The Perception of Procedures Questionnaire: psychometric properties of a brief parent report measure of procedural distress

Pain assessment, cognitive and cortical changes with full mouth rehabilitation in a group of children

BACKGROUND

A change in professionals' perspectives on the value of general anesthesia (GA) for pediatric patients, including those with disabilities, medical conditions, severe oral issues, and challenging behaviors. Full-mouth rehabilitation under GA allows for the comprehensive treatment of all oral health problems in a single visit, without requiring the child's active participation. Extensive dental problems are often associated with severe dental pain, which can impact cognitive function, including perception, attention, memory, reasoning, language, communication, and executive functions. Individuals experiencing pain tend to perform less optimally cognitively.

AIM

This study aimed to investigate changes in cognition, brain function, and cortical alterations in children who underwent extensive dental rehabilitation under GA.

PATIENTS ANDMETHODS

Thirty uncooperative, healthy children aged 6-12 with extensive dental issues were enrolled. Pain levels were assessed using the FLACC and WBFPS scales before treatment, one week after, and three months later. Cognitive assessments, including the WCST, processing speed, digit span, and Trail Making Test, as well as EEG measurements, were also performed.

RESULTS

The results showed a significant improvement in pain levels reported by the children or their caregivers after the dental procedures, both at one week and three months. All cognitive measures, such as digit span, processing speed, and WCST performance, demonstrated substantial improvements after the treatment. The Trail Making Test also exhibited statistically significant variations before and after the dental procedures. Additionally, the MOCA test revealed a notable improvement in cognitive skills following the treatment. Furthermore, the EEG power ratio, an indicator of changes in the power balance within each frequency band, showed a statistically significant difference after the dental procedures.

CONCLUSION

the findings of this study suggest that full-mouth rehabilitation under GA can lead to improved pain management, as well as enhanced cognitive and brain functions in children.

FUTURE PERSPECTIVES

More clinical studies with a longer follow-up period and a different age range of children are required to investigate the connection between brain function and oral rehabilitation involving restorations or occlusion issues.

Effect of a Vibration System on Pain Reduction during Injection of Dental Anesthesia in Children: A Randomized Clinical Trial

Background

The ‘‘gate control” theory suggests pain can be reduced by simultaneous activation of larger diameter nerve fibers using appropriate coldness, warmth, rubbing, pressure, or vibration. This study investigated the efficacy of a device combining cold and vibration, for needle-related procedural pain in children. Methodology. A total of 51 children aged 5–12 years participated in this randomized controlled clinical trial. Half of the children were in the control group and received maxillary buccal infiltration, by injecting 1.8 ml of 2% lidocaine with 1 : 100,000 adrenaline using topical anesthesia 20% benzocaine gel for 15 seconds, while the other half were in the test group and received the same anesthesia using a commercially available external cold and a vibrating device. A face version of Visual Analogue Scale (VAS) was used as a subjective measure to assess the child's pain experience. The parents were requested to evaluate the child's ability to tolerate pain using a behavioral/observational pain scale. Sound, Eyes, and Motor (SEM) scale and Faces, Legs, Activity, Cry, and Consolability (FLACC) scale were used to record the child's pain as perceived by the external evaluator. T-test or Mann–Whitney U-test was used for scale variables, paired sample T-test or Wilcoxon rank t-test was used for before and after data, and chi-square was used for categorical variable, based on the results of normality test.

Results

The results showed a statistically significant reduction in pain after the injection for the test group compared with control using VAS scale (mean = 6.68 (1.09) and 8.42 (0.50); p=0.001) and FLACC scale (mean = 5.92 (1.05) and 8.16 (0.54); p=0.002), but not when using SEM scale (mean 3.22 (0.42) and 4.24 (2.74);p=0.08).

Conclusions

Combined external cold and vibrating devices can be an effective alternative in reducing experienced pain and fear in children undergoing infiltration dental anesthesia. This study was registered with clinical trial registry of the United States National Institutes of Health (NIH) at ClinicalTrials.gov (NCT03953001).

What matters when managing childhood fever in the emergency department? A discrete-choice experiment comparing the preferences of parents and healthcare professionals in the UK

BACKGROUND

Fever among children is a leading cause of emergency department (ED) attendance and a diagnostic conundrum; yet robust quantitative evidence regarding the preferences of parents and healthcare providers (HCPs) for managing fever is scarce.

OBJECTIVE

To determine parental and HCP preferences for the management of paediatric febrile illness in the ED.

SETTING

Ten children's centres and a children's ED in England from June 2018 to January 2019.

PARTICIPANTS

98 parents of children aged 0-11 years, and 99 HCPs took part.

METHODS

Nine focus-groups and coin-ranking exercises were conducted with parents, and a discrete-choice experiment (DCE) was conducted with both parents and HCPs, which asked respondents to choose their preferred option of several hypothetical management scenarios for paediatric febrile illness, with differing levels of visit time, out-of-pocket costs, antibiotic prescribing, HCP grade and pain/discomfort from investigations.

RESULTS

The mean focus-group size was 4.4 participants (range 3-7), with a mean duration of 27.4 min (range 18-46 min). Response rates to the DCE among parents and HCPs were 94.2% and 98.2%, respectively. Avoiding pain from diagnostics, receiving a faster diagnosis and minimising wait times were major concerns for both parents and HCPs, with parents willing-to-pay £16.89 for every 1 hour reduction in waiting times. Both groups preferred treatment by consultants and nurse practitioners to treatment by doctors in postgraduate training. Parents were willing to trade-off considerable increases in waiting times (24.1 min) to be seen by consultants and to avoid additional pain from diagnostics (45.6 min). Reducing antibiotic prescribing was important to HCPs but not parents.

CONCLUSIONS

Both parents and HCPs care strongly about reducing visit time, avoiding pain from invasive investigations and receiving diagnostic insights faster when managing paediatric febrile illness. As such, overdue advances in diagnostic capabilities should improve child and carer experience and HCP satisfaction considerably in managing paediatric febrile illness.

The Use of the Buzzy, Jet Lidokaine, Bubble-blowing and Aromatherapy for Reducing Pediatric Pain, Stress and Fear Associated with Phlebotomy

PURPOSE

This study aimed to investigate the effects of the Buzzy, Jet lidokaine, bubble-blowing and inhalation aromatherapy with lavender essence on pain, stress and fear in children undergoing phlebotomy.

DESIGNS AND METHODS

This study was a prospective, randomized controlled trial. The sample was comprised of children aged 5 to 10 years requiring blood tests. Children were assigned to five subgroups through randomization performed using a computer program: the Buzzy group (n = 39), Jet lidokaine group (n = 39), bubble-blowing group (n = 39), inhalation aromatherapy with lavender essence group (n = 39) and control group (n = 39). The children's levels of pain were evaluated and reported by the parents, observers and the children, who self-reported using the Oucher Pain Scale. The children's fear levels were assessed using the Children's Fear Scale, and salivary cortisol analysis was conducted to evaluate stress levels.

RESULTS

A significant difference was found between the intervention and control groups in terms of levels of pain during and after phlebotomy in favor of the Buzzy group (p < 0.05). There was a significant difference between the fear scores of the children in the intervention and control groups before phlebotomy (p < 0.05). This difference was found to be caused by the bubble-blowing method. There was a significant difference between intervention and control groups fear levels in favor of the Buzzy group during phlebotomy (p < 0.05).

PRACTICE IMPLICATIONS

It is recommended that the Buzzy and bubble-blowing be used during phlebotomy in children to reduce the severity of their pain.

Parental satisfaction with being present in the operating room during the induction of anesthesia prior to pediatric neurosurgical intervention: a qualitative analysis

OBJECTIVE Parental presence in the operating room during the induction of anesthesia (PPIA) has been shown to decrease parent and child anxiety and increase satisfaction with patient experience in outpatient otolaryngological procedures, such as tympanostomy tube placement. PPIA for other procedures, such as a major neurosurgical intervention, has been a practice at the authors' institutions for many years. This practice is not universally accepted across the United States, and the potential benefits for patients and families have not been formally evaluated. The aim of this study is to provide a qualitative analysis of parental and patient satisfaction with PPIA at the authors' institution. METHODS All patients younger than 18 years who underwent surgical intervention at the authors' institution between August 2013 and December 2015 were identified. All surgeries were performed by a single neurosurgeon. A random sample of 96 parents were contacted by telephone for a qualitative, semiscripted interview; 42 parents completed the interviews. The interview consisted of a validated satisfaction assessment in addition to a standardized open-ended questionnaire. Thematic analysis was performed until saturation was achieved, and responses were coded into the predominant themes. Member checking was performed, and a thick description was created. RESULTS The predominant themes identified with PPIA were 1) perception of induction as traumatizing or distressing to witness, 2) positive feelings regarding having been present, 3) satisfaction regarding the overall experience with surgery, 4) variable feelings in parents who decided not to attend induction, and 5) mixed feelings in the interactions with the care team. Parents expressed an array of positive, negative, and neutral impressions of the experience; however, overall, most experiences were positive. Most parents would choose PPIA again if their child required additional surgery. CONCLUSIONS This is the first study to evaluate the benefit of PPIA for pediatric neurosurgical patients. The results show a unique insight into medical communication and patient satisfaction with high-risk surgeries. PPIA may be able to help shape an environment of trust and increase satisfaction with perioperative care.

Observational Coding Systems of Parent-Child Interactions During Painful Procedures: A Systematic Review

BACKGROUND

Parent interactions with their child can influence the child's pain and distress during painful procedures. Reliable and valid interaction analysis systems (IASs) are valuable tools for capturing these interactions. The extent to which IASs are used in observational research of parent-child interactions is unknown in pediatric populations.

OBJECTIVES

To identify and evaluate studies that focus on assessing psychometric properties of initial iterations/publications of observational coding systems of parent-child interactions during painful procedures.

METHODS

To identify and evaluate studies that focus on assessing psychometric properties of initial iterations/publications of observational coding systems of parent-child interactions during painful procedures. Computerized databases searched included PubMed, CINAHL, PsycINFO, Health and Psychosocial Instruments, and Scopus. Timeframes covered from inception of the database to January 2017. Studies were included if they reported use or psychometrics of parent-child IASs. First assessment was whether the parent-child IASs were theory-based; next, using the Society of Pediatric Psychology Assessment Task Force criteria IASs were assigned to one of three categories: well-established, approaching well-established, or promising.

RESULTS

A total of 795 studies were identified through computerized searches. Eighteen studies were ultimately determined to be eligible for inclusion in the review and 17 parent-child IASs were identified from these 18 studies. Among the 17 coding systems, 14 were suitable for use in children age 3 years or more; two were theory-based; and 11 included verbal and nonverbal parent behaviors that promoted either child coping or child distress. Four IASs were assessed as well-established; seven approached well-established; and six were promising.

CONCLUSIONS

Findings indicate a need for the development of theory-based parent-child IASs that consider both verbal and nonverbal parent behaviors during painful procedures. Findings also suggest a need for further testing of those parent-child IASs deemed "approaching well-established" or "promising".

A qualitative analysis of how parents assess acute pain in young children

An accurate and comprehensive pain assessment is crucial for adequate pain management in pre- and early verbal children during painful medical procedures. This study used an inductive approach to explore the processes involved in parental pain assessment and to develop a new model of Parental Assessment of Acute Child Pain. Participants were 19 parents of children aged under 3 years who had previously or were potentially about to experience an intravenous cannula or nasogastric tube insertion. Parental affect regulation, while witnessing their child in acute pain/distress, appeared to be critical to the processes involved in assessing their child’s pain.

Matching doses of distraction with child risk for distress during a medical procedure: a randomized clinical trial

BACKGROUND

Parents often want to provide support to their children during medical procedures, but not all parents are effective in providing distraction after brief training.

OBJECTIVE

The aim of this study was to investigate the effects of three doses of distraction intervention for children at high and medium risk for procedure-related distress.

METHODS

Children undergoing scheduled intravenous insertions for diagnostic or treatment purposes and their parents participated. A computerized application, Children, Parents and Distraction, was used to predict distress risk. Doses of intervention were basic (parents trained on providing distraction), enhanced (basic training plus tailored instructions, environmental modifications, and support and guidance from the research assistant), and professional (a trained research assistant provided distraction). Outcome measures were Observational Scale of Behavioral Distress-Revised for behavioral distress, Oucher for self-reported pain, parent report of child distress, and salivary cortisol for physiological distress.

RESULTS

A total of 574 children, ages 4-10, and their parents participated. The Children, Parents and Distraction predicted that the risk for distress was high for 156 children, medium for 372, and low for 46. Children predicted to have higher risk for distress displayed more behavioral distress (p < .01). Children in the medium-risk group who had the professional intervention displayed significantly less behavioral distress (p < .001). Children in the high-risk group tended to have less behavioral distress when receiving the professional intervention (p = .07). There were no significant group differences for self-report of pain, parent report of distress, or cortisol levels.

DISCUSSION

Some parents may need additional training in providing distraction to their children during procedures, and some children at medium and high risk for distress may need professional support. Parents should be asked about their preferences in acting as the distraction coach and, if willing, be provided as much training and support as possible in the clinical situation.

Validation of a clinically useful measure of children's state anxiety before medical procedures

PURPOSE

Assessment of children's anxiety in busy clinic settings is an important step in developing tailored interventions. This article describes the construct validation of the Children's Anxiety Meter-State (CAM-S), a brief measure of state anxiety.

DESIGN AND METHODS

Existing data were used to investigate the associations between child self-reports of anxiety, parent reports of child anxiety, and observed child distress during an intravenous procedure.

RESULTS

Children's (n = 421) CAM-S scores were significantly associated with all parent measures and observed distress ratings.

PRACTICE IMPLICATIONS

Findings support the use of the CAM-S for assessment of child anxiety in clinical settings.

Parenting stress among caregivers of children with chronic illness: a systematic review

OBJECTIVE

To critically review, analyze, and synthesize the literature on parenting stress among caregivers of children with asthma, cancer, cystic fibrosis, diabetes, epilepsy, juvenile rheumatoid arthritis, and/or sickle cell disease. Method PsychInfo, MEDLINE, and Cumulative Index to Nursing and Allied Health Literature were searched according to inclusion criteria. Meta-analysis of 13 studies and qualitative analysis of 96 studies was conducted. Results Caregivers of children with chronic illness reported significantly greater general parenting stress than caregivers of healthy children (d = .40; p = ≤.0001). Qualitative analysis revealed that greater general parenting stress was associated with greater parental responsibility for treatment management and was unrelated to illness duration and severity across illness populations. Greater parenting stress was associated with poorer psychological adjustment in caregivers and children with chronic illness. Conclusion Parenting stress is an important target for future intervention. General and illness-specific measures of parenting stress should be used in future studies.

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

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

Is parental anxiety and coping associated with girls' distress during a VCUG? Preliminary findings

PURPOSE

We investigated the relationship between parental anxiety/coping strategies and girls' distress during VCUGs.

METHODS

Parents of 32 girls (age 4-10, mean 5.8 years) completed a trait anxiety measure and a measure of parental reactions to children's distress. Post procedure, children, parents and radiology staff rated the level of anxiety, fear, pain and discomfort.

RESULTS

Trends indicated that parents who reported increased anxiety rated their children as experiencing increased distress (r = 0.27, p = 0.071), similarly for medical staff ratings (r = 0.28, p = 0.061). Parents with lower trait anxiety scores reported using more emotion- and problem-focused coping strategies (r = -0.37 and r = -0.40, p < 0.05, respectively). These were related to children experiencing less procedural distress (r = -0.30, p = 0.054; r = -0.33, p = 0.037, respectively) and parents rated as less anxious by staff (r = -0.40, p = 0.014; r = -0.31, p = 0.047, respectively).

CONCLUSIONS

There was a trend toward parental anxiety being related to their child's distress during VCUG. Parental coping strategies resulted in less distress among children and parents. Teaching coping techniques might obviate the need for sedation and help children deal with future stressors.

Factors explaining children's responses to intravenous needle insertions

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

DISCUSSION

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

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

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

Use of music during physical therapy intervention for an infant with Erb's palsy: A single-subject design

Evidence supporting the use of music during pediatric physical therapy intervention is limited. The purpose of this single-subject design was to evaluate the effects of music on patient progress, the amount of crying during therapy, and parent satisfaction with physical therapy services. The subject was an infant girl with Erb's palsy who participated in this study from age 8 months to age 20 months. An A-B-A withdrawal single-subject design was used. The patient's progress was assessed by using the T.I.M.E. The amount of crying was documented in the Crying Log. A parent satisfaction questionnaire was administered three times over the course of the study. The subject's progress in the music intervention period increased on three of five primary subtests of the T.I.M.E. The amount of crying decreased and parent satisfaction increased when music was played during therapy. Music may be used by pediatric physical therapists to decrease the patient's crying, increase parent satisfaction, and possibly to increase the child's rate of progress. Further research conducted with a group of infants and toddlers may help generalize these findings to a wider patient population.

Propofol-fentanyl versus propofol alone for lumbar puncture sedation in children with acute hematologic malignancies: propofol dosing and adverse events

OBJECTIVE

We sought to determine whether the combination of propofol and fentanyl results in lower propofol doses and fewer adverse cardiopulmonary events than propofol and placebo for lumbar puncture in children with acute hematologic malignancies.

DESIGN

Randomized, controlled, double blind, crossover study.

SETTING

Pediatric Sedation Program.

PATIENTS

Children with acute leukemia or lymphoma receiving sedation for lumbar puncture.

INTERVENTIONS

Each patient received two sedations in random order, one with propofol/placebo and one with propofol/fentanyl. The study investigator and patient/parent were blinded to placebo or fentanyl. Data collected included patient age and diagnosis, propofol dose and adverse events. Adverse events included oxygen saturation <94%, airway obstruction, apnea, hypotension, and bradycardia (<5% mean for age). Logistic regression analysis was used to assess probability of adverse events and the Wilcoxon Signed Rank and McNemar's tests were used for paired comparisons.

MEASUREMENTS AND MAIN RESULTS

Twenty-two patients were enrolled. Fourteen patients were male and eight were female. Each patient was studied twice for a total of 44 sedations. The median age was 5.0 yrs (range, 2.2-17.2 yrs). All procedures were successfully completed. The median total dose of propofol was 5.05 mg/kg (range, 2.4-10.2 mg/kg) for propofol/placebo vs. 3.00 mg/kg (range 1.4-10.5 mg/kg) for propofol/fentanyl (p < 0.001). Twelve adverse events occurred in 11 of 22 patients (50.0%) propofol/placebo compared with 6 of 22 (18.2%) propofol/fentanyl (p = 0.02). The most common adverse event was hypotension.

CONCLUSIONS

The combination of propofol and fentanyl vs. propofol alone for lumbar puncture sedation in children with acute hematologic malignancies resulted in lower propofol doses and fewer adverse events.

Sedative preference of families for lumbar punctures in children with acute leukemia: propofol alone or propofol and fentanyl

Propofol is a common sedative/anesthetic used for invasive procedures in children with cancer. The purpose of this study was to determine whether families of children with acute leukemia prefer propofol alone or propofol plus fentanyl for lumbar puncture (LP) sedation. We conducted a randomized, placebo controlled, double blind, crossover study. Each patient was studied twice, once with propofol/placebo and once with propofol/fentanyl. Data collected included the modified Yale Preoperative Anxiety Score (M-YPAS) at baseline and after placebo or fentanyl, Induction Compliance Checklist, recovery excitement, recovery time, and adverse events. After the study, families were asked which sedative regimen they preferred for future LPs. Twenty-two patients received 44 LP sedations: propofol 22, propofol/fentanyl 22. The average age was 6.4+/-4.2 years (mean+/-SD). There were no significant differences between groups in M-YPAS, Induction Compliance Checklist or recovery excitement. Adverse events occurred in 11/22 patients (50%) propofol and 4/22 (18.2%) propofol/fentanyl (P=0.0196). Average recovery time (mean+/-SD) was 36.86+/-17.1 minutes propofol versus 26.36+/-16.4 minutes propofol/fentanyl (P=0.047). Sixteen families (72.7%) chose propofol with fentanyl for future LP sedations (P=0.05). In conclusion, most families prefer propofol and fentanyl for LPs. Propofol with fentanyl was also associated with fewer adverse events and faster recovery.

Assessment of risk factors for emergence distress and postoperative behavioural changes in children following general anaesthesia

BACKGROUND

Emergence distress commonly occurs in children recovering from the immediate effects of general anaesthesia. This study was performed to (1) examine whether parental presence in the operating room during emergence from anaesthesia reduces the incidence or severity of emergence distress behaviour, and (2) assess psychosocial risk factors, including child temperament and sleep behaviour, for development of emergence distress.

METHODS

A randomized and controlled trial of parental presence at emergence was conducted in 100 ASA class I and II children having general anaesthesia for inguinal or penile surgery. Children in the study group had a parent present at induction and emergence of anaesthesia, while children in the control group had a parent present only at induction. Emergence and postanaesthesia care unit (PACU) behaviour was monitored using both the Operating Room Behaviour Rating Scale (ORBRS) and a 7-point Likert type cooperation scale.

RESULTS

One-way anovas showed no significant differences between the control group and the study group on emergence distress behaviour. The frequency of negative postoperative behavioural changes at 1 and 4 weeks postsurgery was low in both groups. Children described as clingy/dependent (chi2 = 5.57, P < 0.06) and children with frequent temper tantrums (chi2 = 7.44, P < 0.02) were more likely to have emergence distress behaviour.

CONCLUSIONS

Parental presence during emergence from anesthesia did not decrease the incidence or severity of emergence distress behaviour in children. Young children and children with a history of temper tantrums or separation anxiety may be more likely to develop such behaviour.

Parental emotional and time costs predict compliance with respiratory syncytial virus prophylaxis

BACKGROUND

Two agents are effective in preventing respiratory syncytial virus (RSV) hospitalization in premature infants: RSV immune globulin (RSV-IG) and palivizumab. RSV-IG is associated with greater parental emotional and time costs, which may account for the more limited adherence to recommended monthly treatment with this agent.

OBJECTIVES

To compare the emotional distress and time costs associated with RSV-IG and palivizumab treatments and to determine the influence of these costs on treatment adherence.

METHODS

We surveyed parents of 82 infants who received RSV-IG (90% of eligible) and parents of 61 infants who received palivizumab (87% of eligible) at Arkansas Children's Hospital by telephone. We measured infant distress during treatment, parental distress, parental time costs, and adherence with recommended monthly prophylaxis.

RESULTS

Half of parents of RSV-IG recipients witnessed their infant in distress during infusion, over half (61%) were upset by observing the needle stick, and 22% observed infusion in the scalp. Fewer than 5% of parents of palivizumab recipients observed their infant in distress or were themselves distressed during treatment. A quarter of parents took time off from work for RSV-IG or palivizumab treatment. RSV-IG recipients completed 62% of recommended monthly treatments compared with 86% completed by palivizumab recipients. Increased parental distress and time costs largely accounted for the reduction in adherence to monthly treatment among RSV-IG recipients.

CONCLUSIONS

The emotional and time costs of RSV-IG treatment far exceed those of palivizumab and predict substantial differences in treatment adherence between the 2 agents. The impact of hidden costs on treatment adherence should be included in economic evaluations of medical procedures.

A critical evaluation of the Parenting Stress Index-Short Form (PSI-SF) in a head start population

Examines psychometric characteristics of the 36-item Parenting Stress Index-Short Form (PSI-SF) in a low-income, predominantly minority population. Relations between the PSI-SF, demographic, and psychosocial factors associated with parenting stress were examined. Internal consistencies for the PSI-SF were very good to excellent. However, confirmatory factor analysis (CFA) indicated that a 3-factor model comprised of Parental Distress, Difficult Child, and Parent-Child Dysfunctional Interaction subscales was only marginally superior to a single-factor model. A series of multiple regression analyses examining the relation of psychosocial and demographic measures to PSI-SF subscales were more supportive of the 3-factor model proposed by Abidin (1995). As anticipated, the PSI-SF Difficult Child subscale was most strongly associated with a measure of child oppositionality, and the Parental Distress subscale was most highly associated with self-reported psychological symptoms and low income. Parent-Child Dysfunctional Interaction was associated with parent reports of psychological symptoms as well as low income and education. The results appear to support the use of the PSI-SF with lower socioeconomic, primarily African American mothers. Additionally, the data provide indirect support for the generalizability of a 3-factor model of parenting stress.

Invasive procedures carried out in conscious children: contrast between North American and European paediatric oncology centres

AIM

To define practice in managing repeated invasive procedures in selected paediatric oncology centres in North America and Europe, especially the United Kingdom; to define and contrast concerns that shape policy making, and to contrast practice, particularly regarding procedures performed on conscious patients.

METHODS

Postal survey: 118 centres of the Pediatric Oncology Group and the United Kingdom Children's Cancer Study Group received questionnaires.

RESULTS

68 questionnaires (58%) were returned (52 from North America, 12 from Europe). For all procedures, North American centres tended to use less effective techniques than European, especially for bone marrow procedures. Many North American centres reported performing these on conscious patients on at least three quarters (25%) or half (30%) the occasions. In contrast, corresponding figures for the European centres were 6% and 0%.

CONCLUSIONS

Many bone marrow procedures are still carried out in the conscious patient despite the safety and effectiveness of modern anaesthetic and deep sedation techniques. There appears to be a greater reluctance to offer these to patients in North American centres than in European ones. This may reflect a misperception that the risks of adverse effects are high. Several non-pharmacological techniques are used, but they remain uncommon.

Parental presence during anaesthesia induction for outpatient surgery of the infant

We conducted a randomized controlled trial of parental presence during anaesthesia induction for outpatient surgery in 73 infants (aged 1-12 months). Effects of parental presence on infant and parental outcomes, including anxiety, health care attitudes and satisfaction with the anaesthesia and surgery experience were evaluated. Results demonstrated that parental presence had no impact on infant behavioural distress during induction. In addition, parents who were present demonstrated comparable anxiety levels and health care attitudes before and after surgery, as well as comparable levels of satisfaction with the surgical experience compared to parents who were absent during induction. We discuss reasons for the lack of treatment effects from parental presence, and new directions for future research to identify subgroups of children who may most benefit from the opportunity to have parents involved in the perioperative period.

Antecedents, concomitants, and consequences of pediatric headache: confirmatory construct validation of two parent-report scales

The aim of the study presented is to examine the psychometric properties of two parent-report scales for the assessment of environmental factors in pediatric headache, namely, the Children's Headache Assessment Scale (CHAS) and the Illness Behavior Encouragement Scale (IBES). Data were gathered in a sample of 160 parents of children suffering from headaches regularly. The internal structure of both scales is investigated by means of confirmatory factor analysis. The internal consistency of the resulting subscales is explored and data on the convergent validity and on the relationship with demographics are presented. Both the CHAS and the IBES appear to be promising assessment tools in a behavioral approach to pediatric headache.

Pharmacologic and psychologic interventions for procedural pain

OBJECTIVE

This study evaluated a combined pharmacologic and psychologic intervention (combined intervention, CI) relative to a pharmacologic-only (PO) intervention in reducing child distress during invasive procedures in childhood leukemia. Predictors of child distress included age, group (CI, PO), and procedural variables (medications and doses, technical difficulty, number of needles required).

METHODOLOGY

This was a randomized, controlled prospective study that compared the PO (n = 45) and CI arms (n = 47), at 1, 6, and >12 months after diagnosis. A cross-sectional control group consisted of parents of 70 patients in first remission before the prospective study. Parent questionnaires, staff and parent ratings, and data on medications administered, technical difficulty of the procedure, and needle insertions were obtained for each procedure. This article reports on the final data point for the project (>12 months).

RESULTS

Mothers and nurses reported lower levels of child distress in the CI than the PO group. The CI and PO groups showed lower levels of child and parent distress than the cross-sectional control group. Distress decreased throughout the time, and child age was inversely related to distress (younger children had more distress) regardless of group. Child distress was associated with staff perceptions of the technical difficulty of the procedure and with child age, but not with medications administered.

CONCLUSIONS

The data showed that pharmacologic and psychologic interventions for procedural distress were effective in reducing child and parent distress and support integration of the two approaches. Younger children experienced more distress and warranted additional consideration. Staff perceptions of the technical difficulty of procedures were complex and potentially helpful in designing intervention protocols.