Pediatric pre-tonsillectomy education programs: A systematic review

Evaluating the accuracy and readability of ChatGPT in providing parental guidance for adenoidectomy, tonsillectomy, and ventilation tube insertion surgery

OBJECTIVES

This study examined the potential of ChatGPT as an accurate and readable source of information for parents seeking guidance on adenoidectomy, tonsillectomy, and ventilation tube insertion surgeries (ATVtis).

METHODS

ChatGPT was tasked with identifying the top 15 most frequently asked questions by parents on internet search engines for each of the three specific surgical procedures. We removed repeated questions from the initial set of 45. Subsequently, we asked ChatGPT to generate answers to the remaining 33 questions. Seven highly experienced otolaryngologists individually assessed the accuracy of the responses using a four-level grading scale, from completely incorrect to comprehensive. The readability of responses was determined using the Flesch Reading Ease (FRE) and Flesch-Kincaid Grade Level (FKGL) scores. The questions were categorized into four groups: Diagnosis and Preparation Process, Surgical Information, Risks and Complications, and Postoperative Process. Responses were then compared based on accuracy grade, FRE, and FKGL scores.

RESULTS

Seven evaluators each assessed 33 AI-generated responses, providing a total of 231 evaluations. Among the evaluated responses, 167 (72.3 %) were classified as 'comprehensive.' Sixty-two responses (26.8 %) were categorized as 'correct but inadequate,' and two responses (0.9 %) were assessed as 'some correct, some incorrect.' None of the responses were adjudged 'completely incorrect' by any assessors. The average FRE and FGKL scores were 57.15(±10.73) and 9.95(±1.91), respectively. Upon analyzing the responses from ChatGPT, 3 (9.1 %) were at or below the sixth-grade reading level recommended by the American Medical Association (AMA). No significant differences were found between the groups regarding readability and accuracy scores (p > 0.05).

CONCLUSIONS

ChatGPT can provide accurate answers to questions on various topics related to ATVtis. However, ChatGPT's answers may be too complex for some readers, as they are generally written at a high school level. This is above the sixth-grade reading level recommended for patient information by the AMA. According to our study, more than three-quarters of the AI-generated responses were at or above the 10th-grade reading level, raising concerns about the ChatGPT text's readability.

Parents' Perception on Post-tonsillectomy Hemorrhage: A Local Survey

INTRODUCTION

Tonsillectomy (often combined with adenoidectomy) is one of the oldest and most common surgical procedures performed in otolaryngology. Post-operative complications following tonsillectomy are generally rare and include post-tonsillectomy hemorrhage, dehydration, velopharyngeal insufficiency, and others. Parents play a crucial role in the care and recovery of their children after tonsillectomy. Their perception and understanding of post-tonsillectomy hemorrhage are essential in managing and addressing this potential complication.

AIM

The purpose of this study is to assess parents' perception of post-tonsillectomy hemorrhage and factors that would lead to its development.

METHODS

A descriptive cross-sectional study was conducted targeting parents of children who had undergone surgical tonsillectomy. Data were collected using a pre-structured online questionnaire, biographical data, tonsillectomy data, child medical and drug history, healthcare staff role, and post-surgical complications and bleeding.

RESULTS

A total of 847 parents completed the study questionnaire, and 431 (50.9%) were fathers. As for education, 164 (19.4%) had a university level of education, and 279 (32.9%) had a post-graduate degree. As for child gender, 445 (52.5%) were males, 232 (27.4%) had undergone the surgery in the first five years of their age, 208 (24.6%) at the age of 6-10 years, and 221 (26.1%) undergone the surgery at the age of 16-18 years. The most reported post-surgical complications included headaches and nausea (52.4%), swelling of the roof of the mouth (51.8%), and infection (48.9%). Primary or secondary post-tonsillectomy hemorrhage was reported among 47 (5.5%) of the children, which was during surgery among 12 (25.5%), within 24 hours after surgery among 14 (29.8%), and after 24 hours of surgery among 21 (44.7%).

CONCLUSION

The current study revealed a high rate of tonsillectomy-associated bleeding with a shortage regarding the role of healthcare staff in child pre-surgical assessment and also in parents' education regarding expected complications.

A Mobile Application for Child-Focused Tonsillectomy Education: Development and User-Testing

OBJECTIVE

Patient education is central to Enhanced Recovery After Surgery protocols, but child-focused materials are lacking. We developed and piloted a mobile application to support accessible, interactive patient and caregiver education about pediatric tonsillectomy.

METHODS

Thirty children ages 5-12 who were preparing for tonsillectomy, their caregivers, and six attending otolaryngologists participated in a user-testing trial of a web-based prototype. The trial measured feasibility, fidelity, and patient-centered outcomes. Patients and caregivers rated usability/likeability on the mHealth App Usability Questionnaire. Otolaryngologists rated quality on the Mobile App Rating Scale. The full mobile application, "Ready for Tonsillectomy," was then developed for iOS and Android.

RESULTS

Enrollment was 88.2%, retention was 90.0%, and use was 96.3%. Mean (SD) patient ratings for usability/likeability were 6.3 (1.1) out of 7; caregiver ratings were 6.5 (1.1). In common themes from open-ended feedback, patients described the application as helpful and appealing, and caregivers described it as informative, easy to understand, calming, and easy to use. Among caregivers who used the application during recovery, 92.3% reported that it helped them manage their child's pain. Providers would recommend the application to many or all of their patients (mean [SD]: 4.7 [0.5] out of 5). Mean provider ratings for domains of engagement, functionality, aesthetics, information quality, subjective quality, and app-specific value ranged from 4.1 to 4.8 out of 5.

CONCLUSION

Feasibility and fidelity were high. Families and otolaryngologists endorsed the resource as an engaging, informative tool that supports positive coping. Our mobile application offers a patient-centered solution readily scalable to other surgeries.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:2455-2463, 2024.

Applying the Participatory Slow Design Approach to a mHealth Application for Family Caregivers in Pediatric Ear, Nose, and Throat Surgery

Pediatric ear, nose, and throat (ENT) surgery is very common, and its outcomes may improve with family education. In this regard, mobile health (mHealth) applications (apps), which are on the rise due to digital transformation, can be beneficial in healthcare. This study outlines the user-centered design and development of a mHealth app (version 5.15.0) to support family caregivers during the perioperative process of pediatric ENT surgery. Conducted over two years in an Italian maternal and child health hospital (January 2020-May 2022), the study employed a participatory design method based on the Information System Research (ISR) framework and guided by the principles of Slow Medicine. Utilizing the Relevance, Rigor, and Design cycles of the ISR framework, the mHealth app's content, functionalities, and technical features were defined and developed. A committee of fifteen experts guided the process with input from 25 family caregivers and 24 healthcare providers enrolled in the study. The mHealth app content was structured around five crucial educational moments characterizing the ENT perioperative period, providing evidence-based information on surgical procedures, strategies for preparing children for hospitalization and surgery, pain management, and post-discharge care. The mHealth app featured a function that sends customized notifications to guide caregivers at specific perioperative stages. The development of mHealth apps by implementing a rigorous, participatory, and Slow design process can foster accessible and family-centered information and care in the field of maternal and child health and beyond.

A service evaluation of the impact of parental information provision on analgesia administration at home posttonsillectomy

INTRODUCTION

Tonsillectomy and adenotonsillectomy are together the most common pediatric surgical procedure and are increasingly performed as day cases. Postoperative pain is commonly severe for 1-2 weeks, but parental analgesia concerns lead to poor analgesia prescription compliance and under administration. This service evaluation assessed parental compliance with analgesia, elicited parental concerns, and obtained parental suggestions for improving the current written advice.

METHODS

Telephone questionnaires were completed on postoperative Days 3/4 and 7 with 42 parents of pediatric (adeno)-tonsillectomy patients over a 6-month period, peri-pandemic. The questionnaire collected categorical data on: analgesia prescribed and administered, the child's symptoms, and healthcare resource use. Qualitative data on barriers to analgesia administration and suggestions for written advice improvement were grouped thematically.

RESULTS

Sore throats were reported by 93.3% parents between discharge and Day 3/4 but only 43.3% parents had 100% compliance with regular paracetamol and ibuprofen in the same time period. Parents frequently avoided morphine administration, expressing concerns about side effects, addiction, and previous experience. Parents were also concerned about using ibuprofen, discrepancies between weight-based and bottle instruction doses, and the length of the analgesia course. Parents would like further written information and reassurance on these topics as well as guidance on tapering or stopping analgesics and whether to wake their child at night.

CONCLUSION

The breadth of unmet information needs identified in this service evaluation, alongside parental suggestions, will be used to improve the current written advice with the aim to improve the postoperative pain experience at home. These include information on length of analgesic course, safety of ibuprofen and paracetamol coadministration for analgesia, and details about morphine administration, including safety, side effects, and indication.

Non-pharmacological interventions to reduce anxiety among children undergoing surgery: A systematic review

A hospitalized child experiences anxiety more frequently as compared to non-hospitalized children. Surgery can be emotionally distressing for children, and subsequently their parents and caregivers, this distress can cause profound adverse impacts on children. We aimed to identify the effect of non-pharmacological interventions on children's (1-18 years) anxiety undergoing surgery. The following databases: Medical Literature Analysis and Retrieval System Online (MEDLINE), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Proquest, Web" of Science, and Cochrane Central Register of Controlled Trials were systematically searched for full-text articles. The review included 15 randomized controlled trials. The risk of bias was assessed using Cochrane Risk of Bias tool. The interventions included in the study were preoperative education, puppet play, therapeutic play, distraction activities, parental presence, and clown therapy. The review presents a narrative reporting of the findings. This review identifies that non-pharmacological interventions are effective in reducing anxiety among children undergoing surgery. There are a limited number of studies from developing countries. Further research is required to underpin the use of these interventions with children before surgery.

Parents' perspective on recovery at home following adenotonsillectomy: a prospective single-centre qualitative analysis

PURPOSE

In North America, pediatric adenotonsillectomy (TA) is conducted as an ambulatory procedure, thus shifting the burden of postoperative care to parents. The purpose of this study was to describe this parental experience.

METHODS

We conducted a prospective single-centre qualitative study, recruiting the families of children (n = 317) undergoing elective TA in 2018. Parents were invited to submit written comments to two open-ended questions. We coded the comments from 144 parents in a grounded theory analysis and report representative exemplars. Themes and subthemes for the problems encountered, and strategies employed by parents, were developed. We then coded and classified factors that helped/hindered parents and developed models of the experience.

RESULTS

Some parents felt ill-prepared for the severity and duration of pain. Specific findings included a lack of strategies to manage pain at night, refusals, and night terrors. Parents identified the use of pain scales, pain diaries, and liaison with the research team as helpful supports at home. Inconsistent messaging was a barrier. The odynophagia associated with elixirs of acetaminophen and ibuprofen was a barrier to achieving analgesia.

CONCLUSIONS

The findings from this qualitative analysis provide insight into the challenges faced by parents when caring for their children at home following TA; these challenges included difficulties managing physical needs and pain. The analysis suggests that educational content should be standardized and include the use of pain scales and diaries, and both pharmacologic and nonpharmacologic strategies. Development of support at home, including a practicable liaison with health care providers, seems to be warranted.

STUDY REGISTRATION

ClinicalTrials.gov (NCT03378830); registered 20 December 2017.

Study protocol for a randomised controlled trial to determine the effectiveness of a mHealth application as a family supportive tool in paediatric otolaryngology perioperative process (TONAPP)

BACKGROUND

Otorhinolaryngology (ORL) surgery is common in children, but hospitalisation, surgery, and home care after discharge are stressful experiences for young patients and their family caregivers. Findings from literature highlight a lack of time in hospitals to support ORL surgery children and their caregivers through the perioperative process, along with the risks of caregivers' autonomous web or social media resources investigation. Therefore, this study aims to evaluate the effectiveness of a mobile health application with content to support ORL patients and their caregivers in the perioperative period to reduce caregiver anxiety and child distress compared to standard care.

METHODS

An open-label, two-arm randomised control trial design is being adopted. The intervention consists of a mobile health application with content to support ORL patients and their caregivers during the perioperative period. One hundred eighty participants will be enrolled and randomly assigned to the experimental group using the mHealth application or the control group. The control group receives standard information and education about the ORL perioperative period from healthcare providers orally or through brochures. The primary outcome is the difference between the intervention and control groups in preoperative caregiver state anxiety. Secondary outcome measures include children's distress before surgery and family preparation for hospitalisation.

DISCUSSION

The results of this study will be critical to the implementation of a new and safe model for the management of care and education in paediatrics. This model can achieve positive organisational and health outcomes by supporting continuity of care and empowering citizens to have informed participation and satisfaction in paediatric health promotion and management.

TRIAL REGISTRATION

Trial identifier: NCT05460689 registry name: ClinicalTrials.gov. Date of registration: July 15, 2022. Last update posted: February 23, 2023.

Systematic review of the development and effectiveness of digital health information interventions, compared with usual care, in supporting patient preparation for paediatric hospital care, and the impact on their health outcomes

Background and aim

Elective surgery can be overwhelming for children, leading to pre-operative anxiety, which is associated with adverse clinical and behavioural outcomes. Evidence shows that paediatric preparation digital health interventions (DHIs) can contribute to reduced pre-operative anxiety and negative behavioural changes. However, this evidence does not consider their design and development in the context of behavioural science. This systematic review used the Theoretical Domains Framework (TDF) to evaluate the design and development of DHIs used to support children up to 14 years of age and their parents, prepare for hospital procedures, and determine any correlation to health outcomes. It also considered whether any behavioural frameworks and co-production were utilised in their design.

Methods

A search of the MEDLINE, EMBASE, PsycINFO, and HMIC databases was carried out, looking for original, empirical research using digital paediatric preparation technologies to reduce pre-operative anxiety and behavioural changes. Limitations for the period (2000-2022), English language, and age applied.

Results

Seventeen studies were included, sixteen randomised control trials and one before and after evaluation study. The results suggest that paediatric preparation DHIs that score highly against the TDF are (1) associated with improved health outcomes, (2) incorporate the use of co-production and behavioural science in their design, (3) are interactive, and (4) are used at home in advance of the planned procedure.

Conclusion

Paediatric preparation DHIs that are co-produced and designed in the context of behavioural science are associated with reduced pre-operative anxiety and improved health outcomes and may be more cost-effective than other interventions.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier: CRD42022274182.

The effect of web-based preoperative information on parents of children who are going through elective ambulatory surgery: A systematic review and meta-analysis

OBJECTIVE

To evaluate the effect of preoperative web-based information to parents of children undergoing elective ambulatory surgery performed with anesthesia. Outcome measures were parental anxiety, knowledge, and satisfaction.

METHOD

The review followed the PRISMA statement. A systematic search of six databases was conducted. Randomized controlled trials, cluster-randomized trials and quasi-randomized controlled trials were eligible for inclusion.

RESULT

Eight studies were included. An effect in favour of web-based information compared to standard information was observed for parental anxiety measured before separation from child (SMD=-0.66, 95% CI=-0.92 to -0.40) and after surgery (SMD=-0.55, 95% CI=-0.95 to -0.16), for parental knowledge measured in-hospital (SMD=1.10, Cl 95%=0.37-1.82), and parental satisfaction after discharge (SMD=1.03, 95% Cl=0.41-1.65). No effect was observed for anxiety at separation, and for satisfaction in-hospital. The certainty of the evidence varied from very low to moderate.

CONCLUSION

Depending on the timing of assessment, web-based information before pediatric surgery may reduce the level of parental anxiety and increase the level of parental knowledge and satisfaction more than standard care.

PRACTICE IMPLICATIONS

Web-based routines can be used to convey pre-operative information to parents before paediatric ambulatory surgery. Still, standardized research that enables further comparison across studies is needed.

Perioperative pain management based on enhanced recovery after surgery in children undergoing adenotonsillectomy: A prospective, randomized controlled trial

Background

Pain management, as a key component of enhanced recovery after surgery (ERAS), can effectively relieve perioperative pain and anxiety. However, there are few studies on the application of pain management based on ERAS in pediatric surgery patients. We aimed to examine the effect of ERAS‐based perioperative pain management in children with obstructive sleep apnea (OSA) undergoing adenotonsillectomy.

Methods

From March 2021 to July 2021, a randomized controlled single‐blind study was conducted on children with OSA and scheduled to undergo adenotonsillectomy. The children were randomly assigned to either control group (n = 60) or ERAS group (n = 60). Traditional analgesia measures were provided to children in the control group, whereas ERAS‐based optimized analgesia measures were provided to children in the ERAS group. The pain scores, anxiety scores and diet quality scores were compared between the two groups.

Results

The pain scores after surgery in the ERAS group were significantly lower than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. Furthermore, the diet quality scores in the ERAS group were significantly higher than those in the control group at 6 h, 1 day, 3 days, and 5 days after surgery. The anxiety scores after surgery in the ERAS group were significantly lower than those in the control group.

Conclusions

Perioperative pain management based on ERAS can significantly alleviate postoperative pain, improve quality of life, and promote the accelerated rehabilitation of children with OSA undergoing adenotonsillectomy.

Level of evidence

1.

Parental Engagement of a Prototype Electronic Diary in an Ambulatory Setting Following Adenotonsillectomy in Children: A Prospective Cohort Study

Adenotonsillectomy is performed in children on an outpatient basis, and pain is managed by parents. A pain diary would facilitate pain management in the ambulatory setting. Our objective was to evaluate the parental response rate and the compliance of a prototype electronic pain diary (e-diary) with cloud storage in children aged 2–12 years recovering from adenotonsillectomy and to compare the e-diary with a paper diary (p-diary). Parents recorded pain scores twice daily in a pain diary for 2 weeks post-operation. Parents were given the choice of an e-diary or p-diary with picture message. A total of 208 patients were recruited, of which 35 parents (16.8%) chose the e-diary. Most parents (98%) chose to be contacted by text message. Eighty-one families (47%) returned p-diaries to us by mail. However, the response rate increased to 77% and was similar to that of the e-diary (80%) when we included data texted to the research phone from 53 families. The proportion of diaries with Complete (e-diary:0.37 vs. p-diary:0.4) and Incomplete (e-diary:0.43 vs. p-diary:0.38) data entries were similar. E-diaries provide a means to follow patients in real time after discharge. Our findings suggest that a smartphone-based medical health application coupled with a cloud would meet the needs of families and health care providers alike.

Pediatric Postoperative Pain Management in Korea: Parental Attitudes Toward Pain and Analgesics, Self-Efficacy, and Pain Management

PURPOSES

This study aimed to explore parental attitudes toward children's pain and analgesic drugs and parental self-efficacy and use of pain relief strategies in children's postoperative pain management in Korea, and to identify the relationships among these variables.

DESIGN AND METHODS

A cross sectional descriptive study was conducted. Participants were 124 parents of hospitalized children (aged 4-9 years) undergoing tonsillectomy in Korea.

RESULTS

A considerable proportion of parents held misconceptions about how children express pain. For example, 87.9% of parents perceived that children always tell their parents when they are in pain. Moreover, parents reported significant attitudinal barriers to analgesic use with 60.5% of parents believed that side effects are something to worry about when giving children pain medication. Parental attitudes to use analgesics were significantly different by children's gender, family income, and length of hospital stay. Emotional support methods such as touch, parental presence, and comfort/reassurance were the frequently used, whereas cognitive-behavioral approaches such as distraction were less frequently used nonpharmacological pain relief strategies. A parent's self-efficacy in managing children's pain significantly correlated with the appropriate use of analgesics and parental use of pain relief strategies.

CONCLUSIONS

Promoting parental self-efficacy in postoperative pain management is important. Educational interventions focused on behavioral changes of parents, including practical guidance for pharmacological and nonpharmacological pain relief strategies, are needed.

PRACTICE IMPLICATIONS

Providing parents with proper, effective education about children's postoperative pain management should not only provide accurate information but should also enhance parents' self-efficacy in assessing and managing children's pain.

The association between pre-tonsillectomy education and postoperative emergency department returns: A retrospective cohort pilot study

INTRODUCTION

Tonsillectomy is the most common pediatric surgery in Canada. Post-tonsillectomy 30-day Emergency Department (ED) visit rates are higher than other pediatric day surgeries. To date, there have been no studies assessing whether additional preoperative education directed by Child Life Specialists impacts preventable ED visits. The primary aim of this study was to evaluate whether additional preoperative tonsillectomy education is feasible and is associated with fewer ED visits and admissions in the immediate postoperative period compared to standard care. The secondary aim of this study was to assess whether this education was associated with a lower ED visit rate for preventable causes.

METHODS

This is a retrospective chart review conducted in an academic tertiary pediatric hospital. Patients undergoing tonsillectomy surgery (from 2014 to 2019) were divided into three groups: consultation with a Child Life Specialist plus educational Booklet plus traditional surgeon-led education (CLS), educational Booklet plus surgeon-led education (Booklet), and traditional surgeon-led education (Traditional). The feasibility of the CLS education was assessed and the 30-day ED visit and admission rates were compared between groups. Visits included patients who returned to ED post-tonsillectomy and were not admitted, whereas admission included those who returned to ED and were admitted.

RESULTS

2081 patients undergoing tonsillectomy were included. 329 (15.8%) presented to the ED (within a median of 5 days), and 92 (4.4%) were admitted. ED visit/admission rates by group were: 14.7%/4.4% (CLS), 15.8%/4.1% (Booklet), and 16.2%/4.7% (Traditional) (p = 0.81/p = 0.84). The most common reason for return to ED was Hemorrhage (4.9%). Patients also returned to the ED for preventable reasons such as dehydration, pain, nausea/vomitting and fevers.

CONCLUSIONS

Additional preoperative tonsillectomy education is feasible but is not associated with fewer ED visits and admissions, or fewer ED visits for preventable causes. Further research is needed to identify the optimal intervention to address the high post-tonsillectomy ED visit rate.

What is the clinical value of mHealth for patients?

Despite growing interest from both patients and healthcare providers, there is little clinical guidance on how mobile apps should be utilized to add value to patient care. We categorize apps according to their functionality (e.g. preventative behavior change, digital self-management of a specific condition, diagnostic) and discuss evidence for effectiveness from published systematic reviews and meta-analyses and the relevance to patient care. We discuss the limitations of the current literature describing clinical outcomes from mHealth apps, what FDA clearance means now (510(k)/de novo FDA clearance) and in the future. We discuss data security and privacy as a major concern for patients when using mHealth apps. Patients are often not involved in the development of mobile health guidelines, and professionals' views regarding high-quality health apps may not reflect patients' views. We discuss efforts to develop guidelines for the development of safe and effective mHealth apps in the US and elsewhere and the role of independent app reviews sites in identifying mHealth apps for patient care. There are only a small number of clinical scenarios where published evidence suggests that mHealth apps may improve patient outcomes.

Effects of a posttonsillectomy management program using a mobile instant messenger on parents' knowledge and anxiety, and their children's compliance, bleeding, and pain

PURPOSE

Pediatric tonsillectomy is a highly common surgery for children. The inclusion of tonsillectomy in the diagnosis-related group payment system in Korea has resulted in a shorter hospital stay for patients who undergo tonsillectomy. This, in turn, provides parents with additional caregiver roles in the home.

OBJECTIVES

This study aimed to investigate the effects of a postdischarge management program (PDMP) using Mobile Instant Messenger (MIM) on parents' knowledge and state anxiety about postoperative care, and their children's compliance with care instructions at home, frequency of bleeding, and pain intensity after tonsillectomy.

DESIGN AND METHODS

A nonequivalent control group nonsynchronized design.

SETTINGS AND PARTICIPANTS

Participants were 52 tonsillectomy children aged 3-7 years and their 52 parents (27 for the experimental group and 25 for the control group) from a hospital, in Korea. The control group received a routine written and oral predischarge education, while the experimental group received a predischarge education and a daily MIM for 7 days. For the experimental group, bidirectional communication between the nurse and parent when necessary using MIM are available during the intervention period.

RESULTS

Parents in the experimental group reported a significantly higher knowledge about postdischarge management and lower state anxiety than the control group. Children in the experimental group showed a significantly greater improvement in compliance with the care instructions at home than the control group. However, bleeding frequency and pain intensity were not significantly lower in the experimental group than that in the control group.

PRACTICAL IMPLICATIONS

Nurses play a critical role in preventing and managing the complications of tonsillectomy. Providing proper parental education about pediatric posttonsillectomy care at home is critical for a successful recovery. With the explosion of smartphone technology, the MIM-based PDMP is a useful and effective strategy in helping parents and children in posttonsillectomy care at home.