Letting kids play their CARDs (Comfort, Ask, Relax, Distract) to help cope with needle-related fear and pain: Results from user testing

This study examined perceptions of children and parents about a new web-based CARD (Comfort, Ask, Relax, Distract) game that teaches children how to cope with needle-related pain and fear. A convenience sample of 15 child-parent dyads (children, 6-12 years) participated. Children played the game on a handheld device while being virtually monitored. Activity tracking revealed most children engaged with multiple components. Children reported they understood the game, it was easy to play, they learned coping strategies and believed they could implement them. Children reported lower fear of needles after playing. Parents liked the simplicity and variety of game activities. Most children and parents reported they would use the game or its coping strategies for future needles and would recommend the game. In summary, children and parents found the CARD web game acceptable and appropriate. Future studies can evaluate its effectiveness when integrated into upcoming needle procedures like COVID-19 vaccinations.

A Longitudinal Randomized Trial of the Effect of Consistent Pain Management for Infant Vaccinations on Future Vaccination Distress

The objective was to determine if consistent pain management during vaccine injections has a beneficial effect on future infant pain reactivity. This was a multicenter, longitudinal, double-blind, double-dummy, add-on, randomized controlled trial. Healthy infants were randomized to 1 of 4 add-on pain management regimens for all vaccinations in the first year of life: 1) placebo control (standard care), 2) parent video education about infant soothing (video), 3) video and oral sucrose solution (sucrose), 4) video and sucrose and topical liposomal lidocaine (lidocaine). At 15-month vaccinations, all active pain interventions were administered (video and sucrose and lidocaine); however, individuals remained blinded to the original treatments given. Pain at 15 months was evaluated during 3 procedure phases (baseline, needle injection, and recovery) by a researcher unaware of group allocation using a validated measure, the Modified Behavioural Pain Scale (range, 0-10). Altogether, 352 infants participated; characteristics did not differ among groups (P > .05). Pain scores did not differ among groups during baseline (P = .642), needle injection (P = .739), or recovery (P = .750) phases. In conclusion, there was no evidence of a long-term benefit of consistent use of pain interventions in the first year of life on future infant pain responsivity at 15-month vaccinations.

PERSPECTIVE

This randomized controlled trial did not find a long-term benefit of consistent pain management during infant vaccinations on future infant pain responsivity at 15 months. The results are relevant to clinicians and researchers studying and evaluating pain interventions in children undergoing medical procedures.

Relative effectiveness of additive pain interventions during vaccination in infants

BACKGROUND

Vaccine injections can cause acute pain and distress in infants, which can contribute to dissatisfaction with the vaccination experience and vaccine hesitancy. We sought to compare the effectiveness of additive pain interventions administered consistently during vaccine injections in the first year of life.

METHODS

We conducted a multicentre, longitudinal, double-blind, add-on, randomized controlled trial. Healthy infants were randomly assigned to 1 of 4 levels of pain management for all vaccine injections at 2, 4, 6 and 12 months: (i) placebo control; (ii) parent-directed video education about infant soothing; (iii) the video plus sucrose administered orally or (iv) the video plus sucrose plus liposomal lidocaine applied topically. All infants benefit from injection techniques that minimize pain. We used a double-dummy design; hence all parents watched a video (active psychological intervention or placebo) and all infants received oral solution (sucrose or placebo) and topical cream (lidocaine or placebo). We assessed infant distress during 3 phases - preinjection (baseline), vaccine injection (needle), and 1 minute postinjection (recovery) - using the Modified Behavioural Pain Scale (range 0-10). We compared scores between groups and across infant ages using a mixed-model repeated-measures analysis.

RESULTS

A total of 352 infants participated in the study, from Jan. 17, 2012, to Feb. 2, 2016. Demographics did not differ among intervention groups (p > 0.05). Baseline pain scores did not differ among intervention groups (p = 0.4), but did differ across ages (p < 0.001). Needle pain scores differed among groups (p = 0.003) and across ages (p < 0.001). The mean (± standard deviation) needle score was 6.3 (± 0.8) in the video-sucrose-lidocaine group compared with 6.7 (± 0.8) in each of the other groups. There were no other between-group differences. Recovery scores did not differ among groups (p = 0.98), but did differ across ages (p < 0.001).

INTERPRETATION

Only liposomal lidocaine provided consistent analgesia within an additive pain intervention regimen during vaccinations in infants. Trial registration: ClinicalTrials.gov, no. NCT01503060.

Association Between Meat and Meat-Alternative Consumption and Iron Stores in Early Childhood

OBJECTIVE

To prevent iron deficiency, 2014 Canadian recommendations for healthy term infants from 6 to 24 months recommend iron-rich complementary foods such as meat and meat alternatives 2 or more times a day. The purpose of our study was to evaluate the association between meat and meat-alternative consumption and iron status in young children and the association between red meat consumption and iron status among children meeting recommendations.

METHODS

Healthy children aged 12 to 36 months were recruited. A cross-sectional study was conducted. Meat and meat-alternative consumption was measured using the NutriSTEP questionnaire. Adjusted multivariable regression analyses were used to evaluate an association between meat consumption and serum ferritin, and iron deficiency (serum ferritin <14 μg/L).

RESULTS

A total of 1043 children were included. Seventy-three percent of children met the recommended daily intake of meat and meat alternatives, and 66% ate red meat in the past 3 days. Eating meat and meat alternatives was not associated with serum ferritin (0.13 μg/L, 95% confidence interval -0.05, 0.31, P = .16), but it was associated with a decreased odds of iron deficiency (odds ratio 0.97, 95% confidence interval 0.94, 0.99, P = .03). Associations between red meat consumption and iron status were not statistically significant. Statistically significant covariates associated with increased odds of iron deficiency included longer breast-feeding duration, daily cow's milk intake of >2 cups, and a higher body mass index z score.

CONCLUSIONS

Daily cow's milk intake of >2 cups, longer breast-feeding duration, and a higher body mass index z score were modifiable risk factors associated with iron deficiency. Eating meat according to recommendations may be a promising additional target for the prevention of iron deficiency in early childhood.

Exposure-based Interventions for the management of individuals with high levels of needle fear across the lifespan: a clinical practice guideline and call for further research

Needle fear typically begins in childhood and represents an important health-related issue across the lifespan. Individuals who are highly fearful of needles frequently avoid health care. Although guidance exists for managing needle pain and fear during procedures, the most highly fearful may refuse or abstain from such procedures. The purpose of a clinical practice guideline (CPG) is to provide actionable instruction on the management of a particular health concern; this guidance emerges from a systematic process. Using evidence from a rigorous systematic review interpreted by an expert panel, this CPG provides recommendations on exposure-based interventions for high levels of needle fear in children and adults. The AGREE-II, GRADE, and Cochrane methodologies were used. Exposure-based interventions were included. The included evidence was very low quality on average. Strong recommendations include the following. In vivo (live/in person) exposure-based therapy is recommended (vs. no treatment) for children seven years and older and adults with high levels of needle fear. Non-in vivo (imaginal, computer-based) exposure (vs. no treatment) is recommended for individuals (over seven years of age) who are unwilling to undergo in vivo exposure. Although there were no included trials which examined children < 7 years, exposure-based interventions are discussed as good clinical practice. Implementation considerations are discussed and clinical tools are provided. Utilization of these recommended practices may lead to improved health outcomes due to better health care compliance. Research on the understanding and treatment of high levels of needle fear is urgently needed; specific recommendations are provided.

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

BACKGROUND

This systematic review evaluated the effectiveness of physical and procedural interventions for reducing pain and related outcomes during vaccination.

DESIGN/METHODS

Databases were searched using a broad search strategy to identify relevant randomized and quasi-randomized controlled trials. Data were extracted according to procedure phase (preprocedure, acute, recovery, and combinations of these) and pooled using established methods.

RESULTS

A total of 31 studies were included. Acute infant distress was diminished during intramuscular injection without aspiration (n=313): standardized mean difference (SMD) -0.82 (95% confidence interval [CI]: -1.18, -0.46). Injecting the most painful vaccine last during vaccinations reduced acute infant distress (n=196): SMD -0.69 (95% CI: -0.98, -0.4). Simultaneous injections reduced acute infant distress compared with sequential injections (n=172): SMD -0.56 (95% CI: -0.87, -0.25). There was no benefit of simultaneous injections in children. Less infant distress during the acute and recovery phases combined occurred with vastus lateralis (vs. deltoid) injections (n=185): SMD -0.70 (95% CI: -1.00, -0.41). Skin-to-skin contact in neonates (n=736) reduced acute distress: SMD -0.65 (95% CI: -1.05, -0.25). Holding infants reduced acute distress after removal of the data from 1 methodologically diverse study (n=107): SMD -1.25 (95% CI: -2.05, -0.46). Holding after vaccination (n=417) reduced infant distress during the acute and recovery phases combined: SMD -0.65 (95% CI: -1.08, -0.22). Self-reported fear was reduced for children positioned upright (n=107): SMD -0.39 (95% CI: -0.77, -0.01). Non-nutritive sucking (n=186) reduced acute distress in infants: SMD -1.88 (95% CI: -2.57, -1.18). Manual tactile stimulation did not reduce pain across the lifespan. An external vibrating device and cold reduced pain in children (n=145): SMD -1.23 (95% CI: -1.58, -0.87). There was no benefit of warming the vaccine in adults. Muscle tension was beneficial in selected indices of fainting in adolescents and adults.

CONCLUSIONS

Interventions with evidence of benefit in select populations include: no aspiration, injecting most painful vaccine last, simultaneous injections, vastus lateralis injection, positioning interventions, non-nutritive sucking, external vibrating device with cold, and muscle tension.

Usability and knowledge testing of educational tools about infant vaccination pain management directed to postnatal nurses

BACKGROUND

Adapting educational tools to meet user needs is a critical aspect of translating research evidence into best clinical practices. The objectives of this study were to evaluate usability and effectiveness of educational tools about infant vaccination pain management directed to postnatal nurses.

METHODS

Mixed methods design. A template pamphlet and video included in a published clinical practice guideline were subjected to heuristic usability evaluation and then the revised tools were reviewed by postnatal hospital nurses in three rounds of interviews involving 8 to 12 nurses per round. Nurses' knowledge about evidence-based pain management interventions was evaluated at three time points: baseline, after pamphlet review, and after video review.

RESULTS

Of 32 eligible postnatal nurses, 29 agreed to participation and data were available for 28. Three overarching themes were identified in the interviews: 1) utility of information, 2) access to information, and 3) process for infant procedures. Nurses' knowledge improved significantly (p < 0.05) from the baseline phase to the pamphlet review phase, and again from the pamphlet review phase to the video review phase.

CONCLUSIONS

This study demonstrated usability and knowledge uptake from a nurse-directed educational pamphlet and video about managing infant vaccination pain. Future studies are needed to determine the impact of implementing these educational tools in the postnatal hospital setting on parental utilization of analgesic interventions during infant hospitalization and future infant vaccinations.

Knowledge translation of the HELPinKIDS clinical practice guideline for managing childhood vaccination pain: usability and knowledge uptake of educational materials directed to new parents

Background

Although numerous evidence-based and feasible interventions are available to treat pain from childhood vaccine injections, evidence indicates that children are not benefitting from this knowledge. Unrelieved vaccination pain puts children at risk for significant long-term harms including the development of needle fears and subsequent health care avoidance behaviours. Parents report that while they want to mitigate vaccination pain in their children, they lack knowledge about how to do so. An evidence-based clinical practice guideline for managing vaccination pain was recently developed in order to address this knowledge-to-care gap. Educational tools (pamphlet and video) for parents were included to facilitate knowledge transfer at the point of care. The objectives of this study were to evaluate usability and effectiveness in terms of knowledge acquisition from the pamphlet and video in parents of newly born infants.

Methods

Mixed methods design. Following heuristic usability evaluation of the pamphlet and video, parents of newborn infants reviewed revised versions of both tools and participated in individual and group interviews and individual knowledge testing. The knowledge test comprised of 10 true/false questions about the effectiveness of various pain management interventions, and was administered at three time points: at baseline, after review of the pamphlet, and after review of the video.

Results

Three overarching themes were identified from the interviews regarding usability of these educational tools: receptivity to learning, accessibility to information, and validity of information. Parents’ performance on the knowledge test improved (p≤0.001) from the baseline phase to after review of the pamphlet, and again from the pamphlet review phase to after review of the video.

Conclusions

Using a robust testing process, we demonstrated usability and conceptual knowledge acquisition from a parent-directed educational pamphlet and video about management of vaccination pain. Future studies are planned to determine the impact of these educational tools when introduced in clinical settings on parent behaviors during infant vaccinations.

Survey of the prevalence of immunization non-compliance due to needle fears in children and adults

Needle fears are a documented barrier to immunization in children and adults. There is a paucity of data, however, regarding the prevalence of needle fears and their impact on immunization compliance. In this cross-sectional survey, a convenience sample of parents (n=883) and children (n=1024) attending a public museum in Toronto, Canada answered questions about needle fears and non-compliance with immunization due to needle fear. Altogether, 24% of parents and 63% of children reported a fear of needles. Needle fear was the primary reason for immunization non-compliance for 7% and 8% of parents and children, respectively. Interventions aimed at improving education about, and access to, analgesic interventions during immunization injections performed in childhood are recommended in order to prevent the development of needle fears and vaccine non-compliance.

Sensitivity of rapid influenza diagnostic testing for swine-origin 2009 a (H1N1) influenza virus in children

BACKGROUND

The rapidly evolving pandemic of novel 2009 swine-origin influenza A (H1N1) virus (S-OIV) demands that accurate and practical diagnostics be urgently evaluated for their potential clinical utility.

OBJECTIVE

To determine the diagnostic accuracy of a rapid influenza diagnostic test (RIDT) and direct fluorescent antibody (DFA) assay for S-OIV by using reverse-transcription polymerase chain reaction (RT-PCR) as the reference standard.

METHODS

We prospectively recruited children (aged 0-17 years) assessed in the emergency department of a pediatric referral hospital and a community pediatric clinic for influenza-like illness between May 22 and July 25, 2009. RIDT (performed on-site) and DFA were compared with RT-PCR to determine their sensitivity and specificity for S-OIV. We also compared the sensitivity of RIDT for S-OIV to that for seasonal influenza over 2 preceding seasons.

RESULTS

Of 820 children enrolled, 651 were from the emergency department and 169 were from the clinic. RIDT sensitivity was 62% (95% confidence interval [CI]: 52%-70%) for S-OIV, with a specificity of 99% (95% CI: 92%-100%). DFA sensitivity was 83% (95% CI: 75%-89%) and was superior to that of RIDT (P < .001). RIDT sensitivity for S-OIV was comparable to that for seasonal influenza when using DFA supplemented with culture as the reference standard. RIDT sensitivity for influenza viruses was significantly higher in children 5 years of age or younger (P = .003) and in patients presenting < or =2 days after symptom onset (P < .001).

CONCLUSIONS

The sensitivity of RIDT for detection of S-OIV is higher than recently reported in mixed adult-pediatric populations but remains suboptimal.

Inadequate pain management during routine childhood immunizations: the nerve of it

BACKGROUND

Immunization is regarded as one of the most significant medical achievements of all time. Recently, increasing attention has been paid to the pain resulting from routine childhood immunizations.

OBJECTIVE

This narrative review summarizes existing knowledge about: (1) the epidemiology of childhood immunization pain; (2) the pain experience of children undergoing immunization; (3) current analgesic practices; (4) barriers to practicing pain management in children; and (5) recommendations for improvements in pain management during immunization.

METHODS

We conducted a search of MEDLINE, PsycINFO, EMBASE, CINAHL, and the Cochrane Central Register of Controlled Trials for primary research and review articles published from inception of the databases through October 2008. Key search terms included immunization, pain, child/infant, vaccine, and intervention. Additional studies were identified through searches of the reference lists in the retrieved articles. No language restrictions were imposed regarding the type of article (eg, full article, abstract) or language.

RESULTS

Vaccine injections are the most common iatrogenic procedure performed in childhood and a major source of distress for children (of all ages), their parents, and the participating health care professionals, as well as a direct cause of vaccine nonadherence. In addition, lack of adequate pain management during immunization exposes children to unnecessary suffering and the potential for long-term consequences, such as fear of needles. Numerous pain management strategies are available to reduce vaccine injection pain, including: (1) physical interventions and injection techniques; (2) psychological interventions; and (3) phar-macologic and combined interventions. However, adoption of pain-relieving techniques into clinical practice has been suboptimal. The underutilization of pain management strategies can be attributed to a lack of knowledge about pain and effective pain prevention strategies, and the persistence of attitudes about pain that interfere with optimal clinical practices. Current analgesic practices could be improved substantially if all stakeholders involved in immunization (eg, policy makers, practitioners, consumers) participate in efforts to reduce pain. Treating pain during childhood immunization has the potential to reduce distress during the procedure and greatly improve satisfaction with the immunization experience through more positive experiences for children and their families. Other potential benefits include improved adherence to immunization schedules and reduced sequelae of untreated pain.

CONCLUSION

Immunization is a global health priority. Medical care can be improved if pain management becomes a routine aspect of the delivery of vaccine injections.

Vaccine-related pain: randomised controlled trial of two injection techniques

OBJECTIVE

To compare acute pain response during immunisation in infants using a slow standard of care injection technique versus a rapid pragmatic technique.

DESIGN

Randomised controlled trial.

SETTING

Single-centre, urban paediatric primary care practice.

SUBJECTS

Healthy infants 4-6 months of age receiving their routine DPTaP-Hib immunisation.

INTERVENTIONS

Standard of care group: slow aspiration prior to injection, slow injection and slow withdrawal. Pragmatic group: no aspiration, rapid injection and rapid withdrawal.

MAIN OUTCOME MEASURES

Immediate infant pain measured by the Modified Behavior Pain Scale (MBPS), crying and parent/paediatrician visual analogue scale (VAS).

RESULTS

113 infants participated; there were no observed differences in age, birth order or prior analgesic use. Mean MBPS scores (95% confidence interval (CI)) were higher (p<0.001) for the standard group compared to the pragmatic group, 5.6 (5 to 6.3) vs 3.3 (2.6 to 3.9). The standard group was more likely to cry, 47/57 (82%) vs 24/56 (43%), to cry longer, median (interquartile range (IQR)) 14.7 s (8.7-35.6) vs 0 s (0-11.30), and to take longer to have the vaccine injected, median (IQR) 8.8 s (7.9-10.3) vs 0.9 s (0.8-1.1), p<0.001 for all comparisons. The median (IQR) VAS scores by parents and paediatricians were higher for the standard group: VAS parent, 3.5 (1.6-5.5) vs 1.9 (0.1-3.1) and VAS paediatrician, 2.8 (2.0-5.1) vs 1.4 (0.2-2.4). There were no adverse events.

CONCLUSION

Immunisation using a pragmatic rapid injection technique is less painful than a slow standard of care technique and should be recommended for routine intramuscular immunisations.

Routine immunization practices: use of topical anesthetics and oral analgesics

BACKGROUND

Immunization pain is a global public health issue. Despite an abundance of data that demonstrate the efficacy of local anesthetics for decreasing immunization pain, their adoption in practice has not been determined. Our objective was to evaluate analgesic use during childhood immunization.

PATIENTS AND METHODS

We used a cluster-sampling survey of pediatricians in the greater Toronto area (who administer immunizations) and multiparous women. By using a self-administered survey, pediatricians reported frequency of analgesic use in their practice for 2 phases of immunization: injection (needle puncture and vaccine administration) and postinjection (hours to days postvaccination). By using an interviewer-administered face-to-face survey, mothers reported analgesic practices for their children.

RESULTS

Of 195 eligible pediatricians, 140 (72%) responded. During the injection phase, 58% rarely or never used analgesics compared with 11% for the postinjection phase. During injection, the local anesthetics lidocaine-prilocaine and tetracaine were used at least sometimes in 12% and 2% of the practices, respectively, whereas acetaminophen and ibuprofen were used in 81% and 46%, respectively. Postinjection, acetaminophen and ibuprofen were used in 89% and 56% of practices. Of 257 eligible mothers, 200 (78%) participated. During injection, analgesics were used in 25% of immunizations (acetaminophen [87%], ibuprofen [7%], and lidocaine-prilocaine [6%]). Postinjection, analgesics were used in 33% of immunizations (acetaminophen [86%] and ibuprofen [14%]).

CONCLUSIONS

A minority of pediatricians and mothers use topical local anesthetics during childhood immunization despite evidence to support their use. Oral analgesics are used more commonly, but this practice is not consistent with scientific evidence. Knowledge-translation strategies are needed to increase the use of local anesthesia.

Community-based case-control study of childhood chronic abdominal pain: role of selected laboratory investigations

OBJECTIVE

To compare laboratory investigation results in children with chronic abdominal pain and in healthy control children. Our hypothesis was that parasitic infection was not a causal factor for chronic abdominal pain and that there would be no difference in leukocyte count, hemoglobin level, or erythrocyte sedimentation rate (ESR) between the 2 groups.

PATIENTS AND METHODS

Children with chronic abdominal pain and healthy control children (5-15 years) were recruited from the practices of 6 primary care pediatricians in Toronto, Canada. Stool samples were analyzed for ova and parasites, and serum samples were used to estimate leukocyte count, hemoglobin, and ESR. A standardized questionnaire was used to gather social, demographic, and clinical information.

RESULTS

A total of 157/200 children (79%) provided samples. Children with chronic abdominal pain were more likely to be female than were control children. Stool samples were positive for parasitic infection in 15 children, with no difference in prevalence between children with chronic abdominal pain (6/87; 7%) and healthy control children (9/70; 13%); P = 0.28). The mean (standard deviation) leukocyte count in children with chronic abdominal pain was 7.4 x 10(9)/L (2.03), compared with 8.3 x 10(9)/L (1.82) in healthy control children. No child had a leukocyte count above 20 x 10(9)/L. The mean (SD) hemoglobin in children with chronic abdominal pain was 131 g/L (8.4), compared with 130 g/L (9.2) in healthy control children. Last, the median ESR in children with chronic abdominal pain was 5 mm/hour, compared with 3 mm/hour in control children.

CONCLUSIONS

The study findings suggest that in the absence of alarming symptoms and signs, parasitic infection is not a causal factor for chronic abdominal pain and that routine screening tests (leukocyte count, hemoglobin, ESR) are not useful.

Pain response to M-M-R vaccination in 4-6 year old children

BACKGROUND

Differences in pain response to two different M-M-R products have previously been demonstrated in 12-month old infants and in 4 â 6 year old children. Objective To determine if the acute and immediate pain response to two licensed M-M-R vaccine products (using a self-report measure) in children 4-6 years of age was similar to that demonstrated in younger infants.

METHODS

Randomized, double blind, study. Subjects were randomly allocated to PriorixA (SmithKline Beecham) or M-M-R IIA (Merck Frosst). The primary outcome measure was pain response to vaccination quantified using a self-report OUCHER pain scale. Secondary outcome measures included pain measurement by proxy (physician and parent) using a visual analog scale (VAS) and measurement of cry and cry duration immediately post-vaccination.

RESULTS

Of the 60 subjects enrolled, 30 received PriorixA and 30 received M-M-R IIA. There were no significant differences between the two groups on age, sex, or previous painful procedure. Post-vaccination, children in the M-M-R IIA group had higher median pain scores compared with children in the PriorixA group for VAS (12.5 vs. 2.0, respectively by paediatricians, p=0.017; 18.5 vs. 5.0, respectively by parents, p=0.235), OUCHER (20 vs. 0.00, respectively, p=0.047). The median duration of crying post M-M-R IIA was higher compared with PriorixA (6 vs. 0 seconds, respectively, p=0.020). Conclusion PriorixA was associated with significantly less pain compared with M-M-R IIA, at the time of injection.

Topical 4% amethocaine gel reduces the pain of subcutaneous measles-mumps-rubella vaccination

OBJECTIVES

Ametop gel (4% amethocaine) is a relatively new topical anesthetic that produces anesthesia within 30 to 45 minutes and therefore may be appropriate for use in busy outpatient settings. The objective of this study was to assess the efficacy and safety of 4% amethocaine in reducing the pain of subcutaneous measles-mumps-rubella vaccination in 1-year-old infants.

METHODS

A double-blind, randomized, placebo-controlled trial was conducted in pediatric outpatient clinics.

RESULTS

A total of 120 infants participated in the study; 60 were followed up for assessment of antibody titers after 1 month. Either 1 g of amethocaine or placebo was applied for 30 minutes before vaccination. The Modified Behavioral Pain Scale was used to assess pain; the mean (standard deviation) pain scores for the amethocaine group (n = 61) was 1.5 (1.6) versus 2.3 (2.2) for the placebo group (n = 59). The rate of vaccination success (88% and 87%) was not different between treatment groups.

CONCLUSIONS

4% Amethocaine significantly reduces the pain of measles-mumps-rubella vaccination in infants when compared with placebo and does not seem to interfere with subsequent development of protective antibody levels. Because of its relatively short application time (30 minutes), 4% amethocaine may be suitable for busy clinics and emergency departments.

Effect of Choice of Measles-Mumps-Rubella Vaccine on Immediate Vaccination Pain in Infants

OBJECTIVE

To compare acute pain response to 2 measles-mumps-rubella vaccines.

DESIGN

Double-blind clinical trial.

SETTING

Hospital for Sick Children, Toronto, Ontario. Patients Forty-nine infants 12 months of age receiving their first measles-mumps-rubella vaccination.

INTERVENTIONS

Random allocation to receive Priorix or M-M-R II.

MAIN OUTCOME MEASURES

Pain responses before (baseline) and after (within 15 seconds) vaccination were quantified by visual analog scale (VAS; range, 0-100), completed by the parent and independently by the pediatrician, and the Modified Behavioral Pain Scale (range, 0-10), scored by a coder blinded to the vaccine allocation. Crying (yes or no) and latency to the first cry after injection were also measured.

RESULTS

Twenty-six infants received Priorix and 23 received M-M-R II. There were no differences between the 2 groups in baseline characteristics or prevaccination baseline pain scores. Median pain scores after vaccination (Priorix vs M-M-R II) were as follows: pediatrician VAS, 15 vs 58 (P =.001); parent VAS, 22 vs 53 (P =.007); and Modified Behavioral Pain Scale, 6 vs 8 (P =.02). Median difference in pain scores (after minus before) for Priorix vs M-M-R II were as follows: pediatrician VAS, 15 vs 53 (P =.003); parent VAS, 22 vs 47 (P =.008); and Modified Behavioral Pain Scale, 3 vs 5 (P =.03). The median latency to first cry was 1.5 seconds in the Priorix group compared with 1 second in the M-M-R II group (P =.26).

CONCLUSIONS

Priorix vaccine causes significantly less pain than M-M-R II at the time of injection for 12-month-old infants receiving their first measles-mumps-rubella vaccination.

Effects of age, gender and holding on pain response during infant immunization

Determinants of infant pain responses are important when assessing the efficacy of analgesics. In a randomized controlled trial, 106 infants aged 2 to 6 months were positioned either supine (SUP) on the examination table or held (HLD) by a parent during routine immunization in a community pediatric office. There was no difference between the SUP and HLD infants in duration of crying, facial grimacing or visual analogue scale (VAS) pain scores. Similarly gender did not affect pain response. In contrast, 2-month-old infants displayed more pain during immunization than did 4 or 6-month-old infants.

Hospitalization of children with acute immune thrombocytopenic purpura - is it necessary?

OBJECTIVE

To identify a target group of children with acute immune thrombocytopenic purpura (ITP) that may not require hospitalization for management.

METHODS

A retrospective chart review was conducted of all children admitted over a two-year period to a tertiary care paediatric hospital with the diagnosis of acute ITP. Patients were classified according to typical and atypical presentations. Typical patients were defined as those aged between one and 10 years, with no hepatomegaly or significant splenomegaly and who had typical laboratory features for ITP. Patients who did not meet these criteria were categorized as atypical. Outcome measures included length of stay (LOS) in hospital; frequency of bone marrow aspiration (BMA); type of treatment; incidence of intracranial hemorrhage (ICH) or severe bleeding; and admission and discharge platelet counts.

RESULTS

There were 74 patients hospitalized for a mean of 3.6 days. No patients suffered an ICH or bleeding requiring transfusion. Patients with typical presentations (42) were compared with patients with atypical presentations (32) and were not significantly different for clinically important outcomes such as admission and discharge platelet counts, serious complications or type of therapy. Typical patients had significantly fewer BMAs than did atypical patients - 22 of 42 (52%) versus 25 of 32 (78%) (P=0.02), and a shorter LOS - 3.1 (+/-0.9) days versus 4.2 (+/-1.8) days (P=0.01).

CONCLUSIONS

Children presenting with ITP have a low incidence of bleeding complications and many of these patients can be managed as outpatients. A multicentre study is needed to properly delineate a low risk group suited for outpatient medical management.

Rapid painless diagnosis of viral respiratory infection

The concordance of nasal compared with nasopharyngeal swabs was assessed for the diagnosis of respiratory viral infections, and the degree of discomfort associated with each procedure was compared. The use of nasal swabs was shown to be as accurate but significantly less painful than nasopharyngeal swabs for virus diagnosis.

Screening for celiac disease in children with recurrent abdominal pain

BACKGROUND

The clinical presentation of celiac disease--a life-long gluten intolerance--may be characterized by chronic abdominal pain. The objective of this study was to determine if children with recurrent abdominal pain had a higher prevalence of antiendomysial antibodies (a serologic marker of celiac disease) compared with healthy children.

METHODS

Children with recurrent abdominal pain and healthy control participants were recruited from the offices of community pediatricians. Serum samples were drawn and antiendomysial antibodies were measured in both groups. Demographic data included age, gender, height, and weight.

RESULTS

A total of 200 children were recruited, of whom 173 (87%) had serum samples drawn. Of these, 92 were children with recurrent abdominal pain and 81 were control participants. Only 2 of the 173 samples (1.2%) were positive for antiendomysial antibody. The frequency of antiendomysial antibody positivity in children with recurrent abdominal pain was 1 in 92 (1%; 95% confidence interval, 0-6%) compared with 1 in 81 (1%; 95% confidence interval, 0-7%) in control participants.

CONCLUSIONS

This community-based case-control study found no association between recurrent abdominal pain and the prevalence of antiendomysial antibody. Therefore, these data do not support screening for celiac disease in the child with classic recurrent abdominal pain in the primary care setting.

Accuracy of clinical assessment of heart murmurs by office based (general practice) paediatricians

AIM

To determine the diagnostic accuracy of physical examination by office based (general practice) paediatricians in the evaluation of heart murmurs.

DESIGN

Each of 30 office based paediatricians blindly examined a random sample of children with murmurs (43% of which were pathological). Sensitivity and specificity were calculated and were related to paediatricians' characteristics.

RESULTS

Mean (SD) sensitivity was 82 (24)% with a mean specificity of 72 (24)% in differentiating pathological from innocent murmurs, with further investigations requested for 54% of assessments. The addition of a referral strategy would have increased mean sensitivity to 87 (20)% and specificity to 98 (8)%. Diagnostic accuracy was not significantly related to the paediatricians' age, education or practice characteristics, but was related to referral practices and confidence in assessment.

CONCLUSIONS

Diagnostic accuracy of clinical assessment of heart murmurs by office based paediatricians is suboptimal, and educational strategies are needed to improve accuracy and reduce unnecessary referrals and misdiagnosis.

Influenza vaccination of high-risk children: a survey of three physician groups

OBJECTIVE

To determine the variability in physician knowledge, attitudes, and behaviours in relation to influenza vaccination of children.

METHOD

A 17-item cross-sectional questionnaire, with follow-up mailings to non-responders, was mailed to a random sample of 100 family physicians and 100 community pediatricians within Metropolitan Toronto and all 130 subspecialists at The Hospital for Sick Children, Toronto.

RESULTS

Of 315 eligible physicians, 243 (77%) responded. Of the three groups, community pediatricians were more likely than either family physicians or subspecialists, to recommend vaccination for all but one of the high-risk conditions. Pediatricians (54%) were also the most likely to use active strategies to contact families of high-risk children compared with family physicians and subspecialists (both 23%). Only 44% of all physicians were themselves vaccinated against influenza.

CONCLUSIONS

Influenza vaccination is recommended by most physicians; however, the responsibility for vaccination appears to fall to those in the community. Physician education plus further research and a review of provincial strategies for improving vaccination are needed.

Influenza vaccination of high-risk children: a survey of three physician groups

OBJECTIVE

To determine the variability in physician knowledge, attitudes, and behaviours in relation to influenza vaccination of children.

METHOD

A 17-item cross-sectional questionnaire, with follow-up mailings to non-responders, was mailed to a random sample of 100 family physicians and 100 community pediatricians within Metropolitan Toronto and all 130 subspecialists at The Hospital for Sick Children, Toronto.

RESULTS

Of 315 eligible physicians, 243 (77%) responded. Of the three groups, community pediatricians were more likely than either family physicians or subspecialists, to recommend vaccination for all but one of the high-risk conditions. Pediatricians (54%) were also the most likely to use active strategies to contact families of high-risk children compared with family physicians and subspecialists (both 23%). Only 44% of all physicians were themselves vaccinated against influenza.

CONCLUSIONS

Influenza vaccination is recommended by most physicians; however, the responsibility for vaccination appears to fall to those in the community. Physician education plus further research and a review of provincial strategies for improving vaccination are needed.

Evaluation of short-course therapy with cefixime or rifampin for eradication of pharyngeally carried group A streptococci. The Ontario GAS Study Group

Therapy to eradicate pharyngeally carried group A streptococci (GAS) has increasingly been used in the management of institutional outbreaks and is now recommended for household contacts of patients with streptococcal toxic shock syndrome. In this randomized, controlled trial, contacts of patients with GAS infections were screened for pharyngeal GAS colonization. Those whose cultures were positive were randomized to receive either cefixime (8 mg/[kg.d]; maximum 400 mg) or rifampin (20 mg/kg; maximum, 600 mg) once a day for 4 days. Two to five days following completion of therapy, repeated cultures were negative for 13 (38%) of 34 rifampin recipients and 71 (77%; 95% CI, 69%-85%) of 97 cefixime recipients. At 10-14 days after treatment, only 53% of cefixime recipients remained culture-negative. Rates of successful clearance improved with increasing age (P < .01); among 17 adults who received cefixime, the success rate was 94%. Four days of therapy with rifampin is not effective for eradication of pharyngeally carried GAS. Four days of therapy with cefixime may be effective for adults, but further studies are needed.

Effect of neonatal circumcision on pain responses during vaccination in boys

Using data from one of our randomised trials, we investigated post-hoc whether male neonatal circumcision is associated with a greater pain response to routine vaccination at 4 or 6 months. Pain response during routine vaccination with diphtheria-pertussis-tetanus (DPT) alone or DPT followed by Haemophilus influenzae type b conjugate (HIB) was scored blind. 42 boys received DPT and 18 also received HIB. After DPT, median visual analogue scores by an observer were higher in the circumcised group (40 vs 26 mm, p = 0.03). After HIB, circumcised infants had higher behavioural pain scores (8 vs 6, p = 0.01) and cried longer (53 vs 19 s, p = 0.02). Thus neonatal circumcision may affect pain response several months after the event.

Use of lidocaine-prilocaine cream for vaccination pain in infants

PURPOSE

To determine whether use of lidocaine-prilocaine 5% cream (EMLA) decreases pain associated with diphtheria-pertussis-tetanus (DPT) vaccination in infants.

METHODS

Randomize, double-blind, controlled trial in outpatient pediatric practice, Toronto, Ontario, Canada. Before vaccination, parents applied 2.5 gm of EMLA or placebo to the infant's leg and covered it with an occlusive dressing for at least 60 minutes. The infant received a 0.5 ml intramuscular injection of DPT at 2 degree to 8 degree C with a 1.6 cm 25-gauge needle; the infant was videotaped. The Modified Behavioral Pain Scale (MBPS) was used to assess baseline and postvaccination pain scores. Latency and duration of infant cry were also measured.

RESULTS

A total of 49 evaluable infants received EMLA, and 47 infants received placebo. There were no significant differences in demographic data; mean age was 5 months; and 50% of the subjects were male. The median difference in pre-vaccination and postvaccination MBPS scores was lower for EMLA than for placebo (p = 0.001). The latency to the first cry was longer for subjects who were treated with EMLA (p = 0.0004)), but the total crying time was shorter (10.3 seconds vs 25.2 seconds; p = 0.027). Of the study group, 90% (45/50) of subjects treated with EMLA and 12% (6/49) of subjects treated with placebo had local skin reactions (p < 0.0001), mainly skin blanching.

CONCLUSIONS

Pretreatment with EMLA decreases infant pain from DPT vaccinations. Application of these data is limited to healthy infants receiving DPT vaccinations.

Physicians' attitudes toward the diagnosis and management of fever in children 3 months to 2 years of age

Ninety-seven primary-care physicians, including 73 family physicians and 24 pediatricians, were surveyed in order to ascertain their knowledge and attitudes regarding fever in children 3 months to 2 years of age. A rectal temperature between 37.0 degrees C and 37.9 degrees C was considered to indicate fever by 35% of physicians. Only 17% believed there was no danger from fever, while 12% believed that fever could cause brain damage. Seizures were considered a principal danger of fever by 49% of physicians, and 22% believed that brain damage could result from typical febrile seizures. While 70% chose relief of discomfort as the main purpose of antipyretic treatment, 30% would use temperature alone as an indication for antipyretics. It is concluded that although many physicians have an acceptable attitude toward the diagnosis and management of fever, a significant number still have exaggerated concerns.