Paediatric Pain Medicine: Pain Differences, Recognition and Coping Acute Procedural Pain in Paediatric Emergency Room

Children's Narratives of Sad Events: Attachment Security and Psychopathological Symptoms

BACKGROUND

This study aims to explore how children's experiences of sadness are related to their coping strategies, attachment, and psychopathology.

METHOD

A sample of 517 children described a sad event and related coping strategies. Events included bullying/quarrelling, frustration, accidents/illness, experienced/anticipated separation, and loss. Coping strategies included constructive coping, disengagement, and absence-of-coping.

RESULTS

Constructive coping was associated with secure attachment. Secure children used constructive and disengagement strategies for frustration, constructive coping particularly for bullying situations, and absence-of-coping for loss. Children reporting absence-of-coping during episodes of frustration exhibited more externalizing symptoms.

CONCLUSIONS

The results highlight relationships between circumstancialdimensions and specific emotional experiences, and the importance of context-specific coping strategies in promoting emotional well-being.

Local Application of Honey for Postoperative Pain Management and Associated Outcomes Following Tonsillectomy in Children: A Systematic Review and Meta-Analysis

BACKGROUND

This study investigates the effect of locally applied honey on pain intensity, analgesia consumption, pain relief and nighttime awakenings in children following tonsillectomy, addressing conflicting evidence and the lack of differentiation between adult and paediatric populations in previous reviews.

METHODS

A systematic search was conducted across multiple databases, including Cochrane Library, ClinicalTrials.gov, MEDLINE, Web of Science and Google Scholar. Randomised controlled trials (RCTs) comparing pain outcomes in children receiving honey in addition to standard treatments versus those receiving standard treatments alone were included. Pain intensity was measured with the VAS tool. Meta-analysis was performed using STATA version 14 software. Also, risk of bias and certainty of evidence were evaluated.

RESULTS

Out of 537 articles, seven studies (n = 710) with RCT design met the inclusion criteria. The average duration for measuring pain intensity was 7.37 days. Pooled effect size showed a statistically significant reduction in pain intensity in the honey intervention group compared to the control group (WMD: -0.90, 95% CI [-1.32, -0.48], p < 0.001, I 2: 92.5%; certainty of evidence: low). Also, the results demonstrated that honey significantly decreased the average time required for pain relief and analgesic consumption in the intervention group compared to the control group. One study was deemed low risk of bias, four studies were of intermediate quality and two studies were evaluated as high.

CONCLUSION

While honey shows promise in reducing post-tonsillectomy pain, cautious use is advised due to the limited quality of evidence. More robust RCTs are needed to address biases and reinforce confidence in the findings.

Training healthcare professionals in hypnosis-derived communication to mitigate procedural pain in children

How professionals communicate during medical procedures may have a significant impact on children and adolescents' pain. Rel@x is a manualized training program designed to develop hypnosis-derived communication skills to mitigate childhood pain and distress. The study aimed to evaluate if this training was associated with an improvement and maintenance in communication skills over time, and measure associations between changes and participants' characteristics. A 9-hour training in hypnosis-derived communication was offered to 78 volunteer healthcare professionals from a tertiary pediatric hospital, and 58 participated in the evaluative study. Participants were evaluated at baseline, immediately after training, and 5 months later (39 ± 10 yrs, 52 women, 54 nurses). We used a video-recorded standardized simulation protocol of blood draw and coded the participants' interactions with the pre-validated Sainte-Justine Hypnotic Communication Assessment Scale (SJ-HCAS) assessing relational, technical, and total skills. We modeled pre-post-follow-up changes over time with latent growth curve models. Satisfaction with Rel@x was consistently excellent (97%). Across the 3 domains, we observed significant improvements of total (+ 61%, 95% CI 53-69%), relational (+ 27%, 95% CI 20-34%), and technical skills (+ 124%, 95% CI 08-140%). Post-training competence levels were 73-91% across domains. A large proportion of acquired skills were maintained at 5 months (55-75%) suggesting a significant effect of the training. Sensitivity analyses confirmed these results (best-case/worst-case skill maintenance ratio: 59-79%/49-73%). Larger improvements in technical skills were associated with younger age and lower baseline skills of participants. The Rel@x training is associated with improved skills in hypnotic communication post-training and at follow-up. This simulation study paves the way for future efficacy studies to examine the effect of hypnotic communication on real patients' pain and distress.

Construction of an Evidence Ecosystem-Based Postoperative Pain Management Programme for Paediatric Patients

AIM

To construct an evidence ecosystem-based postoperative pain management programme for children with postoperative pain management.

DESIGN

A mixed research design that combines qualitative and quantitative studies.

METHODS

According to the literature search and analysis, the postoperative pain management programme for children was constructed from three aspects: assessment of pain intensity of children, management principles and management methods, and the preliminary draft of the programme was finally constructed to include three first-level entries and 11 second-level entries. In January-February 2023, the first draft of the postoperative pain management programme for children was developed based on a literature review using the ecosystem of evidence theory as the research framework; in March-April 2023, the postoperative pain management programme for children was revised and finalised through two rounds of Delphi expert consultation.

RESULTS

In the second round of expert consultation, the return rate of valid questionnaires was 100%, the expert authority coefficient was 0.83, the importance scores and feasibility scores of each entry were > 3.5, the coefficients of variation were < 0.25, the Kendall's harmony coefficients of the importance scores of the entries were 0.650 (χ2 = 273.134, p < 0.001) and those of the feasibility scores were 0.649 (χ2 = 272.720, p < 0.001). The resulting postoperative pain management programme for the affected patients included three level 1, 11 level 2 and eight level 3 entries.

PATIENT OR PUBLIC CONTRIBUTION

The postoperative pain management programme for children constructed based on the evidence ecosystem is practical and scientific, but its effectiveness in clinical practice needs to be further verified by a controlled study design.

OBJECTIVES

Evidence ecosystem; paediatrics, surgery; pain; Delphi method.

Predictors of higher pain in possible open globe injury emergency medical services activations

PURPOSE

To determine predictors of high pain in open globe injury (OGI) cases treated and transported by Emergency Medical Services.

METHODS

The National Emergency Medical Services Information System database was queried for activations of OGI between 2017 and 2021. Demographic, location, medication, and date and time information was collected. Cases were divided based on the intensity of maximum pain reported (low pain: below 5/10, high pain: above 5/10). Logistic regression was used to identify significant predictors of high maximum pain.

RESULTS

Of 53,589 cases of OGI, 20,766 reported high levels of pain. Females were more likely to report high pain than males (OR 1.24, CI 1.195-1.285). All age groups between 16 and 75 years old were more likely to report high pain than patients below 15, while all age groups above 75 were less likely. American Indians/Alaska Natives, Black, and Hispanic Americans were all more likely to report high pain than White Americans (American Indian, OR 1.249, CI 1.067-1.461; Black, OR 1.332, CI 1.277-1.390; Hispanic, OR 1.133, CI 1.064-1.207). OGI cases in the Midwest and South regions were less likely to report high pain than those in the West (Midwest, OR 0.868, CI 0.807-0.933; South, OR 0.800, CI 0.748-0.855). Compared to low pain patients, a greater percentage of high pain patients received opioid analgesia (10.04% vs. 0.44%).

CONCLUSIONS

Demographic factors and location may contribute to higher pain in OGI patients. This information may prove useful in the management of OGI and may warrant further investigation into the nature of open globe trauma.Kindly check and confirm the inserted city is correct for affiliation 3.Correct.

Comparative assessment of the effectiveness of low-level laser therapy and chitosan in postoperative pain and bleeding management after primary molar extraction: A randomized clinical study

BACKGROUND

Dental caries, the leading cause of dental pain and the most prevalent chronic childhood disease globally, significantly impacts children's oral health, with prevalence ranging from 16% to 92.2% in India. Untreated caries in deciduous teeth can lead to pain, dietary changes, sleep disturbances, and enamel defects in permanent teeth. Pediatric dentists manage infected pulp with pulp therapy or extraction. Postoperative complications, such as discomfort and bleeding, are common in extraction cases.

AIM

This study aims to compare the analgesic and hemostatic efficacy of chitosan and low-level laser therapy (LLLT) in pediatric extractions, hypothesizing no significant difference between the two.

MATERIALS AND METHODS

This crossover randomized clinical trial was carried out within 87 primary molars from 29 participants. The study participants were randomized into three distinct groups, each with a specific order of interventions: Group A first received the control, followed by laser, and then chitosan; Group B first underwent the laser intervention, followed by chitosan, and finally the control; and Group C first experienced the chitosan intervention, followed by the control, and then laser. After extraction of the primary molar, properly shaped gauze piece, a 940-nm wavelength diode laser (diode Epic, BioLase, USA) was used in a continuous mode with 400 um diameter fiber tip at an approximately 8 mm away from the teeth socket without contact until 1 min, chitosan Sponge of 7 mm was measured using a periodontal probe and was placed into the extraction socket, respectively. Statistical analyses were performed using SPSS version 23 (IBM), with a significance level set at 5%.

RESULTS

The mean pain score was least for the LLLT group, followed by the Chitosan group and the maximum mean pain score was recorded for the control group and this difference was statistically significant, whereas there was no significant difference regarding the postoperative bleeding after 15 min between three groups. Chitosan was the intervention of choice for both the children and their guardians.

CONCLUSION

Soft-tissue diode lasers can be utilized for postoperative pain management subsequent to deciduous tooth extraction in children. This would reduce the reliance on analgesic medication and eliminate the possibility of adverse effects. Chitosan can serve as a highly effective, dependable, and cost-effective substitute in case of the diode laser's inaccessibility.

Efficacy and safety of the Valsalva maneuver in relieving venipuncture pain in children and adults: A systematic review and meta-analysis

Venipuncture is a common invasive clinical procedure, and pain management during puncture has been of interest to healthcare professionals. The purpose of this systematic review and meta-analysis was to evaluate the efficacy and safety of the Valsalva maneuver (VM) for the relief of venipuncture pain in children and adults. PubMed, Embase, Web of Science, Cochrane Library, CNKI, Wanfang, VIP database, and CBM were searched from inception to December 2023 for all available randomized controlled trials (RCTs) that evaluated the impact of VM on venipuncture. Two reviewers independently performed study selection, data extraction, and risk of bias assessment. Continuous variables were analyzed by mean differences (MD) or standardized mean differences (SMD), whereas dichotomous variables were analyzed by risk ratios (RR). A total of 22 studies involving 1740 participants were included. The pooled results showed that VM relieved pain intensity during venipuncture in children (SMD = -0.89, 95% CI = -1.47 to -0.30, p = 0.003) and adults (SMD = -1.11, 95% CI = -1.46 to -0.77, p < 0.00001), reduced anxiety intensity (SMD = -1.07, 95% CI = -1.68 to -0.47, p = 0.0005), and shortened puncture time (MD = -13.52, 95% CI = -21.14 to -5.90, p = 0.0005). There was no significant difference in the success rate of venous cannulation, MAP, HR, or incidence of adverse events in subjects who performed VM compared to controls. VM was an effective and safe method of pain management that reduced pain intensity during venipuncture in children and adults without significant adverse effects. The results of this meta-analysis need to be further validated by more rigorous and larger RCTs.

Virtual reality therapy in managing cancer pain in middle-aged and elderly: a systematic review and meta-analysis

Background

Virtual reality technology has been proposed to rehabilitate cancer patients. This study aimed to summarize the effectiveness of virtual reality (VR)--based therapies for pain management in middle-aged and elderly cancer patients.

Methods

This meta-analysis was registered in PROSPERO (CRD42023400432). We searched the randomized controlled trials (RCTs) in PubMed, Scopus, the Cochrane Library, Web of Science, and Embase, conducted from construction until November 1, 2024. The study examined the effects of VR treatment on pain levels in middle-aged and elderly cancer patients using RCTs as primary or secondary outcome measures. Articles were evaluated for eligibility according to predetermined criteria, and each of the three researchers independently collected the data. The researchers used the heterogeneous selection effects model to calculate the mean effect sizes.

Results

This meta-analysis included seven RCTs involving 476 patients. The meta-analysis confirmed the significant effect of VR therapy on the management of pain, anxiety, and depression in the middle-aged and elderly cancer population.

Conclusions

Our research shows that VR could be a significant device for cancer pain management in the middle-aged and elderly and that VR scene therapy may be more effective. Nevertheless, it is essential to use caution when interpreting the findings since the number of research included is small.

Medicines management in children and young people: pharmacological approaches to treat pain

Pain management in children is often more complex than in adults, since pain in children can be more challenging to assess and therefore more challenging to treat. It is essential that children's nurses have knowledge and understanding of the physiology of pain and the analgesics available to treat different types of pain. This article describes nociception and provides an overview of the three main groups of analgesics - non-opioids, opioids and adjuvants - that can be used in the pharmacological management of pain in children and young people.

The effect of virtual reality-based interventions on pain in burn wound care in burn patients: A systematic review and meta-analysis

OBJECTIVE

The aim of this systematic review and meta-analysis was to evaluate the effect of virtual reality on pain in adult burn patients.

METHOD

A comprehensive systematic search was conducted on international electronic databases such as PUBMED, Web of Science, Science Direct, CINAHL, Scopus, TÜBİTAK-ULAKBİM, Dergipark and TR Dizin with keywords. This systematic review and meta-anaysis was developed using the PRISMA checklist. The risk of bias was assessed independently for each included study by using the Cochrane risk of bias tools.

RESULTS

Based on the results of systematic review it was decided to include 15 studies in meta analyses. Based on fifteen pooled studies, the estimated SMD was minus 0.62 with a 95 % CI of minus1.15 and minus 0.09 according to the results of the random effects model as recommended by heterogeneity tests. Of pooled 15 studies, 11 studies found less pain score among VR patients, while the remaining four reported higher pain score among VR patients.

CONCLUSIONS

The results show that virtual reality can be used effectively in pain management during burn care in adult patients. Since the number of studies in adult burn patients is very limited, it is recommended to conduct large-sample studies with high level of evidence including nursing interventions on this issue.

Unpacking the relationship between Big Five personality traits and experimental pain: A systematic review and meta-analysis

Pain is essential for survival, but individual responses to painful stimuli vary, representing a complex interplay between sensory, cognitive, and affective factors. Individual differences in personality traits and in pain perception covary but it is unclear which traits play the most significant role in understanding the pain experience and whether this depends on pain modality. A systematic search identified 1534 records (CINAHL, MEDLINE, PsycInfo, PubMed and Web of Science), of which 22 were retained and included in a systematic review. Only studies from the pressure pain domain (n=6) could be compared in a formal meta-analysis to evaluate the relationship between Big Five traits and experimental pain. Pressure pain tolerance correlated positively with Extraversion and negatively with Neuroticism with a trivial effect size (<0.1). While these findings suggest personality might be only weakly related to pain in healthy individuals, we emphasize the need to consider standardization, biases, and adequate sample sizes in future research, as well as additional factors that might affect experimental pain sensitivity.

Bringing Virtual Reality to Mainstream Pediatric Care

Virtual reality (VR) stands as an innovative technology transforming our interactions with the digital world. Its integration into health care has proven advantageous for both patients and health care providers across multiple levels and modalities. Given that VR is becoming increasingly accessible and prevalent, health care providers should explore incorporating the technology into their practices, particularly within the pediatric population, which is becoming progressively more accustomed to the technology. This topic synopsis provides a broad discussion of the current literature, exploring current and probable future applications of VR in pediatric patient care, particularly in improving the hospital experience, facilitating education during hospitalizations, providing an alternative to pharmacological therapy for pain management, and enhancing mental health care practices.

Exploring the family experience of children aged 2-4 years receiving daily vosoritide injections: A qualitative study

PURPOSE

Vosoritide is administered as a daily subcutaneous injection in children with achondroplasia. In clinical trials, families of children aged 2-4 years reported difficulty with drug administration due to child fear, pain, and distress. Study aims were to gain a better understanding of the current vosoritide administration experience in this cohort and to investigate whether topical anaesthesia and ice application prior to injections improved the child and family experience.

DESIGN AND METHODS

A qualitative descriptive study design ensured in-depth understanding of family experience. Parents were interviewed to explore experience of vosoritide administration for their child at two time points, before (Phase 1) and after (Phase 2) the introduction of topical anaesthesia and ice application prior to injections. Interviews were analysed using thematic analysis.

RESULTS

Seven families participated. Children's ages ranged from 2 years 2 months to 3 years 11 months. Five themes emerged from data analysis: (1) The reality of the burden of care; (2) Child experience as the greatest obstacle; (3) Parents juggle multiple emotional considerations; (4) Many factors may impact experience; and (5) Short-term and long-term impacts.

CONCLUSIONS

Administration of vosoritide in this cohort presents multiple challenges for families. Factors which influenced experience differed between families. Responses to topical anaesthesia and ice application also varied between children, improving administration experience for some children and worsening experience for others.

PRACTICE IMPLICATIONS

This study highlights the need for individualised care for young children receiving daily injections. Support should be provided to families to identify factors that improve experience.

The effects of Valsalva maneuver on pain intensity and hemodynamic status during short peripheral cannula insertion in adults: A systematic review and meta-analysis

This systematic review and meta-analysis aimed to summarize the randomized clinical trial studies regarding the effects of Valsalva maneuver on the severity of short peripheral cannula insertion pain and hemodynamic status in adults. A systematic search was conducted on PubMed, Web of Science, Scopus databases, Cochrane, ClinicalTrials.gov, and Google Scholar Search Engine using keywords extracted from Medical Subject Headings, such as "Valsalva Maneuver," "Valsalva's Maneuver," "Forced Expiratory," "Balloon Inflation," "Pain," "Ache," "Cannulation," "Peripheral Intravenous Cannulation," "Peripheral Catheterization," "Vascular Access," "Venous Cannulation," "Venous Catheterization," and "Catheterization," from the inception to January 1, 2022. Finally, 12 and 11 articles were included in the qualitative and quantitative analysis of this systematic review and meta-analysis, respectively. Overall, pain intensity based on both the Numeric Rating Scale and Visual Analog Scale resulted in a large clinical effect (Effect Size: -1.20, 95% Confidence Interval: -1.69 to -0.71, p < 0.001). A large clinical effect was observed in a separate study of both scales because clinical effect has been determined in studies based on the Numeric Rating Scale (Effect Size: -1.26, 95% Confidence Interval: -1.90 to -0.62, p < 0.001 (and Visual Analog Scale (Effect Size: -1.09, 95% Confidence Interval: -1.98 to -0.20, p = 0.016). Valsalva maneuver significantly increased the mean heart rate (Weighted Mean Difference: 1.90, 95% Confidence Interval: 1.56-2.24, p < 0.001), decreased the mean arterial pressure (Weighted Mean Difference: 0.73, 95% Confidence Interval: -0.13 to 1.60, p = 0.096), and caused a non-significant decrease in anxiety (Weighted Mean Difference: -1.95, 95% Confidence Interval: -5.24 to 1.34, p = 0.25). The results showed that Valsalva maneuver significantly reduced pain intensity. Therefore, it is recommended that nurses use it as a convenient and low-cost non-pharmacological intervention to alleviate the severity of pain in non-cardiac patients. Also, it is suggested to conduct the studies with a strong methodological design and consider its effects on hemodynamic parameters in future investigations.

Effectiveness of pre-injection use of cryoanesthesia as compared to topical anesthetic gel in reducing pain perception during palatal injections: a randomized controlled trial

Background

Palatal injections are often painful. We aimed to compare topical ice and 20% benzocaine gel for pre-injection anesthesia before greater palatine nerve block (GPNB) injections.

Methods

A randomized split-mouth clinical trial was conducted among patients aged 15-60-years needing bilateral GPNB injections. A total of 120 palatal sites from 60 patients were randomly allocated to Group A (topical ice) or Group B (20% benzocaine gel). Pain was evaluated using sound, eye, motor (SEM), and the visual analog scale (VAS) in both groups. Inferential analysis was performed using the Mann-Whitney U test.

Results

The mean age of the participants was 20.5 ± 3.9 years. The median VAS score for group A was 11 (Q1 - Q3: 5.25 - 21.75), which was slightly higher than the 10 (Q1 - Q3: 4.0 - 26.75) reported in group B. However, the difference was not statistically significant (P = 0.955). The median SEM score for group A and group B was 3.5 (Q1 - Q3: 3.0 - 4.0) and 4.0 (Q1 - Q3: 3.0 - 4.0), respectively, which was statistically insignificant (P = 0.869).

Conclusion

Using ice as a form of topical anesthetic for achieving pre-injection anesthesia before GPNB was as effective as 20% benzocaine gel.

Graded motor imagery and its phases for individuals with phantom limb pain following amputation: A scoping review

OBJECTIVE

Three-phase graded motor imagery (limb laterality, explicit motor imagery, and mirror therapy) has been successful in chronic pain populations. However, when applied to phantom limb pain, an amputation-related pain, investigations often use mirror therapy alone. We aimed to explore evidence for graded motor imagery and its phases to treat phantom limb pain.

DATA SOURCES

A scoping review was conducted following the JBI Manual of Synthesis and Preferred Reporting Items for Systematic Review and Meta-Analyses extension for Scoping Reviews. Thirteen databases, registers, and websites were searched.

REVIEW METHODS

Published works on any date prior to the search (August 2023) were included that involved one or more graded motor imagery phases for participants ages 18+ with amputation and phantom limb pain. Extracted data included study characteristics, participant demographics, treatment characteristics, and outcomes.

RESULTS

Sixty-one works were included representing 19 countries. Most were uncontrolled studies (31%). Many participants were male (75%) and had unilateral amputations (90%) of varying levels, causes, and duration. Most works examined one treatment phase (92%), most often mirror therapy (84%). Few works (3%) reported three-phase intervention. Dosing was inconsistent across studies. The most measured outcome was pain intensity (95%).

CONCLUSION

Despite the success of three-phase graded motor imagery in other pain populations, phantom limb pain research focuses on mirror therapy, largely ignoring other phases. Participant demographics varied, making comparisons difficult. Future work should evaluate graded motor imagery effects and indicators of patient success. The represented countries indicate that graded motor imagery phases are implemented internationally, so future work could have a widespread impact.

Effects of parental holding on pain response in young children during cystometry: A randomized controlled trial

INTRODUCTION

Cystometry is essential for evaluating bladder function. However, children may react negatively to the physical pain of urethral catheterization or anxiety and fear of an unfamiliar environment. These pain responses during the cystometry procedure may interfere with the cystometry procedure and make it difficult to interpret the cystometry result. In this regard, the International Children's Continence Society has advised performing cystometry while holding infants as an effective nonpharmacological pain management method, but there is insufficient evidence to support this.

PURPOSE

This study aimed to analyze the effect of parental holding on reducing pain in children during cystometry.

METHODS

This was an experimental study in a randomized controlled pre-post test design. A total of 64 participants aged 6-18 months were recruited. During cystometry, the participants in the experimental group were placed on the parent's laps and held in the parents' arms. The participants in the control group were laid down on the examination table. During the procedure, both groups of parents were allowed to touch their children in all ways except holding them and to use the pacifier if they wished. The behavioral (face, leg, activity, cry, consolability scale) and physiological (oxygen saturation and heart rate) pain responses were measured at three-time points (immediately, 3, and 10 min after urethral catheter insertion).

RESULTS

Comparing the two groups, in the experimental group, the behavioral pain response at 3 min after urethral catheter insertion (t = -2.165, p = 0.034) and 10 min after (t = -3.155, p = 0.002) was decreased compared with that immediately after urethral catheter insertion. In addition, oxygen saturation increased more (t = 2.021, p = 0.048), and the heart rate decreased more (t = -2.033, p = 0.047) at 10 min than at 3 min after urethral catheter insertion in the experimental group.

CONCLUSIONS

This study revealed that parental holding could reduce pain responses during cystometry in children. Further research is required to confirm the applicability and usefulness of parental holding during cystometry.

Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study

Introduction

Optimal pain management of symptomatic pulpitis in formative years goes a long way in developing a positive dental attitude. Efforts should be made to increase the success of anesthesia, thus diminishing negative dental experiences. The aim of the study was to assess the efficacy of preemptive analgesia on the success of pulpal anesthesia following inferior alveolar nerve block (IANB) in children with symptomatic irreversible pulpitis and on reducing postendodontic pain.

Materials and methods

The research design was an in vivo, three-group, parallel, quadruple-blind study. A total of 75 patients were randomly allocated to one of the three groups-group I: ibuprofen, group II: combination of ibuprofen and paracetamol, and group III: multivitamin (placebo). Premedication was given 45 minutes before treatment, and patients received IANB in a standardized manner. Pain during pulpectomy was recorded using the face, legs, activity, cry, consolability (FLACC) scale and postoperatively using Wong-Baker's pain rating scale (WBPRS) at 4, 12, and 24 hours. Success was measured if the pain felt was of no or mild intensity.

Results

Success of IANB was 64% for ibuprofen, 72% for the combination group, and 40% for the placebo group, with no statistically significant difference between all groups (p = 0.06) on the FLACC scale. At 4 hours postoperatively, a significant difference (p = 0.02) was found among groups with more children experiencing no or mild pain in groups I and II and the highest number of rescue medications taken by the placebo group.

Conclusion

Ibuprofen and a combination of ibuprofen and acetaminophen as preemptive analgesics had no significant effect on the success rate of IANB, although it was effective in reducing pain at 4 hours postoperatively.

How to cite this article

Gori NA, Patel MC, Bhatt RK, et al. Clinical Assessment of Preemptive Analgesia on Success of Pulpal Anesthesia and Postendodontic Pain in Children with Irreversible Pulpitis: A Randomized Comparative Study. Int J Clin Pediatr Dent 2024;17(1):72-78.

Family Presence at the PICU Bedside: A Single-Center Retrospective Cohort Study

OBJECTIVES

To determine factors associated with bedside family presence in the PICU and to understand how individual factors interact as barriers to family presence.

DESIGN

Mixed methods study.

SETTING

Tertiary children's hospital PICU.

SUBJECTS

Five hundred twenty-three children of less than 18 years enrolled in the Seattle Children's Hospital Outcomes Assessment Program from 2011 to 2017.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Quantitative: Family was documented every 2 hours. Exposures included patient and illness characteristics and family demographic and socioeconomic characteristics. We used multivariable logistic regression to identify factors associated with presence of less than 80% and stratified results by self-reported race. Longer PICU length of stay (LOS), public insurance, and complex chronic conditions (C-CD) were associated with family presence of less than 80%. Self-reported race modified these associations; no factors were associated with lower bedside presence for White families, in contrast with multiple associations for non-White families including public insurance, C-CD, and longer LOS. Qualitative: Thematic analysis of social work notes for the 48 patients with family presence of less than 80% matched on age, LOS, and diagnosis to 48 patients with greater than or equal to 95% family presence. Three themes emerged: the primary caregiver's prior experiences with the hospital, relationships outside of the hospital, and additional stressors during the hospitalization affected bedside presence.

CONCLUSIONS

We identified sociodemographic and illness factors associated with family bedside presence in the PICU. Self-reported race modified these associations, representing racism within healthcare. Family presence at the bedside may help identify families facing greater disparities in healthcare access.

Perioperative Ultrasound-Guided Continuous Caudal Epidural Analgesia in Newborns: A Case Series in a Tertiary Medical Center

Background Caudal epidural anesthesia technique is a relevant method for postoperative analgesia in newborns, allowing for the reduction of drug-induced respiratory depression. The threading of a catheter is, however, uncommon in clinical practice. Our main purpose was to describe our experience regarding caudally inserted epidural catheters in neonates undergoing major abdominal surgery. Methods We included every full-term neonate undergoing surgery under combined caudal epidural-general anesthesia from 2017 to 2022 in our institution. After induction of general anesthesia, an ultrasound-guided caudal epidural injection was performed, and an epidural catheter was inserted for perioperative analgesia. An epidural bolus of ropivacaine was administered to every patient before the surgical incision, and an epidural infusion of ropivacaine 0.05% was administered for 24 hours. Results Retrospectively obtained data included six full-term neonates with American Society of Anesthesiologists (ASA) physical status II to IV. Intraoperatively, good analgesia was achieved without hemodynamic instability or need for additional systemic opioids after induction. At the end of surgery, five of the six neonates were extubated without adverse respiratory events. Postoperatively, effective analgesia was achieved in four cases with an epidural infusion of ropivacaine 0.05%, at a rate between 0.2 and 0.4 mg/kg/h, and intravenous paracetamol. Epidural pain control was not successful in one neonate, and thus an intravenous fentanyl infusion was added. The sixth neonate remained intubated for prolonged mechanical ventilation due to surgical complications, and thus an intravenous fentanyl infusion was introduced for sedation in the neonatal intensive care unit (NICU), not allowing to evaluate the effectiveness of the epidural infusion alone. No other complications related to the epidural catheters were reported. Conclusion Continuous caudal epidural analgesia may be a valuable technique with a low risk of complications, decreasing the incidence of respiratory adverse events in this patient population. Although more cases are needed for a stronger conclusion, it has become a useful analgesic strategy for major abdominal surgery in neonates in our institution.

Editorial to the Special Issue: "Recent Advances in the Management of Chronic Pain"

Chronic pain is a complex biopsychosocial phenomenon with far-reaching implications, not only in terms of clinical care but also in the realms of social and economic impact [...].

Pain Assessment and Management for a Chemically Paralyzed Child Receiving Mechanical Ventilation

BACKGROUND

Pain assessment in the pediatric intensive care unit (PICU) is complex, specifically for children receiving mechanical ventilation who require neuromuscular blockade (NMB). No valid pain assessment method exists for this population. Guidelines are limited to using physiologic variables; it remains unknown how nurses are assessing and managing pain for this population in practice.

OBJECTIVES

To describe how PICU nurses are assessing and managing pain for children who require NMB.

METHODS

A cross-sectional quantitative design was used with an electronic survey. Nurses were asked to respond to 4 written vignettes depicting a child who required NMB and had a painful procedure, physiologic cues, both, or neither.

RESULTS

A total of 107 PICU nurses answered the survey. Nurses primarily used behavioral assessment scales (61.0%) to assess the child's pain. All nurses reported that physiologic variables are either moderately or extremely important, and 27.3% of nurses used the phrase "assume pain present" formally at their organization. When physiologic cues were present, the odds of a nurse intervening with a pain intervention were 23.3 times (95% CI, 11.39-53.92; P < .001) higher than when such cues were absent.

CONCLUSIONS

These results demonstrate variation in how nurses assess pain for a child who requires NMB. The focus remains on behavioral assessment scales, which are not valid for this population. When intervening with a pain intervention, nurses relied on physiologic variables. Decision support tools to aid nurses in conducting an effective pain assessment and subsequent management need to be created.

Effects of aromatherapy with Rosa damascene and lavender on pain and anxiety of burn patients: A systematic review and meta-analysis

Pain and anxiety were considered the most common complications of treatment procedures in burn patients. Non-pharmacological drugs, including aromatherapy, can decrease these issues. This systematic review and meta-analysis aim to summarise the effects of aromatherapy with Rosa damascene (RD) and lavender on the pain and anxiety of burn patients. A systematic search was performed on international electronic databases such as Scopus, PubMed, and Web of Science, as well as on Iranian electronic databases such as Iranmedex and Scientific Information Database (SID) with keywords extracted from Medical Subject Headings such as "Burns", "Pain", "Pain management", "Anxiety", and "Aromatherapy" were performed from the earliest to November 1, 2022. The Joanna Briggs Institute (JBI) critical appraisal checklist assessed the quality of randomised control trials (RCTs) and quasi-experimental studies. STATA v.14 software was used to estimate pooled effect size. Heterogeneity was assessed with I2 value. Random effect model and inverse-variance method using sample size, mean, and standard deviation changes were applied to determine standard mean differences (SMD). The confidence interval of 95% was considered to determine the confidence level. A total of 586 burn patients participated in six studies, including three RCT studies and three quasi-experimental studies. The results based on RCT studies showed RD significantly decreased the dressing pain average when compared to the control group (SMD: -1.61, 95%CI: -2.32 to -0.99, Z = 5.09, I2 : 66.2%, P < 0.001). Aromatherapy with lavender decreased the average pain in the interventional group more than in the control group (SMD: -1.78, 95%CI: -3.62 to 0.07, Z = 1.89, I2 : 97.2%, P = 0.06). Using aromatherapy with RD and lavender significantly decreased pain average in the interventional group than the control group (SMD: -1.68, 95%CI: -2.64 to -0.72, Z = 3.42, I2 : 94.2%, P = 0.001). The results showed RD significantly decreased the anxiety average in the interventional group than the control group (SMD: -2.49, 95%CI: -2.98 to -2.0, Z = 9.94, I2 : 51.6%, P < 0.001). Overall, this study showed that aromatherapy with RD decreased pain and anxiety of dressing procedures in burn patients. Although aromatherapy with lavender decreased pain in the patients, it was not statistically significant. More RCTs studies are required to be able to better judge the effects of aromatherapy with RD and lavender on the pain and anxiety of burn patients.

Efficacy and safety of parecoxib and flurbiprofen axetil for perioperative analgesia in children: a network meta-analysis

Objective

The aim of this study was to systematically review the efficacy and safety of parecoxib and flurbiprofen axetil for perioperative analgesia in children through Bayesian network meta-analysis.

Methods

We systematically searched PubMed, Embase, Cochrane Library, Web of Science, Sinomed, CNKI, VIP, and Wanfang Data databases on 18 July 2022 to obtain randomized controlled trials comparing perioperative parecoxib or flurbiprofen with placebo or standard treatment for pediatric analgesia. The outcomes were the postoperative pain score and the incidence of adverse events. The Gemtc package of R-4.0.3 and Stata 17.0 were used for Bayesian network meta-analysis.

Results

We retrieved 942 articles and 49 randomized controlled trials involving 3,657 patients who met the inclusion criteria. Compared with children who received placebo treatment, those who received flurbiprofen axetil had lower pain sores at each time point within 24 h postoperatively, and those who received parecoxib had lower pain sores at each time point within 12 h postoperatively. Compared with children who received tramadol treatment, both the children who received flurbiprofen axetil or parecoxib had lower pain scores at 8 h postoperatively. The ranking results demonstrated that flurbiprofen axetil had significant superiority in reducing pain scores at 2, 4, and 12 h postoperatively, and parecoxib had significant superiority in reducing pain scores at 0, 0.5, 1, 6, 8, and 24 h postoperatively. In terms of safety, compared with children who received placebo, those who received flurbiprofen axetil or parecoxib had a lower incidence of total adverse events and postoperative agitation. Compared with tramadol, flurbiprofen axetil and parecoxib both significantly reduced the incidence of total adverse events and postoperative nausea and vomiting. Compared with flurbiprofen axetil or fentanyl, parecoxib significantly reduced the incidence of postoperative nausea and vomiting. The ranking results showed that parecoxib was advantageous in decreasing the incidence of total adverse events and postoperative nausea and vomiting.

Conclusion

Flurbiprofen axetil was most effective at reducing pain scores at 2, 4, and 12 h postoperatively. Parecoxib had an advantage in terms of reducing pain scores at 0, 0.5, 1, 6, 8, and 24 h postoperatively, as well as the incidence of total adverse events and postoperative nausea and vomiting.

Systematic trial registration

https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=348886, PROSPERO (CRD42022348886).

Intraindividual change in pain tolerance and negative affect over 20 years: findings from the MIDUS study

Pain tolerance, defined as the ability to withstand physical pain states, is a clinically important psychobiological process associated with several deleterious outcomes, including increased pain experience, mental health problems, physical health problems, and substance use. A significant body of experimental work indicates that negative affect is associated with pain tolerance, such that increased negative affect is associated with decreased pain tolerance. Although research has documented the associations between pain tolerance and negative affect, little work has examined these associations over time, and how change in pain tolerance is related to changes in negative affect. Therefore, the current study examined the relationship between intraindividual change in self-reported pain tolerance and intraindividual change in negative affect over 20 years in a large, longitudinal, observation-based national sample of adults (n = 4,665, Mage = 46.78, SD =12.50, 53.8% female). Results from parallel process latent growth curve models indicated that slope of pain tolerance and negative affect were associated with each other over time (r = .272, 95% CI [.08, .46] p = .006). Cohen's d effect size estimates provide initial, correlational evidence that changes in pain tolerance may precede changes in negative affect. Given the relevance of pain tolerance to deleterious health outcomes, better understanding how individual difference factors, including negative affect, influence pain tolerance over time, are clinically important to reduce disease-related burden.

Certified Child Life Specialist role in implementation of individualized coping plans for children receiving botulinum toxin injections

PURPOSE

The purpose of this paper is to describe the implementation of evidence-based, individualized coping plans and to compare the rates of child anxiety, child cooperation, and parent anxiety before and after implementation of these coping plans for children receiving recurring BoNT-A injections emphasizing the role of Certified Child Life Specialists (CCLSs) within the interdisciplinary team approach.

DESIGN AND METHODS

A retrospective chart review was conducted for children receiving BoNT-A injections at a Physical Medicine clinic pre- and post-implementation of the coping plan. Descriptive statistics were used to evaluate care plan implementation, child cooperation, child anxiety, and parent anxiety.

RESULTS

Post-implementation of coping care plans, children experienced improved cooperation during BoNT-A injections. Parental anxiety decreased once coping plans were implemented. Documentation improved after the implementation of coping plans specific to areas involving cooperation, child's anxiety and distress, and parental anxiety and distress. It was also noted that there was an increase in child anxiety assessments within documentation.

PRACTICE IMPLICATIONS

CCLS were able to utilize their expertise to collaboratively create individualized coping care plans to increase child's cooperation and decrease parental anxiety during BoNT-A injections.

Safety and Tolerability of High-Resolution Esophageal Manometry in Children and Adults

INTRODUCTION

While high-resolution manometry (HRM) is widely accepted as a safe procedure, no study has assessed the safety profile of HRM in clinical practice. This study aimed to determine the safety and tolerability of HRM and to investigate potential determinants of intolerability.

METHODS

We obtained HRM procedure reports, demographics, and clinical data (2005-2022) at a tertiary center using electronic chart review. Our primary outcome was HRM tolerability. Multivariable regression was performed to identify associations between the outcome and covariates including age, sex, race, and comorbidities.

RESULTS

A total of 5,107 patients (60.3% female) were included. Of them, 5,050 patients (98.9%) tolerated HRM well and 57 patients (1.1%) did not. Age had a statistically significant effect on tolerance: those younger than 18 years had more than a 5-fold increase in not tolerating HRM compared with those aged 18-79 years (5.77% vs 0.99%; odds ratio [OR] = 5.44, 95% confidence interval [CI] 1.60-18.45; P = 0.007), and those aged 80 years or older were also more likely to terminate HRM (2.43% vs 0.99%; OR = 2.56, 95% CI 1.13-5.76; P = 0.024). While prior foregut surgery had a significant effect on tolerance (OR = 8.06, 95% CI 2.29-28.39; P = 0.001), other factors of race, sex, body mass index, and psychological or cognitive disorders had no significant impact. No serious complications were identified.

DISCUSSION

HRM is safe and well-tolerated with approximately 1 in every 100 patients being unable to tolerate HRM. Intolerance was more commonly seen in children and seniors due to minor symptoms of discomfort without serious complications. These data points are crucial to counsel patients in whom HRM is being considered.

[Research advances on the application of music therapy in pain management of children with burns]

Pain after burns is a very common problem in children. Severe pain will not only hinder treatment, but also damage children's mental health if not handled in time. Therefore, pain management is very important in treating children with burns. As a safe, effective, and convenient non-drug therapy, music therapy has great advantages in relieving pain and is widely used in a variety of clinical fields. This paper focused on music therapy and its mechanism of pain relief, the current status of research on pain management of pediatric burns, the application and prospect of music therapy in pain management of pediatric burns, etc., to provide reference for clinical application.

Using artificial intelligence to improve pain assessment and pain management: a scoping review

CONTEXT

Over 20% of US adults report they experience pain on most days or every day. Uncontrolled pain has led to increased healthcare utilization, hospitalization, emergency visits, and financial burden. Recognizing, assessing, understanding, and treating pain using artificial intelligence (AI) approaches may improve patient outcomes and healthcare resource utilization. A comprehensive synthesis of the current use and outcomes of AI-based interventions focused on pain assessment and management will guide the development of future research.

OBJECTIVES

This review aims to investigate the state of the research on AI-based interventions designed to improve pain assessment and management for adult patients. We also ascertain the actual outcomes of Al-based interventions for adult patients.

METHODS

The electronic databases searched include Web of Science, CINAHL, PsycINFO, Cochrane CENTRAL, Scopus, IEEE Xplore, and ACM Digital Library. The search initially identified 6946 studies. After screening, 30 studies met the inclusion criteria. The Critical Appraisals Skills Programme was used to assess study quality.

RESULTS

This review provides evidence that machine learning, data mining, and natural language processing were used to improve efficient pain recognition and pain assessment, analyze self-reported pain data, predict pain, and help clinicians and patients to manage chronic pain more effectively.

CONCLUSIONS

Findings from this review suggest that using AI-based interventions has a positive effect on pain recognition, pain prediction, and pain self-management; however, most reports are only pilot studies. More pilot studies with physiological pain measures are required before these approaches are ready for large clinical trial.

Spreading the word: pediatric pain education from treatment to prevention

Pain affects everyone hence one can argue that it is in each individual’s interest to understand pain in order to hold correct and adaptive beliefs and attitudes about pain. In addition, chronic pain is reaching pandemic proportions and it is now well known that people living with chronic pain have a reduced life expectancy. To address and to prevent the growth of this public health disaster, we must start looking beyond adulthood. How children view pain has an impact on their behavioral coping responses which in turn predict persistent pain early in the lifespan. In addition, children who suffer from chronic pain and who are not (properly) treated for it before adolescence have an increased risk of having chronic pain during their adult life. Explaining pain to children and youth may have a tremendous impact not only on the individual child suffering from chronic pain but also on society, since the key to stop the pain pandemic may well lie in the first two decades of life. In order to facilitate the acquisition of adaptive behavioral coping responses, pain education aims to shift people’s view on pain from being an apparent threat towards being a compelling perceptual experience generated by the brain that will only arise whenever the conceivable proof of danger to the body is greater than the conceivable proof of safety to the body. Nowadays a lot of pain education material is available for adults, but it is not adapted to children’s developmental stage and therefore little or not suitable for them. An overview of the state-of-the-art pain education material for children and youth is provided here, along with its current and future areas of application as well as challenges to its development and delivery. Research on pediatric pain education is still in its infancy and many questions remain to be answered within this emerging field of investigation.

Predictors of Adherence to Cancer-Related mHealth Apps in Cancer Patients Undergoing Oncological or Follow-Up Treatment-A Scoping Review

mHealth interventions in cancer care are being increasingly applied in various settings. Nevertheless, there is a phenomenon wherein individuals show different usage patterns, which could affect the effectiveness of the intervention. In general, it is important to know the predictors of app adherence and usage patterns to improve the design and content (i.e., tailoring). The aim of this scoping review was to provide an overview of predictors of adherence to cancer-related mHealth apps in cancer patients. A systematic literature search was conducted in March 2021 in the electronic databases PubMed, CINAHL, and PsychINFO without limitation in year, focusing on cancer patients undergoing oncological or follow-up treatment using mHealth apps. The initial database search yielded a total of N = 8035 records. After title, abstract, and full-text screening, 10 articles met inclusion criteria. Studies were published between 2013 and 2020. Studies focused on children and adolescents (2/10) as well as adults (8/10). The predictors identified could be categorized into sociodemographic variables, cancer-related factors and others. This study provides an initial insight into relevant predictors of app adherence in cancer patients. However, no clear predictor of increased app adherence was found. Further research of usage patterns is therefore needed so that mHealth interventions can be tailored during development.

Kangaroo Care for Relieving Neonatal Pain Caused by Invasive Procedures: A Systematic Review and Meta-Analysis

Objective

Neonates develop significant pain responses during invasive procedures, and nonpharmacological interventions are better means of pain relief. An increasing number of studies have confirmed the effectiveness of kangaroo care (KC) in relieving neonatal pain caused by invasive procedures, but conclusions are inconsistent. In this study, a literature search and meta-analysis were performed to evaluate the effect of kangaroo care on relieving neonatal pain.

Methods

The works of literature related to the application of KC in neonatal invasive procedures in the databases of Pubmed, Embase, Springer Link, Ovid, CNKI, and CBM were searched, and the RCT literature from database establishment to July 2022, was selected to evaluate the risk of bias, combined with statistical pain relief outcome indicators.

Results

12 pieces of literature were finally included in this study, with a total of 1172 newborns, including 585 newborns (49.9%) using KC and 587 newborns (50.1%) using the control group method. Meta-analysis showed that an infant's heart rate during invasive procedures under KC intervention was significantly lower than that of other interventions (MD = -6.77, 95% CI (-13.03, -0.50), Z = -2.12, P=0.03), but compared to other nonpharmacological interventions, there was no clear advantage in the overall evaluation of pain reduction in infants (MD = -0.36, 95% CI (-0.80, 0.08), Z = -1.60, P=0.11).

Conclusion

The heart rate of KC intervention during invasive procedures in infants is significantly lower than that of other interventions, and it can significantly relieve pain in infants, but the effect is not more than that of oral sucrose (or glucose) or standard care. KC combined with oral sucrose may achieve a better pain relief effect in infants, but more studies are still needed to verify it.

Efficacy of Levobupivacaine Versus Levobupivacaine Plus Dexmedetomidine Infiltration for Post-Tonsillectomy Analgesia: A Randomized Controlled Trial

Background. The study evaluated the analgesic effects of levobupivacaine infiltration in the tonsil bed, and a combination of levobupivacaine and dexmedetomidine in patients undergoing tonsillectomy. Methods. Ninety children (ages 3 to 7 years) who were scheduled for a tonsillectomy were allocated randomly into two groups. (L Group): peritonsillar infiltration with 0.25% levobupivacaine (2 ml + 0.5 ml saline 0.9% per tonsil). (LD Group): levobupivacaine 0.25% (2 ml) plus dexmedetomidine 1 μg/kg diluted in 1 ml saline 0.9% (0.5 ml in each tonsil), and administered by peritonsillar infiltration (2.5 ml per tonsil) following intubation 3–5 minutes before operation. To avoid bias, infiltrate a total volume of 2.5 ml in each tonsil. The first analgesic request time was the primary outcome, with postoperative pain score, total analgesic consumption, total oral intake, sedation, and side effects as secondary outcomes. Results. The first rescue analgesia time in the LD group was longer (644.31 ± 112.89 min) than in the L group (551.51 ± 146.16 min, $P$ -value <0.001). The number of patients who required >1 analgesic dose in the L group (n = 13) was higher than in the LD group (n = 5). The LD group consumes a lower total dose of IV paracetamol in the first 24 hours postoperatively (321.89 ± 93.25 mg) than the L group (394.89 ± 183.71 mg, $P<0.00$ -value < 0.050). On the first day postoperatively, patients in the LD group had a higher total oral intake ( $P<0.001$ ). Except for a slight increase in laryngospasm in the L group, there were no side effects. Conclusions. The Children’s peritonsillar infiltration of levobupivacaine and dexmedetomidine improved postoperative pain after adenotonsillectomy. The topically applied levobupivacaine and dexmedetomidine were concomitant with no systemic effects, greater total oral intake on the first day postoperative, and higher family satisfaction.

Non-Pharmacological Management for Vaccine-Related Pain in Children in the Healthcare Setting: A Scoping Review

Purpose

To examine how research was conducted on non-pharmacological management in children with vaccine-related pain in the healthcare setting, so as to provide reference for the relief of vaccine-related pain in children.

Methods

This study conducted a scoping review guided by the methodological framework of Arksey and O'Malley. MEDLINE, Cochrane Library, EMBASE, CINAHL, PubMed databases were searched in detail, and search strategy included the keyword "vaccine", the keyword "pain", and the keyword "children". Two researchers conducted literature screening and data extraction independently, and any disagreements were resolved through team consultation.

Results

This study retrieved 1017 literatures, of which 22 were finally included, including 18 randomized controlled studies, 3 quasi-experimental studies and 1 cohort study. Non-pharmacological management measures were summarized in the study, mainly involving taste, tactile, olfactory, visual, exercise, and postural interventions and injection technique. All the above non-pharmacological management were effective in mitigating vaccine-related pain in children. The study population in the included literatures was mainly neonates and infants. Regarding the analgesic effects of taste intervention, breastfeeding was better than sweeteners, and sweeteners were better than sterile water or non-nutritive sucking. However, there was a lack of comparative studies on the analgesic effects of other non-pharmacological management.

Conclusion

There are many non-pharmacological management measures with varying analgesic effects. Diversified non-pharmacological management measures can provide more analgesic choices for children. For reducing vaccine-related pain in newborns and infants, breastfeeding is recommended first, then sweeteners, and then non-nutritious sucking. In addition to the taste intervention, the analgesic effects of other non-pharmacological management measures need further comparative studies. Moreover, medical staff can use a combination of non-pharmacological analgesic measures to maximize the analgesic effect, and medical staff should also fully consider the analgesia willingness of children and parents.

Effectiveness of art-based distraction in reducing pain and anxiety of hospitalized children during cannulation procedure: A randomized controlled trial

Background

Peripheral venous cannulation (PIVC) is one of the most common needle procedures associated with the therapies of pediatric patients, which causes pain and anxiety in children. Trace Image and Coloring for Kids-Book (TICK-B) is one of the arts-based interventions to relieve pain and anxiety, but none of the existing studies use the TICK-B to decrease children's pain intensity and anxiety levels during PICV.

Objective

This study aimed to investigate the effectiveness of the Trace Image and Coloring for Kids-Book (TICK-B) in decreasing children's pain and anxiety during PIVC.

Methods

A parallel, randomized, double-blind controlled trial was used in this study. Children aged 6-12 years were randomly allocated to one of two groups: intervention or control. The intervention group (n = 48) received the TICK-B during the PIVC, compared to no intervention in the control group (n = 52). The children, their parents, and an observer nurse rated outcomes 1-2 min after completion of the procedure. The patients in both groups were similar in age, gender, duration of hospitalization, injections, mother's age, and education. Faces Pain Scale-Revised (FPS-R), Children's Fear Scale (CFS), and Visual Analog Scale (VAS) were used to measure pain and anxiety. Paired and independent t-tests were used for data analysis.

Results

Patients in the intervention group reported significantly reduced pain levels than those in the control group (p <0.001), as reported by children (3.08 vs. 7.06), parents (3.08 vs. 7.13), and the observer nurse (3.06 vs. 7.13), respectively. Anxiety levels were also significantly lower among patients in the intervention group than in the control group (p <0.001), as reported by children (0.88 vs. 3.17), parents (0.94 vs. 3.19), and the observer nurse (0.85 vs. 2.94), respectively.

Conclusions

TICK-B is an effective technique for reducing children's pain and anxiety during PIVC. TICK-B is a simple, inexpensive, and effective technique that nurses can use to decrease the levels of pain and anxiety of pediatric patients during intravenous cannulation.

Clown therapy for procedural pain in children: a systematic review and meta-analysis

Among the distraction techniques used for the non-pharmacological management of acute pediatric pain, one of the most performed is clown therapy. Despite the presence in the literature of some systematic reviews that evaluate its effectiveness, none of them examines its outcomes on procedural pain which has therefore been investigated in this study. The literature search for randomized controlled trials (RCTs) was performed on the Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycINFO, Web of Science, and Scopus over a time frame ranging from each database setup date to 31 July 2021. The primary outcome was the procedural pain of children. We used the Cochrane Risk of Bias tool to assess the risk of bias of the included studies. Six RCTs were selected for this review, which included a total of 517 pediatric subjects. Children undergoing clown therapy during the venipuncture or peripheral vein cannulation procedure reported less pain than those exposed to the standard of care (SMD =  -0.55; 95% CI: -1.23, 0.13) but the result was not found to be statistically significant. School-aged children and adolescent reported significantly less pain (SMD =  -0.51; 95% CI: -0.92, -0.09). Compared to the standard of care, children's anxiety was significantly lower with clown therapy (SMD =  -0.97; 95% CI: -1.38, -0.56).

CONCLUSION

Clown therapy seems effective in reducing procedural pain in children, particularly for older age groups, but due to poor methodological quality and the high risk of bias of the studies included, the results obtained should be considered with caution.

WHAT IS KNOWN

• Clown therapy is one of the most used techniques in the non-pharmacological management of acute pediatric pain. • Laughter physiologically stimulates the production of beta-endorphins, substances with an effect similar to opiates.

WHAT IS NEW

• Clown therapy seems effective in reducing procedural pain and anxiety in children. • The intervention in school-age children or adolescents produces a statistically significant decrease in the symptom.

The Effect of Parental Presence on Pain Levels of Children During Invasive Procedures: A Systematic Review

AIM

This systematic review was conducted to determine the effect of parental presence on the child's pain intensity during invasive procedures.

DESIGN

A systematic review.

METHOD

The systematic review was conducted in July 2019 and updated in December 2020 to include the latest research published during the publication process by scanning the articles in English. Scopus, Pubmed, Cochrane, Science Direct, MedLine databases were used for scanning. The keywords "parental presence", "family presence", "parent involvement", "invasive procedures", "venipuncture", "painful procedures", "child", "children", "pediatric" were used in the scanning. Preferred Reporting Items for Systematic reviews and Meta-Analyses protocol was followed to prepare the study and the report, and the systematic review was created according to the patient, intervention, comparison, outcomes (PICOS) strategy.

RESULTS

A total of 248 articles were reached, and the full texts of 18 articles were evaluated for eligibility. After the articles excluded by the full-text search were eliminated, six studies, involving 730 children with a sample aged between 0-12 years, were included in the analysis. In 4 studies, it was determined that having a parent with the child during the invasive procedure significantly decreased the pain level, and in 2 studies, there was no statistically significant decrease in the pain level of the children.

CONCLUSIONS

Parental presence and parental involvement during invasive procedures effectively reduced the children's pain levels. Since the number of studies with a high level of evidence regarding the effect of family participation on pain level is limited, it is recommended to conduct more randomized controlled studies.

Comparison of cold spray and shotblocker to reduce intramuscular injection pain: A randomized controlled trial

WHAT IS KNOWN AND OBJECTIVE

It is important to identify effective, easy-to-use and cost-effective non-pharmacological methods in the management of pain caused by medical interventions. The purpose of this study is to compare the effects of cold spray and ShotBlocker on pain in adults in reducing pain caused by intramuscular injection in the adult emergency department.

METHODS

This is a randomized controlled trial with two experimental groups, two placebo groups and a control group. The study was conducted on 195 adults who received diclofenac sodium injections. In the study, the injection procedure was performed by following the same injection protocol in all five groups. In the injection process, cold spray or ShotBlocker was used in the intervention groups based on the group, and cold spray with distilled water or the smooth surface of the ShotBlocker was used in the placebo groups. Following the injection, the pain caused by the injection was evaluated using the Visual Analog Scale.

RESULTS AND DISCUSSION

The study was completed with the remaining 195 patients. In the study, the average pain scores due to injection of the individuals in the cold spray group were lower than those of the control group (p < 0.05). There was no statistically significant difference between the pain score averages due to injection of the individuals in the ShotBlocker group and cold spray, control, ShotBlocker placebo and cold spray placebo groups.

WHAT IS NEW AND CONCLUSION

The routine use of a fast-acting, cost-effective and easy-to-use method, cold spray, to reduce pain in the intramuscular injection will be beneficial in increasing patient satisfaction and quality of care.

Virtual reality therapy to control burn pain: systematic review of randomized controlled trials

BACKGROUND

Virtual reality therapy has been shown to be an excellent alternative to non-pharmacological treatment for the control of burn pain.

OBJECTIVE

To evaluate the effects of virtual reality therapy on pain control in people who have suffered burns published in the scientific literature.

METHOD

Systematic review carried out as recommended by Cochrane®. The search was carried out in the Embase, PubMed, Lilacs and Cochrane Library databases, in the period from March 2021. Randomized clinical trials were included without language restriction and year of publication. The risk of bias was assessed using the Cochrane® tool.

RESULTS

Of the 3755 articles found, only 17 articles were selected for reading in full. Of these, only four articles met the inclusion criteria. The results of the studies showed that the use of virtual reality therapy reduced the intensity of pain in children and adolescents with burns, despite the fact that most results are not statistically significant. No selected study had a high risk of bias.

CONCLUSIONS

Virtual reality therapy has been shown to be effective in controlling pain, reducing the time spent thinking about it and greater distraction during the procedures. However, most randomized clinical trials results were not statistically significant in at least one of the moments when pain was assessed. It is noteworthy that randomized clinical trials are still necessary to administer virtual reality therapy, especially in adults.

Assessing procedural pain in infants: a feasibility study evaluating a point-of-care mobile solution based on automated facial analysis

BACKGROUND

The management of procedural pain in infants is suboptimal, in part, compounded by the scarcity of a simple, accurate, and reliable method of assessing such pain. In this study, we aimed to evaluate the psychometric properties of the PainChek Infant, a point-of-care mobile application that uses automated facial evaluation and analysis in the assessment of procedural pain in infants.

METHODS

Video recordings of 40 infants were randomly chosen from a purposely assembled digital library of 410 children undergoing immunisation as part of their standard care in Prishtina, Kosovo, between April 4, 2017, and July 11, 2018. For each infant recording, four 10 s video segments were extracted, corresponding to baseline, vaccine preparation, during vaccination, and recovery. Four trained assessors did pain assessments on the video segments of 30 infants, using PainChek Infant standard, PainChek Infant adaptive, the Neonatal Facial Coding System-Revised (NFCS-R) single, the NFCS-R multiple, and the Observer administered Visual Analogue Scale (ObsVAS), on two separate occasions. PainChek Infant's performance was compared to NFCS-R and ObsVAS using correlation in changes in pain scores, intra-rater and inter-rater reliability, and internal consistency.

FINDINGS

4303 pain assessments were completed in two separate testing sessions, on Aug 31, and Oct 19, 2020. The study involved videos of 40 infants aged 2·2-6·9 months (median age 3·4 months [IQR 2·3-4·5]). All pain assessment tools showed significant changes in the recorded pain scores across the four video segments (p≤0·0006). All tools were found to be responsive to procedure-induced pain, with the degree of change in pain scores not influenced by pre-vaccination pain levels. PainChek Infant pain scores showed good correlation with NFCS-R and ObsVAS scores (r=0·82-0·88; p<0·0001). PainChek Infant also showed good to excellent inter-rater reliability (ICC=0·81-0·97, p<0·001) and high levels of internal consistency (α=0·82-0·97).

INTERPRETATION

PainChek Infant's use of automated facial expression analysis could offer a valid and reliable means of assessing and monitoring procedural pain in infants. Its clinical utility in clinical practice requires further research.

FUNDING

PainChek.

National survey revealed variable practices in paediatric procedural sedation and patient monitoring

Paediatric procedures requiring sedation are increasingly being performed off site, but there are no national guidelines for paediatric procedural sedation in Finland or studies on it. Therefore, the aim of this survey was to assess national practices for paediatric procedural sedation outside operation rooms and intensive care units in terms of indications, sedative medication, treatment facilities, patient safety and training of the personnel. An online survey including single- and multiple-choice questions and open-ended questions was sent to Finnish paediatricians, paediatric surgeons and paediatric anaesthesiologists via the electronic mailing lists of national societies in December 2019. A total of 71 responses were received. Lumbar puncture (41%), intra-articular injections (38%) and MRI (17%) were the most common procedures that required routine sedation. Benzodiazepines were the most frequently used sedatives during both painful procedures (80%) and imaging (61%). Pulse oximetry monitoring was reported by 75% of the respondents, but other physiological parameters were rarely monitored (ECG 28%; blood pressure 39%; respiratory rate 34%). The level of sedation was not objectively assessed. Adrenaline (72%) and equipment for managing adverse respiratory outcomes (supplemental oxygen 98%; ventilation equipment 92%) were available in most facilities in which sedation was performed. Only one-third of the respondents had undergone training for paediatric procedural sedation, and only 39% of the hospital units compiled statistical data on sedation-related adverse events. The paediatric procedural sedation practices vary across hospitals. National guidelines for patient monitoring and training of personnel could improve treatment quality and patient safety.

Effectiveness of Virtual Reality Interventions for Adolescent Patients in Hospital Settings: Systematic Review

Background

Given the high level of interest and increasing familiarity with virtual reality among adolescents, there is great potential to use virtual reality to address adolescents’ unique health care delivery needs while in hospital. While there have been reviews on the use of virtual reality for specific health conditions and procedures, none to date have reviewed the full scope of virtual reality hospital interventions for adolescents who are often combined with children as a homogenous group, despite the fact that adolescents experience virtual environments different from children.

Objective

The aim of this review was to systematically identify available evidence regarding the use of virtual reality interventions for adolescent patients in hospital settings to evaluate effectiveness, suitability, and safety and identify opportunities for future research.

Methods

PubMed, PsycINFO, Medline, and Scopus databases were searched using keywords and phrases. Retrieved abstracts (n=1525) were double screened, yielding 276 articles for full-text screening. Of these, 8 articles met inclusion criteria. Data were extracted to a standardized coding sheet, and a narrative synthesis was performed due to the heterogeneity of the studies.

Results

Four RCTs and 4 single-case reports were identified for inclusion, all of which aimed to reduce pain or anxiety. The scenarios targeted were burn pain, venipuncture, chemotherapy, preoperative anxiety, and palliative care. Three out of 4 RCTs found significant reductions in pain or anxiety outcomes measures when using virtual reality compared to standard care or other distraction techniques; however, only 1 study combined self-reported experiences of pain or anxiety with any physiological measures. Single-case reports relied primarily upon qualitative feedback, with patients reporting reduced pain or anxiety and a preference for virtual reality to no virtual reality.

Conclusions

Virtual reality can provide a safe and engaging way to reduce pain and anxiety in adolescents while in hospital, particularly when virtual reality software is highly immersive and specifically designed for therapeutic purposes. As VR becomes more accessible and affordable for use in hospitals, larger and more diverse studies that capitalize on adolescents’ interest in and aptitude for virtual reality, and on the full range of capabilities of this emerging technology, are needed to build on these promising results.

Trial Registration

PROSPERO International Prospective Register of Systematic Reviews CRD42020198760; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020198760

The use of virtual reality in children undergoing vascular access procedures: a systematic review and meta-analysis

Venous access procedures are painful and feared by children and their parents. Virtual reality has become increasingly prominent and has been shown to be effective in various procedures. The aim of this meta-analysis was to examine virtual reality's effect on pain and fear in children from 4 to 12 in the context of vascular access. From the 20th to the 26th December 2020, we searched Sciencedirect, Springerlink, CENTRAL, Pubmed and PMC. Studies using virtual reality versus a control in vascular access for children were included in a meta-analysis to evaluate the effect of virtual reality regarding pain as a primary and fear/anxiety as a secondary endpoint during the procedures. The Jadad scale and Delphi List were used to assess study quality. 20,894 citations were identified, 9 met our inclusion criteria. One publication was conducted in two different situations and was thus considered as 2 studies. Compared to standard of care, virtual reality significantly reduced pain (10 studies, 930 participants: standardized mean difference [SMD] 2.54, 95%CI 0.14-4.93, p = 0.038), and fear/anxiety (6 studies, 648 participants: SMD 0.89, 95%Cl 0.16-1.63, p = 0.017). For both parameters, we found significant heterogeneity between studies. This is the first meta-analysis to look at the use virtual reality in young children undergoing vascular access procedures, providing weak to moderate evidence for its use. Although large effect sizes provide evidence for a positive effect of virtual reality in reducing pain and fear, there is significant heterogeneity between studies. More research with larger groups and age stratification is required.

Testicular Torsion in the Absence of Severe Pain: Considerations for the Pediatric Surgeon

Testicular torsion is a surgical emergency. Early diagnosis and surgical treatment are vital in order to preserve the affected gonad. Current surgical teaching emphasizes sudden, severe, persistent, unilateral scrotal pain as a cardinal symptom of testicular torsion. We present the case of unilateral testicular torsion in a 14-year-old patient who presented with the absence of severe pain. Despite a delayed presentation to the emergency department, the gonad could be salvaged successfully. Literature on the topic of testicular torsion presenting with minimal pain is limited. Nevertheless, pediatric surgeons might be faced with cases similar to the one we describe. Underestimating this phenomenon might lead to a delay of treatment. In such cases, ultrasound can be a beneficial addition in the diagnosis and accelerate definitive operative treatment. The presented case clearly demonstrates that, although we do not include testicular torsion without severe pain in our surgical teaching algorithms, we might encounter it in our clinical practice.

Play and medical play in teaching pre-school children to cope with medical procedures involving needles: A systematic review

AIM

Most toddlers experience pain and distress during doctor or dental visits. Aim of this systematic review was to investigate the role of play-based interventions in pain and fear or distress management in pre-school children (aged from 2 to 6 years old) undergoing needle-related medical procedures adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (registration number: CRD42020192161).

METHODS

The key database that was searched was PubMed/MEDLINE along with references of relevant review studies. Only randomised controlled trials (RCTs) that fulfilled inclusion and eligibility criteria were selected for analysis. Methodological quality was evaluated using the Cochrane Collaboration's Risk of Bias Tool for RCTs and Review Manager version 5.4 was utilised in order to calculate standardised mean differences (SMDs) and create a forest plot for included studies that presented data on self-reported pain ratings. Primary outcomes refer to pain, anxiety and fear assessments, while secondary outcomes refer to physiological measures and cortisol levels.

RESULTS

All included RCTs suffered from high risk of bias that relied on selection and blinding methodology, while other sources of bias were also present in some cases. Despite low-quality of evidence, play-based interventions seem to favour less self-reported pain (SMD -0.39; 95% CI: -0.67 to -0.12; I² = 84%).

CONCLUSION

Limitations of evidence, except from high risk of bias, include inconsistency in reporting primary outcome assessments and study designs that preclude reproducibility. Play-based techniques seem to contribute to pre-schoolers' coping towards needle-related medical procedures and further research is warranted in order to explore clinical benefits.

Measures and Effects of Pain Management for Wound Dressing Change in Outpatient Children in Western China

Purpose

The present study investigated the pain management of wound dressing change in outpatient children in western China, and the results may provide a reference to improve the pain management of wound dressing change.

Methods

A cross-sectional survey was performed to investigate the pain management of wound dressing change in outpatient children in western China. A total of 47 hospitals were selected via convenience sampling, and the pain management organization systems, concrete measures and barriers to adequate pain management of these hospitals were investigated.

Results

More than 70% of these hospitals had established pain management systems, analgesic drug management norms and wound care teams. Nurses were the primary providers for wound dressing change in 48.94% of the hospitals. The assessment, documentation or health education of the pain was not standard in 46.81% of the hospitals. Drug and non-drug analgesia measures were used in most hospitals, however, children did not receive adequate analgesia in 70% of the hospitals. Ibuprofen (30.49%) and lidocaine (29.27%) were commonly used analgesic drugs, and distraction (43.01%) was commonly used as a non-drug analgesia measure. The top three barriers to adequate pain management were medical staff lacking analgesic knowledge (82.98%), family members refusing to use analgesics (61.70%) and low compliance of children (55.32%).

Conclusion

The concrete measures for the management of wound dressing pain in children are not standardized, and the analgesic effect is poor. In order to improve the pain management of children, Standardized procedures for pain management (pain assessment, analgesia measures, pain documentation and health education) should be strictly followed during wound dressing change, and the identified barriers should be addressed.

Experience of Registered Nurses of Postoperative Pain Assessment Using Objective Measures among Children at Effia Nkwanta Regional Hospital in Ghana

Introduction: People undergoing surgical operations experience some level of pain. Assessing pain intensity is one of the duties of the nurse and it involves subjective measures (self-report), and objective measures (behavioural and physiological). It has been observed by the researcher that nurses in clinical practice do not assess pain before management more so among children. Also, there is limited research in the area of pain assessment in children who cannot communicate. This study aimed to describe the experiences of registered nurses in assessing postoperative pain among children (0-3 years) using objective measures.

Methods: Descriptive phenomenology was the chosen design. Maximum variation sampling was used to recruit nine registered nurses with experience in nursing children after surgery at Effia Nkwanta Regional Hospital (ENRH) in Ghana. The researchers conducted audio-recorded in-depth interviews, transcribed verbatim and qualitatively analyzed following Colaizzi’s approach to descriptive phenomenology analysis.

Results: The study revealed that the nurses have more experience with using behavioural measures with limited experience with the use of physiological measures. The behavioural measures mostly reported from their experience were changes in facial expression and unusual crying of the child. In general, the nurses do not formally use consistent approaches to assess pain among children.

Conclusion: Given these results, opportunities should be made available for nurses to enhance their skills and utilize evidence-based approaches to formally assess pain among post-operative children.