Comfort First: an evaluation of a procedural pain management programme for children with cancer

Pilot testing "Teach Ted": A digital application for children undergoing blood tests and their parents

Objective

In this pilot study, we evaluated the acceptability and preliminary evidence of the impact of a new educational mobile application, "Teach Ted", for children undergoing blood tests.

Methods

Parents of children (4-10 years) completed questionnaires on anxiety and pain before their child had a blood test, and after using Teach Ted and receiving their blood test. Health professionals at each patient's blood test (e.g. technician/nurse) completed questionnaires on patient outcomes and procedure-related outcomes (e.g. time taken).

Results

Nine parents and eight health professionals participated. All but one parent (n = 8/9) reported Teach Ted was useful. Seventy-eight percent (n = 7/9) reported they would use Teach Ted again. All health professionals who completed the acceptability measure (n = 3/3) strongly agreed that Teach Ted was relevant/helpful. Many parents perceived Teach Ted helped reduce their/child's anxiety (n = 3/5, 60% and n = 4/6, 67% respectively), although child's pain and child's/parent's anxiety remained similar before and after using Teach Ted (all p > 0.05). The average blood test duration was 7.6 min (range ≤1 to 22), which health professionals (n = 3/3) reported was not elongated by offering Teach Ted.

Conclusions

Participants reported that Teach Ted was acceptable. Further evaluation of Teach Ted's impact on patient's outcomes are needed.

Innovation

Teach Ted is an innovative mobile application with potential to educate young children about their upcoming procedure and mitigate negative outcomes.

Captains on call: A qualitative investigation of an intervention to support children with retinoblastoma undergoing regular eye examinations

BACKGROUND

Retinoblastoma is a rare childhood ophthalmic cancer that requires frequent eye examinations under anaesthesia and painful or distressing procedures. This can cause significant anxiety for children and their families.

OBJECTIVE

We evaluated a Starlight Children's Foundation programme, 'Captains on Call', at the Queensland Children's Hospital, which aims to provide positive distraction and reduce stress, anxiety and pain during the perioperative journey for children in the retinoblastoma treatment pathway. This study examined the impact of the programme on the perioperative experience of the children and their families, using a qualitative design.

METHODS

This study was conducted in a paediatric operating suite at a tertiary-level children's hospital in Australia. We interviewed a parent from 20 families (from a cohort of 40 families, including 44 children), whose children received treatment or screening for retinoblastoma, focusing on the programme's impact on the child and family at various stages during the perioperative journey. We undertook a thematic analysis of transcribed interviews.

RESULTS

We identified two themes, each with two sub-themes: (1) the programme positively contributed to the overall treatment journey, by addressing different needs at different times, and helping to reframe a traumatic medical experience, and (2), the programme supported the whole family unit by empowering children through play, and adopting a family systems approach which recognised the impact of cancer treatment on the whole family.

CONCLUSION

This study highlights the value of the Captains on Call programme in supporting children with retinoblastoma and their families during perioperative visits. The Captains, particularly as non-medicalised professionals in a healthcare setting, built trust and rapport with the children through play over repeated episodes of care. The interprofessional collaborative approach with a reflective cycle of practice extended it beyond a programme providing simple distraction. Other retinoblastoma services may benefit from implementing a similar approach.

Exploring reported distress before and pain during needle insertion into a venous access port in children with cancer

BACKGROUND

Venous access port is commonly used during cancer treatment in children, yet little is known about how children experience such needle insertion procedures.

AIM

To study distress before and pain after venous access port needle insertion among children and adolescents with cancer. A second aim was to explore associations between their self-report of procedure-related distress and pain with proxy reports by parents and nurses.

METHOD

The sample included 43 children/adolescents, aged 1-16 years with cancer, treated at two Norwegian university hospitals. The patient, parent(s), and the nurse performing the procedure completed developmentally appropriate 11-point distress and pain scales before and immediately after the venous access port procedure. Data were analysed using descriptive statistics and non-parametric correlations.

ETHICAL ISSUES

The ethical code of conduct was followed and conformed to the ethical guidelines adopted by the Regional Committee for Medicine and Health Research and the data protector officer at the hospitals.

RESULTS

For the youngest children (1-5 years), the median distress proxy score was 8 (range 0-9) and pain proxy score 4 (range 0-10). Median distress and pain scores for children aged 6-12 years were 3 (range 0-9) and 1 (range 0-10), respectively, and for the adolescents (age 13-16) 0 (range 0-6) and 1 (range 0-5), respectively. Patients' self-reported distress and pain correlated highly with parents' (distress: rho = 0.83, p < 0.001, pain: rho = 0.92, p < 0.001) and with nurses' proxy ratings (distress: rho = 0.89, p < 0.001, pain: rho = 0.88, p < 0.001).

CONCLUSION

There were individual age differences in experienced distress/pain associated with venous access port needle insertion, with a trend for younger children to experience higher levels of distress/ pain than the older children. Children's self-report of distress/ pain concurred with both parental and nurse proxy reports.

The effect of visual and/or auditory distraction techniques on children's pain, anxiety and medical fear in invasive procedures: A randomized controlled trial

PURPOSE

This study was conducted to determine the effects of visual and/or auditory distraction techniques applied to children aged 7-12 during invasive procedures on pain, anxiety, and medical fear.

METHODS

This single-blinded, randomized controlled trial was carried out in the pediatric emergency department of a public hospital between November 2021 and March 2022. In the study, 144 children were assigned to three different intervention groups, in which a kaleidoscope, music, and virtual reality were applied during invasive procedures, and the control group in which the standard invasive procedure was applied, by using the stratified block randomization method. The data were collected using a Personal Information Form, Wong-Baker Faces Pain Rating Scale, Children's Anxiety Meter-State, and Child Medical Fear Scale.

RESULTS

In the study, the levels of pain, anxiety, and medical fear after the invasive procedure were lower in the intervention groups than in the control group. In addition, there was no difference between the three different distraction techniques in terms of reducing pain and medical fear, but the virtual reality application was more effective in reducing the level of anxiety.

CONCLUSION

Visual and/or auditory distraction techniques are effective methods that can be used by nurses in pediatric healthcare to reduce invasive procedure-related pain, anxiety, and medical fear.

IMPLICATIONS FOR PRACTICE

This study provides evidence that can guide the use of non-pharmacological methods such as distraction to prevent the traumatic effects of invasive procedures in children.

Parent perceptions of pediatric oncology care during the COVID-19 pandemic: An Australian study

BACKGROUND

We examined parents' perceptions of their child's oncology care during a period of significant COVID-19 restrictions in Australia.

METHODS

Parents of children, 0-18 years, receiving hospital-based cancer treatment, completed a survey examining their COVID-19 exposure and impact, information and knowledge, and perception of their child's medical care. Recruitment occurred between October and November 2020.

RESULTS

Eighty-four parents (95% mothers) completed the survey. Sixty-seven percent of patients were diagnosed pre-COVID-19. The majority of parents (76%) reported negative impacts of COVID-19 on family life, including parenting and emotional well-being despite exposure to COVID-19 cases being very low (4%). Family functioning and parent birthplace were associated with COVID-19 impact and distress. Parents perceived the hospital as a safe place during the pandemic. Very few parents reported delaying presentation to the emergency department (12%). The majority identified no change (69%) or delay (71%) in their child's treatment delivery. Over 90% of parents were confident that COVID-19 did not impact medical decision-making. They felt confident in their COVID-19 knowledge and sought information from trusted sources. Parents reported a positive relationship with their child's care team (93%); however, access to some support services was reduced.

CONCLUSION

Understanding patient and family experiences of pediatric oncology care across international contexts during the pandemic is important to inform present and future health care responses. In the Australian context of low infection rates and strict community restrictions, parents perceived their child's oncology care to be relatively unaffected. However, findings indicate that family well-being was impacted, which warrants further investigation.

General anesthesia, conscious sedation, or nothing: Decision-making by children during painful procedures

BACKGROUND

Following diagnosis, children with cancer suddenly find themselves in an unknown world where unfamiliar adults make all the important decisions. Children typically experience increasing levels of anxiety with repeated invasive procedures and do not adapt to the discomfort. The aim of the present study is to explore the possibility of asking children directly about their medical support preferences during invasive procedures.

PROCEDURE

Each patient was offered a choice of medical support on the day of the procedure, specifically general anesthesia (GA), conscious sedation (CS), or nothing. An ad hoc assessment tool was prepared in order to measure child discomfort before, during, and after each procedure, and caregiver adequacy was measured. Both instruments were completed at each procedure by the attending psychologist.

RESULTS

We monitored 247 consecutive invasive procedures in 85 children and found that children in the 4 to 7 year age group showed significantly higher distress levels. GA was chosen 66 times (26.7%), CS was chosen 97 times (39.3%), and nothing was chosen 5 times and exclusively by adolescents. The child did not choose in 79 procedures (32%). The selection of medical support differed between age groups and distress level was reduced at succeeding procedures.

CONCLUSIONS

Offering children the choice of medical support during invasive procedures allows for tailored support based on individual needs and is an effective modality to return active control to young patients, limiting the emotional trauma of cancer and treatment.

Suggesting a Practical Theory to Oncology Nurses: Case Report of a Child in Discomfort

PURPOSE

Children with cancer are faced with many challenges related to their disease that disturbs their comfort. The aim of this study was to apply Kolcaba's comfort theory for a child with cancer.

DESIGN

A case study design was used.

METHODS

We applied Kolcaba's comfort theory for a young boy with cancer who was sad and in discomfort because of intravenous access procedures. Following Kolcaba's taxonomy of needs for comfort in the spiritual and mental level, we designed a new intervention.

FINDINGS

Kolcaba's comfort theory is an appropriate approach which not only helps to assess and evaluate comfort holistically but also assists in performing innovative interventions to provide comfort for children with cancer.

CONCLUSIONS

Kolcaba's comfort theory is a practical theory for oncology nurses.

CLINICAL RELEVANCE

Nursing theories can improve the quality of clinical care.

Thoracostomy Tube Removal: Implementation of a Multidisciplinary Procedural Pain Management Guideline

OBJECTIVE

Thoracostomy tubes are placed following cardiothoracic surgery for the repair or palliation of congenital heart defects. The aim of this project was to develop and implement a clinical practice guideline for the provision of optimal analgesia during removal of thoracostomy tubes in pediatric postoperative cardiothoracic surgery patients.

METHODS

Methods used include a nonexperimental design utilizing chart audits to determine baseline documentation as well as procedure note evaluation to determine both baseline documentation and compliance with the new guideline. A convenience sample of unit-based nurses completed a knowledge test and a post-implementation survey.

RESULTS

There was a significant increase in nursing knowledge related to the clinical practice guideline education and implementation. Documentation compliance was observed. Nursing satisfaction and feasibility of the new guideline was demonstrated.

DISCUSSION

This project was successful in increasing nursing knowledge of available resources for optimal procedural pain management in pediatric patients requiring thoracostomy tube removal on one in-patient acute care unit.

Pain assessment and management in paediatric oncology: a cross-sectional audit

AIMS AND OBJECTIVES

To describe the pain assessment and management practices documented by health professionals within a tertiary-level Children's Cancer Centre and to evaluate how these practices were compared with international recommendations.

BACKGROUND

Children with cancer are vulnerable to pain due to the intensity of antineoplastic therapy. Therefore, it is imperative to ensure that current pain management practices provided to paediatric oncology inpatients are of a high quality.

DESIGN

A single-site cross-sectional audit.

METHODS

A 24-hour period of documented pain-related care in randomly selected inpatients of an Australian tertiary-level Children's Cancer Centre was examined. The current pain management practices were audited over a two-month period resulting in 258 episodes of pain-related care being reviewed.

RESULTS

Pain related to medical treatment for cancer was common (n = 146/258, 57%) and persistent. The presence of pain was not consistently recorded by health professionals (n = 75/146, 51%). Pain was mild (n = 26/75, 35%) and opioids were the mainstay of pain management interventions (n = 63/112, 56%). Adjuvants were an important component of pain management (n = 47/112, 42%), and nonpharmacological methods of managing pain were under-represented in this audit (n = 38/146, 26%). According to the Pain Management Index, pain was appropriately managed for the majority of children (n = 65/76, 87%).

CONCLUSIONS

Pain management practices did not fully reflect the recommendations of contemporary paediatric pain management. Due to limitations in the documentation of children's pain, it was difficult to determine the effectiveness of pain management interventions.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the ongoing problem of pain for children receiving antineoplastic therapy. It is recommended that health professionals routinely screen for the presence of pain during hospitalisation and assess the efficacy of pain-related care.

Retinoblastoma

Retinoblastoma is a rare cancer of the infant retina that is diagnosed in approximately 8,000 children each year worldwide. It forms when both retinoblastoma gene (RB1) alleles are mutated in a susceptible retinal cell, probably a cone photoreceptor precursor. Loss of the tumour-suppressive functions of the retinoblastoma protein (pRB) leads to uncontrolled cell division and recurrent genomic changes during tumour progression. Although pRB is expressed in almost all tissues, cone precursors have biochemical and molecular features that may sensitize them to RB1 loss and enable tumorigenesis. Patient survival is >95% in high-income countries but <30% globally. However, outcomes are improving owing to increased disease awareness for earlier diagnosis, application of new guidelines and sharing of expertise. Intra-arterial and intravitreal chemotherapy have emerged as promising methods to salvage eyes that with conventional treatment might have been lost. Ongoing international collaborations will replace the multiple different classifications of eye involvement with standardized definitions to consistently assess the eligibility, efficacy and safety of treatment options. Life-long follow-up is warranted, as survivors of heritable retinoblastoma are at risk for developing second cancers. Defining the molecular consequences of RB1 loss in diverse tissues may open new avenues for treatment and prevention of retinoblastoma, as well as second cancers, in patients with germline RB1 mutations.

Individual differences in chemotherapy-induced anticipatory nausea

Anticipatory Nausea (AN) is a severe side effect of chemotherapy that can lead cancer patients to discontinue their treatment. This kind of nausea is usually elicited by the re-exposure of the patients to the clinical context they need to attend to be treated. There has been considerable agreement that AN represents a paradigmatic example of Pavlovian conditioning, and within this framework, several behavioral interventions have been proposed in order to prevent this phenomenon. However, some studies have questioned the validity of the Pavlovian approach, suggesting that CS-US associations are neither necessary nor sufficient for AN to occur. The data and the alternative theories behind such criticisms are discussed. Additionally, it is suggested that animal models of AN could be enriched by taking into account rats' individual differences.