Impact of Parental Acute Psychological Distress on Young Child Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care. J Clin Psychol Med Settings. 2019;26:516-529. [PMID: 30610521 DOI: 10.1007/s10880-018-9596-1]

Acceptability of a novel device to improve child patient experience during venepuncture for blood sampling: Intervention with 'MyShield'

This study aimed to explore the acceptability of a novel device ('MyShield'): a device used for distraction during clinical procedures. It is a cardboard cuff, designed to fit around the arm, either above the elbow or around the wrist and used to hide the procedure from view. This device was tested in practice, to establish acceptability to children, parents and clinical staff. Fifty-eight children tried 'MyShield' during a venepuncture procedure. Feedback from 54 children, 58 parents/carers and 16 clinical staff was collected using surveys and interviews. In 24 cases, observational data were also collected. A large majority of children (94%, n = 51) and parents (96%, n = 56) reported a positive experience when using 'MyShield'; saying they would likely use it again. Potential of 'MyShield' in promoting parent/clinician interaction with the child was highlighted. Data suggests that 'MyShield' may be a useful device for children undergoing venepuncture, when used in conjunction with standard care, and subject to individual preferences and choice. Further work is required to establish mechanism of action and whether use of 'MyShield' has any impact across a range of short- and long-term outcome measures relating to patient experience and effectiveness.

A Qualitative Analysis on the Experiences of Mothers of Children in Burn Intensive Care Unit: "She burned on the outside, me inside..."

Mothers closely follow the complex process due to the burning of their children. Caring for and supporting the child can pose various challenges for mothers. With the phenomenological method, this study was conducted to investigate mothers' experiences staying with their children in the pediatric burn intensive care unit. Twelve mothers participated in the study. The semistructured face-to-face interviews obtained data. After each interview, the research team transcribed the interviews verbatim. Interpretive Phenomenological Analysis was used to analyze the data. The experiences of the mothers were classified in four contexts as a result of the interpretative phenomenological analysis; "first reactions to burn trauma" related to the awareness that the child has been burned, "being a mother in the burn intensive care unit" related to caring for the child as a companion in the burn intensive care unit, "coping" related to how they cope with the problems throughout the whole process, and "requirements" regarding the subjects it needs in the process. It was determined that mothers went through a physically and emotionally challenging process from the beginning of the burn trauma and throughout the intensive care unit. During this challenging process, it was observed that mothers could not use effective coping methods and did not receive the necessary professional support. In line with these results, it is recommended that psychological support programs be applied to the mothers and that care focused on the needs of the mothers should be provided.

Desktop Virtual Reality Offers a Novel Approach to Minimize Pain and Anxiety during Burn Wound Cleaning/Debridement in Infants and Young Children: A Randomized Crossover Pilot Study

Although most scald burn injuries involve children under six, because of the challenges of using head mounted displays with young children there is very little research exploring the use of VR in children under six. The current clinical pilot study measured the analgesic effectiveness of our new desktop VR system (with no VR helmet) in children under six during burn wound care (a within-subjects design with randomized treatment order). Between December 2021-April 2022, nine children with burn injuries (10 months to 5 years age, mean = 18 months) participated. The mean burn size was 10% Total Body Surface Area, range 2-22%. Using nurse's ratings, VR significantly reduced children's pain during burn wound care by 40% on the observational Faces, Legs, Activity, Crying, and Consolability (FLACC) pain scale. Specifically, non-parametric within-subject sign tests compared nurse's ratings of the young patients' pain during burn wound care using usual pain medications with no VR = 6.67, (SD = 2.45) vs. adjunctive Animal Rescue World VR (VR = 4.00, SD = 2.24, p < 0.01). The observational Procedure-Behavior Checklist (PBCL) nurse's scale measured a 34% reduction in anxiety with VR as compared to pharmacologic treatment alone (p < 0.005). Similarly, when using single graphic rating scales the patients' parents reported a significant 36% decrease in their child's pain during VR (p < 0.05), a 38% (p < 0.005) decrease in their child's anxiety during VR, and a significant increase in patients' joy during VR. It can be concluded that during burn wound care with no distraction (traditional pain medications), children under 6 years old experienced severe pain during a 10 min burn wound cleaning session. During burn wound care combining desktop virtual reality and traditional pain medications, the same pediatric patients experienced only mild pain during burn wound cleaning/debridement. VR significantly reduced the children's pain and anxiety during burn wound care.

The effect of a parental preparation video (Take5) on child and parent anxiety during anaesthetic induction: a protocol for a randomised controlled trial

BACKGROUND

Children undergoing anaesthetic induction experience peri-operative anxiety associated with negative outcomes including emergence delirium, short- and long-term maladaptive behaviour and increased postoperative analgesic requirements. This stems from children's limited ability to communicate, cope, and regulate intense emotions, leading to high dependency on parental emotional regulation. Previous interventions including video modelling, education and distraction techniques before and during anaesthetic induction have demonstrated significant reduction of anxiety levels. No existing interventions combines evidenced-based psychoeducation video with distraction techniques to support parents to moderate peri-operative anxiety. This study aims to test the efficacy of the Take5 video (now referred to as 'Take5'), a short and cost-efficient intervention for child peri-operative anxiety.

METHODS

A randomised, controlled, superiority trial of Take5 compared to standard care. Take5 was developed by paediatric anaesthetists, child psychologists and a consumer panel of parents of children who had experienced surgery and anaesthesia. Children aged 3-10 years presenting for elective surgery at a quaternary paediatric facility will be randomly allocated to the intervention group or standard care. Intervention group parents will be shown Take5 prior to accompanying their child for anaesthesia induction. Primary outcomes include child and parent anxiety at induction, measured by the Modified Yale Preoperative Anxiety Scale Short Form (mYPAS-SF), the Peri-operative Adult-Child Behavior Interaction Scale (PACBIS) and the Induction Compliance Checklist (ICC). Secondary outcomes include post-operative pain, emergence delirium, parental satisfaction, cost-effectiveness, parent and child psychological well-being at 3 months post procedure and video intervention acceptability.

DISCUSSION

Perioperative anxiety is associated with negative outcome in children including higher pharmacological intervention, delayed procedures, and poor post-recovery outcomes resulting in financial burden on health systems. Current strategies minimising paediatric procedural distress are resource-intensive and have been inconsistent in reducing anxiety and negative postoperative outcomes. The Take5 video is an evidence-driven resource that is designed to prepare and empower parents. The success of Take5 will be evaluated by measuring differences in patient (acute and 3-month), family (satisfaction, acceptability), clinician (feasibility) and health service (cost) outcomes, with each anticipated to benefit children.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trial Registry (ACTRN12621001337864) and Children's Health Queensland Hospital and Health Service Human Research Ethics Committee (HREC/21/QCHQ/73894).

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.

Intercultural Differences in the Development of Pediatric Medical Traumatic Stress (PMTS) in Children Following Surgical Hospitalization

Background: Illness, surgery and surgical hospitalization are significant stressors for children. Some children who experience such a medical event may develop Pediatric Medical Traumatic Stress (PMTS). PMTS affects physical recovery, and many areas and functions in children’s lives, both short- and long-term. The aim of the study is to examine the difference in the rate of PMTS between the Arab and Jewish populations and the difference in risk factors for the development of this syndrome. Method: The study involved 252 parents of children aged 1–6 who were hospitalized in the surgical ward of Hadassah Medical Center. During hospitalization, parents completed questionnaires to identify risk factors for the development of PMTS. At 3 months from the time of discharge, the children’s level of PMTS was measured. Results: The rate of children diagnosed with PMTS among Arab children was significantly higher than the rate in the Jewish population. The affiliation to an ethnic group affected different socioeconomic, demographic, social, linguistic and cultural background variables, which in turn affected the emergence of PMTS. Conclusion: The study emphasizes the nature of PMTS at the intercultural level, which can be an important source for theoretically understanding both the disorder and culture, as well as for clinical implications in developing population-sensitive treatment.

Management of non-severe burn wounds in children and adolescents: optimising outcomes through all stages of the patient journey

Paediatric burn injuries are common, especially in children younger than 5 years, and can lead to poor physical and psychosocial outcomes in the long term. In this Review, we aim to summarise the key factors and interventions before hospital admission and following discharge that can improve the long-term outcomes of paediatric burns. Care can be optimised through first aid treatment, correct initial assessment of burn severity, and appropriate patient referral to a burns centre. Scar prevention or treatment and patient follow-up after discharge are also essential. As most burn injuries in children are comparatively small and readily survivable, this Review does not cover the perioperative management associated with severe burns that require fluid resuscitation, or inhalational injury. Burns disproportionately affect children from low socioeconomic backgrounds and those living in low-income and middle-income countries, with ample evidence to suggest that there remains scope for low-cost interventions to improve care for those patients with the greatest burden of burn injury. Current knowledge gaps and future research directions are discussed.

Early non-excisional debridement of paediatric burns under general anaesthesia reduces time to re-epithelialisation and risk of skin graft

Reported advantages of early excision for larger burn injuries include reduced morbidity, mortality, and hospital length of stay for adult burn patients. However, a paucity of evidence supports the best option for paediatric burns and the advantages of non-excisional (mechanical) debridement. Procedural sedation and analgesia in the emergency department is a popular alternative to debridement in operating theatres under general anaesthesia. This study aims to evaluate the association between early (< 24 h post-injury) non-excisional debridement under general anaesthesia with burn wound re-epithelialisation time and skin graft requirements. Cohort study of children younger than 17 years who presented with burns of five percent total body surface area or greater. Data from January 2013 to December 2019 were extracted from a prospectively collected state-wide paediatric burns' registry. Time to re-epithelialisation was tested using survival analysis, and binary logistic regression for odds of skin graft requirementto analyse effects of early non-excisional debridement in the operating theatre. Overall, 292 children met eligibility (males 55.5%). Early non-excisional debridement under general anaesthesia in the operating theatre, significantly reduced the time to re-epithelialisation (14 days versus 21 days, p = 0.029)) and the odds of requiring a skin graft in comparison to paediatric patients debrided in the emergency department under Ketamine sedation (OR: 6.97 (2.14-22.67), p < 0.001. This study is the first to demonstrate that early non-excisional debridement under general anaesthesia in the operating theatre significantly reduces wound re-epithelialisation time and subsequent need for a skin graft in paediatric burn patients. Analysis suggests that ketamine procedural sedation and analgesia in the emergency department used for burn wound debridement is not an effective substitute for debridement in the operating theatre.

Parents' lived experiences of parental needs for support at a burn centre

Purpose: A burn injury to a child is a traumatic event and the parent's emotional reactions and coping strategies affect the child's adaptive outcome. It is therefore important that parents get the right support. The aim was to explore parents' lived experiences of their need for support when having a child admitted to a burn centre. Methods: Semi-structured face-to-face interviews were conducted with 22 parents of children age <12 years hospitalised with an accidental burn injury, 9 to 27 days after the burn accident, from April 2017 to July 2018. A Ricoeur-inspired textual analysis method was used. Results: Four themes emerged from the analysis and describe the parents' needs for support. The parents wanted to be taken care of as a whole family and feel safe in the hands of professionals. This, in turn, depended on being informed about the child's condition and treatment, but also on getting help in dealing with feelings of guilt. Not least, parents wanted opportunities to take care of their own fundamental needs in terms of hygiene, food, adequate rest and activities. Conclusion: As an overall understanding the healthcare providers should focus on the family as a whole in care and treatment.

Topical Review: Medical Trauma During Early Childhood

OBJECTIVE

Early childhood is a high-risk period for exposure to traumatic medical events due to injury/illness. It is also one of the most important and vulnerable periods due to rapid development in neurobiological systems, attachment relationships, cognitive and linguistic capacities, and emotion regulation. The aim of this topical review is to evaluate empirical literature on the psychological impact of medical trauma during early childhood (0-6 years) to inform models of clinical care for assessing, preventing, and treating traumatic stress following injury/illness.

METHODS

Topical review of empirical and theoretical literature on pediatric medical traumatic stress (PMTS) during early childhood.

RESULTS

There are important developmental factors that influence how infants and young children perceive and respond to medical events. The emerging literature indicates that up to 30% of young children experience PMTS within the first month of an acute illness/injury and between 3% and 10% develop posttraumatic stress disorder. However, significant knowledge gaps remain in our understanding of psychological outcomes for infants and young children, identification of risk-factors and availability of evidence-based interventions for medical trauma following illness.

CONCLUSIONS

This topical review on medical trauma during early childhood provides: (a) definitions of key medical trauma terminology, (b) discussion of important developmental considerations, (c) summary of the empirical literature on psychological outcomes, risk factors, and interventions, (d) introduction to a stepped-model-of-care framework to guide clinical practice, and (e) summary of limitations and directions for future research.

The Management of Burn Pain in a Pediatric Burns-Specialist Hospital

Appropriate pain management for children who have experienced an acute burn injury is critical to improve patient outcomes and reduce potential morbidities. With 60% of our patients being under the age of 4 years, pain management is crucial in reducing pain and anxiety in both patients and parents. It is imperative that appropriate pain relief is commenced from initial contact with healthcare workers as this will affect the success or failure of future wound procedures. Uncontrolled pain can negatively affect a patient, both short and long term. It may cause anticipatory anxiety for future medical procedures, increased pain and anxiety can decrease wound re-epithelialization which can lead to long-term consequences for growth and mobility, and increased pain can also influence the possibility of patients and families displaying signs of post-traumatic stress disorder. Pain management in the form of pharmaceuticals is imperative during burn wound treatment and should incorporate pain relief targeted at both background and procedural pain. It also requires a multimodal, individualized, and targeted approach combining both pharmaceutical and nonpharmaceutical techniques, including cold running water, multimodal distraction devices, hypnotherapy, and bubbles. We discuss the research and knowledge that our center has gained through treating pediatric patients with burns over the last 20 years.

Parent and Clinician Communication During Paediatric Burn Wound Care: A Qualitative Study

PURPOSE

To thematically describe parent-clinician communication during a child's first burn dressing change following emergency department presentation.

DESIGN AND METHODS

An observational study of parent-clinician communication during the first burn dressing change at a tertiary children's hospital. Verbal communication between those present at the dressing change for 87 families, was audio recorded. The recordings were transcribed verbatim and transcripts were analysed within NVivo11 qualitative data analysis software using qualitative content analysis.

FINDINGS

Three themes, underpinned by parent-clinician rapport-building, were identified. Firstly, knowledge sharing was demonstrated: Clinicians frequently informed the parent about the state of the child's wound, what the procedure will involve, and need for future treatment. Comparatively, parents informed the clinician about their child's temperament and coping since the accident. Secondly, child procedural distress management was discussed: Clinicians and parents had expectations about the likelihood of procedural distress, which was also related to communication about how to prevent and interpret procedural distress (i.e., pain/fear). Finally, parents communicated to clinicians about their own distress, worry and uncertainty, from the accident and wound care. Parents also communicated guilt and blame in relation to injury responsibility.

CONCLUSIONS

This study provides a description of parent-clinician communication during paediatric burn wound care.

PRACTICAL IMPLICATIONS

The results can assist healthcare professionals to be prepared for a range of conversations with parents during potentially distressing paediatric medical procedures.

Long-term medical treatment of patients with severe burns at exposed sites

BACKGROUND

Body parts such as the face and hands are highly exposed during daily life and burns may accumulate in these areas. In addition, residual wounds, scar hyperplasia and contracture often exist in the late stage of a deep burn in these areas, which may affect patients’ appearance, movements, and mental health. However, inadequate attention has been paid to this issue which can result in problems, such as difficulty in healing, possibility of carcinoma, chronic pain and a heavy mental burden.

AIM

To investigate the long-term medical treatment of patients with severe burns at exposed sites following a mass burn casualty event.

METHODS

A retrospective analysis of 13 patients with severe burns at exposed sites was performed to determine their respective long-term medical treatment. A combined wound dressing scheme consisting of traditional Chinese and Western medicine was introduced to repair residual wounds. Active and passive functional exercises with massage, Chinese herbal baths and compression fixation were proposed to ameliorate the condition of the hands. A combination of physical, chemical and photoelectrical measures was adopted for anti-scar treatment. A psychological intervention and recovery guide was provided which corresponded to the patients’ psychological status.

RESULTS

Compared to patients who did not simultaneously receive the same treatment, patients who underwent systematic treatment recovered with a lower wound infection rate (P < 0.05), a shorter healing time (13.6 ± 3.2 d) compared with (19.1 ± 3.5 d) and more bearable pain during wound dressing at three days, one week and two weeks after a Chinese herbal bath (P < 0.05). Satisfactory results were achieved with regard to restored function of patients’ joints and blood supply to nerve endings, closure of the eyelids and the size of mouth opening tended to be normal, and only 7.1% of patients were diagnosed with severe scar hyperplasia and contracture deformity compared with 30.7% in the control group. In addition, the color, thickness, vascular distribution and softness score of the scars improved (P < 0.01), and the effects of the psychological intervention was remarkable as shown by the Self-Rating Anxiety Scale and Self-Rating Depression Scale.

CONCLUSION

A better prognosis can be achieved in patients in the late stage of a burn with active residual wound repair, limb functional exercise, anti-scar and psychological rehabilitation.

Understanding differences in the long-term psychosocial adjustment of pediatric cancer patients and their parents: an individual differences resources model

The experience of childhood cancer is a major life stressor for children and their parents. There is substantial variability among pediatric cancer patients and their parents in their ability to cope with the cancer. Although other models typically focus on the psychological resources families use to broadly cope with a diagnosis of pediatric cancer, we present a model that focuses specifically how parents and children cope with the stress of invasive and often painful treatment episodes. Our resources model is further distinct with its focus on individual differences in personal (e.g., personality traits) and social (e.g., social support) resources and the role these differences may play in psychosocial adjustment of families confronting pediatric cancer. We use findings from the broader pediatric cancer research literature and our own 15-year program of research on individual differences in psychological resources and parents and children's responses to treatment episodes to provide empirical support for our model. Support was found for the six premises of the model: (a) parent resources influence their longer-term psychosocial adjustment, (b) parent resources influence children's responses to treatment episodes, (c) parent resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes, (d) children's personal resources influence how parent responses to treatment episodes, (e) children's resources influence their longer-term psychosocial adjustment, and (f) children's resources indirectly influence their longer-term psychosocial adjustment through their responses to treatment episodes. Understanding how the availability of resources influences parents and children confronting cancer provides a foundation for future research on individual differences in resources and offers other avenues through which clinicians can assess and treat families at risk for poor psychosocial adjustment during treatment and in their life beyond cancer treatments.

Staff Members’ Experience of Providing Parental Support in a National Burn Centre

Background

Paediatric burn injuries affect not only the child but the whole family, especially the parents. Knowledge of how parents are affected psychologically has increased, but there is an ongoing dearth of literature on parental support while hospitalised. There is also very little documentation of the ways in which burn staff members support parents.

Objectives

To explore staff members’ lived experiences of supporting parents with children hospitalised at a burn centre due to a burn injury.

Methods

Four focus group interviews were conducted in 2017 with a total of 21 staff members at the National Burn Centre in Norway. Seven different burn staff professions participated. Data were analysed using a Ricoeur-inspired method for text analysis and managed using NVivo 12Plus.

Results

Four themes were identified in the treatment trajectory: creating a safe, secure and trusting environment from the moment parents enter the burn centre; helping parents deal with feelings of guilt; helping parents navigate in their daily routines while continuing to be a mother or father; and gradually involving parents in wound treatment as preparation for discharge.

Conclusion

Staff must carefully consider their verbal and non-verbal (body) language and how to approach parents from the very moment they enter the burn ward. Most parents are affected by feelings of guilt and these feelings must be addressed and processed. During the treatment trajectory, parents are guided to participate in the daily care of their child and are gradually assisted in taking over the wound treatment prior to discharge.

The role of parental acute psychological distress in paediatric burn re-epithelialization

OBJECTIVES

Following a paediatric burn, parents commonly experience high levels of acute psychological distress, which has been shown to increase child psychological distress as well as child procedural distress. The influence of psychological stress and perceived pain on wound healing has been demonstrated in several laboratory and medical populations. This paper investigates the influence of parental acute psychological distress and procedural behaviour on the child's rate of re-epithelialization, after controlling for child procedural distress.

DESIGN

A prospective observational study with longitudinal outcome.

METHODS

Eighty-three parents of children 1-6 years old reported acute psychological distress (post-traumatic stress symptoms [PTSS], guilt, pre-procedural fear, general anxiety/depression symptoms) in relation to their child's burn. A researcher observed parent-child behaviour at the first dressing change, and parents and nurses reported child procedural distress (pre-, peak-, and post-procedural pain and fear). These variables, along with demographic and injury information, were tested for predicting time to re-epithelialization. Date of re-epithelialization was determined by the treating consultant.

RESULTS

Days to re-epithelialization ranged from 3 to 35 days post-injury. A hierarchical multiple regression analysis found wound depth and size significantly accounted for 28% of the variance in time to re-epithelialization. In Block 2, child peak-procedural pain significantly accounted for 6% additional variance. In Block 3, parental PTSS significantly accounted for 5% additional variance.

CONCLUSIONS

Parental PTSS appears to be an important but under-recognized factor that may influence their child's burn re-epithelialization. Further investigation is required to understand the mechanisms contributing to this association. Statement of contribution What is already known on this subject? Psychological stress delays wound healing, and this relationship has been found in paediatric burn populations with procedural pain. Parental psychological stress is often present after a child's burn and is related to the child's procedural coping and distress. What does this study add? Parental post-traumatic stress is related to delayed child burn re-epithelialization. This association is in addition to procedural pain delaying re-epithelialization.