Distraction techniques for children undergoing procedures: a critical review of pediatric research

Efficacy of Traditional, Complementary, and Integrative Medicine in Pain and Psychological Distress Management for Pediatric Palliative Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

CONTEXT

Traditional, complementary, and integrative medicine (TCIM) is being increasingly used to manage symptoms in patients with palliative needs. However, there is a lack of evidence to guide its use in the pediatric palliative care (PPC) setting.

OBJECTIVES

This study aimed to synthesize and evaluate the current evidence on the effectiveness of TCIM in reducing pain and psychological distress in PPC.

METHODS

Four English electronic databases were searched for randomized controlled trials (RCTs) published between January 2000 and August 2023. The standardized mean difference (SMD) was used to report the pooled magnitude of the treatment effect. The Grading of Recommendations Assessment, Development, and Evaluation system was used to assess the quality of the evidence for each treatment outcome.

RESULTS

Thirty RCTs were included. The interventions were massage (n = 9), music therapy (n = 6), hypnosis (n = 3), acupuncture, aromatherapy, and other TCIM modalities. Compared with the control interventions, music therapy significantly decreased pain (SMD: -1.07; 95% CI: -1.64 to -0.50; P< 0.05; I2 = 72%) and relieved anxiety (SMD: -0.75; 95% CI: -1.35 to -0.15; P< 0.05; I2 = 74%); massage significantly decreased pain (SMD: -0.74; 95% CI: -1.46 to -0.02; P< 0.05; I2 = 83%) and relieved anxiety (SMD: -0.61; 95% CI: -1.21 to -0.01; P< 0.05; I2 = 71%). Hypnosis had significant effects on procedure-related anxiety, pain, and behavioral distress management (P< 0.05). The quality of evidence was rated as "moderate" for the efficacy of music therapy in alleviating pain and anxiety and "low" for the efficacy of all of the other interventions.

CONCLUSIONS

Existing evidence supports the therapeutic benefits of music therapy, massage, and hypnosis on relieving pain and anxiety symptoms in the PPC setting, though the evidence is of low-to-moderate quality.

Extended reality in anesthesia: a narrative review

The application of extended reality (XR) technology is rapidly expanding in the medical field, including anesthesia. This review aims to introduce the current literature on XR utilization to help anesthesiologists adopt this technology in education and clinical practice. XR is useful for both knowledge acquisition and skill training in a wide range of settings, from students to medical professionals. One of its major benefits is harm reduction through simulation scenarios that allow for immersion in clinical situations and opportunities to practice procedures and tasks. These scenarios often involve both technical and non-technical skills, enabling clinicians to enhance their capabilities without risking patient safety. In clinical settings, XR can also be used with patients to increase familiarity with medical procedures, provide education, and reduce anxiety. XR can also serve as a distraction technique, diverting the patient's attention from medical procedures and enhancing comfort, which may contribute to reduced opioid use. Although the potential benefits of XR in anesthesia have been reported in various educational and clinical contexts, challenges, such as limited financial reimbursement and restricted technical accessibility, remain. With further research and technological advancements, XR technology has the potential for widespread adoption in anesthesia practice.

The Effect of Distraction on Pain Management in Children Aged 5 to 12 Years Old With Acute Leukemia Undergoing Bone Marrow Aspiration

Background and Aims

Acute leukemia is considered the most common form of cancer in children. Different painful diagnostic approaches may be applied to diagnose acute lymphoblastic leukemia (ALL) in children suspected of having the disease, such as blood tests and bone marrow aspiration (BMA). Several studies reported that distraction strategies could alleviate pain severity in children. Therefore, the current study aimed to investigate the effectiveness of distraction in pain management in children aged 5-12 years old with acute leukemia undergoing BMA.

Methods

In a quasi-experimental study involving 60 participants, using convenience sampling, they were assigned to control (n = 30) and distraction (n = 30) groups. Children in the distraction group watched TV cartoons during BMA, while children in the control group didn't. The children's level of acute pain was measured using Oucher's scale before, 30, and 60 min after the intervention.

Results

The mean pain severity score immediately before the intervention between the intervention and control groups was markedly different (2.33 ± 1.21 vs. 3.60 ± 1.56, p = 0.005). Also, the mean severity score after 30 min of the second BMA illustrated a significant difference between the intervention and control groups (4.20 ± 1.84 vs. 6.6 ± 2.16, p < 0.001). We observed a considerable difference between the intervention and control groups regarding the mean severity score after 60 min of the second BMA (2.06 ± 0.82 vs. 4.8 ± 2.34, p < 0.001).

Conclusion

The design and implementation of well-developed pain management regularly involving sustained and organized distraction can effectively manage the severity of pain in acute leukemia children undergoing BMA.

Effect of stress ball use on cannulation-related invasive pain in Hemodialysis patients: a randomized controlled, single-blind study

BACKGROUND

Stress ball usage is one of the non-pharmacological methods that help reduce pain and anxiety by diverting an individual's attention elsewhere.

PURPOSE

This study evaluates the impact of stress ball use on pain levels during cannulation in hemodialysis patients.

METHODS

A single-blind, randomized, controlled design was used. Sixty-four participants were divided into experimental (n = 32) and control groups (n = 32). The experimental group used a stress ball for 3 min before and during cannulation, while the control group received routine care without additional intervention. Pain was assessed using the Visual Analog Scale (VAS) after cannulation across 12 sessions. Statistical significance was set at p < 0.05.

RESULTS

The median VAS score in the intervention group was significantly lower than in the control group. The intervention group showed a significant decrease in VAS scores over 12 sessions (p < 0.01). Stress ball usage had an increasing effect over time (p = 0.016). Overall, median VAS scores differed significantly between groups (p < 0.01).

CONCLUSION

Using stress balls during cannulation reduces pain intensity in hemodialysis patients, with increased effectiveness over multiple sessions. Nurses can recommend stress balls as a simple and cost-effective pain management method.

TRIAL REGISTRATION

This study was retrospectively registered at ClinicalTrials.gov (Registration No: NCT06237738) on 2024-01-12.

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

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

Effect of using a kaleidoscope projector and matching cards on fear and vital signs in children aged 3-6 years receiving inhaled medication

AIM

The aim of this study was to investigate the effect of the use of projector kaleidoscope and matching card on children's fear and physiological parameters in children aged 3-6 years receiving inhaled medication.

METHODS

This randomised controlled study was conducted with the guidelines of Consolidated Standards of Reporting Trials (CONSORT). The sample of children was allocated to the projector kaleidoscope group (n = 38), matching card group (n = 38) and control group (n = 38). Fear and vital signs were measured.

RESULTS

In the study, the mean age of the children in the projector kaleidoscope group was 4.39 ± 1.10, the mean age of the children in the matching card group was 4.34 ± 0.96 and the mean age of the children in the control group was 4.28 ± 1.18. There was a statistically significant difference between the post-test scores of the Children's Fear Scale in the evaluation of parents and nurses according to the groups of children. There was a statistically significant difference between the respiratory post-test scores according to the groups of children. It was observed that the mean heart rate of the control group participants was higher than that of the children in the matching card group. There were no statistically significant differences in the post-test saturation values among the groups of children.

CONCLUSION

It was observed that the projector kaleidoscope and matching card reduced fear and prevented increased respiratory rate in children receiving inhaler medication. In addition, it was determined that matching card had more effect on heart and respiratory rate than projector kaleidoscope.

Technology-Based Interventions for Pain in Children Undergoing Surgery: A Systematic Review and Meta-Analysis

AIM

This systematic review and meta-analysis aimed to evaluate the effect of technology-based interventions on the pain of paediatric surgery patients.

BACKGROUND

Recently, the number of technology-based interventions involving multimodal nonpharmacological methods tailored to pain management in paediatric surgery patients has increased. It is crucial to determine the effectiveness of these interventions.

DESIGN

A systematic review and meta-analysis of randomized controlled trials following Cochrane methods was conducted.

REVIEW METHODS

We performed a literature search in the Web of Science, PubMed, CINAHL, Science Direct, MEDLINE, ProQuest and Cochrane Library databases. Two independent researchers screened the literature using specific keywords and selected randomized controlled trials based on the inclusion and exclusion criteria. Each researcher extracted data and assessed the risk of bias in the randomized controlled trials using the Cochrane bias risk assessment tool.

RESULT

We conducted a meta-analysis on 14 randomized controlled trials included in the study. The results showed that technology-based interventions reduced pain scores in paediatric surgery patients. Cochran's Q test results pointed to a high level of heterogeneity among the randomized controlled trials.

CONCLUSION

A meta-analysis result of 14 randomized controlled trials showed that technology-based interventions are effective methods for reducing pain in paediatric surgery patients.

REGISTRATION NUMBER

CRD42021226666.

The benefits of experiencing flow through distracting activities: flow reduces preoperative anxiety in children before surgery, but not postoperative difficulties

BACKGROUND

Distraction is a classic anxiety management strategy in preoperative setting with children: distracting activities take children's attention away from threatening clues. What is less clear is the differential effectiveness of this technique depending on the task, and the degree of children engagement with the distracting task. The present work examined the role of flow (state of intense concentration and absorption in the distracting task) on children's preoperative anxiety.

METHODS

Anxiety and flow in a distracting activity were measured in a sample of 100 children (3 to 10 years-old), at two critical moments of the preoperative period prior to ambulatory surgery under general anesthesia (phase 1: up to separation from the parents; phase 2: up to general anesthesia). Common negative postoperative outcomes were also measured.

RESULTS

As expected, the analysis showed a negative association between the mean level of flow in the distracting activity during waiting periods and the preoperative anxiety of children at critical moments in the two phases (although there was no effect on postoperative recovery).

CONCLUSION

These findings demonstrate the importance of considering the degree of engagement in the distracting activity to understand the effectiveness of this strategy. The results may help provide guidance for better clinical application of this method.

Impact of proxymetacaine on the dynamics of cyclopentolate in White 6- to 7-year-olds

PURPOSE

This study compared the efficacy of cyclopentolate hydrochloride at 10-, 20- and 30-min post-instillation in White 6- to 7-year-olds, with and without prior instillation of proxymetacaine hydrochloride. The primary aim was to determine if accurate autorefraction values can be obtained sooner than the current standard of 30-min post-cycloplegia. The secondary aim was to investigate whether proxymetacaine hydrochloride enhances the efficiency of cyclopentolate.

METHODS

Participants were 112 White 6- to 7-year-olds from the Child Eye Health Study. The right eye received 0.5% proxymetacaine hydrochloride and 1.0% cyclopentolate hydrochloride, and the left eye received only 1.0% cyclopentolate hydrochloride. Non-cycloplegic and cycloplegic refractive error (at 0, 10, 20 and 30 min) was measured using a binocular, open-field autorefractometer. Data were analysed through paired t-tests, concordance analysis, linear regression, equivalence testing and Bland-Altman analysis, using the 95% limits of agreement.

RESULTS

Mean spherical equivalent refraction (SER) (SD) in the right eye at 0-, 10-, 20- and 30-min post-instillation was 0.62 (1.45) D, 1.52 (1.80) D, 1.64 (1.81) D and 1.72 (1.80) D, respectively. Mean left eye SER (SD) were 0.68 (1.24) D, 1.42 (1.66) D, 1.56 (1.66) D and 1.68 (1.72) D, respectively. Bland-Altman analysis showed a high level of agreement, and equivalence testing confirmed that there was no clinically significant difference in SER at 20 and 30 min in both eyes (within ±0.50 D), with mean differences of 0.08 (0.23) D in the right eye and 0.13 (0.30) D in the left eye (p = 0.21). However, SER at 10 and 30 min were equivalent in the right eye only.

CONCLUSIONS

Accurate autorefraction values can be obtained 20-min post-instillation of 1.0% cyclopentolate in white children aged 6-7 years, potentially reducing clinical testing times. Proxymetacaine pre-instillation allows for reliable measurements as early as 10-min post-instillation of cyclopentolate. Further research is needed to validate these findings in non-White populations and to determine the safe discharge time post-proxymetacaine instillation.

Tympanostomy Tubes Under Local Versus General Anesthesia for Children: A Prospective Long-Term Study

OBJECTIVES

Tympanostomy tube insertion (TTI) under local anesthesia (LA) is gaining popularity but literature comparing long-term outcomes for children undergoing TTI under LA versus general anesthesia (GA) is limited. This study compares the long-term quality of life (QoL) between LA and GA in children undergoing TTI. Secondary objectives included long-term behavioral changes, parental satisfaction, tube durability, and postoperative complications.

METHODS

We prospectively followed children aged under 6 who underwent TTI, under LA or GA, 2 years prior. We assessed QoL using validated scales (OM6, PedsQL), analyzed behavioral changes and parental satisfaction through qualitative scales, and retrieved data on tube durability and non-immediate complications.

RESULTS

A total of 84 children (LA = 42; GA = 42) had complete data and a minimum of 1 year of follow-up. Demographic data were similar, except for younger patients in the LA group (1.4 vs. 1.9 years, p = 0.02). LA group exhibited increased fear of health care professionals following TTI (LA: Likert scale 2.1/5, GA: 1.5/5, p = 0.04). Tube retention rate was shorter in the LA group (at 15 months: GA:72%, LA:50%, p = 0.039). Two years post-TTI, there were no differences regarding QoL (OM-6 score; LA: 15.2/100, GA: 21.4/100, p = 0.18, and PedsQL score; LA: 84.3/100, GA: 83.8/100, p = 0.90), parental satisfaction with anesthesia (GA: 4.5/5, LA: 4.6/5, p = 0.56), and postoperative complications (GA: 3/42, LA: 7/42, p = 0.18).

CONCLUSIONS

TTI under LA in children is associated with an increased fear of health care professionals and shorter functionality of tympanostomy tubes as compared to GA. No difference was observed in long-term QoL, parental satisfaction, and complications rate.

LEVEL OF EVIDENCE

3 Laryngoscope, 134:5178-5183, 2024.

How to meet coping strategies and preferences of children during invasive medical procedures: perspectives of healthcare professionals

Children with negative procedural experiences have an increased risk of fear and distress, with psychological consequences for subsequent procedures and future healthcare behaviors. Gaining control and feeling trust are important aspects for children to decrease fear. To enable professionals providing personal care during medical procedures, a systematic, evidence-based approach that supports children in expressing their preferences is needed. This study will gain insight into the experiences and needs of professionals involved in small invasive medical procedures to meet the coping strategies and preferences of children undergoing these procedures. A qualitative design was used to gain insight into professionals' perspectives. Data were collected through online focus groups with various professionals involved in medical procedures, such as anesthetists, laboratory staff, nurses, and pediatricians. Five interdisciplinary focus groups, with a total of 32 participants, were held. One overarching theme was revealed: "Balancing between different actors within the context of the hospital." Professionals reported they had to deal with different actors during a medical procedure: the child, the parent, the colleague, and themselves. Each actor had its own interests. They were aware of the child and parents' priority to gain control and feel trust. Nevertheless, they perceive organizational and personal aspects that hinder addressing these needs.

CONCLUSION

To provide personalized care, professionals experience balancing between the needs and interests of diverse actors during medical procedures. The findings underscore the importance of a policy supporting HCPs in integrating patient-centered care into practice through practical tools and training initiatives such as scenario training.

WHAT IS KNOWN

• Unresolved pain and stress arising from medical procedures can have significant short- and long-term impacts on children. Empowering children to gain control and fostering a sense of trust are crucial factors in reducing fear associated with medical procedures. • Children and parents expect to receive child-tailored care from professionals including respect for their own, unique needs, and boundaries. Professionals should build trustful relationships and provide appropriately tailored autonomy around medical procedures.

WHAT IS NEW

• Healthcare professionals vary in their awareness of children's needs during a medical procedure. Beside this, the organizational dynamics of the hospital, along with the presence of actors such as the child, parent, colleague, and oneself, collectively influence the conduct of medical procedures. • Providing person-centered care during medical procedures can present challenges. The results highlight the significance of a policy to assist healthcare professionals in incorporating patient-centered care into their practice through practical tools and a culture of self-reflections regarding patient-centered values.

Effect of virtual reality video application on fistula puncture-associated pain in patients undergoing hemodialysis: Assessor-blinded randomized trial

OBJECTIVE

To elucidate the effect of virtual reality video application on fistula puncture-associated pain in patients undergoing hemodialysis.

DESIGN

Attention controlled and assessor-blinded randomized trial.

MATERIALS AND METHODS

Attention controlled and assessor-blinded randomized trial was conducted 28 patients at the hemodialysis center of City Hospital. The patients in the intervention group (n = 14) participated in 12 hemodialysis sessions with virtual reality video application under the researcher's supervision. The patients in the control group (n = 14) received a 6-min training session on diet compliance. The Sociodemographic Form and Visual Analog Scale were used to collect data in person at various time points: baseline (t0), during the 1st to 12th hemodialysis sessions (t1-t12), and 1 week after implementation (t13).

RESULTS

Virtual reality video application helped in effectively decreasing pain over time, as revealed by significant differences in the measurements at t1-t12 and t13 (p < 0.05). Time-based variations in within-group differences revealed that the median fistula puncture-associated pain values were significantly higher at baseline and t13 measurements in the intervention group (p < 0.05). In contrast, no significant differences were observed in the median fistula puncture-associated pain values in the control group (p < 0.05).

CONCLUSION

In patients undergoing hemodialysis, the application of virtual reality helps decrease fistula puncture-associated pain values. Advances in technology, particularly virtual reality, may play a vital role in shaping the future of healthcare.

Enhancing Pediatric Dental Care: The Influence of Virtual Reality

OBJECTIVE

 The purpose of this study was to assess the effects of virtual reality (VR) in reducing pain and anxiety levels in children. The study also compared active and passive distraction methods using VR during the delivery of inferior alveolar nerve blocks (IANBs) in dental procedures in children.

MATERIAL AND METHODS

 The study comprised 45 preschool patients, aged between 4 and 6 years, with no prior dental anesthetic experience. The participants were randomly assigned to three groups based on the sort of management style: Group A used the tell-show-do technique, Group B engaged in passive distraction by watching cartoons using a VR headset, and Group C participated in active distraction by playing games using a controller with the VR headset. Pain and anxiety were evaluated using physiological measurements, namely by analyzing the variations in blood pressure, heart rate, and oxygen saturation before and after the administration of IANB. Psychological assessments were conducted using the Wong-Baker faces scale, Modified Dental Anxiety scale questionnaires, and Revised Face, Legs, Activity, Cry and Consolability scale after administering IANB.

RESULTS

 The physiological outcomes revealed no statistically significant differences in blood pressure and oxygen saturation. However, there was a statistically significant increase in the heart rate in group A compared with groups B and C. In terms of psychological measurements, groups B and C exhibited a significant improvement in pain experience and a decrease in anxiety.

CONCLUSION

 This study concluded that VR reduced pain and anxiety levels in its passive and active forms.

A comparative evaluation of the effects of white noise, brown noise, and pink noise on dental anxiety of pediatric patients undergoing dental extraction treatment: A randomized control study

BACKGROUND

Audio-analgesia is one of the unexplored aspects of behavior management in pediatric dentistry, and recently, there have been many new inclusions in shades of noise that were previously just limited to white noise, like brown noise and pink noise.

AIM

The aim of the study was to evaluate and compare the effectiveness of white noise, brown noise, and pink noise on dental anxiety in pediatric patients undergoing primary tooth extraction.

STUDY SETTINGS AND DESIGN

Multiarm, triple-blinded, parallel-group randomized controlled trial.

MATERIALS AND METHOD

Forty children belonging to the age group of 8-12 years having their first dental visit with primary teeth indicated for extraction were included in our study. We evenly divided the 40 children into four groups: Group A (white noise), Group B (pink noise), Group C (brown noise), and Group D (cartoon music), which served as the control. We assessed the patient's anxiety using Venham's Picture Test and a pulse oximeter, as well as their pain using the Visual Analog Scale (VAS) both preoperatively and postoperatively. We also noted changes in the patient's pulse after administering local anesthesia.

RESULTS

All groups have shown significant differences in dental anxiety and pain, preoperatively and postoperatively, but pink noise was found to be effective even in maintaining pulse rate intraoperatively.

CONCLUSION

In pediatric dentistry, audio distraction is an innovative, noninvasive, and effective behavior management technique that can effectively manage dental anxiety in children.

REGISTRATION

The Clinical Trials Registry of India (CTRI) has prospectively registered the study under the CTRI number CTRI/2024/01/061679.

Exploring how 'wish-granting' interventions foster wellbeing for children with life-threatening health conditions and their families: A qualitative study

Wish-granting is a form of positive psychological intervention that seeks to promote child wellbeing by fulfilling a wish of their choice. This study aimed to explore families' experiences of receiving wish-granting interventions to understand how wishes impact wellbeing. Fifty in-depth semi-structured interviews were carried out with 22 families (23 parents, 17 young people); seven charity volunteers; and five health professionals, recruited from the United Kingdom. Interviews were transcribed verbatim and analysed using a thematic framework approach. Findings suggest wishes improve wellbeing by increasing positive emotion; by broadening families' horizons; by providing an alternative focus; and by fostering opportunities for togetherness. To grow and maintain impact, consideration should be given to developing strategies that increase anticipation; keep wish memories alive; encourage children to make wishes that stretch their perceived limitations; and facilitate families to share their experiences and 'give back' to the community.

Soothing venipuncture: Bubble blowing and ball squeezing in reducing anxiety, fear, and pain in children

PROBLEM

The objective of this study was to investigate the impact of bubble-blowing and ball-squeezing interventions on children's levels of anxiety, fear, and pain during venipuncture procedures.

METHODS

This study was designed as a randomized controlled trial. Out of 108 children aged 5-10 years, 72 were allocated to the two experimental groups, while 36 were assigned to the control group. The levels of anxiety, fear, and pain experienced by the children were assessed using the "Wong-Baker FACES® Pain Rating Scale," "Child Anxiety Scale-State," and "Child Fear Scale," respectively. Intergroup comparisons were analyzed using one-way ANOVA, while intragroup comparisons were conducted using Wilks' Lambda analysis.

FINDINGS

It was observed that 50% of the children in the control group, 47.2% in the bubble-blowing group, and 47.2% in the ball-queezing group did not receive information about the painful procedure. Anxiety, fear, and pain scores of all groups were statistically similar in the initial measurement without any intervention. Children in the bubble-blowing and ball-squeezing groups experienced lower anxiety, fear, and pain during and at the end of the painful procedures.

CONCLUSIONS

The study discovered that interventions involving bubble blowing and ball squeezing significantly decreased children's levels of anxiety, fear, and pain both during and after intravenous procedures. Information on procedures, alongside interactive techniques like bubble blowing and ball squeezing, helps pediatric nurses calm children, easing anxiety, fear, and pain. Implementing these strategies enhances treatment experiences and confidence in healthcare.

Ventriloquist intervention prepared with drama technique in reducing pain, anxiety and fear in children during invasive procedures

INTRODUCTION

This study aimed to investigate the effects of a ventriloquist nursing intervention, incorporating drama techniques, on pain, anxiety, and fear experienced by children aged 5 to 10 years undergoing painful medical procedures.

METHODS

This study was designed as a time-series randomized controlled trial. Data were collected from the outpatient units of a Pediatric Hospital in a province in eastern Turkey between 24 May 2023 and 28 October 2023. This study involving a total of 72 children. Pain, anxiety, and fear levels were assessed before, during, and after intravenous cannula insertion.

RESULTS

Randomization ensured that both groups had similar demographics, with an average age of 7.50 ± 1.73 years and an equal distribution of gender. During the painful procedure, it was observed that both groups experienced an increase in pain, anxiety, and fear, though this increase was statistically less significant in the ventriloquist group. Ultimately, in the post-procedure period, children in the ventriloquist group exhibited lower levels of pain, anxiety, and fear compared to the control group (p < 0.05).

CONCLUSION

The findings of this study suggest that ventriloquist nursing interventions, utilizing drama techniques, can effectively reduce pain, anxiety, and fear in children undergoing painful medical procedures.

Interactive and passive mixed reality distraction: effects on cold pressor pain in adults

While interactive distractors are predicted to be more effective in reducing acute pain than passive distractors, the underlying mechanisms remain poorly understood. Previous work using Virtual-Reality (VR) has suggested that interactive distraction may be enhanced by increasing the person's sense of immersion. Despite the possible utility of immersive VR in reducing pain, some people report being disoriented and motion sick, and it doesn't allow for interactions with environment (e.g., following instructions from medical staff). Here, we explore the role of the immersion in the effectiveness of interactive distraction by employing an alternative technology, a Mixed-Reality (MR) headset that limits disorientation by projecting virtual objects into the real world. Healthy volunteers (18-35 years) participated in two experiments employing either a between (N = 84) or a within-subject (N = 42) design to compare Interactive and Passive distraction tasks presented via MR or a standard computer display. For both experiments, a cold-pressor task was used to elicit pain, with pain tolerance and pain perception being recorded. Analysis revealed that whilst interactive distraction was more effective in reducing pain perception and increasing pain tolerance than passive distraction, the interpretation of results was sensitive to experimental design. Comparison of devices did not reveal significant differences in pain tolerance or pain intensity, while pain unpleasantness was significantly reduced during the MR task using a within-subject design. Our findings add to existing VR studies reporting little additional analgesic benefit of new, immersive technologies compared to traditional computers, but underscores the important impact the choice of experimental design can have on the interpretation of results.

Children's participation rights and the role of pediatric healthcare teams: A critical review

AIM

A critical review examined how childrens participation rights as represented in the United Nations Convention on the Rights of the Child inform the work of pediatric teams in healthcare settings.

METHODS

We systematically searched peer-reviewed literature on the enactment of child participation rights, within the context of pediatric teams. Articles were evaluated using the LEGEND (Let Evidence Guide Every New Decision) tool. Data extraction and analysis highlighted themes and disparities between articles, as well as gaps. A total of 25 studies were selected.

RESULTS

We reviewed studies from around the globe, with the majority of papers from the UK. Qualitative and mixed methods approaches were administered. The following observations were made: (1) limited language of children's rights exists in the literature, (2) lack of information regarding the composition of pediatric healthcare teams and how they work with children, (3) children's perspectives on what constitutes good interactions with healthcare providers are replicated, (4) minimal references to theory or philosophical underpinnings that can guide practice.

CONCLUSION

Explicit references to children's participation rights are lacking in the literature which may reflect the absence of rights language that could inform pediatric practice. Descriptive understandings of the tenets of pediatric interprofessional team composition and collaboration are necessary if we are to imagine the child as part of the team along with their family. Despite these shortcomings, the literature alludes to children's ability to discern desirable interactions with healthcare providers.

The effect of video-based education program applied before children's pediatric Magnetic Resonance Imaging (MRI) on anxiety in Turkey: A randomized controlled study

OBJECTIVE

This study is a randomized controlled trial conducted to examine the effects of a Turkish video-based education program on scanned image quality and child and parent anxiety during Magnetic Resonance Imaging (MRI).

DESIGN AND METHODS

The study was conducted with 66 children aged between 4 and 15 years at Zonguldak Bulent Ecevit University Health Practice and Research Hospital, between January 2019 and December 2019. A video-based educational program was applied to an intervention group before MRI.

RESULTS

The video-based education program reduced children's anxiety and fear (p < 0.001). The study also showed a significant reduction in parental stress (p < 0.001). The image quality in the intervention group was better than that in the control group (control group: 3.24 ± 1.20; intervention group: 4.18 ± 0.81) (p = 0.001). Significantly fewer children refused to enter the MRI room in the intervention group than in the control group (p < 0.05).

CONCLUSION

Child-friendly and video-based educational programs can be organized for children and parents in diagnostic and treatment procedures for children in hospitals.

PRACTICE IMPLICATIONS

MRI scans can be uncomfortable for children and require transport to a better-equipped hospital for sedation. They can also cause financial loss for children and their parents and disrupt facility workflow. An educational program to adjust the children and their families will improve the scanning process and its success rate.

Beyond Needles: Pioneering Pediatric Care with Virtual Reality (VR) for TIVAD Access in Oncology

INTRODUCTION

Pediatric oncology patients use totally implantable venous access devices (TIVADs) to enable central venous access. Anxiety, pain and/or discomfort are common despite anesthesia. Virtual reality (VR) is a non-pharmacological approach that may reduce pain and anxiety in these patients. We aimed to assess the use of VR for reducing anxiety/pain in patients with TIVADs while facilitating the task of healthcare providers when accessing a TIVAD.

METHODS

patients 4-18 years old with a TIVAD were prospectively randomized to an intervention group (IG) or a control group (CG). In the IG, VR goggles (Oculus Quest 2, Meta Platforms®, Menlo Park, CA, USA) were used displaying a relaxing video in the Raja Ampat environment (Ecosphere app from Phoria®) while the TIVAD was accessed. The CG was managed as per standard of care. Satisfaction and pain were measured by FPS-R and STAIC scales, respectively.

RESULTS

this is the report of a prospective, randomized (60 per group)-unblinded-, single institution study of 120 pediatric oncology patients enrolled from January to April 2022. Median ages for IG and CG were 9.22 and 10.52 years, respectively. Satisfaction was higher in the IG (4.80) compared to the CG (3.92), p ≤ 0.0001. Regarding pain, mean FPS-R scores were 1.79 for the CG and 0.83 for the IG. Significantly different scores were found in the 12 to 18 years group, p ≤ 0.05. The healthcare professionals index of satisfaction was high (4.50 mean Likert score) for the IG compared to accessing the TIVAD without VR (3.73 mean Likert score).

CONCLUSION

The use of VR helped reduce pain and/or discomfort in pediatric oncology patients, mainly in the older age group as they can better interact with VR. Healthcare providers were satisfied with the help of VR for TIVAD management.

Virtual reality vs. tablet for procedural comfort using an identical game in children undergoing venipuncture: a randomized clinical trial

Introduction

Recent research has explored the effectiveness of interactive virtual experiences in managing pain and anxiety in children during routine medical procedures, compared to conventional care methods. However, the influence of the specific technology used as an interface, 3-dimensions (D) immersive virtual reality (VR) vs. 2D touch screens, during pediatric venipuncture, remains unexamined. This study aimed to determine if immersive VR is more effective than a tablet in reducing pain and anxiety during short procedures.

Methods

An interactive game was designed by clinicians and psychologists, expert in pain theory, hypnosis, and procedural pain and anxiety relief, and was tailored for both VR and tablet use. Fifty patients were randomly assigned to either the Tablet or VR group. The primary outcome measures were pain and anxiety levels during the procedure. Secondary outcome measures included the need for physical restraint, duration of the procedure, enjoyment levels, and satisfaction ratings from both parents and nurses.

Results

Participants, in both groups, had low levels of pain and anxiety. Physical restraint was infrequently used, procedures were brief, and high satisfaction levels were reported by patients, parents, and nurses.

Discussion

This study suggests that the type of technology used as a support for the game has a minimal effect on the child's experience, with both groups reporting low pain and anxiety levels, minimal physical restraint, and high enjoyment. Despite immersive VR's technological advancements, this study underscores the value of traditional tablets with well-designed interactive games in enhancing children's wellbeing during medical procedures.

Clinical Trial Registration

[ClinicalTrials.gov], identifier [NCT05065307].

Effectiveness of Virtual Reality in Reducing Perceived Pain and Anxiety Among Patients Within a Hospital System: Protocol for a Mixed Methods Study

BACKGROUND

Within hospital systems, diverse subsets of patients are subject to minimally invasive procedures that provide therapeutic relief and necessary health data that are often perceived as anxiogenic or painful. These feelings are particularly relevant to patients experiencing procedures where they are conscious and not sedated or placed under general anesthesia that renders them incapacitated. Pharmacologic pain management and topical anesthetic creams are used to manage these feelings; however, distraction-based methods can provide nonpharmacologic means to modify the painful experience and discomfort often associated with these procedures. Recent studies support distraction as a useful method for reducing anxiety and pain and as a result, improving patient experience. Virtual reality (VR) is an emerging technology that provides an immersive user experience and can operate through a distraction-based method to reduce the negative or painful experience often related to procedures where the patient is conscious. Given the possible short-term and long-term outcomes of poorly managed pain and enduring among patients, health care professionals are challenged to improve patient well-being during medically essential procedures.

OBJECTIVE

The purpose of this pilot project is to assess the efficacy of using VR as a distraction-based intervention for anxiety or pain management compared to other nonpharmacologic interventions in a variety of hospital settings, specifically in patients undergoing lumbar puncture procedures and bone marrow biopsies at the oncology ward, patients receiving nerve block for a broken bone at an anesthesia or surgical center, patients undergoing a cleaning at a dental clinic, patients conscious during an ablation procedure at a cardiology clinic, and patients awake during a kidney biopsy at a nephrology clinic. This will provide the framework for additional studies in other health care settings.

METHODS

In a single visit, patients eligible for the study will complete brief preprocedural and postprocedural questionnaires about their perceived fear, anxiety, and pain levels. During the procedure, research assistants will place a VR headset on the patient and the patient will undergo a VR experience to distract from any pain felt from the procedure. Participants' vitals, including blood pressure, heart rate, and rate of respiration, will also be recorded before, during, and after the procedure.

RESULTS

The study is already underway, and results support a decrease in perceived pain by 1.00 and a decrease in perceived anxiety by 0.3 compared to the control group (on a 10-point Likert scale). Among the VR intervention group, the average rating for comfort was 4.35 out of 5.

CONCLUSIONS

This study will provide greater insight into how patients' perception of anxiety and pain could potentially be altered. Furthermore, metrics related to the operational efficiency of providing a VR intervention compared to a control will provide insight into the feasibility and integration of such technologies in routine practice.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/52649.

Modernizing ED Care: Virtual Reality Enhances the Patient Experience during Minor Wide-awake Hand Procedures

Background

Minor procedures in the emergency department (ED) can be distressing for patients. The emergence of virtual reality (VR) offers a promising new tool by immersing patients in an engaging three-dimensional world. Prior studies have shown VR's effectiveness during procedures in reducing pain, anxiety, and procedure duration but have not assessed its efficacy in the ED. This study aims to evaluate the efficacy of VR in managing pain and anxiety during ED minor hand procedures.

Methods

This was a prospective, interventional study at a level I trauma center examining adult patients requiring minor hand procedures. Patients were provided the Oculus Quest 2 VR headset, offering various immersive three-dimensional experiences. Pre- and postprocedure surveys assessed previous VR use, anxiety and pain levels, VR efficacy, and possible adverse effects. Responses were rated on a 10-point Likert scale with paired t tests used to compare scores.

Results

The study included sixteen patients, seven of whom were first-time VR users. Patients experienced a significant decrease in both anxiety and pain levels. Survey results indicated overall benefits from VR in several aspects, with no adverse effects reported, and unanimous patient recommendation of the VR experience to others.

Conclusions

VR is an effective tool to optimize the patient experience during ED hand procedures. The study observed a significant decrease in anxiety and a declining trend in pain levels. Patients believed VR helped manage their pain and would recommend it to others. Given the benefits and high safety profile, VR should become a standard offering in ED minor hand procedures.

Designing and developing a nature-based virtual reality with heart rate variability biofeedback for surgical anxiety and pain management: evidence from total knee arthroplasty patients

OBJECTIVES

Total knee arthroplasty (TKA) is one of the most common joint surgeries, with over a million procedures performed annually in the US. Over 70% of patients report moderate to high pain and anxiety surrounding TKA surgery, and 96% are discharged with an opioid prescription. This population requires special attention as approximately 90% of TKA patients are older adults and one of the riskiest groups prone to misusing opioids. This study aimed to develop and compare the efficacy of nature-based virtual reality (VR) with heart rate variability biofeedback (HRVBF) to mitigate surgical pain and anxiety.

METHODS

This randomized control trial recruited 30 patients (mean age = 66.3 ± 8.2 years, 23 F, 7 M) undergoing TKA surgery and randomly assigned to a control, 2D video with HRVBF, or VR with HRVBF group. A visual analog scale (VAS) was used to measure pain levels before and after the intervention. In addition, a second VAS and the State-Trait Anxiety Inventory (STAI) were used to measure anxiety before and after the intervention. Electrocardiogram (ECG) was used to continuously measure HRV and respiration rate in preoperative and postoperative settings.

RESULTS

VR and 2D-video with HRVBF decreased pain and anxiety post-intervention compared with the control group, p's <.01. On analyzing physiological signals, both treatment groups showed greater parasympathetic activity levels, and VR with HRVBF reduced pain more than the 2D video, p < .01.

CONCLUSIONS

Nature-based VR and 2D video with HRVBF can mitigate surgical pain and anxiety. However, VR may be more efficacious than 2D video in reducing pain.

Usage of immersive virtual reality as a relaxation method in an intensive care unit

INTRODUCTION

The usage of immersive virtual reality (iVR) in the context of an intensive care unit (ICU) is scarce. Our objective was to assess the feasibility of the usage of iVR in critical patients with or without mechanical ventilation (MV) and to determine the anxiety degree before and after each session.

METHODS

Analytical, descriptive, prospective, and cross-sectional research. Pilot test with 20 patients from a polyvalent ICU of a tertiary hospital. Adult patients were included, either connected or not to MV, watchful and calmed (RASS -1/+1) and without delirium (negative CAM-ICU). Oculus Go (Facebook Technologies, LLC) iVR glasses were the model used. The relaxation strategy consisted in the visualization of an experience of 15 min with scenes related to nature and fantasy, relaxing music with a plot. The sessions were individual, with the patient monitored in a fowler position or seated. The anxiety degree before and after each session was evaluated following a reduced version of the Spanish "Cuestionario de Ansiedad Estado-Rasgo (STAI-e)" and they were analysed using T samples coupled (statistical significance when p-value was <0.05).

RESULTS

Incorporation of 20 patients with an average age of 63.9 years old (60% men). A total of 34 sessions of iVR were conducted. 32% patients mechanically ventilated, 32% high-flow oxygen therapy, 36% other breathing supports. 80% of the sessions were completed without serious side effects. A significant decrease in the anxiety degree was observed after each iVR session: first session mean change -2.68 (SD = 2.75), p = 0.000; second session mean change -1.86 (SD = 1.57), p = 0.021; third session mean change -1.67 (SD = 1.63), p = 0.054.

CONCLUSION

The usage of iVR in the context of an ICU is feasible, even with patients mechanically ventilated. iVR reduces the anxiety degree in the critic patient, which suggests that "digital therapies" can be effective to improve the emotional state during their stay in the ICU.

A brief virtual reality intervention for pre-operative anxiety in adults

OBJECTIVE

Virtual reality (VR) is a promising non-pharmacologic tool for managing health care anxiety. We assessed the feasibility and acceptability of a pre-operative VR intervention by adult patients and medical staff and measured anxiety in adult patients pre- and post-VR intervention.

STUDY DESIGN

We recruited 30 patients scheduled to undergo oral surgery and 8 medical staff as participants. The patients completed a verbal demographic survey and rated their anxiety before the VR intervention and at 1 minute and 2 minutes post-intervention. We administered the Acceptability of Intervention Measure to the patients to measure their perceptions of the VR intervention and the Feasibility of Intervention Measure to the medical staff to assess their perception of VR implementation. We performed an analysis of variance to compare pre-operative anxiety over time and assess demographic differences.

RESULTS

The patients showed high and consistent acceptability of the pre-operative use of VR among patients, but acceptability varied among medical staff. The patients experienced a statistically significant reduction of pre-operative anxiety (P = .003).

CONCLUSION

A brief VR pre-intervention is highly accepted by and very beneficial for patients undergoing oral surgery, positively affecting anxiety reduction. The perception of VR by health care providers needs to be explored to increase acceptability.

The effect of virtual reality on pain, fear and emotional appearance during blood draw in pediatric patients at the hematology-oncology outpatient clinic: A randomized controlled study

OBJECTIVE

Invasive attempts can be very painful and stressful for pediatric patients. Virtual Reality (VR) can be used to distract patients undergoing such procedures in pediatric hematology oncology patients.

METHODS

A parallel trial design approach was adopted for this randomized controlled trial, guided by the CONSORT checklist. The study sample (n = 69) was divided into a VR group (n = 34) and a control group (n = 35) using stratified randomization. For the blood draw attempt, no distraction method was applied to the control group, while the children in the VR group were distracted from the procedure with the Epic Roller Coasters VR application. The primary variable assessed was pain, while secondary variables were fear and emotional appearance. The scores of emotional appearance, fear, and pain were compared with a Mann-Whitney U Test.

RESULTS

The pre-procedure emotional appearance score was 11.3 ± 4.3 in the VR group and 11.0 ± 5.0 in the control group, and the post-procedure score was 6.5 ± 3.3 in the VR group and 11.8 ± 5.3 in the control group, indicating a difference in emotional appearance after the procedure. VR group had lower negative emotional appearance, lower pain, and lower fear scores after procedure compared to the control group.

CONCLUSION

VR can be considered an effective approach to reducing the negative emotional appearance and for relieving pain and fear in children aged 4-12 years undergoing blood draw procedures in pediatric hematology and oncology outpatient unit (ClinicalTrials.gov: NCT05675358).

Music Therapy During Basic Daily Care in Critically Ill Children: A Randomized Crossover Clinical Trial

OBJECTIVE

To assess whether music therapy (MT) is effective to reduce pain during daily personal hygiene care (DPHC), a procedure performed in all patients in a pediatric intensive care unit.

METHODS

Fifty critically ill children were enrolled in a crossover controlled clinical trial with random ordering of the intervention, that is, passive MT, and standard conditions, and blind assessment of pain on film recordings. The primary outcome was variation of the Face Legs Activity Cry Consolability (FLACC) score (range, 0-10) comparing before and during DPHC. Secondary outcomes were changes in heart rate, respiratory rate, and mean arterial blood pressure, and administration of analgesic or sedative drugs during DPHC. Mixed-effects linear model analysis was used to assess effect size (95% CI).

RESULTS

The median (Q25-Q75) age and weight of the patients were 3.5 years (1.0-7.6 years) and 15.0 kg (10.0-26.8 kg). Consecutive DPHC were assessed on days 3 (2-5) and 4 (3-7) of hospitalization. In standard conditions, FLACC score was 0.0 (0.0-3.0) at baseline and 3.0 (1.0-5.5) during DPHC. With MT, these values were, respectively, 0.0 (0.0-1.0) and 2.0 (0.5-4.0). Rates of FLACC scores of >4 during DPHC, which indicates severe pain, were 42% in standard conditions and 17% with MT (P = .013). Mixed-effects model analysis found smaller increases in FLACC scores (-0.54 [-1.08 to -0.01]; P = .04) and heart rate (-9.00; [-14.53; -3.40]; P = .001) with MT.

CONCLUSIONS

MT is effective to improve analgesia in critically ill children exposed to DPHC.

TRIAL REGISTRATION

This study was recorded (April 16, 2019) before patient recruitment on the National Library of Medicine registry (NCT03916835; https://clinicaltrials.gov/ct2/show/NCT03916835).

Comparison of trace image colors for kids-book with two active distractions in reducing pain and fear of children during the venipuncture procedure

This study investigated the effectiveness of trace image and coloring for kids-book (TICK-B), cough trick, and balloon inflation techniques in reducing pain and fear in children during venipuncture. The current study is a prospective, controlled, and randomized trial (RCT). School-aged children who required venipuncture were involved in the study. Pediatric patients were randomly assigned to four groups: the TICK-B group, the cough trick group, the inflation of balloons, and the control groups. Before and after the procedure, the children and their parents were interviewed. Wong-Baker (FACES) Pain Rating Scale was applied to measure the severity of pain. Children's Fear Scale was applied to measure children's fear. This study involved the 160 children (mean age, 8.39-2.18 years). The severity of pain and fear levels among the children during and after the procedure were significantly different (p = 0.001). Pain and fear were significantly decreased in children in the intervention groups compared with those in the control group (p < 0.05). In the TICK-B group, participants reported significantly less pain and fear during the venipuncture procedure than in the cough trick, balloon inflation, and control groups (P = 0.001, p = 0.001, p = 0.001) and after the procedure (p = 0.001, p = 0.002, p = 0.002). There was a similar significance found in the level of fear during the procedure (p = 0.001, p = 0.002, p = 0.006), and after the procedure (p = 0.001, p = 0.008, p = 0.015).    Conclusion: TICK-B was the most effective method for decreasing the pain and fear of children associated with venipuncture procedures. Furthermore, the distraction technique of coughing and inflating balloons also proved efficacious in decreasing the pain and fear of children during venipuncture.    Trial registration: The study has been registered with ClinicalTrials.org under the number NCT04983303. It was retrospectively registered on July 26, 2021. What is Known: • Venipuncture, one of the most painful and uncomfortable procedures for children, caused great fear and discomfort during the procedure. What is New: • The TICK-B technique, music listening, and cartoon watching techniques are effective, simple, and safe ways to reduce children's fear and pain. These interventions provide a good way for children and their parents to collaborate during painful medical procedures. • No studies have compared the impact of TICK-B during venipuncture.

Leveraging an efficient preparation method into magnetic resonance examinations of young children aged 3-6

PURPOSE

To evaluate the benefits of a multifaceted concept, ANMTE (Appropriate Number of children, appropriate learning Methods, appropriate adaptive Training, and appropriate Encouragement), proposed by our group, in improving the success rate, efficiency and image quality of Magnetic Resonance (MR) examinations for children from 3 to 6 years old.

METHOD

In this study, 150 participants were included from July 2019 to January 2023, including 50 non-sedated children in ANMTE group, 50 in the group with sedative, and 50 in the group with routine preparations. ANMTE refers to appropriate number of children, appropriate learning methods, appropriate adaptive training, and appropriate encouragement, developed by our group for MR examinations of children from 3 to 6 years old. Group differences in success rate, efficiency, and image quality were evaluated across the three groups using Kaplan-Meier, Log-rank and Chi-square test, respectively.

RESULTS

The rates of successful MR examinations were 44/50 (88 %), 45/50 (90 %), and 36/50 (72 %) for ANMTE group, the group with sedatives and the group with routine preparations, respectively (P = 0.03). Image quality of the 3 groups showed no significant group difference (P = 0.067). In terms of the median duration of MR examinations, ANMTE group was comparable to the group with sedative (both were about 10.0 min), but better than the group with routine preparations (16.5 min) (P = 0.024).

CONCLUSION

We demonstrated the feasibility of our comprehensive nursing method ANMTE in MR examinations of young children, similar to the group with sedative at the success rate and image quality as well as the durations of MR examinations. ANMTE has not only better efficiency but also higher safety as it does not require sedative, which could be promising in clinical routine MR examinations for young children aged 3-6 years old.

The effect of vibrating cold application and puppet use on pain and fear during phlebotomy in children: A randomized controlled study

BACKGROUND

Non-pharmacological methods are often used as a creative strategy to reduce pain and fear in children during a painful procedure such as phlebotomy.

OBJECTIVES

This study was conducted to evaluate the effects of Bee Buzzy and puppet use on pain and fear during phlebotomy in children.

METHODS

This randomized controlled study was conducted in the pediatric phlebotomy unit of a university hospital. The CONSORT checklist was used in this study. The sample of 3-6 years children (n = 105) was divided into groups by block randomization. Children's pain and fear scores were evaluated with the Wong-Baker Faces Pain Rating Scale and Children's Fear Scale by the parents and the nurse who attempted phlebotomy during phlebotomy.

RESULTS

A statistically significant difference was found between the Bee Buzzy and puppet and Bee Buzzy and control groups in pain scores (p < .05). Pain scores were lower in the Bee Buzzy group than in the puppet and control groups. A statistical difference was found between Bee Buzzy and the control group or puppet and control group according to all fear scores (p < .05). Fear scores were lower in the Bee Buzzy and puppet group (p < .05).

CONCLUSIONS

The results show that the use of Bee Buzzy during phlebotomy has a pain-relieving effect, and the use of Bee Buzzy and puppet has an anti-fear effect in 3-6-year-old children.

IMPLICATIONS FOR PRACTICES

The use of Bee-Buzzy and puppets is effective in reducing pain and fear in children as they increase effective communication and distract attention.

CLINICAL TRIAL REGISTRATION

National Institutes of Health (NIH), ClinicalTrials.gov, NCT05827783.

The Effect of Distraction Techniques on Pain, Fear, and Anxiety in Children Undergoing Circumcision: A Meta-Analysis of Randomized Controlled Trials

Circumcision is a common pediatric operation, and distraction technique can be used as an adjunct analgesic method during the perioperative period. The study aims to explore the effect of distraction techniques on reducing pain, fear, and anxiety in children undergoing circumcision. The PubMed, ClinicalTrials.gov, and Embase databases were searched for articles published from January 1, 2000, to December 31, 2023. Only randomized controlled trials (RCTs) were included. Meta-analysis and forest plots were carried out using Review Manager 5.4.1 software, and outcomes were reviewed by two authors independently. We used the Risk of Bias assessment form (ROB2) developed by the Cochrane Collaboration to assess the quality of included studies. PRISMA 2020 guidelines were used in this article to achieve the quantitative and qualitative synthesis of data. A total of seven RCTs were included. The intervention group consisted of 417 patients, while the control group had 245 patients. The meta-analysis and sensitivity analysis results showed that the distraction technique could significantly relieve pain (MD -1.3, 95% confidence interval [CI]: [-1.61 to -0.99], p < .00001), fear (SMD -1.04, 95%CI -1.68 to -0.4, p = .001), and anxiety (SMD -1.07, 95%CI [-1.64 to -0.51], p = .0002). Similarly, therapeutic play significant could significantly relieve fear (MD -0.4, 95%CI [-0.71 to -0.1], p = .01) and anxiety (SMD -1.31, 95%CI [-2.59 to -0.04], p = .04), virtual reality (VR) could significantly relieve anxiety (SMD -0.67, 95%CI [-0.98 to -0.37], p < .0001). Distraction techniques can alleviate perioperative pain, fear, and anxiety in children undergoing circumcision.

Virtual Reality for Decreasing Procedural Pain during Botulinum Toxin Injection Related to Spasticity Treatment in Adults: A Pilot Study

BACKGROUND AND OBJECTIVES

Botulinum toxin injections are commonly used for the treatment of spasticity. However, injection procedures are associated with pain and procedural anxiety. While pharmacological approaches are commonly used to reduce these, innovative technology might be considered as a potential non-pharmacological alternative. Given this context, immersive virtual reality (VR) has shown effectiveness in the management of procedural pain. Our retrospective pilot study aimed to assess the potential added value of virtual reality in the management of pain and anxiety during intramuscular injections of botulinum toxin.

MATERIALS AND METHODS

Seventeen adult patients receiving botulinum toxin injections were included. A numerical rating scale was used to assess pain and anxiety during the injection procedure. The patients reported the pain experienced during previous injections without VR before injection and the pain experienced in the current procedure with VR after the end of the procedure. The level of satisfaction of VR experience, whether or not they agreed to reuse VR for the subsequent toxin botulinum injection, and whether or not they would recommend VR to other patients were assessed.

RESULTS

The use of virtual reality led to a decrease of 1.8 pain-related points compared to the procedure without technology. No significant improvement in the level of anxiety was reported. Patients were very satisfied with their VR experiences (7.9 out of 10), and many would agree to reuse VR in their next injection procedure (88%) and to recommend the use of VR in other patients (100%).

CONCLUSION

VR was useful for managing procedural pain related to botulinum toxin injection in adults, with a high level of satisfaction reported by the patients. VR should be considered as a valuable alternative to pharmacological approaches to manage procedural pain during botulinum toxin injection in adults.

Using Non-Violent Discipline Tools: Evidence Suggesting the Importance of Attunement

Training in non-violent discipline is important to prevent violence against children and ensure that their caregivers remain a safe base for them. This paper aims to deepen understanding of non-violent discipline by exploring attunement as a mechanism in the effectiveness of non-violent discipline tools. Attunement describes the sensitive responsiveness of caregivers towards their children and has been found to be central to the formation of secure attachment bonds and development of self-regulation. It includes understanding or being "in tune with" the child's needs and signals, matching these with appropriate responses. The objective of this paper is to explore attunement in relation to non-violent discipline. Peer-reviewed systematic reviews previously included in a systematic overview of evidence on non-violent discipline options were screened for information relevant to attunement. All reviews were published in English between 1999 and 2018 and offered evidence on at least one non-violent discipline tool. Although no reviews explicitly addressed attunement, evidence was found suggesting its importance in the use and effectiveness of discipline methods. Research directly investigating attunement in discipline is needed.

How to support children to develop and express their coping preferences around minor invasive medical procedures: children's and parents' perspectives

Invasive medical procedures in hospitals are major sources of stress in children, causing pain and fear. Non-pharmacological interventions are indispensable in effective pain and fear management. However, these interventions must be personalized to be effective. This qualitative study aims to gain insight into children's and parents' experiences, needs, and wishes related to supporting children to develop and express their coping preferences for dealing with pain and fear during minor invasive medical procedures in order to decrease pain and fear. A qualitative study using thematic analysis was performed. Data were collected through semi-structured interviews with children and parents who had undergone at least five minor invasive medical procedures in the last year. Nineteen children (8-18 years) and fourteen parents were interviewed individually. The experiences, needs, and wishes expressed in the interviews could be classified into one overarching theme, that of the personal process, and two content-related sub-themes: feeling trust and gaining control. The personal process was divided into two different phases, that of developing and of expressing coping preferences. Children and parents both reported it as a continuous process, different for every child, with their own unique needs. Children and parents expected personalized attention and tailored support from professionals.     Conclusion: Professionals must combine clinical skills with child-tailored care. In the process of searching for and communicating about coping preferences, children's unique needs and personal boundaries will thereby be respected. This gives children and parents increased trust and control during invasive medical procedures. What is Known: • Untreated pain and stress caused by medical procedures can have severe and important short- and long-term consequences for children. Personalized non-pharmacological interventions are an essential element of procedural pain management. What is New: • A personalized coping strategy is important for children when undergoing medical procedures. Each individual child has a personal way of expressing their own coping strategy. Children and their parents need information and the space to develop and express their individual coping preferences. • Children and parents expect to receive child-tailored care from professionals including respect for their own, unique needs and boundaries. Professionals should build trustful relationships and provide appropriately tailored autonomy around medical procedures.

Pediatric staff and their perceptions of music therapy services

PURPOSE

To reveal the benefits, needs, and limitations of music therapy observed by clinical pediatric staff at a children's hospital in the United States of America.

DESIGN AND METHODS

Researchers developed an electronic 13-question survey and distributed the survey in the fall of 2022. Questions included demographics, Likert-type scale, and open-ended queries. Data was collected via Qualtrics and analyzed using descriptive statistics and content analysis.

RESULTS

A total of 83 pediatric staff completed the survey. Staff observed positive benefits, where the highest reported areas were opportunities for dealing with anxiety/stress (94.7%), opportunities for social interaction (93.3%), and quality of life (89.3%). Analysis of free-response questions suggest that staff expect expertise and a nuanced understanding of the needs of each of their clinical units.

CONCLUSION

Results suggest that staff possess an overall positive attitude toward music therapy in all settings served. Music therapists may be valuable for psychosocial and rehabilitative support to hospitalized children and their families.

PRACTICE IMPLICATIONS

Nursing staff may utilize music therapists to improve patient outcomes and reduce the negative effects of hospitalization.

The effect of buzzy®, DistrACTION® cards on reducing pediatric pain and fear during blood collection in the rheumatology polyclinic: A randomized controlled trial

PURPOSE

The aim of this study was to compare the effectiveness of Buzzy® and DistrACTION® Cards in reducing children's pain and fear while taking venous blood samples.

METHODS

This research was designed as a randomized controlled experimental study. The study population consisted of children aged 6-12 years admitted to the Pediatric Rheumatology Diseases Polyclinic in a Faculty of Medicine in Germany. The sample of the study consisted of 96 children (Buzzy® = 32, DistrACTION® Cards = 32, control = 32) who met the patient selection criteria and agreed to participate in the study. The data were obtained using a Child and Family Information Form, the Children Fear Scale (CFS), and the Faces Pain Scale-Revised (FPS-R). The data were evaluated using the Pearson chi-square test, Kruskal-Wallis test, One-way ANOVA test with Bonferroni correction, and Fisher-Freeman-Halton.

FINDINGS

In the study, the average age of the children was 9.21 ± 2.15 years. The Buzzy® group had the lowest pain and procedural fear scores (self-report = 0.88 ± 1.13, 0.31 ± 0.47; parent report = 0.75 ± 0.98, 0.34 ± 0.48, and researcher report = 0.81 ± 1.00, 0.31 ± 0.54, respectively) than the DC, and control groups.

CONCLUSIONS

The Buzzy® method was effective in reducing venipuncture pain and fear in children.

PRACTICE IMPLICATIONS

Nurses can use the Buzzy® methods to help reduce venipuncture pain and fear in children. The clinical trial registration number is NCT05560074. (https://clinicaltrials.gov/ct2/show/study/NCT05560074).

The Effect of Distraction Methods During Venous Blood Sampling on Pain Levels in School-Age Children: A Systematic Review

OBJECTIVES

This systematic review was conducted to examine the available evidence on the effects of distraction methods during venous blood sampling on pain levels in school-age children.

DESIGN

A systematic review.

DATA SOURCES

Pubmed, Web of Science, Scopus, Science Direct were searched using search terms.

REVIEW/ANALYSIS METHODS

A systematic review of all relevant articles published between June 2017 and June 2022, was conducted according to Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

The applied search strategy identified 612 articles in four databases. A total of 2,032 school-age children in the 15 studies who met the study inclusion criteria were included in the review. Four studies used active distraction, eight studies used passive distraction, and three studies used both distraction methods.

CONCLUSIONS

Active and passive distractions are efficacious interventions during venous blood sampling in reducing pain in school-age children. However, more studies are needed to determine the superiority between these two methods.

The Effect of 2 Different Distraction Methods on Pain, Fear, and Anxiety Levels During Venous Blood Draw in Children in a Pediatric Emergency Unit: A Randomized Controlled Study

BACKGROUND

Blood draw procedures can cause pain, fear, and anxiety in the pediatric population.

PURPOSE

To compare the effects of watching cartoons either with virtual reality (VR) or via a tablet on pain, fear, and anxiety during venous blood draw procedures in children.

METHODS

A randomized controlled study was conducted with 159 children aged 5 to 12 years in the pediatric emergency unit. The 3 groups included cartoons with VR (n = 53) or a tablet (n = 53), and a control group (n = 53).

RESULTS

Children in the 2 intervention groups had lower perceptions of pain, fear, and anxiety, with those watching cartoons via VR having the lowest perceptions.

CONCLUSIONS

Findings from this study showed a reduction in the perception of pain, fear, and anxiety in children who watched cartoons with VR or tablets during blood draw procedures. Nurses should consider using these nonpharmacological methods to reduce pain, fear, and anxiety, among pediatric patients.

The effect of finger puppet on pain and emotional manifestation for venous blood collection in the pediatric emergency department: A randomized controlled trial

AIM

To determine the effect of distraction with a finger puppet for venous blood collection in the pediatric emergency department on children's pain and emotional manifestation.

METHODS

Randomized controlled trial with 80 children (aged 3-6 years) who applied to the pediatric emergency department between October 2021 and March 2022. The attention of child was distracted from the procedure by playing with finger puppets before and during the venous blood collection in the finger puppet group. The children in the control group underwent routine blood collection. The procedural pain was measured with the Face, Legs, Activity, Cry, Consolability Scale (FLACC) and the emotional response was measured with the Children's Emotional Manifestation Scale (CEMS).

RESULTS

The mean FLACC pain scores of the children in the finger puppet group were statistically significantly lower than the children in the control group (p < 0.001). It was also found that the finger puppet group's mean scores of CEMS before and during the procedure were statistically lower than those of the control group (p < 0.001).

CONCLUSIONS

Finger puppets can be used to reduce pain and positively change children's emotional responses during painful procedures such as blood collection.

Exploring the needs of children and caregivers to inform design of an artificial intelligence-enhanced social robot in the pediatric emergency department

Background & Objective

Socially assistive robots (SARs) are a promising tool to manage children's pain and distress related to medical procedures, but current options lack autonomous adaptability. The aim of this study was to understand children's and caregivers' perceptions surrounding the use of an artificial intelligence (AI)-enhanced SAR to provide personalized procedural support to children during intravenous insertion (IVI) to inform the design of such a system following a user-centric approach.

Methods

This study presents a descriptive qualitative needs assessment of children and caregivers. Data were collected via semi-structured individual interviews and focus groups. Participants were recruited from two Canadian pediatric emergency departments (EDs) between April 2021 and January 2022.

Results

Eleven caregivers and 19 children completed 27 individual interviews and one focus group. Three main themes were identified: A. Experience in the clinical setting, B. Acceptance of and concerns surrounding SARs, and C. Features that support child engagement with SARs. Most participants expressed comfort with robot technology, however, concerns were raised about sharing personal information, photographing/videotaping, and the possibility of technical failure. Suggestions for feature enhancements included increasing movement to engage a child's attention and tailoring language to developmental age. To enhance the overall ED experience, participants also identified a role for the SAR in the waiting room.

Conclusion

Artificial intelligence-enhanced SARs were perceived by children and caregivers as a promising tool for distraction during IVIs and to enhance the overall ED experience. Insights collected will be used to inform the design of an AI-enhanced SAR.

Assessment of pain management adequacy among hospitalized pediatric patients: institutional-based cross-sectional study

Background

As the evidence showed, despite the magnitude of the effects that pain can have on a child, it is often inadequately assessed and treated. However, whether pain is adequately treated or not, evidence is lacking in the study setting.

Objectives

This study assessed pain management adequacy among hospitalized pediatric patients at the University of Gondar Comprehensive Specialized Hospital, Ethiopia.

Methods

An institution-based cross-sectional study was conducted among pediatric patients admitted to the University of Gondar Comprehensive and Specialized Hospital between June and August 2021. Eligible patients were enrolled in the study using consecutive sampling techniques. Data were collected using a structured interview-based questionnaire and a review of the patient's medical records that were prepared after reviewing earlier studies. Pain management adequacy was determined using the pain management index (PMI) score. Statistical Software for Social Sciences (SPSS) version 22 was used for data entry and analysis. Descriptive statistics such as frequencies, percentages, and means with standard deviation were used to describe the respective variables. Logistic regression was used to assess predictor variables of pain management adequacy. A p-value <0.05 at a 95% CI was considered statistically significant.

Results

Of the 422 participants enrolled in the study, most (58.1%) were males, with a mean age of 3.9 ± 0.8 years. Pain medication was prescribed to 62.8% (95% CI: 57.3-68.2) of the participants. About 63.3% (95% CI: 58.8%-68%) received inadequate analgesics. The type of painkillers administered also did not match the severity of the pain. Pediatric patients less than 1 month and between 1 month and 1 year (AOR = 2.891, 95% CI: 1.274-12.899 and AOR = 2.657, 95% CI: 1.350-5.175), respectively, and patients with severe and moderate levels of pain (AOR = 3.448, 95% CI: 1.902-6.251 and AOR = 5.345, 95% CI: 1.956-9.828), respectively, were found to have inadequate pain medication compared with their counterparts.

Conclusion

This study revealed that pain was hardly managed based on its severity. Overall, two-thirds of pediatric patients received inadequate pain medication. This indicates majority of patients experienced pain did not manage appropriately.

Nonorganic (Behavioral) Signs and Their Association With Epidural Corticosteroid Injection Treatment Outcomes and Psychiatric Comorbidity in Cervical Radiculopathy: A Multicenter Study

OBJECTIVE

To determine the association between cervical nonorganic pain signs and epidural corticosteroid injection outcomes and coexisting pain and psychiatric conditions.

PATIENTS AND METHODS

Seventy-eight patients with cervical radiculopathy who received epidural corticosteroid injection were observed to determine the effects that nonorganic signs have on treatment outcome. A positive outcome was a decrease of 2 or more points in average arm pain, coupled with a score of 5 on a 7-point Patient Global Impression of Change scale 4 weeks after treatment. Nine tests in 5 categories (abnormal tenderness, regional disturbances deviating from normal anatomy, overreaction, discrepancies in examination findings with distraction, and pain during sham stimulation) were modified from previous studies and standardized. Other variables examined for their association with nonorganic signs and outcomes included disease burden, psychopathology, coexisting pain conditions, and somatization.

RESULTS

Of the 78 patients, 29% (n=23) had no nonorganic signs, 21% (n=16) had signs in 1 category, 10% (n=8) had signs in 2 categories, 21% (n=16) had signs in 3 categories, 10% (n=8) had signs in 4 categories, and 9% (n=7) had signs in 5 categories. The most common nonorganic sign was superficial tenderness (44%; n=34). Mean number of positive nonorganic categories was higher in individuals with negative treatment outcomes (2.5±1.8; 95% CI, 2.0 to 3.1) compared with those with positive outcomes (1.1±1.3; 95% CI, 0.7 to 1.5; P=.0002). Negative treatment outcomes were most strongly associated with regional disturbances and overreaction. Positive associations were noted between nonorganic signs and multiple pain (P=.011) and multiple psychiatric (P=.028) conditions.

CONCLUSION

Cervical nonorganic signs correlate with treatment outcome, pain, and psychiatric comorbidities. Screening for these signs and psychiatric symptoms may improve treatment outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT04320836.

Parents' perceptions of their child's pain assessment in hospital care: A cross-sectional study

PURPOSE

A prerequisite for successful pain management is identifying the pain and assessing its intensity. The aim of this study was to describe parents' perceptions of their child's pain assessment in hospital care.

DESIGN AND METHODS

This study was a descriptive cross-sectional study. A questionnaire was completed by parents (n = 261) whose child was hospitalized in one of the pediatric units (n = 6) of the University Hospital in Finland. Quantitative data were analyzed using statistical methods; open-ended data were analyzed using inductive content analysis.

RESULTS

Parents reported that their children experienced moderate (36%) to severe pain (42%) during hospitalization. The most intense pain experienced by the children was associated with needle-related procedures (41%). A large proportion of parents (83%) were involved in their child's pain assessment. Parents were satisfied with their child's pain assessment but perceived some shortcomings. Parents hoped that a variety of methods would be used to assess their child's pain and that the parents' and child's views on pain would be taken into account.

CONCLUSIONS

Most children experience moderate to severe pain during hospitalization. Parents are often involved in pain assessment but are rarely instructed to use pain scales.

PRACTICE IMPLICATIONS

Child's pain should be assessed regularly and frequently enough. It is important that the child and parents are involved in shared decision-making about pain assessment and treatment, and they have opportunities to ask questions. Guidance should be offered to parents about the use of pain assessment scales.

Pain research and children and adolescents with severe intellectual disability: ethical challenges and imperatives

Children with severe intellectual disabilities encounter inequities in pain-related care, yet little pain research involves this population. A considerable issue with pain research in this population is its ethical complexity. This Viewpoint delineates the ethical challenges of pain research involving children (aged 2-12 years) and adolescents (aged 13-21 years) with severe intellectual disabilities. There are two main issues. First, some of the standard methods for assessing pain and pain sensitivity are not suitable for individuals with severe intellectual disability, who are often non-verbal and unable to understand or follow instructions. Second, children and adolescents with severe intellectual disability cannot provide informed consent or assent to participate in pain research, and their dissent is not always recognised. The existing ethical guidelines for pain research by the International Association for the Study of Pain provide helpful, but general, guidance. This Viewpoint supplements these guidelines and uses a well established framework for assessing the ethics of clinical research to highlight points relevant to designing, doing, reviewing, and evaluating research involving children and adolescents with severe intellectual disability, focusing on issues that are unaddressed in existing guidance.

The Impact and Influence of Hospital Clowns on Hospitalized Children Undergoing Painful Procedures: A Mixed Methods Study

Hospital clowns are widely used in pediatric settings. However, the field of pain and pain experience in children is complex and multifaceted. Therefore, the aim of this study was to expand knowledge on the impact and influence of hospital clowns on 4 to 15-year-old children's experiences of managing painful procedures and conditions. A convergent mixed method study was conducted integrating findings from three individual studies: a prospective non-blinded study and two focused ethnographic studies. The findings illuminated a child-clown interaction characterized by a close relationship evolving during a continuous, mutually focused attention, conceptualized as WE. This WE represent a responsive interaction between child and clown, which supported the child during the procedures, and generated three integrated findings: an age-differentiated approach; understanding the child's condition; and previous experiences as a part of the child's history. The WE approach strengthened the child's competences and ability to manage during painful procedures.

Safety and feasibility of the paediatric post-cardiac catheterisation Wrap: a pilot study

OBJECTIVE

The paediatric post-cardiac catheterisation Wrap (Wrap), an innovative medical safety device, swaddles young paediatric patients in a supine position aiding in immobilisation post-cardiac catheterisation. This pilot study investigated the feasibility and safety of using the Wrap on young paediatric patients during their bed rest period following cardiac catheterisation with femoral access.

SETTING

Boston Children's Hospital Cardiac Catheterization Lab.

PARTICIPANTS

20 patients, ages 1-5 years and weighing 3-25 kg.

METHODS

Investigator-developed tools used to collect data included the Demographic and Outcome Measures Data Tool, the Parent/Caregiver Satisfaction, and Provider Ease of Use tools. They measured: 1. The feasibility of using the Wrap 2. Wrap ease of use from the nurse providers' perspective 3. Parent satisfaction related to the Wrap 4. Frequency of Wrap non-bleeding-related adverse events 5. Frequency of rebleeding at femoral groin access sites.

RESULTS

The Wrap was feasible and safe; increased nurse provider satisfaction by allowing visualisation of the groin access sites while minimising the need for hands-on care; and increased parent satisfaction by allowing parents to hold and provide comfort while their child was on bed rest.

IMPLICATIONS FOR RESEARCH

The Wrap is a safe alternative to the current practice of swaddling with a bath blanket. Further studies are warranted to assess the Wrap's effectiveness in reducing the incidence of rebleeding events in the post-cardiac catheterisation period and explore clinical use outside of the Cardiac Catheterization Lab.

Effect of Distraction Interventions on Anxiety in Children Undergoing Surgery: A Meta-Analysis

Due to the unfamiliarity of the surroundings, children having surgery endure worry and tension. Untreated anxiety in children impairs postoperative healing and causes changes in postoperative behavior. The purpose of this review was to determine the efficacy of distraction therapies on anxiety in children undergoing surgery. The systematic review was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standards. PubMed via MEDLINE, CINAHL, ProQuest, Web of Science, and the Cochrane Central Register of Controlled Trials were used to find relevant trials. Full-text papers published in English from January 1, 2000 to December 31, 2021 were included. Children undergoing surgery aged 1 to 18 years were included. A data extraction form was created to extract data from the selected studies. According to the Cochrane risk of bias assessment tool, studies were classified as “low risk,” “high risk,” or “unclear risk.” Review Manager software was used to do a quantitative meta-analysis. Thirteen studies looked at the effect of distraction intervention on children. Nine of them were selected for meta-analysis. The distraction interventions included in this review were: handheld video game, play dough and play with blocks and puzzles, tablet-based interactive distraction, animated video, painting and storytelling, age-appropriate video, distraction with video glasses, watching a movie, and bringing favorite toy during hospital stay. Meta-analysis showed that distraction interventions are effective on preoperative anxiety in children (standardized mean difference = –17.07, 95% confidence interval: 27.11–7.02, p = 0.0009).