain-Attending Verbalizations: An Experimental Lab-Based Study

OBJECTIVES

Early memories of pain contribute to fear and may underlie the maintenance and development of chronic pain into adulthood. Accordingly, understanding determinants that may impact children's pain memory development is key. This study examined (a) the effect of a brief engaging pain educational video in healthy children before undergoing an experimental pain task upon children's recalled pain intensity and pain-related fear and (b) the moderating role of parental pain- and non-pain-attending verbalizations before and after the pain task.

METHODS

Seventy-seven children (8-15 years old) participated in an experimental heat pain task, including actual heat pain stimuli delivered through a thermode on their forearm. Children were randomized to the experimental group (i.e., watching a pain educational video) or the control group (i.e., no video). Children's recalled pain intensity and pain-related fear were elicited 2 weeks later.

RESULTS

Findings showed that recalled pain intensity (but not recalled pain-related fear) of children who watched the pain educational video was significantly lower compared to the control group (p = .028). Further, parental pain-attending verbalizations before the pain task moderated the impact of the video upon children's recalled pain intensity (p = .038). Specifically, children in the control group, but not the experimental group, whose parents used less pain-attending verbalizations recalled higher pain intensity, whereas children whose parents used more pain-attending verbalizations recalled lower pain intensity.

CONCLUSIONS

As children's pain memories have important implications for pain assessment, treatment, and health across the lifespan, these findings might have important implications for the prevention of development or maintenance of maladaptive pain-related outcomes.

Development and validation of the Distracting Ingenuity Promotion Scale for paediatric nurses to support the psychological outcomes of paediatric patients and their families: A survey-based cross-sectional cohort study

AIM

To develop and validate the Distracting Ingenuity Promotion Scale (DIPS) for paediatric nurses.

DESIGN

Cross-sectional study using anonymized self-administered questionnaires.

METHODS

From July-November 2013, paediatric nurses working in the wards or outpatient departments in 39 medical institutions in Japan were enrolled in the survey. Data were analysed using the Student's t-test, Mann-Whitney U test and analysis of variance test. Exploratory and confirmatory factor analyses were performed to validate the factors in the DIPS. Cronbach's α was used to calculate the reliability of the DIPS.

RESULTS

The DIPS included five subscales comprising 21 items. The goodness-of-fit indices for confirmatory factor analysis had a Comparative Fit Index of 0.923 and a Root Mean Square Error of Approximation of 0.059 and fulfilled the standard external validity criteria. Cronbach's α was 0.707-0.826 for each subscale and 0.895 for the overall scale.

Pain Coping Strategies in Pediatric Patients with Acute Leukemias in the First Month of Therapy: Effects of Treatments and Implications on Procedural Analgesia

Simple Summary

Children with leukemia have to adapt to several pain episodes related to medical procedures and to the treatment effects. This is one of the first multi-disciplinary studies involving different perspectives of pediatric hematologists, anesthetists, and psychologists. The aim of this study is to understand how specific coping strategies could be associated with the treatments’ factors and with the dosage of sedation analgesic drugs during bone marrow aspirates. Results underlined that patients’ coping with pain, such as distraction, could be influenced by treatment factors and by their age. The use of particular pain coping strategies (especially the request for social support) was associated with a lower demand for hypnotic sedative drugs during sedation for bone marrow aspirate. Contrarily, the catastrophic attitude was recognized as a negative factor that influenced a major dosage of propofol for the bone morrow sedations. Health professionals should strengthen these useful coping strategies and dampen the catastrophizing one.

Abstract

Children with leukemia experience difficulties adapting to medical procedures and to the chemotherapy’s adverse effects. Study’s objectives were to identify which coping strategies could be associated with the treatments’ factors and with the dosage of sedation analgesic drugs during bone marrow aspirates. A total of 125 patients (mean = 6.79 years; standard deviation = 3.40), majority with acute lymphoblastic leukemia (90.4%) and their parents received, one month after diagnosis, the Pediatric Pain Coping Inventory. Data on the severe treatment effects and on the dosage of drugs in sedation-analgesia were also collected. An ANCOVA model (R² = 0.25) showed that, weighing the age factor (F = 3.47; df = 3; p = 0.02), the number of episodes of fever (F = 4.78; df = 1; p = 0.03), nausea (F = 4.71; df = 1; p = 0.03) and mucositis (F = 5.81; df = 1; p = 0.02) influenced the use of distraction. Cognitive self-instructions (R² = 0.22) were influenced by the number of hospitalizations (F = 5.14; df = 1; p = 0.03) and mucositis (F = 8.48; df = 3; p = 0.004) and by child’s age (F = 3.76; df = 3; p = 0.01). Children who sought parental support more frequently (F = 9.7; df = 2; p = 0.0001) and who tended not to succumb to a catastrophic attitude (F = 13.33; df = 2; p = 0.001) during the induction treatment phase required lower drug dosages, especially propofol. The clinical application of these results could be to encourage the use of cognitive self-instructions and search for social support.

The Moderating Role of Attention Control in the Relationship Between Pain Catastrophizing and Negatively-Biased Pain Memories in Youth With Chronic Pain

The present study examined the role of attention control in understanding the development of negatively-biased pain memories as well as its moderating role in the relationship between pain catastrophizing and negatively-biased pain memories. Youth with chronic pain (N = 105) performed a cold pressor task (CPT) and completed self-report measures of state/trait pain catastrophizing and attention control, with the latter comprising both attention focusing and attention shifting. Two weeks after the CPT, youth's pain-related memories were elicited via telephone allowing to compute pain and anxiety memory bias indices (ie, recalling pain intensity or pain-related anxiety, respectively, as higher than initially reported). Results indicated no main effects of attention control and pain catastrophizing on pain memories. However, both components of attention control (ie, attention focusing and attention shifting) moderated the impact of pain catastrophizing on youth's memory bias, with opposite interaction effects. Specifically, whereas high levels of attention shifting buffered the influence of high pain catastrophizing on the development of pain memory bias, high levels of attention focusing strengthened the influence of high pain catastrophizing on the development of anxiety memory bias. Interaction effects were confined to trait catastrophizing (ie, not state catastrophizing). Theoretical and clinical implications are discussed. PERSPECTIVE: This article investigates the role of attention control in the development of negatively-biased pain memories in children with chronic pain. Findings underscore the importance of targeting differential components of attention control and can inform intervention efforts to minimize the development of negatively biased pain memories in youth with chronic pain.

Distraction Using Buzzy or Handheld Computers During Venipuncture

OBJECTIVES

Venipuncture is one of the most frequently performed painful procedures in children. The aim of this study was to investigate the effectiveness of 2 analgesic strategies for venipuncture in children in a specific setting like a blood-drawing center.

METHODS

This was a prospective randomized controlled trial. It was conducted in the blood-drawing center of a tertiary level children's hospital in Italy, between November 2014 and February 2015. Eligible patients were children aged from 4 to 12 years referred to the blood-drawing center for venipuncture. Enrolled children were randomized to be distracted by Buzzy device or by playing with a handheld computer. The procedural pain was measured with the faces pain scale-revised by children aged from 4 to 7 years and with a numerical rating scale by children aged from 8 to 12 years.

RESULTS

Two hundred children with a median age of 8 years were enrolled in the study. The self-reported procedural pain was not statistically different between the Buzzy group and the handheld computer group: median (interquartile range) = 3.0 (1.0-4.8) and 2.0 (1.0-4.8), respectively (P = 0.72). Children reported significant pain in 25% of cases with both distraction strategies. The procedural success rate at the first attempt was not significantly different in the 2 groups.

CONCLUSIONS

Analgesia provided by Buzzy or by a handheld computer was not significantly different in children undergoing venipuncture in a blood-drawing center, with the great proportion of them reporting no or mild pain during procedure.

The Impact of Parental Pain-attending and Non-pain-attending Responses on Child Pain Behavior in the Context of Cancer-related Painful Procedures: The Moderating Role of Parental Self-oriented Distress

OBJECTIVES

Literature has demonstrated inconsistent findings regarding the impact of parental responses on child pain-related outcomes. Yet, research into factors that may underlie inconsistent findings regarding the variable impact of parental responses is lacking. The current study investigated the moderating role of parental distress in understanding the impact of parental pain-attending (eg, reassuring the child) and non-pain-attending (eg, distracting the child with humor) responses on child pain behavior (eg, crying).

METHODS

Children (18 y and younger) with leukemia, undergoing a lumbar puncture (LP) and/or bone marrow aspiration procedure, and one of their parents, were recruited from the Pediatric Ghent University Hospital. Parent-child interactions were videotaped after the procedure allowing coding of parental responses and child pain behavior. Parents self-reported on experienced personal distress.

RESULTS

Participants consisted of 42 children (24 boys, 18 girls) with leukemia and one of their parents. Children were 0.6 to 15 (7.08±4.39) years old. Findings indicated a positive association between parental pain-attending and child pain behavior, but only when parents reported high levels of distress (β=0.56, P=0.001). No association was observed for parents reporting low levels of distress (β=-0.09, ns). Parental non-pain-attending responses contributed to lower child pain behavior (β=-0.24, P=0.045), independently of parental distress (β=-0.07, ns).

DISCUSSION

The current findings point to the moderating role of parental distress in understanding the impact of parental responses on child pain behavior and highlight the importance of interventions targeting parental emotion regulation to promote optimal child pain outcomes.

A randomized trial of iPad distraction to reduce children's pain and distress during intravenous cannulation in the paediatric emergency department

OBJECTIVES

We compared the addition of iPad distraction to standard care, versus standard care alone, to manage the pain and distress of intravenous (IV) cannulation.

METHODS

Eighty-five children aged 6 to 11 years requiring IV cannulation (without child life services present) were recruited for a randomized controlled trial from a paediatric emergency department. Primary outcomes were self-reported pain (Faces Pain Scale-Revised [FPS-R]) and distress (Observational Scale of Behavioral Distress-Revised [OSBD-R]), analyzed with two-sample t-tests, Mann-Whitney U-tests, and regression analysis.

RESULTS

Forty-two children received iPad distraction and 43 standard care; forty (95%) and 35 (81%) received topical anesthesia, respectively (P=0.09). There was no significant difference in procedural pain using an iPad (median [interquartile range]: 2.0 [0.0, 6.0]) in addition to standard care (2.0 [2.0, 6.0]) (P=0.35). There was no significant change from baseline behavioural distress using an iPad (mean ± SD: 0.53 ± 1.19) in addition to standard care (0.43 ± 1.56) (P=0.44). Less total behavioural distress was associated with having prior emergency department visits (odds ratio [95% confidence interval]: -1.90 [-3.37, -0.43]) or being discharged home (-1.78 [-3.04, -0.52]); prior hospitalization was associated with greater distress (1.29 [0.09, 2.49]). Significantly more parents wished to have the same approach in the future in the iPad arm (41 of 41, 100%) compared to standard care (36 of 42, 86%) (P=0.03).

CONCLUSIONS

iPad distraction during IV cannulation in school-aged children was not associated with less pain or distress than standard care alone. The effects of iPad distraction may have been blunted by topical anesthetic cream usage.

CLINICAL TRIALS REGISTRATION

ClinicalTrials.gov: NCT02326623.

Interventions to Improve the Cast Removal Experience for Children and Their Families: A Scoping Review

BACKGROUND

Cast removal can be a distressing experience for a child. This scoping review aims to provide a comprehensive review of interventions designed to reduce anxiety and improve the child's and family's experience of pediatric cast removal.

METHODS

A scoping review was conducted (Medline, Embase, PsycINFO, CINAHL, Scopus, grey literature sources).

INCLUSION CRITERIA

studies published January 1975-October 2019 with a primary focus on pediatric patients undergoing cast removal/cast room procedures. Screening, full text review, data extraction, and quality appraisal were conducted in duplicate.

RESULTS

974 unique articles and 1 video were screened. Nine articles (eight unique studies) with a total of 763 participants were included. Interventions included the following, alone or in combination: noise reduction, electronic device use, preparatory information, music therapy, play therapy, and child life specialist-directed intervention. Heart rate was used as a primary (88%) or secondary (12%) outcome measure across studies. Each study reported some positive effect of the intervention, however effects varied by age, outcome measure, and measurement timing. Studies scored low on outcome measure validity and blinding as assessed by the Joanna Briggs Institute Critical Appraisal Checklist for Randomized Controlled Trials.

CONCLUSION

Various methods have been tested to improve the pediatric cast removal experience. Results are promising, however the variation in observed effectiveness suggests a need for the use of consistent and valid outcome measures. In addition, future research and quality improvement projects should evaluate interventions that are tailored to a child's age and child/family preference.

Children's Perspectives on Outpatient Physician Visits: Capturing a Missing Voice in Patient-Centered Care

Actively involving children in their healthcare is a core value of patient-centered care. This is the first study to directly obtain children's detailed perspectives on positive and negative aspects of outpatient physician visits in a primary care setting (e.g., checkups) and their preferred level of participation. Individual interviews were conducted with 167 children (female n = 82, male n = 85; ages 7-10, Mage = 8.07 years, SD = 0.82). Open-ended questions were used so that children's responses were not confined to researchers' assumptions, followed by close-ended questions to meet specific objectives. Quantitative content analysis, correlations, logistic regression, and Cochran's Q were used to explore the data. Children were highly fearful of needle procedures (61%), blood draws (73%), pain (45%), and the unknown (21%). Children indicated that they liked receiving rewards (32%) and improving their health (16%). Children who were more fearful during physician visits wanted more preparatory information (ExpB = 1.05, Waldx2(1) = 9.11, p = 0.003, McFadden's R2 2 = 0.07) and more participation during the visit (ExpB = 1.04, Waldx2(1) = 5.88, p = 0.015, McFadden's R2 2 = 0.03). Our results can inform efforts to promote positive physician visit experiences for children, reduce procedural distress, and foster children's ability to take an active role in managing their health.

Desenhos de Crianças Submetidas a Cirurgias Eletivas

Resumo O presente artigo tem por objetivo investigar as memórias que as crianças têm sobre a cirurgia a qual foram submetidas. Participaram desta pesquisa 80 crianças com idade entre 6 e 12 anos, internadas num hospital infantil para a realização de cirurgia eletiva de pequeno porte, divididas em quatro grupos de intervenção. Foram utilizados desenhos como forma de instrumento de coleta de dados. A pesquisa ocorreu em duas etapas: na primeira, cada grupo recebeu a sua preparação no hospital, e na segunda, cerca de quinze dias após a cirurgia. Pôde-se constatar, após uma análise dos desenhos, que todos os grupos retrataram a condição de hospitalização e cirurgia, e trouxeram detalhes sobre os aspectos relacionados a esta temática.

Effectiveness of Conventional Cognitive-Behavioral Therapy and Its Computerized Version on Reduction in Pain Intensity, Depression, Anger, and Anxiety in Children with Cancer: A Randomized, Controlled Trial

Background: Experiencing painful procedures during life is inevitable. Poor pain management is associated with negative effects on the quality of life, remaining for a long time after the experience. Long-term negative effects of pain possess a significant cost burden on society. Nowadays, computers are globally available, and computerized psychological interventions can reduce negative emotions. Objectives: The present study aimed at examining the effectiveness of conventional cognitive-behavioral therapy (CBT) and its computerized version on reduction in pain intensity, depression, anger, and anxiety in children with cancer. Methods: The present randomized, controlled, clinical trial was performed on three groups of conventional CBT, computerized CBT (cCBT), and control. Children with cancer, referring to Shafa Hospital of Ahvaz, Iran, constituted the study samples. A total of 15 children aged 9 - 12 years were assigned to each group by using the lottery method. All three groups received routine medical treatments during the study, but the two intervention groups also received psychological interventions as a complementary treatment. The control group received routine medical treatment and underwent cCBT intervention after the study. The data-i e, pre- and post-tests, were collected by a masters’ student in clinical psychology that was blind to the study objectives. Data were analyzed by MANCOVA, ANOVA, and t-tests of differential scores. Results: The findings of the study indicated that both interventions could reduce negative emotions associated with cancer (i. e, pain, anger, anxiety, and depression) in children compared with the control group (P < 0.0001). In addition, there were no significant differences between the two intervention groups (P < 0.01). It means both interventions were useful to reduce pain and enhance adjustment. Conclusions: The cCBT can be utilized in case of no access to psychologists and psychological services.

Mandatory Pain Assessment in a Pediatric Emergency Department: Failure or Success?: A Retrospective Study

OBJECTIVE

Pain control is a priority in patient evaluation. Despite the proliferation of guidelines, pain is still underassessed and undertreated, especially in children. To improve efficiency and to adhere to best medical practice, our triage software was upgraded; it included mandatory pain scoring for the admission of a child to the pediatric emergency service, thereby limiting the chances of overlooking a child experiencing pain. We conducted this study to verify the effect of routine versus mandatory pain scoring on pain management under the hypothesis that mandatory pain assessment would improve reevaluation and pain treatment.

METHODS

This retrospective case-control study was conducted in our Pediatric Emergency Department (ED). We collected data with regard to pain assessment and reassessment at triage and during the entire stay in the ED, and also with regard to the drugs eventually administered. We reviewed the charts of 1274 patients admitted with the older triage software and those of 1262 patients admitted with the newer triage software (intervention group).

RESULTS

Pain was evaluated significantly more frequently in the intervention group at triage, during the medical evaluation, and at discharge. In the intervention group, a smaller percentage of patients were treated for pain at both triage and during their stay in the ED (P=0.078 and 0.048). Pain reassessment resulted lower in the intervention group (P<0.01).

DISCUSSION

Mandatory pain assessment improved the pain evaluation rate. This did not, however, translate into better treatment and management of pain in the pediatric emergency setting.

Parent-Child Reminiscing about Past Pain as a Preparatory Technique in the Context of Children's Pain: A Narrative Review and Call for Future Research

Pain permeates childhood and remains inadequately and/or inconsistently managed. Existing research and clinical practice guidelines have largely focused on factors influencing the immediate experience of pain. The need for and benefits of preparing children for future pain (e.g., painful procedures) has been well established. Despite being a robust predictor of future pain and distress, memories of past painful experiences remain overlooked in pediatric pain management. Just as autobiographical memories prepare us for the future, children’s memories for past pain can be harnessed to prepare children for future painful experiences. Children’s pain memories are malleable and can be reframed to be less distressing, thus reducing anticipatory distress and promoting self-efficacy. Parents are powerful agents of change in the context of pediatric pain and valuable historians of children’s past painful experiences. They can alter children’s pain memories to be less distressing simply by talking, or reminiscing, about past pain. This narrative review summarizes existing research on parent–child reminiscing in the context of acute and chronic pediatric pain and argues for incorporation of parent–child reminiscing elements into preparatory interventions for painful procedures.

The role of narrative in the development of children's pain memories: influences of father- and mother-child reminiscing on children's recall of pain

Negatively biased memories for pain (ie, recalled pain is higher than initial report) robustly predict future pain experiences. During early childhood, parent-child reminiscing has been posited as playing a critical role in how children's memories are constructed and reconstructed; however, this has not been empirically demonstrated. This study examined the role of parent-child reminiscing about a recent painful surgery in young children's pain memory development. Participants included 112 children (Mage = 5.3 years; 60% boys) who underwent a tonsillectomy and one of their parents (34% fathers). Pain was assessed in hospital and during the recovery phase at home. Two weeks after surgery, parents and children attended a laboratory visit to participate in a structured narrative elicitation task wherein they reminisced about the surgery. Four weeks after surgery, children completed an established pain memory interview using the same previously administered scales through telephone. Narratives were coded for style (elaboration) and content (pain and emotion) based on coding schemes drawn from the developmental psychology literature. Findings revealed that a more elaborative parental reminiscing style in addition to greater use of emotional words predicted more accurate/positively biased pain memories. Greater parental use of pain words predicted more negatively biased pain memories. Although there were no sex and parent-role differences in pain memory biases, mothers and fathers differed in how they reminisced with their boys vs girls. This research underscores the importance of parent-child reminiscing in children's pain memory development and may be used to inform the development of a parent-led memory reframing intervention to improve pediatric pain management.

Children's self-reports of fear and pain levels during needle procedures

Aim

The objective was to determine the levels of and potential relationships between, procedure-related fear and pain in children.

Design

Clinical based cross-sectional.

Methods

Ninety children aged between 7-18 years were included consecutively and self-reported levels of pain and fear on a 0-100 mm visual analogue scales (VAS) when undergoing routine needle insertion into a subcutaneously implanted intravenous port following topical anaesthesia.

Results

The needle-related fear level was reported to be as high as the needle-related pain level (mean VAS: 14 mm and 12 mm, respectively, N = 90). With fear as the dependent variable, age and pain were significantly associated and explained 16% of the variance. With pain as the dependent variable, fear was significantly associated and explained 11% of the variance. A post hoc analysis indicated that younger children reported their fear levels to be higher than their pain levels.

Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures

BACKGROUND

Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress.

METHODS

Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized.

RESULTS

Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred.

CONCLUSIONS

LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

Children’s Fear and Pain During Medical Procedures: A Quality Improvement Study With a Humanoid Robot

Background

Pediatric patients undergo a variety of painful medical procedures.

Purpose

The goal of this quality improvement study was to introduce a humanoid robot (MEDi®) programmed with strategies, such as distraction and deep breathing, at inpatient and outpatient units to determine any preliminary effects on children’s pain and fear during medical procedures.

Methods

A nonrandomized two-group pre- and posttest design was used to compare pain and fear of children before and after intervention versus standard care. A total of 46 children aged 2–15 years undergoing various medical procedures in a pediatric hospital, and their parents completed the Children’s Fear Scale and the Faces Pain Scale-Revised. The former was used both before and after the procedure, while the latter only after the procedure.

Results

Children ( n = 18), who interacted with the robot before and during a procedure, and their parents reported significantly lower levels of fear and pain than did children ( n = 28) and their parents in standard care, ps < .05.

Conclusions

The use of a humanoid robot programmed with psychological strategies to support coping may enhance children’s experiences of care for pain management.

Role of anxiety in young children's pain memory development after surgery

Pediatric pain is common, and memory for it may be distressing and have long-lasting effects. Children who develop more negatively biased memories for pain (ie, recalled pain is higher than initial pain report) are at risk of worse future pain outcomes. In adolescent samples, higher child and parent catastrophic thinking about pain was associated with negatively biased memories for postsurgical pain. This study examined the influence of child and parent anxiety on the development of younger children's postsurgical pain memories. Seventy-eight children undergoing a tonsillectomy and one of their parents participated. Parents reported on their anxiety (state and trait) before surgery, and trained researchers observationally coded children's anxiety at anaesthesia induction. Children reported on their postsurgical pain intensity and pain-related fear for 3 days after discharge. One month after surgery, children recalled their pain intensity and pain-related fear using the same scales previously administered. Results revealed that higher levels of postsurgical pain and higher parent trait anxiety predicted more negatively biased memories for pain-related fear. Parent state anxiety and child preoperative anxiety were not associated with children's recall. Children who developed negatively biased pain memories had worse postsurgical pain several days after surgery. These findings underscore the importance of reducing parental anxiety and effective postsurgical pain management to potentially buffer against the development of negatively biased pain memories in young children.

Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study

Several studies have shown the efficacy of psychological interventions in reducing preoperative anxiety in children undergoing surgery. This study aims to investigate the effectiveness of a specific non-pharmacological technique, the relaxation-guided imagery, in reducing both preoperative anxiety and postoperative pain in a sample of 60 children (6-12 years old) undergoing minor surgery who were randomly assigned to the experimental group (N = 30) or the control group (N = 30). The first group received the relaxation-guided imagery, before the induction of general anesthesia; the second group received standard care. The levels of preoperative anxiety and postoperative pain were assessed using, respectively, the modified Yale Preoperative Anxiety Scale and the Face, Legs, Activity, Cry, and Consolability Scale. The results showed a statistically significant difference between groups, with less anxiety and less pain for children included in the experimental group (p < .001; p < .001).Conclusion: Results suggest that relaxation-guided imagery reduces preoperative anxiety and postoperative pain in children. Future studies should focus on developing protocols and studying the eventual reduction of administered drugs for anesthesia and pain. What is Known: • Literature suggests the usefulness of relaxation-guided imagery in reducing anxiety and pain in the perioperative period. • Stronger evidences are needed to support the application of relaxation-guided imagery as routine care in pediatric surgery. What is New: • To our knowledge, this is the first randomized study to investigate the efficacy of relaxation-guided imagery in reducing preoperative anxiety and postoperative pain within a single pediatric sample. • The present study provides stronger evidence in an area that is lacking in research.

Why is running a marathon like giving birth? The possible role of oxytocin in the underestimation of the memory of pain induced by labor and intense exercise

Pain can be overestimated, underestimated or reported accurately at recall. The way pain is remembered seems to depend on certain factors, including the type of pain or, in other words, its cause, the context, and the meaning it has for the person suffering from it. For instance, episodes of chronic pain, as well as pain related to surgery, are often overestimated at recall. Interestingly, research shows that pain induced by parturition or marathon running is often underestimated at recall despite the fact that both are not only physically grueling but also emotionally intense experiences. However, both processes can likewise be considered positive events, as opposed to most that involve pain. On the neurophysiological level, one of the similarities between giving birth and running a marathon is the particular involvement of the oxytocin system. Oxytocin is involved both in parturition and intense exercise, for various reasons. During labor, oxytocin mediates uterine contractions, while in the case of extensive running it might be involved in the maintenance of fluid balance. It also has well-documented analgesic properties and plays an important role in memory formation and recall. It has been suggested that oxytocin modulates the output of the central nucleus of the amygdala (CeA) during the fear recall. Moreover, it has been demonstrated that oxytocin can impair fear learning and influence the memory of both positive and negative emotionally salient stimuli. We propose that the reason for pain to be remembered in a more favorable light is the central action of oxytocin in the central nucleus of the amygdala, first and foremost during the encoding phase.

Procedural Pain in Lumbar Punctures and the Impact of Preparation in Pediatric Cancer Patients

Aim: Childhood cancer patients are subjected to recurring painful medical procedures. In low- and middle-income countries (LMIC), where the majority of the world’s childhood cancer patients live, pain management is often unsatisfactory due to limited resources. This study aimed to evaluate the possibility of conducting a preprocedural preparation for lumbar punctures (LPs) at a pediatric oncology unit in a LMIC and to assess whether this intervention would decrease procedural pain and fear. Methods: Patients aged 5–18 who underwent LPs between February 25, 2017, and April 12, 2017, were eligible and invited to participate. Included patients were interviewed to assess the procedural pain and fear in conjunction with the LP and the patients’ understanding of why an LP was done. Closest caregivers and the medical staff were interviewed to compare the perceptions of pain. The study was conducted in two separate phases; patients included in the period of February 25–March 9 underwent LP according to routines without preparation while patients included in the period of March 10–April 12 received procedural preparation with information. Results from the interviews from the two study groups were compared. Results: Out of 79 patients who met the inclusion criteria, 76 were included and preparation was successfully implemented for 25 of them. The pain decreased significantly (P = 0.022) after preparation. The physicians underestimated the patients’ pain (P < 0.0001). The understanding of the reason for the LP increased significantly among patients (P = 0.0081) and their caregivers (P < 0.0001). Conclusions: Preparation by preprocedural information, created to fit the situation at a state-run hospital in a LMIC, is feasible and efficient.

Understanding pain physiology and its application to person with intellectual disability

The issue of pain warrants attention as, by virtue of having an intellectual disability, a person may have associated medical or physical conditions and associated factors increasing their risk of pain disorders. People with intellectual disability experiencing pain need to be provided with the best possible care. The focus of this article is on the exploration of pain: physiology and types; manifestations and responses in the context of intellectual disability in order to promote effective, knowledgeable assessment and management of pain for this client group. Pain is a subjective, complex, physiological and psychological phenomenon that can be acute or chronic and may be classified according to its cause. Within the experience of pain, the concept of total pain describes the physical, psychological, social and spiritual factors that influence the experience of pain.

Effects of Watching Cartoons During an Echocardiography on Infants and Preschool Children. A Prospective Randomized Study

Echocardiography is currently the main diagnostic technique in pediatric cardiology, but sometimes it is difficult to use in very young children, as a complete and accurate study depends on the patient's and family's cooperation. Children's behavior is one of the main problems for this procedure, and interventions like sedative medication have been used to facilitate its performance. The aim of this study was to analyze the effects of TV entertainment in infants and preschool children during echocardiography. We designed an experimental study in children with a heart murmur. An examination room was prepared with a TV on the ceiling, giving the children an unobstructed view during the echocardiography procedure. Fifty-eight patients were randomized into two groups: TV intervention vs. usual care (consisting of other distraction measures). The primary outcome was echocardiography time, but we also assessed blood pressure, quality of technique, child behavior, and parents' stress level. The TV group showed a statistically significant reduction in duration of the echocardiography and systolic and diastolic blood pressure, as well as better quality of technique and child behavior. Consequently, we recommend the use of a TV as a simple and useful distraction method for improving echocardiography in young children.

Study protocol for a randomised controlled trial of humanoid robot-based distraction for venipuncture pain in children

INTRODUCTION

Intravenous insertion (IVI) is a very common procedure in the emergency department (ED). IVI is often painful and stressful for both children and their families. Currently, distraction therapy is not used as a standard of care for IVI in North America. We propose that interaction with a humanoid robot may effectively distract children during IVI thereby reducing their pain and distress.

METHODS AND ANALYSIS

This randomised controlled superiority trial will be conducted in a Canadian paediatric ED. We plan to recruit 80 patients. Children will be eligible if they (1) are 6 to 11 years of age, (2) need an IVI, (3) are fully conscious and alert, (4) have sufficient knowledge of the English language to understand and complete the study assessments and (5) are accompanied by a legal guardian. Our primary objective is to compare patient-reported pain and distress with the use of distraction (via a humanoid robot) versus standard care in children. The primary outcomes will be (1) self-reported pain, as measured by the Faces Pain Scale-Revised and (2) observed distress, as measured by the Observational Scale of Behavioural Distress-Revised. Secondary outcomes will include (1) measuring parental anxiety, (2) examining the association between parental anxiety and child outcomes and (3) children's degree of engagement with the humanoid robot via the Intrinsic Motivation Inventory tool. First enrolment occurred in April 2017 and is ongoing.

ETHICS AND DISSEMINATION

This study has been approved by the Health Research Ethics Board (University of Alberta). Informed consent to participate will be obtained from all participants' parents/guardian, in conjunction with assent from the participant themselves. This study data will be submitted for publication regardless of results. Purchase of the robot was facilitated through a Stollery Children's Hospital Foundation donation. Recruitment costs are supported by the Women and Children's Health Research Institute.

TRIAL REGISTRATION NUMBER

NCT02997631; Pre-results.