Out of the mouth of babes: a lot about pain has nothing to do with pain

Caregivers' physiological responses during toddler vaccinations: associations with psychological and behavioral responses

OBJECTIVE

This study investigated biological, psychological, and behavioral aspects of caregivers' responses to toddlers' pain-related distress by measuring caregivers' high-frequency heart rate variability (HRV) responses during toddler vaccination pain and examining associations with caregivers' behavioral responses and psychological stress.

METHODS

Participants included caregiver-toddler dyads (N = 194) from a longitudinal cohort-sequential study who were observed during toddlers' 12-, 18-, or 24-month routine vaccinations. Changes in caregiver HRV were analyzed using growth curve modeling. Conditional growth curve models examined associations between caregiver HRV and caregivers' concurrent behavior and psychological stress.

RESULTS

The unconditional growth curve model indicated a slight linear decrease in caregiver HRV (i.e., vagal withdrawal) across the 3 min post-needle (unstandardized B = -0.06, p = .049). In conditional growth curve models, higher levels of parenting stress were associated with less vagal withdrawal during the post-needle period (standardized B = 0.47, unstandardized B = 0.02, p = .003). Caregivers' behavioral responses (i.e., use of soothing and distress-promoting behaviors), state anxiety, and general anxiety symptomology were not significantly associated with HRV responses.

CONCLUSIONS

Caregiver parasympathetic nervous system activity levels changed minimally from baseline to post-needle and decreased slightly across the post-needle period. Caregivers' self-reported parenting stress was associated with their parasympathetic responses to the procedure. Findings support an improved understanding of the mechanisms underlying caregivers' responses to children's pain-related distress in a naturalistic setting.

When thinking about pain contributes to suffering: the example of pain catastrophizing

ABSTRACT

The extensive literature on the potent role negative thoughts about pain have on the experience of pain and pain-related suffering has documented associations with important neurobiological processes involved in amplifying nociceptive signals. We focus this review on pain catastrophizing (pCAT)- appraisals of pain as threatening, overwhelming, and unmanageable- and review the evidence that these thoughts are learned in childhood through experience and observation of others, particularly caretakers and parents. For children who have learned pCAT, repeated exposures to pain over time activate pCAT and likely contribute to further amplification of pain through changes in the neurobiological pain regulatory systems, which overlap with those regulating the stress response. We propose that repeated pain and stress exposures throughout childhood, adolescence, and into adulthood alter the neurobiology of pain via a repetitive positive feedback loop that increases risk for heightened pain sensitivity over time with repeated exposures. At some point, often precipitated by an acute episode of pain and possibly influenced by allostatic load, pCAT contributes to persistence of episodic or acute pain and exacerbates pain-related suffering. This developmental trajectory is not inevitable, as the impact of pCAT on pain and pain-related suffering can be influenced by various factors. We also present future directions for work in this area.

Health Care Professionals' and Parents' Perspectives on the Use of AI for Pain Monitoring in the Neonatal Intensive Care Unit: Multisite Qualitative Study

BACKGROUND

The use of artificial intelligence (AI) for pain assessment has the potential to address historical challenges in infant pain assessment. There is a dearth of information on the perceived benefits and barriers to the implementation of AI for neonatal pain monitoring in the neonatal intensive care unit (NICU) from the perspective of health care professionals (HCPs) and parents. This qualitative analysis provides novel data obtained from 2 large tertiary care hospitals in Canada and the United Kingdom.

OBJECTIVE

The aim of the study is to explore the perspectives of HCPs and parents regarding the use of AI for pain assessment in the NICU.

METHODS

In total, 20 HCPs and 20 parents of preterm infants were recruited and consented to participate from February 2020 to October 2022 in interviews asking about AI use for pain assessment in the NICU, potential benefits of the technology, and potential barriers to use.

RESULTS

The 40 participants included 20 HCPs (17 women and 3 men) with an average of 19.4 (SD 10.69) years of experience in the NICU and 20 parents (mean age 34.4, SD 5.42 years) of preterm infants who were on average 43 (SD 30.34) days old. Six themes from the perspective of HCPs were identified: regular use of technology in the NICU, concerns with regard to AI integration, the potential to improve patient care, requirements for implementation, AI as a tool for pain assessment, and ethical considerations. Seven parent themes included the potential for improved care, increased parental distress, support for parents regarding AI, the impact on parent engagement, the importance of human care, requirements for integration, and the desire for choice in its use. A consistent theme was the importance of AI as a tool to inform clinical decision-making and not replace it.

CONCLUSIONS

HCPs and parents expressed generally positive sentiments about the potential use of AI for pain assessment in the NICU, with HCPs highlighting important ethical considerations. This study identifies critical methodological and ethical perspectives from key stakeholders that should be noted by any team considering the creation and implementation of AI for pain monitoring in the NICU.

Caregiver Ratings of Toddler Pain: The Role of Caregiver Psychological Predictors

INTRODUCTION/AIM

Young children's limited ability to self-report pain necessitates an understanding of the factors that influence pain ratings. The current paper examines the relative prediction of caregiver psychological factors and toddler pain behaviors on caregiver pain ratings post-vaccination.

METHODS

One hundred fifty-six parent-toddler dyads were video recorded during pediatric vaccinations. Child pain behaviors were coded before, during, and after the needle using the Face, Legs, Activity, Cry, Consolability Scale and the Neonatal Facial Coding System). Caregivers rated their child's pain after the needle, reported pre- and post-needle worry during the visit, and completed rating scales assessing other areas of psychological functioning within 2 weeks after the appointment. Regression models were estimated to examine the relative contribution of child and caregiver factors to the prediction of caregiver pain ratings.

RESULTS

The regression model predicting caregiver pain ratings from the toddlers' pain-related distress (facial activity immediately after the needle, overall pain-related behavior immediately after, 1-min and 2-min post-needle) and caregiver worry were significant (adjusted R-square = 0.21), with caregiver pre- and post-needle worry being the only significant predictors of caregiver pain ratings.

CONCLUSIONS

This study outlines that although child distress behavior remains a significant influence on pain ratings during toddlerhood, when caregiver worry (pre- and post-needle) was entered into the model, they were the only significant predictors of caregiver pain ratings.

A Measure of Caregivers' Distress-Promoting Behaviors During Toddler Vaccination: Validation of the OUCHIE-RV

OBJECTIVE

The current study discusses the development and preliminary validation of an observational measure of caregivers' distress-promoting behavior (OUCHIE-RV) in the context of toddler routine vaccination.

METHODS

Measure validation was based on a sample of caregiver-toddler dyads (N = 223) from a longitudinal cohort-sequential study who were observed during toddlers' 12-, 18-, or 24-month routine vaccinations. Validity was assessed using correlations and cross-lagged path analysis and associations were tested between OUCHIE-RV composite scores and toddlers' pain-related distress as well as caregivers' state anxiety, soothing behaviors, heart rate, and heart rate variability. Interrater reliability was examined using intraclass correlations (ICC) and kappa coefficients.

RESULTS

Results of a cross-lagged path analysis indicated positive concurrent (β = .27 to β = .37) and cross-lagged predictive associations (β = .01 to β = .34) between OUCHIE-RV composite scores (reflecting the frequency and intensity of caregivers' distress-promoting behavior) and toddlers' pain-related distress. OUCHIE-RV composite scores were negatively associated with caregivers' concurrent use of physical comfort (r = -.34 to -.24) and rocking (r = -.36 to -.19) and showed minimal associations with caregivers' use of verbal reassurance (r = .06 to .12), state anxiety (r = -.02 to r = .09), heart rate (r = -.15 to r = .05), and heart rate variability (r = -.04 to r = .13). Interrater reliability was strong (Cohen's k = .86 to .97, ICC = .77 to .85).

CONCLUSIONS

Findings provide support for the validity and reliability of the OUCHIE-RV as a research tool for measuring caregiver behaviors that promote toddlers' pain-related distress during routine vaccinations and contribute to a better understanding of the dynamics of caregiver-toddler interaction in acute pain contexts.

Parents' Physiological Reactivity to Child Distress and Associations with Parenting Behaviour: A Systematic Review

This systematic review and narrative synthesis characterized parents' physiological stress responses to child distress and how parents' physiological and behavioural responses relate. The review was pre-registered with PROSPERO (#CRD42021252852). In total, 3,607 unique records were identified through Medline, Embase, PsycINFO, and CINAHL. Fifty-five studies reported on parents' physiological stress responses during their young child's (0-3 years) distress and were included in the review. Results were synthesized based on the biological outcome and distress context used and risk of bias was evaluated. Most studies examined cortisol or heart rate variability (HRV). Small to moderate decreases in parents' cortisol levels from baseline to post-stressor were reported across studies. Studies of salivary alpha amylase, electrodermal activity, HRV, and other cardiac outcomes reflected weak or inconsistent physiological responses or a paucity of relevant studies. Among the studies that examined associations between parents' physiological and behavioural responses, stronger associations emerged for insensitive parenting behaviours and during dyadic frustration tasks. Risk of bias was a significant limitation across studies and recommendations for future research are discussed.