The management of pain associated with pediatric procedures

Massage therapy for paediatric procedural pain: A rapid review

Background

Pain is a common paediatric problem, and procedural pain, in particular, can be difficult to manage. Complementary therapies are often sought for pain management, including massage therapy (MT). We assessed the evidence for use of MT for acute procedural pain management in children.

Methods

We searched five main databases for (i) primary studies in English, (ii) included children 0 to 18 years of age, (iii) compared MT for procedural pain management to standard care alone or placebo, and (iv) measured pain as the primary or secondary outcome. The data were extracted by one author and verified by a second author. Randomized controlled trials were evaluated using the Cochrane Risk of Bias tool.

Results

Eleven paediatric trials of procedural pain in neonatal, burn, and oncology populations, a total of 771 participants, were identified. Eight reported statistically significant reductions in pain after MT compared to standard care. Pain was measured using validated pain scales, or physiologic indicators. The studies were heterogeneous in population, techniques, and outcome measures used. No adverse events associated with MT were identified.

Conclusion

MT may be an effective nonpharmacologic adjunct for management of procedural pain in children.

The Effects of Two Methods on Venipuncture Pain in Children: Procedural Restraint and Cognitive-Behavioral Intervention Package

BACKGROUND

Invasive interventions can produce fear, anxiety, and pain in children. This may negatively affect the children's treatment and care.

AIM

This study was conducted to determine the effects of procedural restraint (PR) and cognitive-behavioral intervention package (CBIP) on venipuncture pain in children between 6-12 years of age.

DESIGN

Quasi-experimental study.

SETTINGS

The study was conducted in the pediatric blood collection service of the hospital in Turkey between October 1, 2015, and April 1, 2016.

PARTICIPANTS/SUBJECTS

The population of the study consisted of children admitted to the blood collection service during the study period who met the inclusion criteria.

METHODS

The children included in the study were divided into two groups. Group 1 (n = 31) received PR in accordance with routine clinical practice. Group 2 (n = 30) received the CBIP. The data were collected by the researchers using a questionnaire, the visual analog scale (VAS), and the Wong-Baker FACES (WB-FACES) Pain Rating Scale.

RESULTS

The children in the PR group had a mean VAS score of 5.90 ± 3.22 and a mean WB-FACES score of 8.70 ± 2.22. The children in the CBIP group had a mean VAS score of 2.43 ± 2.02 and a mean WB-FACES score of 2.80 ± 2.49. A statistically significant difference was found between the mean VAS and WB-FACES pain scores of the groups (p < .05).

CONCLUSIONS

The results of this study showed that the children in the CBIP group had a lower pain level during venipuncture compared to those restrained for the procedure.

Use of needle-free injection systems to alleviate needle phobia and pain at injection

Needle phobia affects at least 10% of the general population. Subcutaneous injections are used for many reasons, including immunizations, administration of medications such as insulin and heparin, and to provide local anesthesia, both for surgery and for intravenous cannulation. Whatever the reason for its application, the injection itself may cause discomfort and/or pain. In children, in patients with needle phobia, in those who require frequent intravenous cannulations, or in those who need daily medication, the pain at injection can reach unbearable intensity that could lead to refusal of medical care. Various approaches are employed to alleviate the pain caused by intravenous cannulation. These include the use of topical analgesia [i.e., EMLA, Ametop (tetracaine], Numby Stuff and ethylchloridespray], skin infiltration with lidocaine using 25-30-gauge needles and jet injectors. This article will review the complex topic of needle phobia and needle pain, and will summarize the currently available alternatives and the new developments intended to reduce the intensity of injection pain.

Cancer pain management in children

The World Health Organization document Cancer Pain Relief and Palliative Care in Children (WHO, 1998) advocates the global application of the principles of pain management and palliative care for children with cancer. The principles of pain management include the application of the WHO analgesic ladder, appropriate opioid dose escalation, the use of adjuvant analgesics, and the use of non-pharmacological methods of pain control. These principles of pain management should be incorporated into the treatment protocols of all children with cancer, acknowledging that treatment options may be limited for some children.

Pediatric sedation for procedures titrated to a desired degree of immobility results in unpredictable depth of sedation

OBJECTIVE

To test the hypothesis that the need to attain immobility during pediatric sedation for procedures determines the depth of sedation, which cannot always be predicted.

DESIGN

A retrospective review of sedation documents of 301 consecutive sedations of pediatric patients undergoing various procedures

SETTING

Division of Critical Care sedation service within a children's hospital.

MEASUREMENTS AND MAIN RESULTS

The medical records and sedation forms of our most recent 301 consecutive sedations were retrospectively reviewed. Based on the data gathered, the patients were categorized according to their achieved level of immobility, their level of consciousness according to the definitions of the American Academy of Pediatrics, the procedures for which sedation was administered, and the sedatives used. A total of 125 males and 89 females received 301 sedations. Their ages ranged from 22 days to 29 years (mean 7 y + 6 y). We recognized four categories of immobility for procedures. In category 1, some motion was allowed during painless and noninvasive procedures to the extent that it did not risk the patient nor hinder the successful performance of the procedures. In category 2, the patients were kept motionless during painless and noninvasive procedures. In category 3, the patients were kept motionless during painful and invasive procedures with the addition of local anesthetic. In category 4, the patients remained motionless throughout their painful or invasive procedure without the use of local anesthetics. There were 32, 10, 156 and 103 sedations in each category, respectively. Conscious sedation (CS) was observed in six sedations (19%) in category 1 of immobility; it was observed in none (0%) in category 2, in 4 sedations (2.6%) in category 3, and in 1 sedation (1%) in category 4. Deep sedation (DS) was noted in 26 category 1 sedations (81%), in 10 category 2 sedations (100%), in 136 category 3 sedations (87%), and in 63 category 4 sedations (61%). General anesthesia (GA) was only observed in categories 3 and 4 in 16 sedations (10%) and 39 sedations (38%), respectively. Intravenous (IV) ketamine, as a single agent or in combination with other agents, was the most frequently used sedative (88%) followed by IV benzodiazepines (64%), propofol (39%), opiates (15%), and barbiturates (5%). A total of 59 (19%) adverse events were encountered during the 301 sedations. In categories 1 and 2, no adverse event (0%) was encountered. In category 3, 19 adverse events took place (32%), and 40 adverse events (68%) (P< 0.05) occurred in category 4.

CONCLUSIONS

Pediatric sedation results in 4 categories of immobility. Complete immobility during painful and invasive procedures is associated with a higher incidence of adverse events. The depth of sedation (ie, CS, DS, or GA) required to achieve each category of immobility is unpredictable and varies from patient to patient. Thus, granting a limited sedation authority (conscious sedation only) to physicians may be of limited practical value.

Invasive procedures carried out in conscious children: contrast between North American and European paediatric oncology centres

AIM

To define practice in managing repeated invasive procedures in selected paediatric oncology centres in North America and Europe, especially the United Kingdom; to define and contrast concerns that shape policy making, and to contrast practice, particularly regarding procedures performed on conscious patients.

METHODS

Postal survey: 118 centres of the Pediatric Oncology Group and the United Kingdom Children's Cancer Study Group received questionnaires.

RESULTS

68 questionnaires (58%) were returned (52 from North America, 12 from Europe). For all procedures, North American centres tended to use less effective techniques than European, especially for bone marrow procedures. Many North American centres reported performing these on conscious patients on at least three quarters (25%) or half (30%) the occasions. In contrast, corresponding figures for the European centres were 6% and 0%.

CONCLUSIONS

Many bone marrow procedures are still carried out in the conscious patient despite the safety and effectiveness of modern anaesthetic and deep sedation techniques. There appears to be a greater reluctance to offer these to patients in North American centres than in European ones. This may reflect a misperception that the risks of adverse effects are high. Several non-pharmacological techniques are used, but they remain uncommon.

Behavioral and cognitive interventions in the treatment of pain in children

A wide range of behavioral and cognitive techniques have been found to be efficacious for helping children to cope with acute pain. Research into the clinical applicability of these interventions is at an early stage but increasingly is being recognized as an important future direction. Many existing interventions and assessment tools are reasonably easy to use, allowing practitioners to have the tools to identify children most vulnerable to pain and to significantly reduce pain-related distress in these children. For additional information from the Internet, please visit the UCLA Pediatric Pain Program Web site: http:¿members.xoom.com/UCLAPAIN/.

Structuring psychosocial care in pediatric oncology

The requirements for high quality psychosocial care for children with cancer and their families are steadily increasing. As an additional supplement to medical and nursing care, psychosocial work has to consider both the requirements of the medical treatment and the associated stress factors. It is essential to structure the different possibilities of intervention in a way which guarantees the practice of psychosocial care within the ongoing medical care. This requires a standardized psychosocial care manual. In July 1994, a 'Manual for Psychological Care in Pediatric Oncology' was put into practice and has been continually improved in the Department of Pediatric Hematology/Oncology of the University of Bonn. It contains special indications for different standards of psychosocial care, is oriented according to the phases and situations of medical treatment, and consists of a health education program as well as special care measurements. The latter are related to both the stressors primarily caused by the requirements of familial adherence to medical and nursing care and the stressors primarily caused by factors of the individual or the familial life circumstances. The theoretical basis of this manual and concrete information for its use are described in this paper.

Cognitive behavioral interventions for children during painful procedures: research challenges and program development

The purpose of this report is to describe a pilot program designed to introduce the use of cognitive behavioral interventions for painful pediatric procedures at a university hospital, and to discuss the challenges that occurred during this process. Participants in the program included ten parents and their children who were newly diagnosed with leukemia, and staff who provided treatment for these children. Measures included direct videotaped observations of the children, perceptions of pain and anxiety completed by children, parents, and staff, and parent and staff ratings of satisfaction with the program. Results indicated strong acceptance of the interventions. This report discusses the challenges encountered, implications of the findings, and plans for future program development.

Pain and pain management in newborn infants: a survey of physicians and nurses

BACKGROUND

Despite an increased awareness among clinicians regarding pain and pain management for infants undergoing surgery, pain associated with procedures performed outside the operating room may not be adequately managed.

PURPOSE

To examine the beliefs and self-described behavior of physicians and nurses regarding the management of procedural pain in newborn infants.

METHODS

A survey was distributed to 467 clinicians (nurses and physicians) working in 11 level II and 4 level III nurseries in a large metropolitan area. Respondents were asked to rate the painfulness of 12 common bedside nursery procedures and how often pharmacologic and nonpharmacologic (comfort) measures are currently used and should be used for those procedures. Demographic data were also collected.

RESULTS

Surveys were completed by 374 clinicians (80% response rate). Physicians and nurses believe infants feel as much pain as adults and that 9 of the 12 listed procedures are moderately to very painful. Neither pharmacologic nor comfort measures are believed to be used frequently, even for the most painful procedures. Physicians and nurses believe both pharmacologic and comfort measures should be used more frequently, but nurses believe comfort measures should be used more frequently than do physicians. Beliefs about infant pain and procedural pain were related to pain management preferences. Physicians' but not nurses' ratings were associated with significant personal pain.

CONCLUSIONS

Despite their beliefs that infants experience significant procedure-related pain, clinicians believe pain management for infants remains below optimal levels. Barriers to more consistent and effective pain management need to be identified and surmounted.

Pearls, pitfalls, and updates for pain management

Pain management is one of the most challenging areas we encounter as emergency physicians. However, many of us fail to adequately meet this challenge. This article discusses frequently encountered pain syndromes and pain management options.

Cognitive behavioral pain and anxiety interventions in pediatric oncology centers and bone marrow transplant units

Although research conducted on the treatment of pain and anxiety in children has found a number of cognitive behavioral interventions to be effective, it is not known to what extent this research has been put into practice. The purpose of this project was to obtain information on the use of cognitive behavioral interventions to help children and families cope with the pain and anxiety experienced during lumbar punctures and bone marrow aspirations. In this descriptive study, 15 Pediatric Bone Marrow Transplant Units and 32 Pediatric Hematology/Oncology Centers from across the country were surveyed using a questionnaire developed to obtain information on the use and effectiveness of cognitive behavioral interventions and the availability of support services. This survey indicates that most centers use a number of cognitive behavioral interventions to help children cope with painful procedures. However, some interventions, such as providing information before procedures and positive reinforcement after procedures, are used more frequently than interventions, such as rhythmic breathing, distraction, and imagery, that require more time and training. A variety of support services were available, although psychological services were primarily available on an as needed basis and support groups were not usually offered on an ongoing basis. In general, nurses are the major providers of these interventions, with other professionals providing interventions specific to their training. Nurses need to continue to study appropriate ways to incorporate use of effective cognitive behavioral interventions into the routine care of children with cancer.

The silent ones: a review of sampling issues and biases pertinent to the area of pediatric oncology procedural pain

Pain related to procedures for pediatric oncology patients is a salient topic. Although these procedures can cause much distress, this area has been neglected in research. Previous research has suffered from serious sampling problems, such as using small, nonrepresentative, biased samples. In addition, little is known about the influence of sociocultural factors on the phenomena of pain in children. This article presents the results of a review of the past 10 years of pertinent literature, argues that sociocultural influences on pain need to be studied, and offers suggestions for improving sampling designs.

[Ambulatory 24-hour home pH-metry: parental and familial reactions. Prospective study of 100 cases]

BACKGROUND

The ambulatory twenty-four hour esophageal pHmetry is nowadays a common mode of assessment of gastro-esophageal reflux in children. The aim of this study was to evaluate the impact of the test on child and family's ordinary daily life.

MATERIAL AND METHODS

One-hundred children (64 boys, 36 girls) were included in this study during a 10-month period from August 1992 until May 1993. Mean age was 2 years 9 months (range: 22 days--12 years). Forms with a list of questions concerning parental understanding of the test, child's reaction after introduction of the pH-electrode, general reactions in the household, and eventual disturbance of the child's temper and appetite, were given to the parents. Six months later, 81 families were contacted by telephone and asked the same questions. Children were divided into three groups: those under 1 year of age (n = 38), from 1 to 4 years (n = 35), and more than 4 years (n = 27).

RESULTS

One child aged 2 months had to be admitted to hospital due to the mother's overanxiety. The majority of parents (80%) assumed they knew about the principles of the test, with little change once the test was over. Those whose child had previously been submitted to the test were less apprehensive. When the test was first initiated, 81% of parents feared it would cause some discomfort, either due to pain (69%), or to poor acceptance at home (25%) with the risk of having the catheter accidently removed. Once the catheter had been positioned with the parents close to the child at that time, its presence was judged by them tolerable in 88.9% of cases. Once at home, 84.8% of the parents were not worried, as the child was calm (83.8%) and also due to the possibility for them to get in touch with the physician if necessary (86.9%). No change in routine daily life was reported by 80.8% of the families; in only 19.2% was the child reported to be overwhelmed with the test. When asked if the test should be undertaken another time, 91.9% would still prefer it as a home procedure, the only families requesting it be done in hospital being those with a history of sudden death syndrome.

CONCLUSION

pHmetry test as a 24-hour procedure done at home may be the source of some discomfort and anxiety both to the child and parents; yet it appears to be generally well-accepted, both for its non-aggressive and diagnostic value.

A randomized, controlled trial of oral midazolam and buffered lidocaine for suturing lacerations in children (the SLIC Trial)

STUDY OBJECTIVE

To evaluate the efficacy of oral midazolam (0.3 mg/kg) and buffered lidocaine in reducing the anxiety associated with the repair of childhood lacerations.

DESIGN

Prospective, randomized, double-blind, placebo-controlled trial.

SETTING

Community-based emergency department.

PARTICIPANTS

Children younger than 10 years.

INTERVENTIONS

Each subject was randomized into one of four treatment groups: A, midazolam and buffered lidocaine (n = 25); B, placebo and buffered lidocaine (n = 27); C, midazolam and plain lidocaine (n = 32); and D, placebo and plain lidocaine (n = 23).

RESULTS

Anxiety level was scored on a scale of 1 to 4 on the basis of predetermined behavior criteria before and during repair. Parents independently rated the child's distress using a visual analog scale. Vital signs were measured on admission and at discharge. There were no significant differences among the treatment groups for age, location and length of laceration, or initial anxiety scores. Midazolam decreased the number of children with anxiety levels 3 and 4 by 24% (95% CI, 7.5% to 41.3%). There was a 33% reduction of the parents' distress rating with midazolam (P < .01). Buffered lidocaine had no effect on anxiety level.

CONCLUSION

Oral midazolam (0.3 mg/kg) is a safe and effective treatment for reducing anxiety during the suturing of lacerations in children less than 10 years of age. In this study, buffered lidocaine had no effect on anxiety level.

Pediatric analgesia and sedation

Sedation and analgesia are essential components of the ED management of pediatric patients. Used appropriately, there are a number of medications and techniques that can be used safely in the emergency care of infants and children. Emergency physicians should be competent in the use of multiple sedatives and analgesics. Adequate equipment and monitoring, staff training, discharge instructions and continuous quality management should be an integral part of the ED use of these agents.

The relationship between children's coping styles and psychological interventions for cold pressor pain

This study examined the hypothesis that matching pain management interventions to children's preferred coping methods would increase pain tolerance and decrease self-reported pain during the cold pressor pain paradigm. Children aged 8-10 years were classified as 'attenders' (focusing on the stimulus) or 'distractors' (focusing away from the stimulus) based upon their spontaneous coping responses during a baseline exposure to the cold pressor. Children were then randomly assigned to 1 of 3 intervention conditions (sensory focusing, imagery, or no intervention) and completed the cold pressor procedure again 2 weeks later. A significant interaction was found between coping style and intervention. Children who were classified as distractors demonstrated greater tolerance when taught to use imagery techniques (a 'matched' intervention). Although pain ratings tended to be lower for distractors using imagery, the significant interaction resulted from an increase in ratings for the distractors using sensory focusing (i.e., a 'mismatched' intervention). Results suggest that, for distractors, interventions that are consistent with natural coping methods are most effective in enhancing abilities to cope with pain, while a mismatched intervention reduces coping abilities. The findings also suggest further study regarding how to provide effective pain intervention with attenders, since neither intervention enhanced coping in this group.

Pharmacological management of pain in children

This article examines the use of analgesics and psychopharmacological adjuvants in children experiencing pain. Peripheral analgesics are effective for mild to moderate pain. Narcotics are effective but may produce dependence and tolerance as well as untoward side effects. Major tranquilizers, minor tranquilizers, tricyclic antidepressants, and stimulants have all been used as adjuvants in pain management. Major tranquilizers are now discouraged because of potential serious adverse effects. Benzodiazepines are relatively safe and decrease anxiety accompanying pain. Tricyclics may be used with caution. Stimulants have received little attention but may be useful in treating both pain and depression in the physically ill.

Implications of developmental research for interviewing children

This article first provides a brief review of recent research to update the investigative interviewer on children's development of cognition, memory and language. Next, we review results of studies which have focused on the development of children's specific knowledge about the legal system, and identify developmental and motivational factors which may influence children's willingness to report in legal settings. Next, clinical and research literature of young children's experience in pediatric settings offers ecologically compelling data for understanding children's reports of abusive touch, and strategies used for preparing children for medical procedures may be drawn on for preparation of children in sexual abuse cases. Finally, several issues are identified for future research.

Intranasal midazolam as a sedative for children during laceration repair

We performed a retrospective chart review to determine the onset, duration, safety, and clinical sedative effects of 0.2 to 0.5 mg/kg intranasal midazolam in young children during laceration repair. Of 408 children treated for lacerations during an 8-month period, 42 (10%) received intranasal midazolam. Documentation was adequate for detailed analysis in 40 cases. Data are reported as mean +/- standard deviation and the frequency with 95% confidence limit (CL) estimates. The mean age of the study population was 32 +/- 9 months (range 12 months to 6 years), and the mean body mass was 14.5 +/- 3 kg. Topical or injected local anesthesia was used in 37 cases. Overall, 73% (CL 56% to 85%) of the children achieved adequate sedation. However, those receiving 0.2 to 0.29 mg/kg had adequate sedation in only 27% (CL 6% to 60%) of the cases compared with 80% (CL 52% to 95%) and 100% (CL 79% to 100%) when 0.3 to 0.39 and 0.4 to 0.5 mg/kg respectively were administered. When achieved, sedation occurred within 12 +/- 4 minutes, recovery occurred at 41 +/- 9 minutes, and discharge occurred at 56 +/- 11 minutes. No vomiting or clinically significant oxygen desaturation (defined as a drop of > 4% or to < 91%) was observed. We conclude that intranasal midazolam is a safe and effective sedative for laceration repair under local anesthesia in preschool-aged children. We recommend a dose of 0.3 to 0.5 mg/kg, with treatment failure less likely after 0.4 to 0.5 mg/kg compared with less than 0.3 mg/kg.

Premedicating children for painful invasive procedures

Children with cancer experience a great deal of anxiety concerning their treatment and invasive tests such as bone marrow aspirations (BMAs) and lumbar punctures (LPs). Responses of pain, fear, and anxiety are well documented and may cause regression, developmental delay, sleeping and eating problems, nausea and vomiting, nightmares, and depression. Diagnostic and treatment procedures need not cause such adverse effects if sufficient pharmacological sedation, analgesia, and anesthesia are used. However, studies show that inappropriate interventions such as underdosing and limited use of medications occur because of certain myths, beliefs, and lack of pharmacological knowledge on the part of health professionals. Studies that specifically address premedication for painful procedures in children with cancer have shown that only a small percentage of children receive premedications and that there is no clear consensus or standard for either drugs or dosages. The issue of premedicating children before procedures remains controversial and deserves further investigation. This study explored the attitudes and perceptions of oncology physicians and nurses concerning medicating children before procedures. Findings showed that most pediatric oncology specialists medicate their patients before invasive procedures and that the most common premedications used are Versed; Demerol, Phenergan, Thorazine; chloral hydrate; Ativan; fentanyl; Demerol; and Xylocaine. Most pediatric oncology specialists believe that premedication is necessary for children for BMAs and LPs.

Pain in the pediatric oncology patient

Pediatric oncology nurses face many challenges in treating the pain associated with childhood cancer. The type and severity of pain children with cancer experience varies from acute, short-term, procedure-related pain to the progressive chronic pain associated with terminal illness. In addition, the unfounded fears of using strong narcotic analgesics and the underutilization of psychological techniques to treat pain in children limit the effectiveness of pain management. Armed with objective data, pediatric oncology nurses can work with other members of the cancer treatment team to provide relief from the pain associated with the diagnosis and treatment of childhood cancer.

Clinicians' quick reference guide to acute pain management in infants, children, and adolescents: operative and medical procedures. Pain Management Guideline Panel. Agency for Health Care Policy and Research, US Department of Health and Human Services

The management of pain is an important part of a health professional's role. The challenge for clinicians is to balance pain control with concern for patient safety and side effects of pain treatments. This is the second of two articles presenting the clinical highlights of the Agency for Health Care Policy and Research's Panel to develop clinical practice guidelines for pain management. This article presents the clinical highlights related to the assessment and management of pain in infants and children.

Chloral hydrate for emergent pediatric procedural sedation: a new look at an old drug

Chloral hydrate has been time honored for pediatric procedural sedation, but its efficacy in sedation for emergency department (ED) procedures is unreported. It is hypothesized that chloral hydrate is safe and effective for ED pediatric sedation. Ninety-five consecutive children ranging from 1-10 years and requiring procedural intervention in a municipal teaching hospital ED were included in a nonrandomized controlled trial. Patients with respiratory depression, somnolence, allergy, multisystem trauma, head injury, or abdominal pain were excluded. Forty-two subjects received chloral hydrate 25 to 50 mg/kg orally at physician discretion, and 53 subjects served as controls. Cooperation with procedural completion was rated by the treating physician using the four-point sedation scoring system modified from Moody et al (1 = poor, 4 = excellent). The two groups' sedation scores were compared by the Mann Whitney U test with significance at P less than .05. Age-related subgroups of children were similarly compared. The treatment group achieved sedation score of 2.86, whereas controls had sedation score of 2.75 (P = 0.63, beta error 20% at 0.37 score difference). Subgroup analysis of children less than 6 years old (2.95 experimental versus 2.57 control) and less than 4 years old (3.00 experimental versus 2.32 control) reveals statistically significant differences (P less than .0001 and P = .01, respectively) in favor of higher sedation scores in the chloral hydrate group. Time to sedation was 42.7 minutes, time to recovery was 42.0 minutes, and no adverse drug effects were noted.(ABSTRACT TRUNCATED AT 250 WORDS)

Scientific inquiry in childhood cancer psychosocial research. Theoretical, conceptual, and methodologic issues in the investigation and behavioral treatment of procedure-related distress

This paper discusses the current status of scientific inquiry in childhood cancer psychosocial research. The investigation and behavioral treatment of procedure-related distress serves as a model for illustrating and outlining some of the theoretical, conceptual, and methodologic issues and problems that exist in the area of childhood cancer psychosocial research. Specifically, issues related to the process of scientific inquiry, theoretical/conceptual modeling, measurement and assessment, and behavioral treatment strategies are discussed. Examples of how these issues have been addressed in our investigations of procedure-related distress are presented and recommendations for facilitating growth and development in the field of childhood cancer psychosocial research are offered.

Iontophoresis versus subcutaneous injection: a comparison of two methods of local anesthesia delivery in children

The relative efficacy of local lidocaine anesthesia administered by subcutaneous injection and by iontophoresis was studied in 13 pediatric renal dialysis patients (ages 11-19 years: mean age 15.8 years). Each patient served as his own control at 3 assessment periods. Each type of anesthetic delivery method was administered to either of 2 fistula sites. Patients used visual analogue scales to rate pain, anxiety, and satisfaction for each method. Behavioral observations were made by an observer and a nurse. Paired sample t tests were used to compare the 2 drug delivery methods for patient, observer, and nurse ratings across assessment periods. There were no significant differences between methods for ratings of anxiety before or during the procedure. The injection of lidocaine was rated as more painful by the observer and nurse (with a trend for patients) than the use of iontophoresis. But, the patients and nurse rated the injection method as more effective. Iontophoresis was never rated as superior to the injection method, even after turning over control of drug delivery by iontophoresis to the patient (sessions 2 and 3). Patients were more satisfied with iontophoresis at session 2 when they took over control, but lost enthusiasm by session 3. Three subjects withdrew from the study due to cutaneous burns and prolonged anesthesia delivery time with iontophoresis. Iontophoresis appears to be effective in reducing the pain of dialysis needle insertion but requires further investigation before it can be considered a viable alternative to subcutaneous injection.