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

BACKGROUND

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

AIM

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

METHOD

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

ETHICAL ISSUES

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

RESULTS

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

CONCLUSION

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

Overview of radiotherapy-induced chronic pain in childhood cancer survivors: A narrative review

Radiotherapy is an important aspect of oncological treatment in several childhood cancers. However, radiotherapy is known to have numerous side effects, including detrimental effects on growth, neurocognitive impairment, and the development of secondary malignancies. One less studied long-term side effect of pediatric radiotherapy treatment is chronic pain. While the short-term toxicities of radiotherapy resolve over a few weeks to months, the chronic pain caused by radiotherapy-induced tissue damage can significantly affect children's quality of life. As long-term childhood cancer survivors age into adulthood, they are typically followed up by a wide variety of doctors, not all of whom may be familiar with radiotherapy-induced chronic pain and its management. The aim of this review is to discuss the various common manifestations of radiotherapy-related pain in children, as well as ways to identify and manage these. Common radiotherapy-related side effects leading to chronic pain symptoms include radiation fibrosis, enteritis, dermatitis, lymphedema, neuropathic pain, and effects on bone development. The pathophysiology, evaluation and management of these are briefly summarized in this review. This is followed by an overview of radiotherapy techniques that allow greater sparing of normal tissue, minimizing future painful side effects. Finally, the assessment of pain in children is described, as well as strategies for management, and red flag symptoms that should prompt urgent specialist referral. In conclusion, a good understanding of the long-term side effects of radiotherapy treatment in children is essential for the various medical professionals that follow-up the child in the years after treatment. For young children, the evaluation of pain is in itself a challenge, and effects on growth, development, and learning are crucial. For older children, social and psychological factors become increasingly important. As radiation therapy techniques continue to advance, the spectrum and incidence of chronic pain syndromes may change over time.

Consistency of pediatric pain ratings between dyads: an updated meta-analysis and metaregression

Accurate assessment of pediatric pain remains a challenge, especially for children who are preverbal or unable to communicate because of their health condition or a language barrier. A 2008 meta-analysis of 12 studies found a moderate correlation between 3 dyads (child-caregiver, child-nurse, and caregiver-nurse). We updated this meta-analysis, adding papers published up to August 8, 2021, and that included intraclass correlation/weighted kappa statistics (ICC/WK) in addition to standard correlation. Forty studies (4,628 children) were included. Meta-analysis showed moderate pain rating consistency between child and caregiver (ICC/WK = 0.51 [0.39-0.63], correlation = 0.59 [0.52-0.65], combined = 0.55 [0.48-0.62]), and weaker consistency between child and health care provider (HCP) (ICC/WK = 0.38 [0.19-0.58], correlation = 0.49 [0.34-0.55], combined = 0.45; 95% confidence interval 0.34-0.55), and between caregiver and HCP (ICC/WK = 0.27 [-0.06 to 0.61], correlation = 0.49 [0.32 to 0.59], combined = 0.41; 95% confidence interval 0.22-0.59). There was significant heterogeneity across studies for all analyses. Metaregression revealed that recent years of publication, the pain assessment tool used by caregivers (eg, Numerical Rating Scale, Wong-Baker Faces Pain Rating Scale, and Visual Analogue Scale), and surgically related pain were each associated with greater consistency in pain ratings between child and caregiver. Pain caused by surgery was also associated with improved rating consistency between the child and HCP. This updated meta-analysis warrants pediatric pain assessment researchers to apply a comprehensive pain assessment scale Patient-Reported Outcomes Measurement Information System to acknowledge psychological and psychosocial influence on pain ratings.

Detection and assessment of postoperative pain in children with cognitive impairment: A systematic literature review and meta-analysis

Background and Objective

Children with cognitive impairment (CI) are at risk of experiencing pain. Several specific pain rating scales have been developed to date. Thus, the aim of this meta‐analysis was to estimate the degree of reliability of different pain assessment scales for the postoperative pain in children with CI.

Databases and Data Treatment

PubMed, Scopus and Web of Science databases were approached: all studies validating and/or using pain assessment tool in children (0–20 years) with CI published in English from the 1st of January 2000 to the 1st of January 2022 were included. Only studies reporting the interclass correlation coefficient (ICC) to evaluate the concordance between caregivers’ and external researchers’ scores were eligible.

Results

Twelve studies were included (586 children with CI, 60% males; weighted mean age 9.9 years – range 2–20). Five of them evaluated the Non‐Communicating Children's Pain Checklist‐Postoperative Version (NCCPC‐PV) scale whereas four the original and revised Face, Legs, Activity, Cry, Consolability (FLACC) scale. The analysis showed an overall ICC value of 0.76 (0.74–0.78) for the NCCPC‐PV scale, with a high heterogeneity index (I² = 97%) and 0.87 (0.84–0.90) for the FLACC scale, with a discrete I² index (59%).

Conclusions

The NCCPC‐PV and FLACC pain rating scales showed the strongest evidence for validity and reliability for assessing postoperative pain in children with CI. However, due to the high heterogeneity of the studies available, these results should not be considered conclusive.

Significance

This review is focused on the assessment of pain in children with CI in the postoperative period. Simplified observation‐based pain assessment tools that rely on evaluating non‐verbal expressions of pain should be recommended for children with difficulties to communicate their feelings. Even if there is a high degree of heterogeneity in clinical presentations among youth with CI, two tools (NCCPC‐PV and FLACC) have emerged as reliable and valid in this population.

Association of obstructive sleep apnea and total sleep time with health-related quality of life in children undergoing a routine polysomnography: a PROMIS approach

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) negatively impacts health-related quality of life (HR-QoL) in adults, but few pediatric studies have explored this relationship or the relationships between HR-QoL domains.

METHODS

Patients aged 8-17 years visiting the sleep laboratory from July 2019 to January 2020 for overnight polysomnography participated in the study. Controls seen for problems other than sleep disturbance were recruited from Department of Pediatrics outpatient clinics. HR-QoL was assessed by Patient-Reported Outcome Measure Information System (PROMIS) profile questionnaires, version 2.0. Statistical analysis was conducted using R 3.6.0 (R Foundation for Statistical Computing, Vienna, Austria).

RESULTS

One hundred twenty-two patients were included in the final analysis. Sixty-four patients were males (52.4%). Twenty-nine (23.8%) had mild OSA, 8 (6.6%) had moderate OSA, 17 (13.9%) had severe OSA, 46 (37.7%) were without OSA, and 22 (18.0%) were controls. Patients referred for polysomnography had lower physical function mobility compared with controls (P = .03). Increased OSA severity was linearly associated with a decrease in physical function mobility (P = .008). Correlation analysis revealed that physical function mobility was positively associated with total sleep time (P = .02) and negatively associated with apnea-hypopnea index (P = .01). Age was positively associated with fatigue (P = .02) and negatively associated with deep sleep (P < .001). Regression analysis revealed that physical function mobility was positively associated with total sleep time (P = .02) and negatively associated with apnea-hypopnea index (P = .04) after controlling for age, sex, and number of arousals.

CONCLUSIONS

OSA and total sleep time were associated with problems with physical function mobility after adjusting for age, sex, and number of arousals.

CITATION

Xu S, Turakhia S, Miller M, et al. Association of obstructive sleep apnea and total sleep time with health-related quality of life in children undergoing a routine polysomnography: a PROMIS approach. J Clin Sleep Med. 2022;18(3):801-808.

Pediatric Pain Assessment in the Emergency Department: Patient and Caregiver Agreement Using the Wong-Baker FACES and the Faces Pain Scale-Revised

OBJECTIVE

This study aimed to assess the agreement between patients presenting to the pediatric emergency department (ED) with acute pain and their caregivers when using the Wong-Baker FACES (WBF) and Faces Pain Scale-Revised (FPS-R).

METHODS

This was a prospective, observational study examining patients 3 to 7.5 years old presenting to a pediatric ED with acute pain. Participants completed the WBF and FPS-R twice during their ED evaluation. Caregivers rated their child's pain using both the WBF and FPS-R at the same time points. Intraclass correlations (ICCs) were calculated between caregiver and child reports at each time point, and Bland-Altman plots were created.

RESULTS

Forty-six subjects were enrolled over 5 months. Mean age was 5.5 ± 1.2 years. Average initial child pain scores were 6.6 ± 2.8 (WBF) and 6.1 ± 3.3 (FPS-R), and repeat scores were 3.3 ± 3.4 (WBF) and 3.1 ± 3.3 (FPS-R). Average initial caregiver pain scores were 6.3 ± 2.4 (WBF) and 6.2 ± 2.3 (FPS-R), and repeat scores were 3.4 ± 2.0 (WBF) and 3.4 ± 2.1 (FPS-R). On initial assessment, ICCs between children and caregivers using the FPS-R and WBF were 0.33 and 0.22, respectively. On repeat assessment, the ICCs were 0.31 for FPS-R and 0.26 for WBF. Bland-Altman plots showed poor agreement but no systematic bias.

CONCLUSION

There was poor agreement between caregivers and children when using the WBF and FPS-R for assessment of acute pain in the ED. Caregiver report should not be used as a substitute for self-report of pain if possible.

[Parents' satisfaction in onco-hematology units]

INTRODUCTION

patient satisfaction is a quality of care predictor that allows to identify specific areas of improvement. Frequently, parents are who provide this information when their children are too young or cannot communicate. The aim of the study was to determine parents' satisfaction with paediatric oncology care and its relationship with sociodemographic variables.

MATERIAL AND METHODS

a cross-sectional observational study was carried out. Parents whose children suffered from cancer and were treated in the oncology ward and oncology day hospital in Asturias were included. A questionnaire with sociodemographic variables and the Cuestionario de Calidad de Cuidados de Enfermería (CUCACE), that evaluates experience and satisfaction with care through two dimensions (range from 0 to 100), were used.

RESULTS

24 parents agreed to particape. The average in experience dimension of CUCACE was 88,99 and 87,01 in satisfaction. All participants referred as positive the treat received at the units, however, 41,7% declared it should be enhanced. No relationship between satisfaction and sociodemographic variables were found.

CONCLUSIONS

Parents of children with cancer demonstrated high satisfaction with care. Information and communication with medical staff need to be strengthened.

Stress and Perception of Procedural Pain Management in Chinese Parents of Children With Cancer

OBJECTIVES

Children with cancer are exposed to repeated painful and invasive procedures. This study examines Chinese parents' stress and perception toward their children's procedural pain control.

METHODS

We recruited 265 parents of children (aged <18 years) diagnosed with hematological cancer (74.7%) and solid tumors (25.3%) from two major public hospitals. Parents used a scale (0-10) to rate perceived pain experienced by their child when undergoing lumbar puncture (LP), bone marrow aspirate, or/and biopsy. They reported their stress level and attitudes toward analgesics using the adapted Pain Flexibility Scale for Parents and Parental Medication Attitude Questionnaire. General linear modeling was used to identify factors associated with perception outcomes.

RESULTS

Parents (72.8% mothers, age 36.5 [6.8] years) expressed that they were worried (31.7%) and had difficulty with concentration (57.7%) when the child was in pain. Among parents whose children had undergone LP (n = 207), 39.1% perceived that their child still experienced severe pain (pain score >7) even with existing pain control measures. Parents reported concerns over side effects of analgesics (69.4%) and addiction (35.1%). Half of the parents (47.2%) perceived that analgesics should only be reserved for severe pain. Parents who were older (estimate = 2.07, SE = 0.87; P = 0.0054) and had lower education attainment (estimate = -3.38, SE = 1.09; P = 0.0021) had a more negative attitude toward analgesics use. Higher parental distress was associated with avoidance of analgesics use (r_s = 0.17, P = 0.0052).

CONCLUSION

Our findings suggested that subgroups of Chinese parents demonstrated distress with their child's pain and harbored misconceptions over analgesics use. Future work includes devising targeted psychoeducation interventions for these parents.

Family functioning in pediatric heart transplantation: Variables associated with poor outcomes

Family functioning is integral in a child's life and is linked to quality of life in health as well as disease. This has been scarcely studied in pediatric orthotopic heart transplantation (pOHT). In this study, we evaluate demographic and clinical factors associated with family functioning in this patient population. Pediatric post-transplant families were recruited in an outpatient setting (n = 71). The PedsQL Family Impact Module was administered, along with the Parent and Adolescent Medication Barriers Scales (PMBS; AMBS) and the McArthur socioeconomic scale. Associations between clinical and demographic variables and scaled scores were evaluated. In our sample, patients with congenital heart disease, developmental delay, and enteral feeding had lower total impact (P = .026; P = .011; P = .008) and parent self-reported HRQL scores (P = .018; P = .012; P = .005). Patients with developmental delay and enteral feeding also had lower family functioning summary scores (P = .025; P = .031). Higher parent educational status was associated with lower total impact scores (P = .043). Higher PMBS scores demonstrated negative correlation with total impact (P < .001), parent self-reported HRQL (P < .001), and family functioning summary scores (P = .003). Multiple linear regression analysis identified developmental delay, parental education, and PMBS as independent variables associated with family functioning. Our study highlights important factors impacting family functioning in pOHT. Developmental delay, higher parental education, and PMBS were associated with poorer family functioning. Our findings emphasize the need for a multi-disciplinary approach including serial psychological assessment and interventions in the management of pOHT patients in order to optimize family functioning.

Patient-Reported Pain Outcomes for Children Attending an Emergency Department With Limb Injury

OBJECTIVES

The aim of this study was to describe patient-reported pain outcomes at various stages of an emergency department (ED) visit for pediatric limb injury.

METHODS

This prospective cohort consisted of 905 patients aged 4 to 17 years with acute limb injury and a minimum initial pain score of 4/10. Patients reported pain scores and treatments offered and received at each stage of their ED visit. Multiple logistic regression was used to identify predictors for severe pain on initial assessment and moderate or severe pain at ED discharge.

RESULTS

The initial median pain score was 6/10 (interquartile range, 4-6) and decreased at discharge to 4/10 (interquartile range, 2-6). Stages of the ED visit where the highest proportion of patients reported severe pain (score, ≥8 of 10) were fracture reduction (26.0% [19/73]; 95% confidence interval [CI], 17.1%-37.5%), intravenous insertion (24.4% [11/45]; 95% CI, 13.8%-39.6%), and x-ray (23.7% [158/668]; 95% CI, 20.6%-27.0%). Predictors of severe pain at initial assessment included younger age (odds ratio [OR], 0.92; 95% CI, 0.87-0.97), female sex (OR, 0.58; 95% CI, 0.40-0.84), and presence of fracture (OR, 1.58; 95% CI, 1.07-2.33) whereas, at discharge, older age (OR, 1.14; 95% CI, 1.06-1.23) predicted moderate/severe pain (score, ≥4 of 10).

CONCLUSIONS

These results on the location and predictors of severe pain during an ED visit for limb injury can be used to target interventions to improve pain management and patient outcomes.

Psychosocial difficulties identified by health care providers as they predict pain-related quality of life in children with cancer

This study examined the predictive validity of the Psychosocial Care Checklist (PCCL), a psychosocial screener completed by a pediatric cancer health care provider (HCP), on child pain-related and nausea-related quality of life (QOL), and whether these associations are moderated by family psychosocial risk (Psychosocial Assessment Tool, PAT). Caregivers (N = 122) of children newly diagnosed with cancer and 62 HCPs (11 social workers, 17 nurses, 34 oncologists) at two Canadian sites participated. Near diagnosis (T1) and six months later (T2), caregivers reported on child QOL and family psychosocial risk, which was categorized as universal (typical distress), targeted (targetable distress), or clinical (severe distress). HCPs completed the PCCL at T1 and T2. HCP identification of more psychosocial problems in PCCL at T1 predicted reduced child pain-related (but not nausea-related) QOL at T2 among children with universal risk. The PCCL scores did not predict pain-related QOL in families with higher psychosocial needs (i.e., targeted and clinical). HCPs may have difficulty identifying psychosocial problems among families with high risk in a manner that predicts child's pain-related QOL. A hybrid model of psychosocial screening that includes both HCP and caregiver reports is recommended to best match family problems and interventions to improve QOL.

Local Anesthesia With General Anesthesia for Pediatric Bone Marrow Procedures

BACKGROUND

Pediatric patients with cancer undergo repeated painful procedures, including bone marrow aspirations and biopsies (BMABs). Optimal management of procedure-related pain can reduce discomfort, anxiety, and distress.

METHODS

Children with neuroblastoma were randomly assigned to 1 of 2 arms on a prospective, single-blind, crossover trial conducted at Memorial Sloan Kettering Cancer Center from October 2016 to January 2018 (www.clinicaltrials.gov, identifier NCT02924324). Participants underwent 2 sequential BMABs: one with general anesthesia (GA) alone, the other with GA plus local anesthesia (LA) (GA + LA). The objective was to assess procedure-related pain and its interference with quality of life (QoL) with GA versus GA + LA. Primary outcome was percentage of participants requiring postprocedural opioids. Secondary outcomes were total opioid and nonopioid analgesics, pain scores, time to first analgesic, QoL, and toxicity. Management of postprocedural pain was standardized.

RESULTS

Of 56 participants randomly assigned (3-16.5 years old), 46 completed both procedures. There was no significant difference in percentage of participants requiring opioids with GA versus GA + LA (24% vs 20%, P = .5). Pain scores in the recovery room were significantly lower for GA + LA versus GA (median [IQR]: 0 [0-2] vs 2 [0-4], P = .002). There were no statistically significant differences in total opioid or nonopioid analgesic, 6- and 24-hour pain scores, median time to first analgesic, or pain interference. No adverse events occurred.

CONCLUSIONS

LA was associated with significant improvement in pain scores in the immediate recovery period. LA did not reduce postprocedural opioid use, nor did it improve QoL for patients undergoing BMAB with GA.

Pediatric chronic pain and caregiver burden in a national survey

Background and aims Caring for children with chronic pain incurs burdens of cost and time for families. We aimed to describe variation in caregiver burden among parents of adolescents with chronic pain who responded to a nationally-representative survey. Our secondary aim was to identify child and parent characteristics associated with increased caregiver burden. Methods We used de-identified, publicly-available data from the 2016 National Survey of Children's Health (NSCH), designed to be representative of non-institutionalized children in the United States. We analyzed data for households where an adolescent age 12-17 years old was reported by a parent to have chronic pain. Outcomes included the parent's time spent on the child's health needs, reduced labor force participation, and out-of-pocket medical costs. Results Data on 1,711 adolescents were analyzed. For adolescents with chronic pain, 15% of parents reported spending at least 1 h/week on their child's health care, 14% reported cutting back on paid work, and 36% reported spending ≥$500 on their child's health care in the past 12 months. Adolescents' general health status and extent of specialized health care needs predicted increased caregiver burden across the three measures. Conversely, no consistent differences in caregiver burden were noted according to demographic or socioeconomic characteristics. Conclusions Among adolescents with chronic pain identified on a nationally-representative survey, parents frequently reported reducing work participation and incurring out-of-pocket expenses in providing health care for their child. Caregiver burdens increased with indicators of greater medical complexity (e.g. presence of comorbidities, need for specialized health care) and poorer overall adolescent health status. Implications We add a national-level perspective to studies previously performed in clinical samples addressing caregiver burden in pediatric chronic pain. Initiatives to reduce the burden of caring for children with chronic pain, described in prior work, may be especially beneficial for families with adolescents whose chronic pain is accompanied by other health problems or requires coordination of care among multiple providers.

Perspectives on Cancer Pain Assessment and Management in Children

OBJECTIVE

To report evidence regarding pain assessment and management for children and adolescents receiving treatment for cancer.

DATA SOURCES

Published research and clinical guidelines.

CONCLUSION

Children and adolescents experience multiple sources of pain across the cancer continuum. They require developmentally relevant approaches when assessing and managing pain. This review suggests that consideration of the developmental stage and age of the child are essential in both pain assessment and pain management.

IMPLICATIONS FOR NURSING PRACTICE

Pediatric oncology nurses play a key role in developmentally appropriate pain assessment, identification of potential strategies to manage pain, and delivery of pharmacologic and nonpharmacologic therapies.

The challenge of pain assessment in children with cognitive disabilities: Features and clinical applicability of different observational tools

Children with cognitive disabilities are at greater risk of experiencing pain. It has been shown that this paediatric population often receive inadequate pain management. Pain may be very difficult to assess, especially in a defined subgroup with non-communicating intellectual disability or severe cognitive disability. Accordingly, several observational pain assessment tools have been proposed to overcome this issue. Due to the absence of an ideal measurement tool, accurate pain assessment requires, after a case-by-case analysis, selecting the more appropriate tool or a variety of combined instruments. The aim of this work is to provide a comprehensive review of the pain assessment tools commonly used in cognitively impaired children. Critical discussion on features and clinical applicability may suggest how to overcome this difficult challenge. Furthermore, this review will help further research aiming to design new instruments and to improve already-in-use tools.

Síntomas en niños con cáncer y estrategias de cuidado familiar

Introducción: Los síntomas de dolor y náusea vómito en los niños con cáncer son ocasionados por la enfermedad o tratamiento de quimioterapia. El manejo de estos síntomas es un reto en los familiares. Objetivos: Describir y analizar la relación entre los síntomas de dolor y náusea vómito en los niños con cáncer y describir las estrategias de cuidado familiar ante estos síntomas. Materiales y Métodos: Estudio descriptivo correlacional, con muestra de 31 niños y familiares de una clínica oncopediatrica de Veracruz México. Diligenciaron los instrumentos Escala de dolor con caras-Revisada, Clasificación de Náusea-Vómito Inducido por Quimioterapia y Cuestionario de estrategias de cuidado familiar para el manejo de síntomas. Los datos se analizaron con estadística descriptiva e inferencial con Rho de Spearman, utilizando el programa SPSS 20.0. Resultados: Los niños padecen dolor moderado (48%), leve (29%) e intenso (23%).  Tienen náusea-vómito agudo (74%), anticipatorio (16%) y retardado (10%). Existe asociación entre la náusea-vómito retardado con el anticipatorio (r =435<0,05). Los familiares contrarrestan el dolor del niño con estrategias de espiritualidad, distracción y fármacos. Ante la náusea-vómito evitan ambientes con olor a comida y consumo de líquidos calientes. Discusión: Según el tipo de cáncer y tratamiento, es la intensidad del dolor en el niño. La náusea-vómito se considera el síntoma más problemático durante la quimioterapia. Conclusiones: La investigación aporta datos científicos para indagar a futuro estos síntomas y posibles secuelas físicas y psicológicas (depresión, ansiedad) en los niños con cáncer, así como la efectividad de las estrategias familiares para tratar estos síntomas.Como citar este artículo: Díaz-Morales K, Reyes-Arvizu J, Morgado-Nájera K, Everardo-Domínguez D. Síntomas en niños con cáncer y estrategias de cuidado familiar. Rev Cuid. 2019; 10(1): e597. http://dx.doi.org/10.15649/cuidarte.v10i1.597

Improving the Utilisation of Nitrous Oxide in Paediatric Patients to Manage Procedural Pain and Procedural Anxiety

The aim in this study was to understand current practice and use of nitrous oxide for management of procedural-related pain and procedural anxiety, to identify perceived barriers to use of nitrous oxide and to develop an understanding of patients, families, and nurse awareness and knowledge of the use of nitrous oxide in an Australian tertiary pediatric oncology/hematology short stay unit. Three online questionnaires (patients, parents, and nursing staff) were developed and completed between September and November 2015. Most children and young people (61%) report receiving nitrous oxide for at least one procedure. Patients, parents, and nurses rated nitrous oxide as highly effective and would like more access to nitrous oxide for the child's pain management. Several barriers to use were reported. These findings suggest that nitrous oxide is effective for pain management; however, its use is inconsistent. Findings can potentially develop standardized processes and improve nurse education and accreditation, which may increase the safety, efficacy, and utilization of nitrous oxide for children's procedural pain management.

Perspectives of children, family caregivers, and health professionals about pediatric oncology symptoms: a systematic review

OBJECTIVES

To evaluate the existing body of evidence to determine the current state of knowledge regarding the perspectives of the following groups: (1) children with cancer, (2) family caregivers, and (3) healthcare professionals, about symptoms, as well as factors that may influence the symptom reports.

METHODS

A systematic search was performed for all types of studies that included the perspectives of at least two groups of participants' symptom reports. Children included anyone younger than 19 years of age who was diagnosed with any type of cancer. Electronic searches were conducted in five English databases and four Chinese databases. The appraisal of methodological quality was conducted using the GRADE criteria. Data were extracted into matrix tables.

RESULTS

Thirty-three studies were included. The pediatric oncology symptoms reported by children, family caregivers, and healthcare professionals were synthesized. Findings suggested that family caregivers' symptom reports were more closely aligned with children's reports than with the healthcare professionals' reports. Influencing factors on the different symptom reports included the children's diagnosis, symptom characteristics, social-demographic factors, and family caregivers' psychosocial status.

CONCLUSIONS

Children with cancer should be the primary reporters for their symptoms. When there are reporters other than the children, the potential discrepancy between the different perspectives needs to be carefully considered.

Psychometric properties of the parent́s perception uncertainty in illness scale, spanish version

OBJECTIVE

To analyze the psychometric properties of the Parents' Perception of Uncertainty in Illness Scale, parents/children, adapted to Spanish.

METHOD

A descriptive methodological study involving the translation into Spanish of the Parents' Perception of Uncertainty in Illness Scale, parents/children, and analysis of their face validity, content validity, construct validity and internal consistency.

RESULTS

The original version of the scale in English was translated into Spanish, and approved by its author. Six face validity items with comprehension difficulty were reported; which were reviewed and adapted, keeping its structure. The global content validity index with expert appraisal was 0.94. In the exploratory analysis of factors, 3 dimensions were identified: ambiguity and lack of information, unpredictability and lack of clarity, with a KMO=0.846, which accumulated 91.5% of the explained variance. The internal consistency of the scale yielded a Cronbach alpha of 0.86 demonstrating a good level of correlation between items.

CONCLUSION

The Spanish version of "Parent's Perception of Uncertainty in Illness Scale" is a valid and reliable tool that can be used to determine the level of uncertainty of parents facing the illness of their children.

Health Care Utilization and Costs Associated With Pediatric Chronic Pain

The population prevalence of pediatric chronic pain is not well characterized, in part because of a lack of nationally representative data. Previous research suggests that pediatric chronic pain prolongs inpatient stay and increases costs, but the population-level association between pediatric chronic pain and health care utilization is unclear. We use the 2016 National Survey of Children's Health to describe the prevalence of pediatric chronic pain, and compare health care utilization among children ages 0 to 17 years according to the presence of chronic pain. Using a sample of 43,712 children, we estimate the population prevalence of chronic pain to be 6%. In multivariable analysis, chronic pain was not associated with increased odds of primary care or mental health care use, but was associated with greater odds of using other specialty care (odds ratio [OR] = 2.01, 95% confidence interval [CI] = 1.62-2.47; P < .001), complementary and alternative medicine (OR = 2.32, 95% CI = 1.79-3.03; P < .001), and emergency care (OR = 1.62, 95% CI = 1.29-2.02; P < .001). In this population-based survey, children with chronic pain were more likely to use specialty care but not mental health care. The higher likelihood of emergency care use in this group raises the question of whether better management of pediatric chronic pain could reduce emergency department use.

PERSPECTIVE

Among children with chronic pain, we show high rates of use of emergency care but limited use of mental health care, which may suggest opportunities to increase multidisciplinary treatment of chronic pain.

Supporting Parents' Pain Care Involvement With Their Children With Acute Lymphoblastic Leukemia: A Qualitative Interpretive Description

Children with acute lymphoblastic leukemia experience pain from the disease, treatment, and procedures. Parents can be effective in managing their child's pain, but little is systematically known about how they do this. Appreciative inquiry was used to frame the study within a strengths-based lens and interpretive descriptive methods were used to describe pain sources, parents' pain care role, and key structures supporting parents pain care involvement. Eight paediatric oncology clinic nurses and 10 parents participated. Six key themes per group were identified. Parent themes included establishing therapeutic relationships, relearning how to care for my child, overcoming challenges and recognizing pain, learning parent specific strategies, empowering to take active pain care role, and maintaining relationships. Nurse themes included establishing therapeutic relationships, preparing parents to care for their child, facilitating pain assessment, teaching parents best pain care, empowering parents, and maintaining relationships. These findings can be used to guide clinical practice and future research.