Impact of parent-directed education on parental use of pain treatments during routine infant vaccinations: a cluster randomized trial

Moments that matter: childhood pain treatment shapes pain for life-we can do better every time in every child

BACKGROUND

Needle procedures, such as vaccinations, blood draws, and intravenous cannulation, are the most frequent source of childhood pain, causing fear and reducing the uptake of medical procedures. Every child has the right to expect pain relief, and we have evidence-based tools to reduce needle procedure-related pain. Therefore, the lack of analgesic provision for needle pain is not justified. We argue that better informed and motivated healthcare professionals and families can advocate for appropriate pain relief in every child, every time.

OBSERVATIONS

Engaging communication campaigns are needed to educate our healthcare professionals. Evidence-based modalities such as topical anaesthesia, sucrose or breastfeeding, comfort positioning, and age-appropriate distractions should be available for every child during needle procedures. However, high-quality information is not enough to change behaviour-healthcare professionals need to be motivated, encouraged, and inspired. Parents and carers should be empowered to advocate for their children and be aware that their child has the right to receive pain relief during these procedures. CONCLUSIONS AND RELEVANCE: This is a call to action-we need collaboration between academics, healthcare professionals, industry and charities, to expedite behavioural change and parental advocacy through high-quality communication strategies. Effective pain management in infants and children can play a crucial role in promoting the uptake of vaccinations and medical procedures and can influence future attitudes to pain.

Soothing and Distress Behaviors of Infants, Parents, and Clinicians During Childhood Vaccinations

OBJECTIVES

The purpose of this study was to describe the behaviors of infants who were born preterm, their parents, and clinicians during 2-, 6-, 12-, and 18-month vaccinations.

METHODS

Vaccination sessions were video recorded for 3-5 minutes. The proportion of 5-second intervals in which distress and soothing behavior by infants, parents, and clinicians was coded using the Measure of Adult and Infant Soothing and Distress. Coding consisted of three phases: baseline/anticipatory (60 seconds prior to first needle), procedure (first needle to removal of final needle), and recovery (up to 180 seconds after removal of final needle).

RESULTS

A total of 64 infants were included. Distress behavior by infants during the baseline phase ranged from 13% (12-month vaccinations) to 29% (2-month). There was limited anticipatory soothing behavior from parents (10% [12-month] to 50% [2-month]) and clinicians (6% [12-month] to 17% [2-month]). Distress behavior in infants during the procedure ranged from 43% (18-month) to 96% (2-month). There was limited soothing behavior during the procedure from parents (10% [12-month] to 81% [12-month]) and clinicians (13% [12-month] to 71% [2-month]). Few infants received additional pain-reducing interventions, including skin-to-skin contact, 24% oral sucrose, and topical anesthetic.

DISCUSSION

Despite infant distress, there was limited anticipatory behavior from parents and clinicians. Two-month-old infants displayed the most distress across all time points yet received the least amount of treatment and proximal parent and clinician behavior. Additional implementation efforts are required to increase awareness and practice uptake among parents and clinicians to ensure infants receive equitable and effective pain management.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Despite evidence of the long-term implications of unrelieved pain during infancy, it is evident that infant pain is still under-managed and unmanaged. Inadequately managed pain in infancy, a period of exponential development, can have implications across the lifespan. Therefore, a comprehensive and systematic review of pain management strategies is integral to appropriate infant pain management. This is an update of a previously published review update in the Cochrane Database of Systematic Reviews (2015, Issue 12) of the same title.

OBJECTIVES

To assess the efficacy and adverse events of non-pharmacological interventions for infant and child (aged up to three years) acute pain, excluding kangaroo care, sucrose, breastfeeding/breast milk, and music.

SEARCH METHODS

For this update, we searched CENTRAL, MEDLINE-Ovid platform, EMBASE-OVID platform, PsycINFO-OVID platform, CINAHL-EBSCO platform and trial registration websites (ClinicalTrials.gov; International Clinical Trials Registry Platform) (March 2015 to October 2020). An update search was completed in July 2022, but studies identified at this point were added to 'Awaiting classification' for a future update.  We also searched reference lists and contacted researchers via electronic list-serves.  We incorporated 76 new studies into the review.  SELECTION CRITERIA: Participants included infants from birth to three years in randomised controlled trials (RCTs) or cross-over RCTs that had a no-treatment control comparison. Studies were eligible for inclusion in the analysis if they compared a non-pharmacological pain management strategy to a no-treatment control group (15 different strategies). In addition, we also analysed studies when the unique effect of adding a non-pharmacological pain management strategy onto another pain management strategy could be assessed (i.e. additive effects on a sweet solution, non-nutritive sucking, or swaddling) (three strategies). The eligible control groups for these additive studies were sweet solution only, non-nutritive sucking only, or swaddling only, respectively. Finally, we qualitatively described six interventions that met the eligibility criteria for inclusion in the review, but not in the analysis.  DATA COLLECTION AND ANALYSIS: The outcomes assessed in the review were pain response (reactivity and regulation) and adverse events. The level of certainty in the evidence and risk of bias were based on the Cochrane risk of bias tool and the GRADE approach. We analysed the standardised mean difference (SMD) using the generic inverse variance method to determine effect sizes.  MAIN RESULTS: We included total of 138 studies (11,058 participants), which includes an additional 76 new studies for this update. Of these 138 studies, we analysed 115 (9048 participants) and described 23 (2010 participants) qualitatively. We described qualitatively studies that could not be meta-analysed due to being the only studies in their category or statistical reporting issues. We report the results of the 138 included studies here. An SMD effect size of 0.2 represents a small effect, 0.5 a moderate effect, and 0.8 a large effect. The thresholds for the I2 interpretation were established as follows: not important (0% to 40%); moderate heterogeneity (30% to 60%); substantial heterogeneity (50% to 90%); considerable heterogeneity (75% to 100%). The most commonly studied acute procedures were heel sticks (63 studies) and needlestick procedures for the purposes of vaccines/vitamins (35 studies). We judged most studies to have high risk of bias (103 out of 138), with the most common methodological concerns relating to blinding of personnel and outcome assessors. Pain responses were examined during two separate pain phases: pain reactivity (within the first 30 seconds after the acutely painful stimulus) and immediate pain regulation (after the first 30 seconds following the acutely painful stimulus). We report below the strategies with the strongest evidence base for each age group. In preterm born neonates, non-nutritive sucking may reduce pain reactivity (SMD -0.57, 95% confidence interval (CI) -1.03 to -0.11, moderate effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.61, 95% CI -0.95 to -0.27, moderate effect; I2 = 81%, considerable heterogeneity), based on very low-certainty evidence. Facilitated tucking may also reduce pain reactivity (SMD -1.01, 95% CI -1.44 to -0.58, large effect; I2 = 93%, considerable heterogeneity) and improve immediate pain regulation (SMD -0.59, 95% CI -0.92 to -0.26, moderate effect; I2 = 87%, considerable heterogeneity); however, this is also based on very low-certainty evidence. While swaddling likely does not reduce pain reactivity in preterm neonates (SMD -0.60, 95% CI -1.23 to 0.04, no effect; I2 = 91%, considerable heterogeneity), it has been shown to possibly improve immediate pain regulation (SMD -1.21, 95% CI -2.05 to -0.38, large effect; I2 = 89%, considerable heterogeneity), based on very low-certainty evidence. In full-term born neonates, non-nutritive sucking may reduce pain reactivity (SMD -1.13, 95% CI -1.57 to -0.68, large effect; I2 = 82%, considerable heterogeneity) and improve immediate pain regulation (SMD -1.49, 95% CI -2.20 to -0.78, large effect; I2 = 92%, considerable heterogeneity), based on very low-certainty evidence.  In full-term born older infants, structured parent involvement was the intervention most studied. Results showed that this intervention has little to no effect in reducing pain reactivity (SMD -0.18, 95% CI -0.40 to 0.03, no effect; I2 = 46%, moderate heterogeneity) or improving immediate pain regulation (SMD -0.09, 95% CI -0.40 to 0.21, no effect; I2 = 74%, substantial heterogeneity), based on low- to moderate-certainty evidence. Of these five interventions most studied, only two studies observed adverse events, specifically vomiting (one preterm neonate) and desaturation (one full-term neonate hospitalised in the NICU) following the non-nutritive sucking intervention. The presence of considerable heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of evidence of very low to low certainty based on GRADE judgements.

AUTHORS' CONCLUSIONS

Overall, non-nutritive sucking, facilitated tucking, and swaddling may reduce pain behaviours in preterm born neonates. Non-nutritive sucking may also reduce pain behaviours in full-term neonates. No interventions based on a substantial body of evidence showed promise in reducing pain behaviours in older infants. Most analyses were based on very low- or low-certainty grades of evidence and none were based on high-certainty evidence. Therefore, the lack of confidence in the evidence would require further research before we could draw a definitive conclusion.

Impact of parent-targeted eHealth educational interventions on infant procedural pain management: a systematic review

OBJECTIVE

The objective of this review was to determine whether electronic health (eHealth) educational interventions about infant procedural pain and pain management impact parental outcomes (eg, mental health, knowledge uptake), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response).

INTRODUCTION

Pain in infants is a common concern for parents. Routine postpartum care for infants in early life requires them to endure painful procedures, such as immunizations, yet infants often receive little to no pain management. Parents are an essential component of effective pain management, although they may not be aware of the roles they play. Despite the increased number of eHealth resources available to educate parents about infant pain management, their impact has yet to be synthesized.

INCLUSION CRITERIA

This review considered studies that evaluated eHealth educational interventions targeted at parents during pregnancy and up to 1 year postpartum. Interventions included, but were not limited to, mobile applications, web-based applications, websites, videos, interactive training, hands-on direct simulation, short message service (SMS), and desktop applications. Primary outcomes included parental outcomes (eg, stress or anxiety, self-efficacy, knowledge, attitudes), eHealth outcomes (eg, acceptance, use), and pain management outcomes (eg, parental involvement, infant pain response). Experimental, quasi-experimental, and observational study designs were included.

METHODS

MEDLINE, CINAHL, PsycINFO, Embase, Scopus, Web of Science, and SciELO were searched for studies published in English up to June 14, 2021. Citation lists of relevant reviews and included studies were also searched for additional peer-reviewed articles. Two independent reviewers conducted critical appraisal using standardized tools from JBI, and data extraction, using a data extraction form designed by the authors. Statistical pooling of quantitative data was not possible due to heterogeneity; thus, the findings were reported narratively.

RESULTS

A total of 4163 unique studies were screened, with 11 studies ultimately included for synthesis. Five articles were randomized controlled trials, 5 articles were analytical cross-sectional studies, and 1 article was quasi-experimental. Studies reported on 4 unique eHealth educational interventions, all of which used video format and primarily targeted the postnatal period. The findings for all primary outcomes were mixed but suggested either improvements in outcomes or no impact. The certainty of evidence was determined as low or very low across primary outcomes for reasons related to imprecision, risk of bias, and indirectness.

CONCLUSIONS

Although heterogeneity of findings limited quantitative synthesis of data, this review suggests that short and engaging educational videos have the potential to positively impact parents' knowledge, confidence, and desire to be involved in procedural pain management for their children. Most of the interventions presented in this review describe evidence-based information about procedural pain management strategies that are known to be effective for infant populations. Thus, it is reasonable to assume that infant pain response should be lower when parents appropriately apply the strategies. However, the findings of this review were not able to confirm this assumption. More research is needed to evaluate the impact of parent-targeted pain management education on infant pain response.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020151569.

The feasibility, acceptability and preliminary efficacy of parent-targeted interventions in vaccination pain management of infants: a pilot randomized control trial (RCT)

Aim: To evaluate the feasibility, acceptability and preliminary efficacy of parent interventions for improving the use of pain management strategies during vaccination of infants, a two-armed pilot randomized control trial (RCT) was conducted. Materials & methods: 151 parents were randomized in two groups: Group 1) 'Be Sweet to Babies' videos and a tip sheet (n = 76); Group 2) As per Group 1 plus a motivational interviewing informed Affirmative Statements and Questions (AS&Q) (n = 75). Results & conclusion: Feasibility was evaluated by success of the recruitment (151 people in a week), rates of completed consent forms (85%), and surveys (59%). Over 94% satisfaction with interventions, processes and 88% intention to recommend the strategies to others determined the acceptability. Preliminary efficacy was evident by over 95% use of pain management strategies following the interventions. Clinical trial registration number: NCT03968432.

[Pediatric pain treatment and prevention for hospitalized children]

INTRODUCTION

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

OBJECTIVES

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

METHODS

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable "Factsheet Pain in Children: Management" and reviews best evidence and practice.

RESULTS

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind-body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

CONCLUSION

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

Parent-Targeted Education Regarding Infant Pain Management Delivered During the Perinatal Period: A Scoping Review

All infants experience pain in early life from procedures. Parents recognize pain as a prevalent issue, reporting a strong desire for more information on infant pain. The aim of this study was to explore and map the current evidence of parent-targeted educational interventions about infant pain, delivered throughout the perinatal period. Records were identified in PubMed, CINAHL, EMBASE, and ERIC databases and hand searching recent publications in 3 relevant journals. Records in English that described or evaluated educational interventions on infant pain management aimed at parents during the perinatal period were eligible for review and those not related to pain or aimed at healthcare providers were excluded. Evaluation was completed following the Methodology for JBI Scoping Reviews and standardized critical appraisal instruments from the Joanna Briggs Institute. Initial search yielded 6946 records, with 9 included in analysis. Six studies were quantitative, 2 qualitative, and 1 mixed methods. Included interventions contained information about parent-led pain management strategies for infants in the neonatal intensive care unit (n = 4), full term (n = 4), or both (n = 1). Despite being an area of high concern for parents of newborns, few studies addressed parent-targeted education regarding infant pain. Future research examining the impact and efficacy of these interventions addressing parental and neonatal outcomes is warranted.

Effectiveness of a parent-targeted video on neonatal pain management: Nonrandomized pragmatic trial

The “Be sweet to babies” video is a knowledge translation tool targeted at parents on the use of analgesic strategies during painful procedures performed in neonates. This study aimed to evaluate the effectiveness of the Portuguese version of this video on maternal involvement in neonatal pain management during the newborn screening blood test. Nonrandomized, pragmatic clinical trial. The study was conducted in a rooming‐in unit. All mothers received a pamphlet regarding neonatal pain management and were invited to participate in daily education sessions conducted by nurses, which included the video. The intervention group included mothers who voluntarily watched the video, while the control group was comprised of mothers who did not attend the education sessions or left the session before watching the video. Data were collected by interviews conducted by the research team. Descriptive and inferential analysis considered a confidence interval of 95%. A total of 73 mothers were included in the study. Analgesic strategies were used in 14 (40%) of the procedures in the intervention group and 9 (24%) in the control group, a clinically important difference of 16% points between groups, although no statistically significant difference was found (P = .13). Breastfeeding was the most commonly used strategy. Watching the video increased the chance of implementing analgesic strategies by 2.1 times (P = .19), while nurses suggesting the use of analgesia increased this chance by 5.5 times (P = .006). Although no statistical significance was found, the results suggest the clinical significance and feasibility of the “Be sweet to babies” video as a KT tool targeted at parents on neonatal pain management during nonurgent painful procedures. In addition, maternal involvement in pain care significantly increased when pain relief strategies were recommended by nurses, which suggests that nurses have a key role in facilitating parental participation.

Impact of Videotaped Information on the Experience of Parents of Children with Acute Lymphoblastic Leukemia

Videotaped information has been shown to be effective in reducing parental anxiety and facilitating knowledge transfer in various clinical settings. There is lack of literature on the use of videotaped information during the pediatric oncology initial family disclosure meeting. The purpose of this study was to deliver an informative DVD, highlighting information on childhood acute lymphoblastic leukemia (ALL), to parents of children with newly diagnosed ALL and to assess if the DVD provided increased levels of satisfaction and decreased levels of anxiety in parents around the time of diagnosis. We surveyed 24 parents of children on active treatment for ALL, diagnosed between the ages of 1 and 18 years from 2008 to 2016 at The Hospital for Sick Children, Toronto, Canada. Parents were provided a survey questionnaire assessing levels of satisfaction with information communicated by the healthcare team and anxiety following verbal disclosure and were asked to report satisfaction and anxiety levels immediately following viewing the DVD intervention. Twenty-three/24 (95.8%) parents surveyed reported seeking information from additional resources after disclosure. Of the 24 parents who watched the DVD, 12 (50.0%) watched it once, while 12 (50.0%) watched it twice or more. All parents were satisfied with DVD information, and there was a significant decrease in anxiety after viewing (P = 0.03). All 24 parents felt that the DVD was a useful educational tool. Videotaped information after verbal disclosure is an effective educational resource and is associated with reduced anxiety among parents of children with ALL.

Pediatric pain treatment and prevention for hospitalized children

Introduction:

Prevention and treatment of pain in pediatric patients compared with adults is often not only inadequate but also less often implemented the younger the children are. Children 0 to 17 years are a vulnerable population.

Objectives:

To address the prevention and treatment of acute and chronic pain in children, including pain caused by needles, with recommended analgesic starting doses.

Methods:

This Clinical Update elaborates on the 2019 IASP Global Year Against Pain in the Vulnerable “Factsheet Pain in Children: Management” and reviews best evidence and practice.

Results:

Multimodal analgesia may include pharmacology (eg, basic analgesics, opioids, and adjuvant analgesia), regional anesthesia, rehabilitation, psychological approaches, spirituality, and integrative modalities, which act synergistically for more effective acute pediatric pain control with fewer side effects than any single analgesic or modality. For chronic pain, an interdisciplinary rehabilitative approach, including physical therapy, psychological treatment, integrative mind–body techniques, and normalizing life, has been shown most effective. For elective needle procedures, such as blood draws, intravenous access, injections, or vaccination, overwhelming evidence now mandates that a bundle of 4 modalities to eliminate or decrease pain should be offered to every child every time: (1) topical anesthesia, eg, lidocaine 4% cream, (2) comfort positioning, eg, skin-to-skin contact for infants, not restraining children, (3) sucrose or breastfeeding for infants, and (4) age-appropriate distraction. A deferral process (Plan B) may include nitrous gas analgesia and sedation.

Conclusion:

Failure to implement evidence-based pain prevention and treatment for children in medical facilities is now considered inadmissible and poor standard of care.

An audit of paediatric pain prevalence, intensity, and treatment at a South African tertiary hospital

INTRODUCTION

Pain in paediatric inpatients is common, underrecognised, and undertreated in resource-rich countries. Little is known about the status of paediatric pain prevention and treatment in low- and middle-income countries.

OBJECTIVES

This audit aimed to describe the prevalence and severity of pain in paediatric patients at a tertiary hospital in South Africa.

METHOD

A single-day prospective observational cross-sectional survey and medical chart review of paediatric inpatients at Grey's Hospital, Pietermaritzburg, South Africa.

RESULTS

Sixty-three children were included, and mean patient age was 9.7 years (SD 6.17). Most patients (87%) had pain during admission, with 29% reporting preexisting (possibly chronic) pain. At the time of the study, 25% had pain (median pain score 6/10). The worst pain reported was from needle procedures, including blood draws, injections, and venous cannulation (34%), followed by surgery (22%), acute illness/infection (18%), and other procedures (14%). Pharmacological treatments included WHO step 1 (paracetamol and ibuprofen) and step 2 (tramadol, tilidine, and morphine) analgesics. The most effective integrative interventions were distraction, swaddling, and caregiver participation. Although a pain narrative was present in the majority of charts, only 16% had documented pain intensity scores.

CONCLUSION

The prevalence of pain in hospitalised children in a large South African Hospital was high and pain assessment inadequately documented. There is an urgent need for pain education and development of guidelines and protocols, to achieve better pain outcomes for children. This audit will be repeated as part of a quality-improvement initiative.

Effectiveness of a hospital-based postnatal parent education intervention about pain management during infant vaccination: a randomized controlled trial

BACKGROUND

Parents have reported that they want to learn how to reduce pain in infants during vaccinations. Our objective was to compare different levels of intensity of postnatal education about pain mitigation on parental self-reported use of interventions at future infant vaccinations.

METHODS

We conducted a longitudinal, 3-group parallel, add-on, randomized controlled trial on the postnatal ward of a hospital. New mothers, unaware of the hypothesis, were randomly assigned to 1 of 3 intervention groups and 3 follow-up groups (i.e., 9 groups, 3 × 3). The 3 intervention groups were control (general immunization information), pain pamphlet (pain mitigation information), and pain pamphlet and pain video (pain mitigation information). Both pain mitigation education groups also received general immunization information. The 3 follow-up groups were 2-, 4- and 6-month infant vaccinations. Mothers reported use of breastfeeding, sucrose and topical anesthetics during infant vaccinations in a telephone survey.

RESULTS

Of 3420 participants, follow-up was available for 2549 (75%): 36.1%, 34.2% and 29.7% reported on pain mitigation practices at 2-, 4- and 6-month vaccinations, respectively (p = 0.9). Maternal characteristics did not differ (p > 0.05): mean age, 33.6 years; 58% were primipara. Utilization of any intervention (breastfeeding, sucrose or topical anesthetics) was 53.2%, 61.4% and 63.0% for control, pain pamphlet, and pain pamphlet and pain video groups, respectively (p < 0.001); both pain education groups had higher utilization than the control group, but did not differ from one another. Uptake differed among intervention groups at 2 and 4 months but not at 6 months.

INTERPRETATION

Hospital-based postnatal education increased parental use of pain interventions at infant vaccinations and can be added to existing education.

TRIAL REGISTRATION

ClinicalTrials.gov, no. NCT01937143.

Development of an Intervention to Reduce Pain and Prevent Syncope Related to Adolescent Vaccination

INTRODUCTION

There is a lack of research into the perspectives of patients, parents, and clinicians regarding strategies for vaccine-related pain and syncope prevention that may improve the adolescent vaccination experience and encourage future vaccination.

OBJECTIVE

To develop an intervention on the basis of preference for strategies to reduce pain and prevent syncope associated with adolescent vaccination.

METHODS

We conducted focus groups and interviews with 8 recently vaccinated Kaiser Permanente Northwest (KPNW) members aged 11 to 17 years and their parents to explore perceptions of pain and syncope after vaccination as well as receptivity to potential interventions. Additionally, we interviewed 7 clinical staff who routinely vaccinate children. We conducted content analysis to identify promising interventions and conducted a data synthesis workshop to select a final intervention for piloting.

RESULTS

All participants expressed willingness to use previsit education, breathing exercises, social support or distraction, and water consumption. Patients and parents expressed a need for verbal education and messaging about potential vaccine-related outcomes, and clinicians noted a need to identify patients who are anxious before a vaccination visit. Most participants suggested a "comfort menu" intervention, to include comfort and distraction items that medical staff offer adolescents before and during vaccination.

CONCLUSION

Patients, parents, and clinicians acknowledged the value of interventions to reduce pain and syncope after adolescent vaccination. Stakeholders identified a comfort menu as the intervention to be piloted at 2 KPNW pediatric clinics. Further research is needed to test the effectiveness of the "Vaccination Comfort Menu" intervention in improving vaccination experiences and continued receipt of vaccinations.

A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology

INTRODUCTION

Pain remains common, underrecognized, and undertreated in children's hospitals and pediatric clinics. Over 200,000 patients experience needle pain annually in our institution, caused by blood draws, intravenous access, vaccinations, and injections on all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics.

OBJECTIVES

We implemented a hospital-based, system-wide initiative called the "Children's Comfort Promise," and created a new standard of care for needle procedures that required staff to consistently offer 4 strategies: (1) topical anesthetics, (2) sucrose or breastfeeding for infants 0 to 12 months, (3) comfort positioning (including swaddling, skin-to-skin, or facilitated tucking for infants; sitting upright for children), and (4) age-appropriate distraction.

METHODS

The protocol was established system-wide in one of the largest children's hospitals in the United States using a staggered implementation approach over a 3-year period to allow for unit-specific customization and facilitation of knowledge transfer from one unit to another. All departments were required to offer all 4 strategies with appropriate education at least 95% of the time.

RESULTS

Comparison of baseline audits with continuous postimplementation audits revealed that wait times for services decreased, patient satisfaction increased, and staff concerns about implementation were allayed (eg, concerns about wait times and success rates of venipuncture after topical anesthesia).

CONCLUSION

This is the first report of a successful system-wide protocol implementation to reduce or eliminate needle pain, including pain from vaccinations, in a children's hospital across all inpatient units, emergency departments, outpatient laboratories, and ambulatory clinics through consistent use of topical anesthesia, sucrose/breastfeeding, positioning, and distraction.

A Systematic Review of the Psychometric Properties of the Modified Behavioral Pain Scale (MBPS)

PROBLEM

Clinicians and researchers require a valid way to assess procedural pain experienced by infants and children. The Modified Behavioral Pain Scale (MBPS) has been used to assess immunisation pain. However, it is unknown whether it is valid for this purpose and whether use can be extended to other procedures. The aim of this study was to rigorously assess evidence addressing the psychometric properties of this scale and to provide recommendations for its use.

ELIGIBILITY CRITERIA

Psychometric evaluation studies reporting feasibility, reliability, validity, or utility data for the MBPS applied to children (birth to 18years) and randomised controlled trials (RCT) using the MBPS were included.

SAMPLE

Twenty-eight studies (8 psychometric and 20 RCTs) were included.

RESULTS

Studies were of varying quality. Sufficient data was available to cautiously accept the MBPS as valid for assessing immunisation related pain in infants aged 2 to 22months. There was insufficient data to support the psychometrics in other age groups or in circumstances other than immunisation. There is no data addressing the clinical utility of the MBPS.

CONCLUSIONS

It is not possible at this time to confidently accept the MBPS as suitable for assessing all procedural pain in young children.

IMPLICATIONS

Studies to evaluate the capacity of the MBPS to assess pain in a range of procedures and to distinguish between pain and non-pain related distress are needed if it is to be recommended.

Video-based patient decision aids: A scoping review

OBJECTIVE

This study reviews the published literature on the use of video-based decision aids (DA) for patients. The authors describe the areas of medicine in which video-based patient DA have been evaluated, the medical decisions targeted, their reported impact, in which countries studies are being conducted, and publication trends.

METHOD

The literature review was conducted systematically using Medline, Embase, CINAHL, PsychInfo, and Pubmed databases from inception to 2016. References of identified studies were reviewed, and hand-searches of relevant journals were conducted.

RESULTS

488 studies were included and organized based on predefined study characteristics. The most common decisions addressed were cancer screening, risk reduction, advance care planning, and adherence to provider recommendations. Most studies had sample sizes of fewer than 300, and most were performed in the United States. Outcomes were generally reported as positive. This field of study was relatively unknown before 1990s but the number of studies published annually continues to increase.

CONCLUSION

Videos are largely positive interventions but there are significant remaining knowledge gaps including generalizability across populations.

PRACTICE IMPLICATIONS

Clinicians should consider incorporating video-based DA in their patient interactions. Future research should focus on less studied areas and the mechanisms underlying effective patient decision aids.

Parent Attitudes Toward Pain Management for Childhood Immunizations

OBJECTIVES

Evidence-based pain-limiting strategies for pediatric immunizations remain underutilized, with barriers identified to date mostly pertaining to health care providers and systems of care. The present study sought to quantify and investigate parent attitudes toward pain management as another potential barrier to the routine use of pain-mitigating strategies during immunizations.

MATERIALS AND METHODS

Questionnaires measuring parent attitudes, willingness to pay, and perceived barriers for using pain management for immunizations were completed by 259 parent/guardians of children ages 0 to 5 years attending appointments at an urban primary care clinic in the Midwestern United States.

RESULTS

Parent attitudes toward pain management for immunization were relatively normally distributed and varied from strongly positive to negative, with 33% of parents disagreeing that they were concerned about the pain their child may experience and 50% agreeing that there are no lasting negative effects from immunization pain. Negative parent attitudes were associated with willingness to spend less in money or time for pain management and with greater perceived significance of cost, time, and other barriers for using pain-mitigating strategies.

DISCUSSION

Some parents perceive limited value in trying to reduce pain during immunizations such that they may be hesitant to invest much time or effort in interventions. Greater success of translating evidence-based pain management into practice therefore may require accounting for differences in parent attitudes by tailoring educational efforts and pain management options accordingly.

Four steps to eliminate or reduce pain in children caused by needles (part 1)

Dr Stefan Friedrichsdorf speaks to Jade Parker, Commissioning Editor: Stefan J Friedrichsdorf, MD, is medical director of the Department of Pain Medicine, Palliative Care and Integrative Medicine at Children’s Hospitals and Clinics of Minnesota, Minneapolis/St Paul, MN, USA, home to one of the largest and most comprehensive programs of its kind in the country. The interdisciplinary pain team is devoted to prevent and treat acute, procedural, neuropathic, psycho-social-spiritual, visceral, and chronic/complex pain for all inpatients and outpatients in close collaboration with all pediatric subspecialties at Children’s Minnesota. The palliative care team also provides holistic care for pediatric patients with life-threatening diseases and adds an extra layer of support to the care of children with serious illness and their families. Integrative medicine provides and teaches integrative (‘non-pharmacological’) therapies, such as massage, acupuncture/acupressure, biofeedback, aromatherapy and self-hypnosis, to provide care that promotes optimal health and supports the highest level of functioning in all individual children’s activities. Children's Minnesota became the first children's hospital to system-wide implement a “Children's Comfort Promise: We promise to do everything to prevent and treat pain,” resulting in decrease or elimination of needle pain caused by vaccinations, blood draws, intravenous access, and injections in more than 200,000 children annually.

ABM Clinical Protocol #23: Nonpharmacological Management of Procedure-Related Pain in the Breastfeeding Infant, Revised 2016

A central goal of The Academy of Breastfeeding Medicine is the development of clinical protocols for managing common medical problems that may impact breastfeeding success. These protocols serve only as guidelines for the care of breastfeeding mothers and infants and do not delineate an exclusive course of treatment or serve as standards of medical care. Variations in treatment may be appropriate according to the needs of an individual patient. These guidelines are not intended to be all-inclusive, but to provide a basic framework for physician education regarding breastfeeding.

Guidance on how to achieve comprehensible patient information leaflets in four steps

Comprehensible information leaflets can improve a patient's knowledge. However, in clinical studies leaflets are often introduced without meticulously verifying their comprehensibility. In an attempt to provide a feasible guidance on how to design comprehensible leaflets we complied and evaluated an easy-to-use development procedure. In January 2015, a literature search was performed to identify evidence for readily available quality assurance strategies as a starting point for a standardized strategy to develop and validate written patient information. The suggested development strategy is a consecutive four-step procedure that comprised already validated distinct quality assessments: (i) an initial requirement analysis specifying the needs and constraints of the target population and evidence-based preparation of the leaflets, (ii) a readability assessment, (iii) the Suitability Assessment of Materials instrument and (iv) iterative consumer test in the target population. The consecutive combination of pertinent and previously validated quality assessments provides an easy-to-use guidance on how to create comprehensibly written patient information, particularly for small-scale research projects with time and money constraints.

Process Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials

BACKGROUND

This systematic review evaluated the effectiveness of process interventions (education for clinicians, parent presence, education of parents [before and on day of vaccination], and education of patients on day of vaccination) on reducing vaccination pain, fear, and distress and increasing the use of interventions during vaccination.

DESIGN/METHODS

Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Critical outcomes were pain, fear, distress (when applicable), and use of pain management interventions. Data were extracted according to procedure phase (preprocedure, acute, recovery, combinations of these) and pooled using established methods. Analyses were conducted using standardized mean differences (SMD) and risk ratios (RR).

RESULTS

Thirteen studies were included. Results were generally mixed. On the basis of low to very low-quality evidence, the following specific critical outcomes showed significant effects suggesting: (1) clinicians should be educated about vaccine injection pain management (use of interventions: SMD 0.66; 95% confidence interval [CI]: 0.47, 0.85); (2) parents should be present (distress preprocedure: SMD -0.85; 95% CI: -1.35, -0.35); (3) parents should be educated before the vaccination day (use of intervention preprocedure: SMD 0.83; 95% CI: 0.25, 1.41 and RR, 2.08; 95% CI: 1.51, 2.86; distress acute: SMD, -0.35; 95% CI: -0.57, -0.13); (4) parents should be educated on the vaccination day (use of interventions: SMD 1.02; 95% CI: 0.22, 1.83 and RR, 2.42; 95% CI: 1.47, 3.99; distress preprocedure+acute+recovery: SMD -0.48; 95% CI: -0.82, -0.15); and (5) individuals 3 years of age and above should be educated on the day of vaccination (fear preprocedure: SMD -0.67; 95% CI: -1.28, -0.07).

CONCLUSIONS

Educating individuals involved in the vaccination procedure (clinicians, parents of children being vaccinated; individuals above 3 y of age) is beneficial to increase use of pain management strategies, reduce distress surrounding with vaccination, and to reduce fear. When possible, parent presence is also recommended for children undergoing vaccination.

Non-pharmacological management of infant and young child procedural pain

BACKGROUND

Infant acute pain and distress is commonplace. Infancy is a period of exponential development. Unrelieved pain and distress can have implications across the lifespan.  This is an update of a previously published review in the Cochrane Database of Systematic Reviews, Issue 10 2011 entitled 'Non-pharmacological management of infant and young child procedural pain'.

OBJECTIVES

To assess the efficacy of non-pharmacological interventions for infant and child (up to three years) acute pain, excluding kangaroo care, and music. Analyses were run separately for infant age (preterm, neonate, older) and pain response (pain reactivity, immediate pain regulation). 

SEARCH METHODS

For this update, we searched the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library (Issue 2 of 12, 2015), MEDLINE-Ovid platform (March 2015), EMBASE-OVID platform (April 2011 to March 2015), PsycINFO-OVID platform (April 2011 to February 2015), and CINAHL-EBSCO platform (April 2011 to March 2015). We also searched reference lists and contacted researchers via electronic list-serves. New studies were incorporated into the review. We refined search strategies with a Cochrane-affiliated librarian. For this update, nine articles from the original 2011 review pertaining to Kangaroo Care were excluded, but 21 additional studies were added.

SELECTION CRITERIA

Participants included infants from birth to three years. Only randomised controlled trials (RCTs) or RCT cross-overs that had a no-treatment control comparison were eligible for inclusion in the analyses. However, when the additive effects of a non-pharmacological intervention could be assessed, these studies were also included. We examined studies that met all inclusion criteria except for study design (e.g. had an active control) to qualitatively contextualize results. There were 63 included articles in the current update.

DATA COLLECTION AND ANALYSIS

Study quality ratings and risk of bias were based on the Cochrane Risk of Bias Tool and GRADE approach. We analysed the standardized mean difference (SMD) using the generic inverse variance method.

MAIN RESULTS

Sixty-three studies, with 4905 participants, were analysed. The most commonly studied acute procedures were heel-sticks (32 studies) and needles (17 studies). The largest SMD for treatment improvement over control conditions on pain reactivity were: non-nutritive sucking-related interventions (neonate: SMD -1.20, 95% CI -2.01 to -0.38) and swaddling/facilitated tucking (preterm: SMD -0.89; 95% CI -1.37 to -0.40). For immediate pain regulation, the largest SMDs were: non-nutritive sucking-related interventions (preterm: SMD -0.43; 95% CI -0.63 to -0.23; neonate: SMD -0.90; 95% CI -1.54 to -0.25; older infant: SMD -1.34; 95% CI -2.14 to -0.54), swaddling/facilitated tucking (preterm: SMD -0.71; 95% CI -1.00 to -0.43), and rocking/holding (neonate: SMD -0.75; 95% CI -1.20 to -0.30). Fifty two of our 63 trials did not report adverse events. The presence of significant heterogeneity limited our confidence in the findings for certain analyses, as did the preponderance of very low quality evidence.

AUTHORS' CONCLUSIONS

There is evidence that different non-pharmacological interventions can be used with preterms, neonates, and older infants to significantly manage pain behaviors associated with acutely painful procedures. The most established evidence was for non-nutritive sucking, swaddling/facilitated tucking, and rocking/holding. All analyses reflected that more research is needed to bolster our confidence in the direction of the findings. There are significant gaps in the existing literature on non-pharmacological management of acute pain in infancy.

Why are children still crying? Going beyond "evidence" in guideline development to improve pain care for children: the HELPinKIDS experience

The failure to translate research evidence into day-to-day clinical practices is identified as a significant reason for suboptimal quality care across the health system, including procedural pain management in children. Clinical practice guidelines (CPGs) have been developed to assist in this process by synthesizing and interpreting research evidence for end users. Numerous CPGs have been developed for procedural pain management in children, yet gaps persist in the adoption of best practices. This article reviews the experience and approach of 1 guideline development group, the Help ELiminate Pain in KIDS Team (HELPinKIDS), in incorporating implementation considerations and knowledge translation (KT) strategies within the process of guideline development for the HELPinKIDS CPG about childhood vaccination pain management to facilitate greater uptake of the CPG. Specific areas that will be addressed include partnerships with stakeholders, rigor of guideline development, issues of implementation, and editorial independence. The work of HELPinKIDS was guided by a KT map, which identified, at a high level, the target audiences, key messages, tools, and strategies that could be used to communicate, disseminate, and implement the CPG into diverse settings. Examples of impact at both the individual and systems levels from HELPinKIDS KT activities are also presented.

HELPinKids&Adults Knowledge Synthesis of the Management of Vaccination Pain and High Levels of Needle Fear: Limitations of the Evidence and Recommendations for Future Research

The HELPinKids&Adults knowledge synthesis for the management of vaccination-related pain and high levels of needle fear updated and expanded upon the 2010 HELPinKIDS knowledge synthesis and clinical practice guideline for pain mitigation during vaccine injections in childhood. Interventions for vaccine pain management in adults and treatment of individuals with high levels of needle fear, phobias, or both were included, thereby broadening the reach of this work. The present paper outlines the overarching limitations of this diverse evidence base and provides recommendations for future research. Consistent with the framing of clinical questions in the systematic reviews, the Participants, Intervention, Comparison, Outcome, Study design (PICOAS) framework was used to organize these predominant issues and research directions. The major limitations we identified across systematic reviews were an overall dearth of trials on vaccination, lack of methodological rigor, failure to incorporate important outcomes, poor study reporting, and various sources of heterogeneity. Future research directions in terms of conducting additional trials in the vaccination context, improving methodological quality and rigor, assessment of global acceptability and feasibility of interventions, and inclusion of outcomes that stakeholders consider to be important (eg, compliance) are recommended. Given concerns about pain and fear are known contributors to vaccine hesitancy, improving and expanding this evidence base will be integral to broader efforts to improve vaccine compliance and public health worldwide.

A randomized trial of rotavirus vaccine versus sucrose solution for vaccine injection pain

OBJECTIVE

Sucrose solutions are analgesic in infants. Oral rotavirus vaccine contains sucrose, however, it is not known if it possesses analgesic properties. The objective was to compare the analgesic effectiveness of rotavirus vaccine to sucrose solution when administered prior to injectable vaccines.

METHODS

Infants 2-4 months of age receiving oral rotavirus vaccine and two separate injectable vaccines on the same day were randomized to rotavirus vaccine (Rotarix) first followed by the injectable vaccines and sucrose (Tootsweet) afterwards, or vice versa. Pain was assessed by blinded raters using the Numerical Rating Scale (NRS, range 0-10) (parents, clinicians), or Modified Behavioural Pain Scale (MBPS, range 0-10) and cry duration (observers). Data were analyzed using t-tests or χ(2)-tests; Bonferroni correction was applied to correct for multiple comparisons, as appropriate.

RESULTS

Altogether, 120 infants participated: 60 were randomized to rotavirus vaccine first. Groups did not differ in demographics, including; age (p=0.448) and sex (p=0.464). The mean pain score (standard deviation) for both vaccine injections did not differ between infants given rotavirus vaccine first versus sucrose solution first: observer MBPS, parent NRS and clinician NRS scores were 7.4 (1.6) vs. 7.7 (1.6), 4.9 (2.1) vs. 5.8 (2.1), and 4.2 (2.1) vs. 4.6 (2.2), respectively. Similarly, there was no difference between groups in cry duration.

CONCLUSION

Rotavirus vaccine did not differ from sucrose solution in reducing injection-induced pain. Based on the findings, it is recommended that rotavirus vaccine be administered prior to injectable vaccines in infants aged 2 and 4 months.