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Turgut A, Özcan İlçe A, Öztürk H. The Effect of Immersive Virtual Reality Application on Anxiety, Pain, and Parental Satisfaction in the Perioperative Process of Children: A Randomized Controlled Trial. Pain Manag Nurs 2024:S1524-9042(24)00188-7. [PMID: 38955550 DOI: 10.1016/j.pmn.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Revised: 06/03/2024] [Accepted: 06/04/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To determine the effects of virtual reality (VR) interventions on pre- and postoperative anxiety, pain, and parental satisfaction in children. DESIGN A randomized controlled trial. METHODS Children undergoing surgery for the first time and their families were randomly assigned to the control or VR group. The control group received conventional education regarding the perioperative process. The VR group watched a VR video illustrating the operating theater and explaining the perioperative process. The primary outcome of interest was preoperative anxiety, evaluated using the Children's State Anxiety Scale. Secondary outcomes of interest included postoperative pain ratings using the Wong-Baker Faces Pain Rating Scale and parental satisfaction scores using the PedsQL Health Care Satisfaction Scale. RESULTS The analysis included 70 children and their families (control = 35, VR = 35). Demographic characteristics were similar between the groups. Children in the VR group had significantly lower preoperative anxiety scores (p < .001) and postoperative anxiety scores (p = .010) compared to the control group. Parental satisfaction scores were significantly higher in the VR group (p < .001). The VR group had lower postoperative pain scores, but this difference was not statistically significant (p > .05). CONCLUSIONS Preoperative education using VR tours may reduce preoperative anxiety and increase parental satisfaction. However, the lack of baseline measurements limits our ability to definitively attribute these effects to the VR intervention. Despite this, VR is a promising nonpharmacological strategy for managing children's anxiety and increasing parental satisfaction. CLINICAL IMPLICATIONS Virtual reality interventions offer an effective nonpharmacological strategy for perioperatively managing children's anxiety and increasing parental satisfaction.
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Affiliation(s)
- Aykut Turgut
- Department of Nursing, Faculty of Health Sciences, Bolu Abant Izzet Baysal University, Gölköy Campus, Bolu, Turkey.
| | - Arzu Özcan İlçe
- Department of Nursing, Faculty of Health Sciences, Bolu Abant Izzet Baysal University, Gölköy Campus, Bolu, Turkey
| | - Hülya Öztürk
- İzzet Baysal Training and Research Hospital, Bolu Abant Izzet Baysal University, Gölköy Campus, Bolu, Turkey
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Tsze DS, Thiele C, Hirschfeld G, Dayan PS. Clinically significant differences in self-reported pain scores in children with headaches. Acad Emerg Med 2024; 31:547-554. [PMID: 38400616 DOI: 10.1111/acem.14879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 01/05/2024] [Accepted: 01/20/2024] [Indexed: 02/25/2024]
Abstract
OBJECTIVES Changes in pain scores that represent clinically significant differences in children with headaches are necessary for study design and interpretation of findings reported in studies. We aimed to determine changes in pain scores associated with a minimum clinically significant difference (MCSD), ideal clinically significant difference (ICSD), and patient-perceived adequate analgesia (PPAA) in this population. METHODS We performed a secondary analysis of two prospective studies of children with headaches presenting to an emergency department. Two serial assessments were performed in children aged 6-17 and 4-17 years who self-reported their pain intensity using the Verbal Numerical Rating Scale (VNRS) and Faces Pain Scale-Revised (FPS-R), respectively. Children qualitatively described any endorsed change in pain score; those who received an analgesic were asked if they wanted additional analgesics to decrease their pain intensity. We used receiver operating characteristic curve-based methodology to identify changes in pain scores associated with "a little less" (MCSD) and "much less" (ICSD) pain and patients declining additional analgesics because they experienced adequate analgesia after treatment (PPAA). RESULTS We analyzed 105 children: 63.8% were female and the median (IQR) age was 13 (10-15) years. Ninety-eight children were analyzed for the VNRS and 101 were analyzed for the FPS-R. For the VNRS, raw change and percent reductions in pain scores associated with MCSD, ICSD, and PPAA were 2/10 and 25%, 4/10 and 56%, and 3/10 and 50%, respectively, and for the FPS-R, 2/10 and 25%, 4/10 and 67%, and 4/10 and 60%, respectively. The area under the curve (AUC) associated with a MCSD for both scales ranged from 94% to 98%; the AUC associated with an ICSD or PPAA for both scales ranged from 76% to 83%. CONCLUSIONS We identified changes in pain score associated with patient-centered outcomes in children with headaches suitable for designing trials and assigning clinical significance to changes in pain scores reported in studies.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Christian Thiele
- Faculty of Business and Health, University of Applied Sciences Bielefeld, Bielefeld, Germany
| | - Gerrit Hirschfeld
- Faculty of Business and Health, University of Applied Sciences Bielefeld, Bielefeld, Germany
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Bourke J, Munteanu S, Merza E, Garofolini A, Taylor S, Malliaras P. Efficacy of heel lifts for lower limb musculoskeletal conditions: A systematic review. J Foot Ankle Res 2024; 17:e12031. [PMID: 38878299 PMCID: PMC11296721 DOI: 10.1002/jfa2.12031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Revised: 06/03/2024] [Accepted: 06/03/2024] [Indexed: 06/23/2024] Open
Abstract
INTRODUCTION The objective of this systematic review is to determine the benefits and harms of heel lifts to any comparator for lower limb musculoskeletal conditions. METHODS Ovid MEDLINE, Ovid AMED, Ovid EMCARE, CINAHL Plus and SPORTDiscus were searched from inception to the end of May 2024. Randomised, quasi-randomised or non-randomised trials comparing heel lifts to any other intervention or no-treatment were eligible for inclusion. Data was extracted for the outcomes of pain, disability/function, participation, participant rating of overall condition, quality of life, composite measures and adverse events. Two authors independently assessed risk of bias and certainty of evidence using the GRADE approach at the primary time point 12 weeks (or next closest). RESULTS Eight trials (n = 903), investigating mid-portion Achilles tendinopathy, calcaneal apophysitis and plantar heel pain were included. Heel lifts were compared to exercise, ultrasound, cryotherapy orthotics, stretching, footwear, activity modification, felt pads and analgesic medication. No outcome was at low risk of bias and few effects (2 out of 47) were clinically important. Low-certainty evidence (1 trial, n = 199) indicates improved pain relief (55.7 points [95% CI: 50.3-61.1], on a 100 mm visual analogue scale) with custom orthotics compared to heel lifts at 12 weeks for calcaneal apophysitis. Very low-certainty evidence (1 trial, n = 62) indicates improved pain and function with heel lifts over indomethacin (35.5 points [95% CI: 21.1-49.9], Foot Function Index) at 12 months for plantar heel pain. CONCLUSIONS Few trials have assessed the benefits and harms of heel lifts for lower limb musculoskeletal conditions. Only two outcomes out of 47 showed clinically meaningful between group differences. However, due to very low to low certainty evidence we are unable to be confident in the results and the true effect may be substantially different. REGISTRATION PROSPERO registration number CRD42022309644.
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Affiliation(s)
- Jaryd Bourke
- Physiotherapy DepartmentSchool of Primary and Allied Health CareFaculty of Medicine Nursing and Health ScienceMonash UniversityClaytonVictoriaAustralia
| | - Shannon Munteanu
- Discipline of PodiatrySchool of Allied HealthHuman Services and SportLa Trobe UniversityMelbourneVictoriaAustralia
| | - Eman Merza
- Physiotherapy DepartmentSchool of Primary and Allied Health CareFaculty of Medicine Nursing and Health ScienceMonash UniversityClaytonVictoriaAustralia
| | | | - Simon Taylor
- Institute for Health and Sport (IHES)Victoria UniversityMelbourneVictoriaAustralia
| | - Peter Malliaras
- Physiotherapy DepartmentSchool of Primary and Allied Health CareFaculty of Medicine Nursing and Health ScienceMonash UniversityClaytonVictoriaAustralia
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Belardo ZE, Talwar D, Blumberg TJ, Nelson SE, Upasani VV, Sankar WN, Shah AS. Opioid Analgesia Compared with Non-Opioid Analgesia After Operative Treatment for Pediatric Supracondylar Humeral Fractures: Results from a Prospective Multicenter Trial. J Bone Joint Surg Am 2023; 105:1875-1885. [PMID: 37956188 PMCID: PMC10695340 DOI: 10.2106/jbjs.23.00223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
BACKGROUND Minimal pain and opioid use after operative treatment for pediatric supracondylar humeral fractures have been previously described; however, opioid-prescribing practices in the United States remain variable. We hypothesized that children without an opioid prescription would report similar postoperative pain compared with children prescribed opioids following closed reduction and percutaneous pinning (CRPP) of supracondylar humeral fractures. METHODS Children who were 3 to 12 years of age and were undergoing CRPP for a closed supracondylar humeral fracture were prospectively enrolled in a multicenter, comparative study. Following a standardized dosing protocol, oxycodone, ibuprofen, and acetaminophen were prescribed at 2 hospitals (opioid cohort), and 2 other hospitals prescribed ibuprofen and acetaminophen alone (non-opioid cohort). The children's medication use and the daily pain that they experienced (scored on the Wong-Baker FACES Scale) were recorded at postoperative days 1 to 7, 10, 14, and 21, using validated text-message protocols. Based on an a priori power analysis, at least 64 evaluable subjects were recruited per cohort. RESULTS A total of 157 patients were evaluated (81 [52%] in the opioid cohort and 76 [48%] in the non-opioid cohort). The median age at the time of the surgical procedure was 6.2 years, and 50% of the subjects were male. The mean postoperative pain scores were low overall (<4 of 10), and there were no significant differences in pain ratings between cohorts at any time point. No patient demographic or injury characteristics were correlated with increased pain or medication use. Notably, of the 81 patients in the opioid cohort, 28 (35%) took no oxycodone and 40 (49%) took 1 to 3 total doses across the postoperative period. Patients rarely took opioids after postoperative day 2. A single patient in the non-opioid cohort (1 [1%] of 76) received a rescue prescription of opioids after presenting to the emergency department with postoperative cast discomfort. CONCLUSIONS Non-opioid analgesia following CRPP for pediatric supracondylar humeral fractures was equally effective as opioid analgesia. When oxycodone was prescribed, 84% of children took 0 to 3 total doses, and opioid use fell precipitously after postoperative day 2. To improve opioid stewardship, providers and institutions can consider discontinuing the routine prescription of opioids following this procedure. LEVEL OF EVIDENCE Therapeutic Level II . See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Zoe E. Belardo
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Divya Talwar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Todd J. Blumberg
- Department of Orthopaedics and Sports Medicine, Seattle Children’s Hospital, Seattle, Washington
| | - Susan E. Nelson
- Department of Orthopaedics, University of Rochester Medical Center, Rochester, New York
| | | | - Wudbhav N. Sankar
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Apurva S. Shah
- Division of Orthopaedics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
- The Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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Aarts LAM, van Geffen GJ, Smedema EAL, Smits RM. Therapeutic communication improves patient comfort during venipuncture in children: a single-blinded intervention study. Eur J Pediatr 2023; 182:3871-3881. [PMID: 37330438 PMCID: PMC10570224 DOI: 10.1007/s00431-023-05036-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 05/12/2023] [Accepted: 05/22/2023] [Indexed: 06/19/2023]
Abstract
The aim of this study was to examine whether therapeutic communication improves children's comfort during venipuncture compared to standard communication. This study was registered in the Dutch trial register (NL8221), December 10, 2019. This single-blinded interventional study was carried out in an outpatient clinic of a tertiary hospital. Inclusion criteria were age between 5 and 18 years, use of topical anesthesia (EMLA) and sufficient understanding of the Dutch language. 105 children were included, 51 assigned to the standard communication group (SC group) and 54 patients to the therapeutic communication group (TC group). The primary outcome measure was self-reported pain based on the Faces Pain Scale Revised (FPS-R). Secondary outcome measures were observed pain (numeric rating scale (NRS)), self-reported/observed anxiety in child and parent (NRS), self-reported satisfaction in child, parent and medical personnel (NRS), and procedural time. No difference was found for self-reported pain. Self-reported and observed anxiety (by parents and medical personnel) was lower in the TC group (p-values ranged from p = 0.005 to p = 0.048). Procedural time was lower in the TC group (p = 0.011). Satisfaction level of medical personnel was higher in the TC group (p = 0.014). Conclusion: TC during venipuncture did not result in lower self-reported pain. However, secondary outcomes (observed pain, anxiety and procedural time) were significantly improved in the TC group. What is Known: • Medical procedures, especially needle related procedures, cause anxiety and fear in children and adults. • In adults communication techniques based on hypnosis are effective in reducing pain and anxiety during medical procedures. What is New: • Our study found that with a small change in communication technique (called therapeutic communication or TC), the comfort of children during venipuncture improves. • This improved comfort was mainly reflected by reduced anxiety scores and shorter procedural time. This makes TC suitable for the outpatient setting.
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Affiliation(s)
- Lonneke A. M. Aarts
- Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Geert-Jan van Geffen
- Department of Anesthesiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Eva A. L. Smedema
- Department of Pediatrics, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Rosanne M. Smits
- Department of Medical Psychology, Amalia Children’s Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
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Chiappini E, Bestetti M, Masi S, Paba T, Venturini E, Galli L. Discomfort relief after paracetamol administration in febrile children admitted to a third level paediatric emergency department. Front Pediatr 2023; 11:1075449. [PMID: 36969272 PMCID: PMC10034175 DOI: 10.3389/fped.2023.1075449] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 01/05/2023] [Indexed: 03/29/2023] Open
Abstract
Background international guidelines recommend treating fever in children not at a predefined body temperature limit but based on the presence of discomfort. However few studies evaluated discomfort relief after administration of antipyretics in children. Methods Between 1st January and 30th September 2021 a single-center prospective observational study was performed in febrile children consecutively admitted to a pediatric emergency department and treated with paracetamol orally. For each child, body temperature, presence and severity of discomfort, defined using a previously published semiquantitative likert scale, were evaluated at baseline and 60 min after administration of paracetamol, and differences were analyzed. Results 172 children (males: 91/172; 52.9%; median age: 41.7 months) were included. Significant reductions in body temperature (median body temperature at T0: 38.9 °C; IQR: 38.3-39.4, median body temperature at T60: 36.9 °C; IQR: 36.4-37.5; P < 0.0001), and in the level of discomfort (proportion of children with severe discomfort at T0: 85% and at T60:14%; P < 0.0001) were observed. Severe discomfort at T60 persisted in a minority of children (24/172; 14%) and it was not related to body temperature values. Conclusions paracetamol in febrile children is associated not only with significantly reduction in body temperature but also with discomfort relief.
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Affiliation(s)
- Elena Chiappini
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
- Correspondence: Elena Chiappini
| | - Matilde Bestetti
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Stefano Masi
- Department of Health Sciences, University of Florence, Florence, Italy
- Department of Emergency Medicine, Anna Meyer Children's University Hospital, Florence, Italy
| | - Teresa Paba
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Elisabetta Venturini
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
| | - Luisa Galli
- Pediatric Infectious Disease Unit, Anna Meyer Children's University Hospital, Florence, Italy
- Department of Health Sciences, University of Florence, Florence, Italy
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Shearer HM, Verville L, Côté P, Hogg-Johnson S, Fehlings DL. Clinical course of pain intensity in individuals with cerebral palsy: A prognostic systematic review. Dev Med Child Neurol 2023; 65:24-37. [PMID: 35871758 DOI: 10.1111/dmcn.15358] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Revised: 05/19/2022] [Accepted: 06/22/2022] [Indexed: 11/30/2022]
Abstract
AIM To describe the clinical course of pain intensity in individuals with cerebral palsy (CP) resulting from usual care or specific interventions. METHOD We conducted an exploratory prognostic systematic review searching electronic databases from inception to 31st December 2021. Evidence from low and moderate risk-of-bias studies was synthesized. RESULTS We retrieved 2275 citations; 18 studies met the inclusion criteria and 10 were synthesized. The course of pain intensity in children with CP receiving usual care was stable over 15 weeks (χ2 [2] = 1.8, p = 0.5). Children who received continuous intrathecal baclofen (CITB) reported significant pain intensity reduction (visual analogue scale [VAS] = -4.2 out of 10, 95% confidence interval [CI] = -6.3 to -2.1]) 6 months postinsertion but similar children receiving usual care had no significant change over 6 months (VAS = 1.3 out of 10, 95% CI = -1.3 to 3.6). Children receiving botulinum neurotoxin A (BoNT-A) injections had significant decreases in pain after 1 month (numeric rating scale = -6.5, 95% CI = -8.0 to -5.0). Adults with chronic pain receiving usual care reported stable pain intensity over time; pain intensity improved in ambulatory adults exercising and those treated surgically for cervical myelopathy. INTERPRETATION The course of pain intensity in individuals with CP is unclear. Evidence suggests that children and adults receiving usual care had stable pain intensity over the short or long term. Interventions (CITB and BoNT-A in children and exercise and surgical treatment for cervical myelopathy in adults) had pain intensity reduction. Larger study samples are needed to confirm these results. WHAT THIS PAPER ADDS Pain intensity was stable in children with cerebral palsy (CP) receiving usual care. Adults with CP and chronic pain receiving usual care had stable, persistent pain intensity. Children receiving continuous intrathecal baclofen via pump and botulinum neurotoxin A reported significantly lower pain intensities. Adults with chronic pain and dyskinetic CP and cervical myelopathy reported significantly lower pain intensity with exercise or cervical decompression. Limited high-quality evidence exists describing non-procedural pain changes in individuals with CP.
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Affiliation(s)
- Heather M Shearer
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Leslie Verville
- Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Pierre Côté
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada
| | - Sheilah Hogg-Johnson
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Institute for Disability and Rehabilitation Research, Faculty of Health Sciences, Ontario Tech University, Oshawa, ON, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.,Research and Innovation, Canadian Memorial Chiropractic College, Toronto, ON, Canada
| | - Darcy L Fehlings
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada.,Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON, Canada.,Department of Paediatrics, University of Toronto, Toronto, ON, Canada
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Tsze DS, Lubell TR, Carter RC, Chernick LS, DePeter KC, McLaren SH, Kwok MY, Roskind CG, Gonzalez AE, Fan W, Babineau SE, Friedman BW, Dayan PS. Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial. Acad Emerg Med 2022; 29:465-475. [PMID: 34822214 PMCID: PMC10695685 DOI: 10.1111/acem.14422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/31/2021] [Accepted: 11/21/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches. METHODS We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events. RESULTS Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes. CONCLUSIONS Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Tamar R. Lubell
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Robert C. Carter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Lauren S. Chernick
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Kerrin C. DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Son H. McLaren
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Maria Y. Kwok
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Cindy G. Roskind
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Ariana E. Gonzalez
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
| | - Weijia Fan
- Department of Biostatistics, Mailman School of Public Health, Columbia University, New York, New York, USA
| | - Shannon E. Babineau
- Departments of Pediatrics and Neurology, Sidney Kimmel Medical College of Thomas Jefferson University, Morristown, New Jersey, USA
| | - Benjamin W. Friedman
- Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, New York, USA
| | - Peter S. Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, New York, USA
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Grabinski ZG, Boscamp NS, Zuckerman WA, Zviti R, O'Brien A, Martinez M, Tsze DS. Efficacy of Distraction for Reducing Pain and Distress Associated With Venipuncture in the Pediatric Posttransplant Population: A Randomized Controlled Trial. Pediatr Emerg Care 2022; 38:e811-e815. [PMID: 34034337 DOI: 10.1097/pec.0000000000002458] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Distraction can reduce pain and distress associated with painful procedures but has never been studied in children with solid organ transplants. We aimed to determine whether there is a difference in pain and distress associated with venipuncture in pediatric posttransplant patients who receive distraction compared with those who do not. METHODS Randomized controlled trial of children aged 4 to 17 years with solid organ transplants undergoing venipuncture in the outpatient setting. Patients were randomized to receive distraction or no distraction. The primary outcome was the Faces Pain Scale-Revised. Secondary outcomes were the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale. Exploratory outcomes included the number of venipuncture attempts, time to successful venipuncture, and satisfaction of phlebotomists and parents. RESULTS Median age of the 40 children enrolled was 11.5 years. Type of transplants included the heart (67.5%), kidney (22.5%), liver (7.5%), and more than 1 organ (2.5%). There was no difference between the Faces Pain Scale-Revised scores in distraction and no distraction groups (1.4; 95% confidence interval, 0.9-1.9; and 1.3, 95% confidence interval, 0.5-2.1, respectively). There was also no difference in the Observational Scale of Behavioral Distress-Revised; Faces, Leg, Activity, Cry, Consolability; and Children's Hospital of Eastern Ontario Pain Scale scores, number of venipuncture attempts, or time to successful venipuncture. Phlebotomists were more satisfied with the venipuncture when distraction was implemented. CONCLUSIONS In children with solid organ transplants, there was no difference in pain and distress associated with venipuncture between those who did and did not receive distraction. There was also no difference in other procedure-related outcomes except for greater phlebotomist satisfaction when distraction was implemented.
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Affiliation(s)
- Zoe G Grabinski
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine
| | | | | | - Ronald Zviti
- Division of Nephrology, Department of Pediatrics
| | - Ann O'Brien
- Division of Nephrology, Department of Pediatrics
| | - Mercedes Martinez
- Division of Hepatology and Gastroenterology, Department of Pediatrics, Columbia University Irving Medical Center, New York, NY
| | - Daniel S Tsze
- From the Division of Pediatric Emergency Medicine, Department of Emergency Medicine
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10
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Matula ST, Irving SY, Deatrick JA, Steenhoff AP, Polomano RC. The Prevalence, Intensity, Assessment, and Management of Acute Pain in Hospitalized Children in Botswana. Pain Manag Nurs 2022; 23:548-558. [PMID: 34987004 DOI: 10.1016/j.pmn.2021.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Revised: 11/28/2021] [Accepted: 11/30/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND There is very limited clinical and observational data on acute pain experienced by children in sub-Saharan Africa. AIMS To report the prevalence and intensity of acute pain, pain management practices, and describe associations between acute pain outcomes, children's and parents or guardian's demographics in hospitalized children aged 2 months to 13 years in Botswana. DESIGN A descriptive correlational prospective observational study using five repeated cross-sectional samples. SETTINGS Two referral hospitals in Botswana. PARTICIPANTS The sample size included 308 children and 226 parents or guardians. Data were collected between November 2018 and February 2019 from children, their parents or guardians (<7 years child), and the health record for pain documentation and treatment. MEASURES Pain was measured using Faces Pain Scale-Revised for children ≥7 years, revised Face, Legs, Activity, Cry, Consolability scale for children <7 years and numeric rating scale for parents or guardians. RESULTS There are 1,290 data points for children of which 1,000 were children <7 years and 999 data points for parents or guardians of children <7 years were used in analysis. Fifty percent of children <7 years were in pain using the revised Face, Legs, Activity, Cry, Consolability scale, whereas parents indicated 46% to be in pain. The pain prevalence for children ≥7 years was estimated at 54%. Pain was documentated at a rate of 54 % on the health records. Acetaminophen was most common analgesic across all age groups. Univariate associations of child <7 years pain intensity was statistically significant (p ≤ .05) for weight, diagnosis, residence, and parent relationship. Parents reported pain intensity was statistically significant (p ≤ .05) for child sex, weight, diagnosis, residence, surgery, parent or guardian age and education. Only age and surgery were significant for children ≥7 years. CONCLUSIONS Acute pain prevalence and intensity among hospitalized children in Botswana is low.
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Affiliation(s)
- Samuel T Matula
- Faculty of Health Sciences, School of Nursing, University of Botswana, Gaborone, Botswana.
| | - Sharon Y Irving
- Division of Anesthesiology and Critical Care Medicine/Critical Care Nursing, University of Pennsylvania, Nurse Practitioner, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | | | - Andrew P Steenhoff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana
| | - Rosemary C Polomano
- University of Pennsylvania, Philadelphia, Pennsylvania; School of Nursing, Professor of Anesthesiology and Critical Care, Perelman School of Medicine, Philadelphia, Pennsylvania
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11
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Clinical Interpretation of Self-Reported Pain Scores in Children with Acute Pain. J Pediatr 2022; 240:192-198.e2. [PMID: 34478746 PMCID: PMC8712366 DOI: 10.1016/j.jpeds.2021.08.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 07/06/2021] [Accepted: 08/24/2021] [Indexed: 01/03/2023]
Abstract
OBJECTIVE To identify self-reported pain scores that best represent categories of no pain, mild, moderate, and severe pain in children, and a pain score that accurately represents a child's perceived need for medication, that is, a minimum pain score at which a child would want an analgesic. STUDY DESIGN Prospective cross-sectional cohort study of children aged 6-17 years presenting to a pediatric emergency department with painful and nonpainful conditions. Pain was measured using the 10-point Verbal Numerical Rating Scale. Receiver operating characteristic -based methodology was used to determine pain scores that best differentiated no pain from mild pain, mild pain from moderate pain, and moderate pain from severe pain. Descriptive statistics were used to determine the perceived need for medication. RESULTS We analyzed data from 548 children (51.3% female, 61.9% with a painful condition). The scores that best represent categories of pain intensity are as follows: 0-1 for no pain; 2-5 for mild pain; 6-7 for moderate pain; and 8-10 for severe pain. The area under the curve for the cut points differentiating each category ranged from 0.76 to 0.88. The median pain score representing the perceived need for medication was 6 (IQR, 4-7; range, 0-10). CONCLUSIONS We identified population-level self-reported pain scores in children associated with categories of pain intensity that differ from scores conventionally used. Implementing our findings may provide a more accurate representation of the clinical meaning of pain scores and reduce selection bias in research. Our findings do not support the use of pain scores in isolation for clinical decision making or the use of a pain score threshold to represent a child's perceived need for medication.
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12
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Whitley GA, Hemingway P, Law GR, Jones AW, Curtis F, Siriwardena AN. The predictors, barriers and facilitators to effective management of acute pain in children by emergency medical services: A systematic mixed studies review. J Child Health Care 2021; 25:481-503. [PMID: 32845710 PMCID: PMC8422593 DOI: 10.1177/1367493520949427] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
We aimed to identify predictors, barriers and facilitators to effective pre-hospital pain management in children. A segregated systematic mixed studies review was performed. We searched from inception to 30-June-2020: MEDLINE, CINAHL Complete, PsycINFO, EMBASE, Web of Science Core Collection and Scopus. Empirical quantitative, qualitative and multi-method studies of children under 18 years, their relatives or emergency medical service staff were eligible. Two authors independently performed screening and selection, quality assessment, data extraction and quantitative synthesis. Three authors performed thematic synthesis. Grading of Recommendations Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research were used to determine the confidence in cumulative evidence. From 4030 articles screened, 78 were selected for full text review, with eight quantitative and five qualitative studies included. Substantial heterogeneity precluded meta-analysis. Predictors of effective pain management included: 'child sex (male)', 'child age (younger)', 'type of pain (traumatic)' and 'analgesic administration'. Barriers and facilitators included internal (fear, clinical experience, education and training) and external (relatives and colleagues) influences on the clinician along with child factors (child's experience of event, pain assessment and management). Confidence in the cumulative evidence was deemed low. Efforts to facilitate analgesic administration should take priority, perhaps utilising the intranasal route. Further research is recommended to explore the experience of the child. Registration: PROSPERO CRD42017058960.
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Affiliation(s)
- Gregory A Whitley
- Community and Health Research Unit, University of Lincoln, UK,Gregory A Whitley, Community and Health Research Unit, Sarah Swift Building, University of Lincoln, Brayford Wharf East, Lincoln LN5 7AT, Lincolnshire, UK.
| | - Pippa Hemingway
- Faculty of Medicine and Health Sciences, University of Nottingham, UK
| | - Graham R Law
- Community and Health Research Unit, University of Lincoln, UK
| | - Arwel W Jones
- Department of Allergy, Immunology and Respiratory Medicine, Monash University, Australia
| | - Ffion Curtis
- Lincoln Institute for Health, University of Lincoln, UK
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13
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Jaaniste T, Wood JG, Johnson A, Nguyen H, Chan DB, Powell A, Pfeiffer G, Wong B, Champion GD. Trajectory of Pain, Functional Limitation, and Parental Coping Resources Following Pediatric Short-stay Surgery: Factors Impacting Rate of Recovery. Clin J Pain 2021; 37:698-706. [PMID: 34369414 DOI: 10.1097/ajp.0000000000000966] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 04/02/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Although there are many benefits of short-stay hospital admissions for high volume, pediatric surgical procedures, this model of care places greater responsibility on parents for the management of children's pain. This study aimed to document the trajectory of child pain outcomes and a range of parent-reported functional outcomes following discharge from a short-stay surgical admission. Moreover, we aimed to document the trajectory of parental perceived personal coping resources. Second, we assessed whether parental dispositional factors, assessed before hospital discharge, predicted the child's pain intensity and parent-reported functional recovery. METHODS Participants included children (aged 4 to 14 y) admitted for a short-stay tonsillectomy or appendectomy, and their parents. Parents completed a questionnaire before discharge from hospital. Demographic and surgical information was recorded from medical records. Following discharge, daily assessments of pain and functioning were carried out over a 10-day period using iPods or mobile phones. Predischarge and postdischarge data were obtained for 55 child and parent dyads. RESULTS Pain intensity scores returned to low levels (2/10 or less) by day 5 for appendectomy and day 10 for tonsillectomy. Parents' perceived personal coping resources increased more slowly following tonsillectomy than appendectomy. Controlling for time since surgery and parental coping resources, parental pain-related catastrophizing was a significant predictor of child pain and functional recovery. DISCUSSION Short-stay surgery results in parents facing considerable burden in managing their child's pain and functional impairment over a 10-day period. The potential value of screening for parental pain-related catastrophizing before discharge from hospital warrants further consideration and may enable identification of children likely to experience poorer recovery.
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Affiliation(s)
- Tiina Jaaniste
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - Jordan G Wood
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - Anya Johnson
- Work and Organisational Studies, University of Sydney Business School, Darlington, NSW, Australia
| | - Helena Nguyen
- Work and Organisational Studies, University of Sydney Business School, Darlington, NSW, Australia
| | - David Bertrand Chan
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - Alexandra Powell
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - Genevieve Pfeiffer
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - Brandon Wong
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
| | - G David Champion
- Department of Pain, Sydney Children's Hospital, Randwick
- School of Women's and Children's Health, University of New South Wales, Kensington
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14
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Virtual Reality to Reduce Procedural Pain During IV Insertion in the Pediatric Emergency Department: A Pilot Randomized Controlled Trial. Clin J Pain 2021; 37:94-101. [PMID: 33177370 DOI: 10.1097/ajp.0000000000000894] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 10/26/2020] [Indexed: 01/19/2023]
Abstract
OBJECTIVE The objective of this study was to evaluate the feasibility of using virtual reality (VR) for distraction during intravenous (IV) insertion in the pediatric emergency department (ED) and of conducting a full-scale randomized controlled trial. MATERIALS AND METHODS Children aged 8 to 17 years old attending a tertiary care pediatric ED were randomized to interactive VR or an attention control (video on a tablet) for distraction during their IV insertion. Feasibility was determined by recruitment rates, acceptability of the intervention, response rates to outcome measures, and safety or technical problems. Satisfaction questionnaires and pain, fear, and distress scores were completed by the child, caregiver, nurse, and research assistant. Immersion in the intervention was rated by the child. Heart rate was measured. RESULTS Children were recruited between February 2018 and May 2019. A total of 116 children were screened and 72.3% of eligible children were enrolled. Overall, 60 children were randomized to either VR (n=32) or attention control (n=28). Children, caregivers, and nurses were highly satisfied with both distraction methods. There were no significant safety, technical, or equipment issues. There was minimal disruption to clinical workflow in both groups due to study protocols. There was a clinically significant reduction in pain in the VR group. There was no significant difference in fear or distress. Children reported higher immersion in the VR environment. Heart rate increase from baseline was higher in the VR group. DISCUSSION Our data support the feasibility of using VR for distraction during IV insertion and of conducting a full-scale randomized controlled trial. Identifying eligible patients and minimizing the number of outcome measures will be important considerations for future research.
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15
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Ali S, Ma K, Dow N, Vandermeer B, Scott S, Beran T, Issawi A, Curtis S, Jou H, Graham TAD, Sigismund L, Hartling L. A randomized trial of iPad distraction to reduce children's pain and distress during intravenous cannulation in the paediatric emergency department. Paediatr Child Health 2021; 26:287-293. [PMID: 34630780 PMCID: PMC8496185 DOI: 10.1093/pch/pxaa089] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 07/07/2020] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVES We compared the addition of iPad distraction to standard care, versus standard care alone, to manage the pain and distress of intravenous (IV) cannulation. METHODS Eighty-five children aged 6 to 11 years requiring IV cannulation (without child life services present) were recruited for a randomized controlled trial from a paediatric emergency department. Primary outcomes were self-reported pain (Faces Pain Scale-Revised [FPS-R]) and distress (Observational Scale of Behavioral Distress-Revised [OSBD-R]), analyzed with two-sample t-tests, Mann-Whitney U-tests, and regression analysis. RESULTS Forty-two children received iPad distraction and 43 standard care; forty (95%) and 35 (81%) received topical anesthesia, respectively (P=0.09). There was no significant difference in procedural pain using an iPad (median [interquartile range]: 2.0 [0.0, 6.0]) in addition to standard care (2.0 [2.0, 6.0]) (P=0.35). There was no significant change from baseline behavioural distress using an iPad (mean ± SD: 0.53 ± 1.19) in addition to standard care (0.43 ± 1.56) (P=0.44). Less total behavioural distress was associated with having prior emergency department visits (odds ratio [95% confidence interval]: -1.90 [-3.37, -0.43]) or being discharged home (-1.78 [-3.04, -0.52]); prior hospitalization was associated with greater distress (1.29 [0.09, 2.49]). Significantly more parents wished to have the same approach in the future in the iPad arm (41 of 41, 100%) compared to standard care (36 of 42, 86%) (P=0.03). CONCLUSIONS iPad distraction during IV cannulation in school-aged children was not associated with less pain or distress than standard care alone. The effects of iPad distraction may have been blunted by topical anesthetic cream usage. CLINICAL TRIALS REGISTRATION ClinicalTrials.gov: NCT02326623.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
- Women & Children’s Health Research
Institute, Edmonton, Alberta
| | - Keon Ma
- Faculty of Medicine & Dentistry, University of
Alberta, Edmonton, Alberta
| | - Nadia Dow
- Alberta Health Services, Edmonton,
Alberta
| | - Ben Vandermeer
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
- Alberta Research Centre for Health Evidence, Department of
Pediatrics, Faculty of Medicine & Dentistry, University of
Alberta, Edmonton, Alberta
| | - Shannon Scott
- Faculty of Nursing, University of Alberta,
Edmonton, Alberta
| | - Tanya Beran
- Department of Community Health Sciences, Cumming School of
Medicine, University of Calgary, Calgary, Alberta
| | - Amir Issawi
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
| | - Sarah Curtis
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
- Women & Children’s Health Research
Institute, Edmonton, Alberta
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
- Women & Children’s Health Research
Institute, Edmonton, Alberta
| | - Timothy A D Graham
- Alberta Health Services, Edmonton,
Alberta
- Department of Emergency Medicine, Faculty of Medicine
& Dentistry, University of Alberta, Edmonton, Alberta
| | | | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine &
Dentistry, University of Alberta, Edmonton, Alberta
- Alberta Research Centre for Health Evidence, Department of
Pediatrics, Faculty of Medicine & Dentistry, University of
Alberta, Edmonton, Alberta
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16
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Buzzy versus EMLA: Abstract omits clinical noninferiority and time and cost savings: A commentary on Lescop et al. (2021). Int J Nurs Stud 2021; 121:104011. [PMID: 34256940 DOI: 10.1016/j.ijnurstu.2021.104011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022]
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17
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Ali S, Manaloor R, Ma K, Sivakumar M, Beran T, Scott SD, Vandermeer B, Beirnes N, Graham TAD, Curtis S, Jou H, Hartling L. A randomized trial of robot-based distraction to reduce children's distress and pain during intravenous insertion in the emergency department. CAN J EMERG MED 2021; 23:85-93. [PMID: 33683608 DOI: 10.1007/s43678-020-00023-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 08/08/2020] [Indexed: 12/27/2022]
Abstract
OBJECTIVES Our objectives were to evaluate the effectiveness of humanoid robot-based distraction on reducing distress and pain in children undergoing intravenous insertion. METHODS A two-arm, open-label randomized controlled trial was conducted April 2017-May 2018, in a pediatric emergency department (ED). A sample of 86 children aged 6-11 years who required intravenous insertion were recruited. Exclusion criteria included hearing/visual impairments, neurocognitive delay, sensory impairment to pain, previous enrollment, and ED clinical staff discretion. Outcome measures included the Observed Scale of Behavioral Distress-Revised (OSBD-R) (distress) and the Faces Pain Scale-Revised (FPS-R) (pain). RESULTS Of the 86 children recruited (median age 9 years, IQR 7,10); 55% (47/86) were male, 9% (7/82) were premature, 82% (67/82) had a previous ED visit, 31% (25/82) had a previous hospitalization and 78% (64/82) had previous intravenous insertion. Ninety-six percent (78/81) received topical anesthetic prior to intravenous insertion. Total OSBD-R distress score was 1.49 ± 2.36 (standard care) versus 0.78 ± 1.32 (robot) (p < 0.05). FPS-R pain score was 4 (IQR 2,6) (standard care) versus 2 (IQR 0,4) (robot) (p = 0.13). Parental anxiety immediately after the procedure was 36.7 (11.1) (standard care) versus 31.3 (8.5) (robot) (p = 0.04). Parents were more satisfied with pain management in the robotic distraction group (95% vs 72% very satisfied) (p = 0.002). CONCLUSIONS Humanoid robot-based distraction therapy is associated with a modest positive impact on child distress for pediatric intravenous insertion, but not pain. It can be considered a potential tool in the ED toolkit for procedural pain-associated distress reduction. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT02997631.
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Affiliation(s)
- Samina Ali
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada. .,Women and Children's Health Research Institute (WCHRI), Edmonton, AB, Canada.
| | - Robin Manaloor
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Keon Ma
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Mithra Sivakumar
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | - Tanya Beran
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Shannon D Scott
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
| | - Ben Vandermeer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.,Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada
| | - Natasha Beirnes
- Child Life Department, Stollery Children's Hospital, Edmonton, AB, Canada
| | - Timothy A D Graham
- Department of Emergency Medicine, University of Alberta, Edmonton, AB, Canada
| | - Sarah Curtis
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.,Women and Children's Health Research Institute (WCHRI), Edmonton, AB, Canada
| | - Hsing Jou
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada
| | - Lisa Hartling
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, 3-583 Edmonton Clinic Health Academy, 11405-87 Avenue, Edmonton, AB, T6G 1C9, Canada.,Women and Children's Health Research Institute (WCHRI), Edmonton, AB, Canada.,Department of Pediatrics, Alberta Research Centre for Health Evidence, University of Alberta, Edmonton, AB, Canada
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18
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Lalloo C, Mesaroli G, Makkar M, Stinson J. Outcome Measures for Pediatric Pain: Practical Guidance on Clinical Use in Juvenile Arthritis. Arthritis Care Res (Hoboken) 2020; 72 Suppl 10:358-368. [PMID: 33091266 DOI: 10.1002/acr.24217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 04/04/2020] [Indexed: 11/09/2022]
Affiliation(s)
- Chitra Lalloo
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Giulia Mesaroli
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
| | - Mallika Makkar
- The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Jennifer Stinson
- The Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Non-steroidal or opioid analgesia use for children with musculoskeletal injuries (the No OUCH study): statistical analysis plan. Trials 2020; 21:759. [PMID: 32883371 PMCID: PMC7469310 DOI: 10.1186/s13063-020-04503-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Accepted: 06/11/2020] [Indexed: 11/29/2022] Open
Abstract
Background Pediatric musculoskeletal injuries cause moderate to severe pain, which should ideally be addressed upon arrival to the emergency department (ED). Despite extensive research in ED-based pediatric pain treatment, recent studies confirm that pain management in this setting remains suboptimal. The No OUCH study consist of two complementary, randomized, placebo-controlled trials that will run simultaneously for patients presenting to the ED with an acute limb injury and a self-reported pain score of at least 5/10, measured via a verbal numerical rating scale (vNRS). Caregiver/parent choice will determine whether patients are randomized to the two-arm or three-arm trial. In the two-arm trial, patients will be randomized to receive either ibuprofen alone or ibuprofen in combination with acetaminophen. In the three-arm trial, patients can also be randomized to a third arm where they would receive ibuprofen in combination with hydromorphone. This article details the statistical analysis plan for the No OUCH study and was submitted before the trial outcomes were available for analysis. Methods/design The primary endpoint of the No OUCH study is self-reported pain at 60 min, recorded using a vNRS. The principal safety outcome is the presence of any adverse event related to study drug administration. Secondary effectiveness endpoints include pain measurements using the Faces Pain Scale-Revised and the visual analog scale, time to effective analgesia, requirement of a rescue analgesic, missed fractures, and observed pain reduction using different definitions of successful analgesia. Secondary safety outcomes include sedation measured using the Ramsay Sedation Score and serious adverse events. Finally, the No OUCH study investigates the reasons given by the caregiver for selecting the two-arm (Non-Opioid) or three-arm (Opioid) trial, caregiver satisfaction, physician preferences for analgesics, and caregiver comfort with at-home pain management. Discussion The No OUCH study will inform the relative effectiveness of acetaminophen and hydromorphone, in combination with ibuprofen, and ibuprofen alone as analgesic agents for patients presenting to the ED with an acute musculoskeletal injury. The data from these trials will be analyzed in accordance with this statistical analysis plan. This will reduce the risk of producing data-driven results and bias in our reported outcomes. Trial registration ClinicalTrials.gov NCT03767933. Registered on December 7, 2018.
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20
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Gelfand AA, Ross AC, Irwin SL, Greene KA, Qubty WF, Allen IE. Melatonin for Acute Treatment of Migraine in Children and Adolescents: A Pilot Randomized Trial. Headache 2020; 60:1712-1721. [DOI: 10.1111/head.13934] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2020] [Revised: 07/06/2020] [Accepted: 07/20/2020] [Indexed: 12/13/2022]
Affiliation(s)
- Amy A. Gelfand
- Department of Neurology UCSF Child & Adolescent Headache Program San Francisco CA USA
| | - Alexandra C. Ross
- Department of Pediatrics UCSF Child & Adolescent Headache Program San Francisco CA USA
| | - Samantha L. Irwin
- Department of Neurology UCSF Child & Adolescent Headache Program San Francisco CA USA
| | - Kaitlin A. Greene
- Division of Pediatric Neurology Department of Pediatrics Oregon Health & Science University Portland OR USA
| | - William F. Qubty
- Pediatric Headache Program Dell Medical School University of Texas at Austin Austin TX USA
| | - I. Elaine Allen
- Department of Epidemiology & Biostatistics University of California San Francisco San Francisco CA USA
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21
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Ranakusuma RW, McCullough AR, Safitri ED, Pitoyo Y, Widyaningsih W, Del Mar CB, Beller EM. Oral prednisolone for acute otitis media in children: a pilot, pragmatic, randomised, open-label, controlled study (OPAL study). Pilot Feasibility Stud 2020; 6:121. [PMID: 32874679 PMCID: PMC7455987 DOI: 10.1186/s40814-020-00671-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 08/19/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Acute otitis media (AOM) is associated with high antibiotic prescribing rates. Antibiotics are somewhat effective in improving pain and middle ear effusion (MEE); however, they have unfavourable effects. Alternative treatments, such as corticosteroids as anti-inflammatory agents, are needed. Evidence for the efficacy of these remains inconclusive. We conducted a pilot study to test feasibility of a proposed large-scale randomised controlled trial (RCT) to assess the efficacy of corticosteroids for AOM. METHODS We conducted a pilot, pragmatic, parallel, open-label RCT of oral corticosteroids for paediatric AOM in primary and secondary/tertiary care centres in Indonesia. Children aged 6 months-12 years with AOM were randomised to either prednisolone or control (1:1). Physicians were blinded to allocation. Our objectives were to test the feasibility of our full RCT procedures and design, and assess the mechanistic effect of corticosteroids, using tympanometry, in suppressing middle ear inflammation by reducing MEE. RESULTS We screened 512 children; 62 (38%) of 161 eligible children were randomised and 60 were analysed for the primary clinical outcome. All study procedures were completed successfully by healthcare personnel and parents/caregivers, despite time constraints and high workload. All eligible, consenting children were appropriately randomised. One child did not take the medication and four received additional oral corticosteroids. Our revised sample size calculation verified 444 children are needed for the full RCT. Oral corticosteroids did not have any discernible effects on MEE resolution and duration. There was no correlation between pain or other symptoms and MEE change. However, prednisolone may reduce pain intensity at day 3 (Visual Analogue Scale mean difference - 7.4 mm, 95% confidence interval (CI) - 13.4 to - 1.3, p = 0.018), but cause drowsiness (relative risk (RR) 1.8, 95% CI 1.1 to 2.8, p = 0.016). Tympanometry curves at day 7 may be improved (RR 1.8, 95% CI 1.0 to 2.9). We cannot yet confirm these as effects of corticosteroids due to insufficient sample size in this pilot study. CONCLUSIONS It is feasible to conduct a large, pragmatic RCT of corticosteroids for paediatric AOM in Indonesia. Although oral corticosteroids may reduce pain and improve tympanometry curves, it requires an adequately powered clinical trial to confirm this. TRIAL REGISTRATION Study registry number: ACTRN12618000049279. Name of registry: the Australian New Zealand Clinical Trials Registry (ANZCTR). Date of registration: 16 January 2018.
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Affiliation(s)
- Respati W. Ranakusuma
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Amanda R. McCullough
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
| | - Eka D. Safitri
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Yupitri Pitoyo
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Widyaningsih Widyaningsih
- Clinical Epidemiology and Evidence-Based Medicine Unit, Dr. Cipto Mangunkusumo General Hospital – Faculty of Medicine Universitas Indonesia, Diponegoro 71, Jakarta, 10430 Indonesia
| | - Christopher B. Del Mar
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
| | - Elaine M. Beller
- Institute for Evidence-Based Healthcare, Bond University, 14 University Drive, Robina, QLD 4226 Australia
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Ellerton K, Tharmarajah H, Medres R, Brown L, Ringelblum D, Vogel K, Dolphin A, McKellar S, Bridson F, John-White M, Craig S. The VRIMM study: Virtual Reality for IMMunisation pain in young children-protocol for a randomised controlled trial. BMJ Open 2020; 10:e038354. [PMID: 32819997 PMCID: PMC7443262 DOI: 10.1136/bmjopen-2020-038354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Pain caused by routine immunisations is distressing to children, their parents and those administering injections. If poorly managed, it can lead to anxiety about future medical procedures, needle phobia and avoidance of future vaccinations and other medical treatment. Several strategies, such as distraction, are used to manage the distress associated with routine immunisations. Virtual reality (VR), a technology which transports users into an immersive 'virtual world', has been used to manage pain and distress in various settings such as burns dressing changes and dental treatments. In this study, we aim to compare the effectiveness of VR to standard care in a general practice setting as a distraction technique to reduce pain and distress in 4-year-old children receiving routine immunisations. METHODS AND ANALYSIS The study is a randomised controlled clinical trial comparing VR with standard care in 100 children receiving routine 4-year-old vaccination. Children attending a single general practice in metropolitan Melbourne, Australia will be allocated using blocked randomisation to either VR or standard care. Children in the intervention group will receive VR intervention prior to vaccination in addition to standard care; the control group will receive standard care. The primary outcome is the difference in the child's self-rated pain scores between the VR intervention and control groups measured using The Faces Pain Scale-Revised. Secondary outcomes include another measure of self-rated pain (the Poker Chip Tool), parent/guardian and healthcare provider ratings of pain (standard 100 mm visual analogue scales) and adverse effects. ETHICS AND DISSEMINATION Ethics approval has been obtained in Australia from the Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee (NREEC 18-010). Recruitment commenced in July 2019. We plan to submit study findings for publication in a peer-reviewed journal and presentation at relevant conferences. TRIAL REGISTRATION NUMBER ACTRN12618001363279.
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Affiliation(s)
- Kirrily Ellerton
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Harishan Tharmarajah
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
- Monash University Department of General Practice, Notting Hill, Victoria, Australia
| | - Rimma Medres
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
- Monash University Health Service, Clayton, Victoria, Australia
| | - Lona Brown
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - David Ringelblum
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Kateena Vogel
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Amanda Dolphin
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Sue McKellar
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Fiona Bridson
- Wellness on Wellington General Practice, Rowville, Victoria, Australia
| | - Marietta John-White
- Emergency Department, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
| | - Simon Craig
- Emergency Department, Monash Medical Centre Clayton, Clayton, Victoria, Australia
- Department of Paediatrics, Monash University School of Clinical Sciences at Monash Health, Clayton, Victoria, Australia
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23
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Noble J, Zarling B, Geesey T, Smith E, Farooqi A, Yassir W, Sethuraman U. Analgesia Use in Children with Acute Long Bone Fractures in the Pediatric Emergency Department. J Emerg Med 2020; 58:500-505. [DOI: 10.1016/j.jemermed.2019.09.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 09/12/2019] [Accepted: 09/13/2019] [Indexed: 01/30/2023]
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Abstract
OBJECTIVES The primary objective of this study was to evaluate the management of pain after traumatic injury in the pediatric emergency department (ED) as measured by time to analgesic administration and pain resolution, stratified by triage acuity level. METHODS This is a retrospective descriptive study evaluating the management of children who presented with pain after injury to an urban level 1 trauma center. Consecutive enrollment of 1000 patients identified by ICD-9 codes that included all injuries or external causes for injury (700-999 and all E codes) and who had pain identified by triage pain assessment was performed. For analysis, patients were grouped according to triage level. RESULTS Fifty-one percent (511/1000) of patients achieved pain resolution, and an additional 20% (200/1000) of patients had documented improvement in pain score during their ED visit. Triage acuity level 1 group received medications the fastest with a median time of 12 minutes (interquartile range, 10-53 minutes); 65.3% of patients (653/1000) received a pain medication during their ED visit; 54.3% of these patients received oral medications only. Average time to intravenous line placement was 2 hours 35 minutes (SD, 2 hours 55 minutes). Only 1.9% of patients received any medications prior to arrival. CONCLUSIONS Higher-acuity patients received initial pain medications and had initial pain score decrease before lower-acuity patients. Given the retrospective nature of the study, we were unable to clearly identify barriers that contributed to delay in or lack of pain treatment in our patient population.
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25
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Prevention of oral mucositis with cryotherapy in children undergoing hematopoietic stem cell transplantations-a feasibility study and randomized controlled trial. Support Care Cancer 2020; 28:4869-4879. [PMID: 31993753 PMCID: PMC7447624 DOI: 10.1007/s00520-019-05258-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 12/20/2019] [Indexed: 02/02/2023]
Abstract
PURPOSE To evaluate the feasibility of oral cryotherapy (OC) in children and to investigate if OC reduces the incidence of severe oral mucositis (OM), oral pain, and opioid use in children undergoing hematopoietic stem cell transplantation (HSCT). METHODS Fifty-three children, 4-17 years old, scheduled for HSCT in Sweden were included and randomized to OC or control using a computer-generated list. OC instructions were to cool the mouth with ice for as long as possible during chemotherapy infusions with an intended time of ≥ 30 min. Feasibility criteria in the OC group were as follows: (1) compliance ≥ 70%; (2) considerable discomfort during OC < 20%; (3) no serious adverse events; and (4) ice administered to all children. Grade of OM and oral pain was recorded daily using the WHO-Oral Toxicity Scale (WHO-OTS), Children's International Oral Mucositis Evaluation Scale, and Numerical Rating Scale. Use of opioids was collected from the medical records. RESULTS Forty-nine children (mean age 10.5 years) were included in analysis (OC = 26, control = 23). The feasibility criteria were not met. Compliance was poor, especially for the younger children, and only 15 children (58%) used OC as instructed. Severe OM (WHO-OTS ≥ 3) was recorded in 26 children (OC = 15, control = 11). OC did not reduce the incidence of severe OM, oral pain, or opioid use. CONCLUSION The feasibility criteria were not met, and the RCT could not show that OC reduces the incidence of severe OM, oral pain, or opioid use in pediatric patients treated with a variety of conditioning regimens for HSCT. TRIAL REGISTRATION ClinicalTrials.gov id: NCT01789658.
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26
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Whitley GA, Hemingway P, Law GR, Wilson C, Siriwardena AN. Predictors of effective management of acute pain in children within a UK ambulance service: A cross-sectional study. Am J Emerg Med 2019; 38:1424-1430. [PMID: 31864872 DOI: 10.1016/j.ajem.2019.11.043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 10/25/2019] [Accepted: 11/28/2019] [Indexed: 10/25/2022] Open
Abstract
OBJECTIVE We aimed to identify predictors of effective management of acute pain in children in the pre-hospital setting. METHODS A retrospective cross-sectional study using electronic clinical records from one large UK ambulance service during 01-Oct-2017 to 30-Sep-2018 was performed using multivariable logistic regression. We included all children <18 years suffering acute pain. Children with a Glasgow Coma Scale score of <15, no documented pain or without a second pain score were excluded. The outcome measure was effective pain management (abolition or reduction of pain by ≥2 out of 10 using the numeric pain rating scale, Wong-Baker FACES® scale or FLACC [face, legs, activity, crying and consolability] scale). RESULTS 2312 patients were included for analysis. Median (IQR) age was 13 (9-16), 54% were male and the cause of pain was trauma in 66% of cases. Predictors of effective pain management include children who were younger (0-5 years) compared to older (12-17 years) (adjusted odds ratio [AOR] 1.53; 95% confidence interval [CI] 1.18-1.97), administered analgesia (AOR 2.26; CI 1.87-2.73), attended by a paramedic (AOR 1.46; CI 1.19-1.79) or living in an area of low deprivation (index of multiple deprivation [IMD] 8-10) compared to children in an area of high deprivation (IMD 1-3) (AOR 1.37; CI 1.04-1.80). Child sex, type of pain, transport time, non-pharmacological treatments and clinician experience were not significant. CONCLUSION These predictors highlight disparity in effective pre-hospital management of acute pain in children. Qualitative research is needed to help explain these findings.
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Affiliation(s)
- Gregory Adam Whitley
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom.
| | - Pippa Hemingway
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, England, United Kingdom
| | - Graham Richard Law
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom
| | - Caitlin Wilson
- North West Ambulance Service NHS Trust, Bolton, England, United Kingdom
| | - Aloysius Niroshan Siriwardena
- Community and Health Research Unit, School of Health and Social Care, University of Lincoln, Lincoln, England, United Kingdom
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Jaaniste T, Noel M, Yee RD, Bang J, Tan AC, Champion GD. Why Unidimensional Pain Measurement Prevails in the Pediatric Acute Pain Context and What Multidimensional Self-Report Methods Can Offer. CHILDREN (BASEL, SWITZERLAND) 2019; 6:E132. [PMID: 31810283 PMCID: PMC6956370 DOI: 10.3390/children6120132] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/22/2019] [Accepted: 11/22/2019] [Indexed: 11/29/2022]
Abstract
Although pain is widely recognized to be a multidimensional experience and defined as such, unidimensional pain measurement focusing on pain intensity prevails in the pediatric acute pain context. Unidimensional assessments fail to provide a comprehensive picture of a child's pain experience and commonly do little to shape clinical interventions. The current review paper overviews the theoretical and empirical literature supporting the multidimensional nature of pediatric acute pain. Literature reporting concordance data for children's self-reported sensory, affective and evaluative pain scores in the acute pain context has been reviewed and supports the distinct nature of these dimensions. Multidimensional acute pain measurement holds particular promise for identifying predictive markers of chronicity and may provide the basis for tailoring clinical management. The current paper has described key reasons contributing to the widespread use of unidimensional, rather than multidimensional, acute pediatric pain assessment protocols. Implications for clinical practice, education and future research are considered.
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Affiliation(s)
- Tiina Jaaniste
- Department of Pain and Palliative Care, Sydney Children’s Hospital, Randwick, NSW 2031, Australia; (R.D.Y.); (J.B.); (G.D.C.)
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Melanie Noel
- Department of Psychology, University of Calgary, Calgary, AB T2N 1N4, Canada;
- Alberta Children’s Hospital Research Institute, Calgary, AB T3B 6A8, Canada
- Hotchkiss Brain Institute, Calgary, AB T2N 1N4, Canada
| | - Renee D. Yee
- Department of Pain and Palliative Care, Sydney Children’s Hospital, Randwick, NSW 2031, Australia; (R.D.Y.); (J.B.); (G.D.C.)
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia;
| | - Joseph Bang
- Department of Pain and Palliative Care, Sydney Children’s Hospital, Randwick, NSW 2031, Australia; (R.D.Y.); (J.B.); (G.D.C.)
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia;
| | | | - G. David Champion
- Department of Pain and Palliative Care, Sydney Children’s Hospital, Randwick, NSW 2031, Australia; (R.D.Y.); (J.B.); (G.D.C.)
- School of Medicine, University of New South Wales, Sydney, NSW 2052, Australia;
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Abstract
Introduction: Pre-hospital analgesic treatment of injured children is suboptimal, with very few children in pain receiving analgesia. Studies have identified a number of barriers to pre-hospital pain management in children which include the route of analgesia administration. The aim of this review is to critically evaluate the pre-hospital literature, exploring the safety and efficacy of intranasal (IN) analgesics for children suffering pain. Methods: We performed a rapid evidence review, searching from inception to 17 December 2018, CINAHL, MEDLINE and Google Scholar. We included studies of children < 18 years suffering pain who were administered any IN analgesic in the pre-hospital setting. Our outcomes were effective pain management, defined as a pain score reduction of ≥ 2 out of 10, safety and rates of analgesia administration. Screening and risk of bias assessments were performed in duplicate. We performed a narrative synthesis. Results: From 310 articles screened, 23 received a full-text review resulting in 10 articles included. No interventional studies were found. Most papers reported on the use of intranasal fentanyl (INF) (n = 8) with one reporting IN ketamine and the other IN S-ketamine. Narrative synthesis showed that INF appeared safe and effective at reducing pain; however, its ability to increase analgesia administration rates was unclear. The effectiveness, safety and ability of IN ketamine and S-ketamine to increase analgesia administration rates were unclear. There was no evidence for IN diamorphine for children in this setting. Conclusion: Interventional studies are needed to determine with a higher confidence the effectiveness and safety of IN analgesics (fentanyl, ketamine, S-ketamine, diamorphine) for children in the pre-hospital setting.
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Affiliation(s)
| | - Richard Pilbery
- Yorkshire Ambulance Service NHS Trust: ORCID iD: https://orcid.org/0000-0002-5797-9788
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29
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Tsze DS, Hirschfeld G, Baeyer CL, Suarez LE, Dayan PS. Changes in Pain Score Associated With Clinically Meaningful Outcomes in Children With Acute Pain. Acad Emerg Med 2019; 26:1002-1013. [PMID: 30636350 DOI: 10.1111/acem.13683] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Revised: 12/19/2018] [Accepted: 12/24/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Identifying changes in pain score associated with clinically meaningful outcomes is necessary when using self-report measures to assess pain in children. We aimed to determine the changes in pain score associated with a minimum clinically significant difference (MCSD), ideal clinically significant difference (ICSD), and patient-perceived adequate analgesia (PPAA) and to evaluate for differences based on initial pain intensity and patient characteristics. METHODS This was a cross-sectional study of children 6 to 17 and 4 to 17 years old who were assessed using the Verbal Numerical Rating Scale (VNRS) and Faces Pain Scale-Revised (FPS-R), respectively. Children qualitatively described any endorsed change in pain score; those who received an analgesic were asked if they wanted additional analgesics to decrease their pain intensity. We used a receiver operating characteristic curve-based methodology to identify changes in pain score associated with "a little less" and "much less" pain (MCSD and ICSD, respectively) and patients declining additional analgesics because of adequate analgesia (PPAA). RESULTS We enrolled 431 children with painful conditions. For the VNRS, raw change and percent reductions in pain scores associated with MCSD, ICSD, and PPAA were 2/10 and 20%, 3/10 and 44%, and 2/10 and 29%, respectively, and for the FPS-R, 2/10 and 33%, 4/10 and 60%, and 4/10 and 40%, respectively. Raw change in pain scores increased with increasing initial pain intensity, but percent reductions remained stable. There were no significant differences based on patient characteristics such as age, sex, and race/ethnicity. CONCLUSION Our findings provide patient-centered outcomes in children that are suitable for designing trials and are generalizable across patient characteristics.
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Affiliation(s)
- Daniel S. Tsze
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Gerrit Hirschfeld
- Faculty of Business and Health University of Applied Sciences Bielefeld BielefeldGermany
| | - Carl L. Baeyer
- Faculty of Medicine University of Manitoba Winnipeg Manitoba Canada
| | - Leonor E. Suarez
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
| | - Peter S. Dayan
- Department of Emergency Medicine Division of Pediatric Emergency Medicine Columbia University College of Physicians and Surgeons New York NY
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30
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Lown EA, Banerjee A, Vittinghoff E, Dvorak CC, Hartogensis W, Melton A, Mangurian C, Hu H, Shear D, Adcock R, Morgan M, Golden C, Hecht FM. Acupressure to Reduce Treatment-Related Symptoms for Children With Cancer and Recipients of Hematopoietic Stem Cell Transplant: Protocol for a Randomized Controlled Trial. Glob Adv Health Med 2019; 8:2164956119870444. [PMID: 31453017 PMCID: PMC6696841 DOI: 10.1177/2164956119870444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Revised: 06/02/2019] [Accepted: 07/02/2019] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND We describe the study design and protocol of a pragmatic randomized controlled trial (RCT) Acupressure for Children in Treatment for a Childhood Cancer (ACT-CC). OBJECTIVE To describe the feasibility and effectiveness of an acupressure intervention to decrease treatment-related symptoms in children in treatment for cancer or recipients of a chemotherapy-based hematopoietic stem cell transplant (HSCT). DESIGN Two-armed RCTs with enrollment of 5 to 30 study days. SETTING Two pediatric teaching hospitals. PATIENTS Eighty-five children receiving cancer treatment or a chemotherapy-based HSCT each with 1 parent or caregiver. INTERVENTION Patients are randomized 1:1 to receive either usual care plus daily professional acupressure and caregiver delivered acupressure versus usual care alone for symptom management. Participants receive up to 20 professional treatments. MAIN OUTCOME A composite nausea/vomiting measure for the child. SECONDARY OUTCOMES Child's nausea, vomiting, pain, fatigue, depression, anxiety, and positive affect. PARENT OUTCOMES Depression, anxiety, posttraumatic stress symptoms, caregiver self-efficacy, and positive affect. Feasibility of delivering the semistandardized intervention will be described. Linear mixed models will be used to compare outcomes between arms in children and parents, allowing for variability in diagnosis, treatment, and age. DISCUSSION Trial results could help childhood cancer and HSCT treatment centers decide about the regular inclusion of trained acupressure providers to support symptom management.
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Affiliation(s)
- E Anne Lown
- Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
| | - Anu Banerjee
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Eric Vittinghoff
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco, California
| | - Christopher C Dvorak
- Division of Pediatric Allergy, Immunology, & Blood and Marrow Transplantation, University of California, San Francisco, California
| | - Wendy Hartogensis
- Osher Center for Integrative Medicine, University of California, San Francisco, California
| | - Alexis Melton
- Division of Pediatric Allergy, Immunology, & Blood and Marrow Transplantation, University of California, San Francisco, California
| | - Christina Mangurian
- Department of Psychiatry, School of Medicine, University of California, San Francisco, California
| | - Hiroe Hu
- Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
| | - Deborah Shear
- Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
| | - Robyn Adcock
- Compass Care/Integrative Pediatric Pain and Palliative Care (IP3), UCSF Benioff Children’s Hospital, San Francisco, California
| | - Michael Morgan
- Social and Behavioral Sciences, School of Nursing, University of California, San Francisco, California
| | - Carla Golden
- Department of Pediatric Hematology-Oncology, UCSF Benioff Children’s Hospital, Oakland, California
| | - Frederick M Hecht
- Osher Center for Integrative Medicine, University of California, San Francisco, California
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Cravero JP, Agarwal R, Berde C, Birmingham P, Coté CJ, Galinkin J, Isaac L, Kost‐Byerly S, Krodel D, Maxwell L, Voepel‐Lewis T, Sethna N, Wilder R. The Society for Pediatric Anesthesia recommendations for the use of opioids in children during the perioperative period. Paediatr Anaesth 2019; 29:547-571. [PMID: 30929307 PMCID: PMC6851566 DOI: 10.1111/pan.13639] [Citation(s) in RCA: 86] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 03/25/2019] [Accepted: 03/27/2019] [Indexed: 12/13/2022]
Abstract
Opioids have long held a prominent role in the management of perioperative pain in adults and children. Published reports concerning the appropriate, and inappropriate, use of these medications in pediatric patients have appeared in various publications over the last 50 years. For this document, the Society for Pediatric Anesthesia appointed a taskforce to evaluate the available literature and formulate recommendations with respect to the most salient aspects of perioperative opioid administration in children. The recommendations are graded based on the strength of the available evidence, with consensus of the experts applied for those issues where evidence is not available. The goal of the recommendations was to address the most important issues concerning opioid administration to children after surgery, including appropriate assessment of pain, monitoring of patients on opioid therapy, opioid dosing considerations, side effects of opioid treatment, strategies for opioid delivery, and assessment of analgesic efficacy. Regular updates are planned with a re-release of guidelines every 2 years.
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Affiliation(s)
- Joseph P. Cravero
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Rita Agarwal
- Pediatric Anesthesiology DepartmentLucille Packard Children's Hospital, Stanford University Medical SchoolStanfordCalifornia
| | - Charles Berde
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Patrick Birmingham
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Charles J. Coté
- Department of AnesthesiologyMass General Hospital for Children, Harvard UniversityBostonMassachusetts
| | - Jeffrey Galinkin
- Anesthesiology DepartmentChildren's Hospital of Colorado, University of ColoradoAuroraColorado
| | - Lisa Isaac
- Department of Anesthesia and Pain MedicineHospital for Sick Children, University of TorontoTorontoOntarioCanada
| | - Sabine Kost‐Byerly
- Pediatric Anesthesiology and Critical Care MedicineJohns Hopkins University HospitalBaltimoreMaryland
| | - David Krodel
- Department of AnesthesiologyAnn and Robert H. Lurie Children's Hospital Northwestern University Feinberg School of MedicineEvanstonIllinois
| | - Lynne Maxwell
- Department of Aneshtesiology and Critical Care MedicineChildren's Hospital of Philadelphia, Perelman School of Medicine at the University of PennsylvaniaPhiladelphia
| | - Terri Voepel‐Lewis
- Department of AneshteiologyC. S. Mott Children's Hospital, University of Michigan Medical SchoolAnn ArborMichigan
| | - Navil Sethna
- Department of Anesthesiology, Critical Care, and Pain MedicineBoston Children's Hospital, Harvard Medical SchoolBostonMassachusetts
| | - Robert Wilder
- Department of Anesthesiology and Perioperative MedicineMayo ClinicRochesterMinnesota
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32
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Chan E, Hovenden M, Ramage E, Ling N, Pham JH, Rahim A, Lam C, Liu L, Foster S, Sambell R, Jeyachanthiran K, Crock C, Stock A, Hopper SM, Cohen S, Davidson A, Plummer K, Mills E, Craig SS, Deng G, Leong P. Virtual Reality for Pediatric Needle Procedural Pain: Two Randomized Clinical Trials. J Pediatr 2019; 209:160-167.e4. [PMID: 31047650 DOI: 10.1016/j.jpeds.2019.02.034] [Citation(s) in RCA: 93] [Impact Index Per Article: 18.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Revised: 01/29/2019] [Accepted: 02/26/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of a virtual reality distraction for needle pain in 2 common hospital settings: the emergency department (ED) and outpatient pathology (ie, outpatient laboratory). The control was standard of care (SOC) practice. STUDY DESIGN In 2 clinical trials, we randomized children aged 4-11 years undergoing venous needle procedures to virtual reality or SOC at 2 tertiary Australian hospitals. In the first study, we enrolled children in the ED requiring intravenous cannulation or venipuncture. In the second, we enrolled children in outpatient pathology requiring venipuncture. In the ED, 64 children were assigned to virtual reality and 59 to SOC. In pathology, 63 children were assigned to virtual reality and 68 to SOC; 2 children withdrew assent in the SOC arm, leaving 66. The primary endpoint was change from baseline pain between virtual reality and SOC on child-rated Faces Pain Scale-Revised. RESULTS In the ED, there was no change in pain from baseline with SOC, whereas virtual reality produced a significant reduction in pain (between-group difference, -1.78; 95% CI, -3.24 to -0.317; P = .018). In pathology, both groups experienced an increase in pain from baseline, but this was significantly less in the virtual reality group (between-group difference, -1.39; 95% CI, -2.68 to -0.11; P = .034). Across both studies, 10 participants experienced minor adverse events, equally distributed between virtual reality/SOC; none required pharmacotherapy. CONCLUSIONS In children aged 4-11 years of age undergoing intravenous cannulation or venipuncture, virtual reality was efficacious in decreasing pain and was safe. TRIAL REGISTRATION Australia and New Zealand Clinical Trial Registry: ACTRN12617000285358p.
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Affiliation(s)
- Evelyn Chan
- General Pediatrics, Monash Children's Hospital, Clayton, Victoria, Australia; General Medicine, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Michael Hovenden
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Emma Ramage
- Pediatric Emergency Department, Monash Medical Centre, Clayton, Victoria, Australia
| | - Norman Ling
- Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Jeanette H Pham
- Melbourne Medical School, University of Melbourne, Parkville, Victoria, Australia
| | - Ayesha Rahim
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Connie Lam
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Linly Liu
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Samantha Foster
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Ryan Sambell
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia
| | - Kasthoori Jeyachanthiran
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Catherine Crock
- School of Psychology, Centre for Social and Early Emotional Development, Faculty of Health, Deakin University, Geelong, Victoria, Australia
| | - Amanda Stock
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia
| | - Sandy M Hopper
- Emergency Department, Royal Children's Hospital, Parkville, Victoria, Australia; Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Simon Cohen
- Pain Management, Monash Children's Hospital, Clayton, Victoria, Australia
| | - Andrew Davidson
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Karin Plummer
- Anaesthesia and Pain Management Research Group, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Erin Mills
- Pediatric Emergency Department, Monash Medical Centre, Clayton, Victoria, Australia
| | - Simon S Craig
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia; Pediatric Emergency Department, Monash Medical Centre, Clayton, Victoria, Australia
| | - Gary Deng
- DataConnect, Melbourne, Victoria, Australia
| | - Paul Leong
- School of Clinical Sciences, Monash University and Monash Health, Clayton, Victoria, Australia; Monash Lung & Sleep, Monash Medical Centre, Clayton, Victoria, Australia.
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Tsze DS, Pan SS, DePeter KC, Wagh AM, Gordon SL, Dayan PS. Intranasal hydromorphone for treatment of acute pain in children: A pilot study. Am J Emerg Med 2019; 37:1128-1132. [PMID: 30902361 DOI: 10.1016/j.ajem.2019.03.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Revised: 03/07/2019] [Accepted: 03/08/2019] [Indexed: 10/27/2022] Open
Abstract
OBJECTIVES We aimed to describe the analgesic efficacy, duration of analgesia, and adverse event profile associated with intranasal hydromorphone in children with acute pain presenting to an emergency department. METHODS Prospective dose titration pilot study of otherwise healthy children 4 to 17-years-old with moderate to severe pain who required a parenteral opioid. All patients received an initial intranasal hydromorophone dose of 0.03 mg/kg. The need for additional analgesia was assessed at 15 and 30 min; an additional 0.015 mg/kg was given at each assessment, if required. Need for rescue analgesic, pain intensity and adverse events were assessed until 6 h after hydromorphone administration or until patients were discharged, underwent a procedure to treat their painful condition, or received a rescue analgesic. RESULTS We enrolled 35 children. Fifteen, 11, and 9 children required a total dose of 0.03, 0.045, and 0.06 mg/kg, respectively. Patients in each dose group experienced an absolute decrease in pain score of ≥3/10 and percent reduction >40% within 5-15 min of completing dose-titration administration of hydromorphone. Duration of analgesia (i.e. time until rescue analgesic administered) >1 h was observed in 85.7% of patients. Patients not requiring rescue analgesics had mild or no pain until discharged or their painful conditions were treated. Three (8.6%) patients required a rescue analgesic <1 h after hydromorphone administration. There were no major adverse events. CONCLUSIONS Intranasal hydromorphone led to rapid, clinically significant and frequently sustained decreases in pain intensity in children. No major adverse events were observed in this preliminary sample. Clinical Trials Registration Number: NCT02437669.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA.
| | - Sharon S Pan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Kerrin C DePeter
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Anju M Wagh
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephen L Gordon
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University College of Physicians and Surgeons, New York, NY, USA
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Ballard A, Khadra C, Adler S, D Trottier E, Bailey B, Poonai N, Théroux J, Le May S. External cold and vibration for pain management of children undergoing needle-related procedures in the emergency department: a randomised controlled non-inferiority trial protocol. BMJ Open 2019; 9:e023214. [PMID: 30782698 PMCID: PMC6340451 DOI: 10.1136/bmjopen-2018-023214] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
INTRODUCTION Needle-related procedures are considered as the most important source of pain and distress in children in hospital settings. Considering the physiological and psychological consequences that could result from these procedures, management of pain and distress through pharmacological and non-pharmacological methods is essential. Therefore, it is important to have interventions that are rapid, easy-to-use and likely to be translated into clinical practice for routine use. The aim of this study will be to determine whether a device combining cold and vibration (Buzzy) is non-inferior to a topical anaesthetic (liposomal lidocaine 4% cream) for pain management of children undergoing needle-related procedures in the emergency department. METHODS AND ANALYSIS This study will be a randomised controlled non-inferiority trial comparing the Buzzy device to liposomal lidocaine 4% cream for needle-related pain management. A total of 346 participants will be randomly assigned in a 1:1 ratio to one of the two study groups. The primary outcome will be the mean difference in pain intensity between groups during needle-related procedures. A non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. A Non-inferiority margin of 0.70 on the Color Analogue Scale will be considered. The secondary outcomes will be the level of distress during the procedure, the success of the procedure at first attempt, the occurrence of adverse events, the satisfaction of both interventions and the memory of pain 24 hours after the procedure. The primary outcome will be assessed for non-inferiority and the secondary outcomes for superiority. ETHICS AND DISSEMINATION This study protocol was reviewed and approved by the institutional review board of the study setting. Findings of this trial will be disseminated via peer-reviewed publications and conference presentations. TRIAL REGISTRATION NUMBER NCT02616419.
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Affiliation(s)
- Ariane Ballard
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada
| | - Christelle Khadra
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada
| | - Samara Adler
- Faculty of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Evelyne D Trottier
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Benoit Bailey
- Division of Emergency Medicine, Department of Pediatrics, CHU Sainte-Justine, Montreal, Quebec, Canada
| | - Naveen Poonai
- Department of Emergency Medicine, London Health Sciences Centre, London, Ontario, Canada
- Department of Pediatrics, Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Children's Health Research Institute, London Health Sciences Centre, London, Ontario, Canada
| | - Jean Théroux
- School of Health Professions, Murdoch University, Murdoch, Western Australia, Australia
| | - Sylvie Le May
- Faculty of Nursing, University of Montreal, Montreal, Quebec, Canada
- CHU Sainte-Justine Research Centre, Montreal, Quebec, Canada
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Recommendations for selection of self-report pain intensity measures in children and adolescents: a systematic review and quality assessment of measurement properties. Pain 2018; 160:5-18. [DOI: 10.1097/j.pain.0000000000001377] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
Pain scales using faces are commonly used tools for assessing pain in children capable of communicating. However, some children require other types of pain scales because they have difficulties in understanding faces pain scales. The goal of this study was to develop and validate the "Pain Block" concrete ordinal scale for 4- to 7-year-old children. This was a multicenter prospective observational study in the emergency department. Psychometric properties (convergent validity, discriminative validity, responsivity, and reliability) were compared between the "Pain Block" pain scale and the Faces Pain Scale-Revised (FPS-R) to assess the validity of the "Pain Block" scale. A total of 163 children (mean age, 5.5 years) were included in this study. The correlation coefficient between the FPS-R and the Pain Block scale was 0.82 for all participants which increased with age. Agreement between the 2 pain scales was acceptable, with 95.0% of the values within the predetermined limit. The differences in mean scores between the painful group and nonpainful group were 3.3 (95% confidence interval, 2.6-4.1) and 3.8 (95% confidence interval, 3.1-4.6) for FPR-S and Pain Block, respectively. The pain scores for both pain scales were significantly decreased when analgesics or pain-relieving procedures were administered (difference in Pain Block, 2.4 [1.4-3.3]; and difference in FPS-R, 2.3 [1.3-3.3]). The Pain Block pain scale could be used to assess pain in 4- to 7-year-old children capable of understanding and counting up to the number 5, even if they do not understand the FPS-R pain scale.
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Reynolds SL, Bryant KK, Studnek JR, Hogg M, Dunn C, Templin MA, Moore CG, Young JR, Walker KR, Runyon MS. Randomized Controlled Feasibility Trial of Intranasal Ketamine Compared to Intranasal Fentanyl for Analgesia in Children with Suspected Extremity Fractures. Acad Emerg Med 2017; 24:1430-1440. [PMID: 28926159 DOI: 10.1111/acem.13313] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2017] [Revised: 08/12/2017] [Accepted: 09/10/2017] [Indexed: 01/01/2023]
Abstract
OBJECTIVES We compared the tolerability and efficacy of intranasal subdissociative ketamine to intranasal fentanyl for analgesia of children with acute traumatic pain and investigated the feasibility of a larger noninferiority trial that could investigate the potential opioid-sparing effects of intranasal ketamine. METHODS This randomized controlled trial compared 1 mg/kg intranasal ketamine to 1.5 μg/kg intranasal fentanyl in children 4 to 17 years old with acute pain from suspected isolated extremity fractures presenting to an urban Level II pediatric trauma center from December 2015 to November 2016. Patients, parents, treating physicians, and outcome assessors were blinded to group allocation. The primary outcome, a tolerability measure, was the frequency of cumulative side effects and adverse events within 60 minutes of drug administration. The secondary outcomes included the difference in mean pain score reduction at 20 minutes, the proportion of patients achieving a clinically significant reduction in pain in 20 minutes, total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the emergency department (ED) stay, and the feasibility of enrolling children presenting to the ED in acute pain into a randomized trial conducted under U.S. regulations. All patients were monitored until 6 hours after their last dose of study drug or until admission to the hospital ward or operating room. RESULTS Of 629 patients screened, 87 received the study drug and 82 had complete data for the primary outcome (41 patients in each group). The median (interquartile range) age was 8 (6-11) years and 62% were male. Baseline pain scores were similar among patients randomized to receive ketamine (73 ± 26) and fentanyl (69 ± 26; mean difference [95% CI] = 4 [-7 to 15]). The cumulative number of side effects was 2.2 times higher in the ketamine group, but there were no serious adverse events and no patients in either group required intervention. The most common side effects of ketamine were bad taste in the mouth (37; 90.2%), dizziness (30; 73.2%), and sleepiness (19; 46.3%). The most common side effects of fentanyl were sleepiness (15; 36.6%), bad taste in the mouth (9; 22%), and itchy nose (9; 22%). No patients experienced respiratory side effects. At 20 minutes, the mean pain scale score reduction was 44 ± 36 for ketamine and 35 ± 29 for fentanyl (mean difference = 9 [95% CI = -4 to 23]). Procedural sedation with ketamine occurred in 28 ketamine patients (65%) and 25 fentanyl patients (57%) prior to completing the study. CONCLUSIONS Intranasal ketamine was associated with more minor side effects than intranasal fentanyl. Pain relief at 20 minutes was similar between groups. Our data support the feasibility of a larger, noninferiority trial to more rigorously evaluate the safety, efficacy, and potential opioid-sparing benefits of intranasal ketamine analgesia for children with acute pain.
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Affiliation(s)
- Stacy L. Reynolds
- Department of Emergency Medicine; Carolinas Medical Center
- Levine Children's Hospital Emergency Department
| | - Kathleen K. Bryant
- Department of Emergency Medicine; Carolinas Medical Center
- Levine Children's Hospital Emergency Department
| | | | - Melanie Hogg
- Department of Emergency Medicine; Carolinas Medical Center
| | - Connell Dunn
- Department of Emergency Medicine; Carolinas Medical Center
| | - Megan A. Templin
- Center for Outcomes Research and Evaluation; Carolinas HealthCare System; Charlotte NC
| | - Charity G. Moore
- Center for Outcomes Research and Evaluation; Carolinas HealthCare System; Charlotte NC
| | - James R. Young
- Department of Emergency Medicine; Carolinas Medical Center
- Levine Children's Hospital Emergency Department
| | | | - Michael S. Runyon
- Department of Emergency Medicine; Carolinas Medical Center
- Levine Children's Hospital Emergency Department
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Abstract
Synopsis Accurate, reliable, and timely assessment of pain is critical for effective management of musculoskeletal pain conditions. The assessment of pain in infants, children, and adolescents with and without cognitive impairment can be particularly challenging to clinicians for a number of reasons, including factors related to the consultation (eg, heterogeneous patient population, time constraints), the clinician (eg, awareness/knowledge of available pain scales), standardized assessment scales (eg, availability, psychometric properties, and application of each scale), the patient (eg, developmental stage, ability to communicate), and the context in which the interaction took place (eg, familiarity with the setting and physiological and psychological state). As a result, pain is frequently not assessed or measured during the consultation and, in many instances, underestimated and undertreated in this population. The purpose of this article is to provide clinicians with an overview of scales that may be used to measure pain in infants, children, and adolescents. Specifically, the paper reviews the various approaches to measure pain intensity; identifies factors that can influence the pain experience, expression, and assessment in infants, children, and adolescents; provides age-appropriate suggestions for measuring pain intensity in patients with and without cognitive impairment; and identifies ways to assess the impact of pain using multidimensional pain scales. J Orthop Sports Phys Ther 2017;47(10):712-730. doi:10.2519/jospt.2017.7469.
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Dry Needling Versus Cortisone Injection in the Treatment of Greater Trochanteric Pain Syndrome: A Noninferiority Randomized Clinical Trial. J Orthop Sports Phys Ther 2017; 47:232-239. [PMID: 28257614 DOI: 10.2519/jospt.2017.6994] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Study Design Prospective, randomized, partially blinded. Background Greater trochanteric pain syndrome (GTPS) is the current terminology for what was once called greater trochanteric or subgluteal bursitis. Cortisone (corticosteroid) injection into the lateral hip has traditionally been the accepted treatment for this condition; however, the effectiveness of injecting the bursa with steroids is increasingly being questioned. An equally effective treatment with fewer adverse side effects would be beneficial. Objective To investigate whether administration of dry needling (DN) is noninferior to cortisone injection in reducing lateral hip pain and improving function in patients with GTPS. Methods Forty-three participants (50 hips observed), all with GTPS, were randomly assigned to a group receiving cortisone injection or DN. Treatments were administered over 6 weeks, and clinical outcomes were collected at baseline and at 1, 3, and 6 weeks. The primary outcome measure was the numeric pain-rating scale (0-10). The secondary outcome measure was the Patient-Specific Functional Scale (0-10). Medication intake for pain was collected as a tertiary outcome. Results Baseline characteristics were similar between groups. A noninferiority test for a repeated-measures design for pain and averaged function scores at 6 weeks (with a noninferiority margin of 1.5 for both outcomes) indicated noninferiority of DN versus cortisone injection (both, P<.01). Medication usage (P = .74) was not different between groups at the same time point. No adverse side effects were reported. Conclusion Cortisone injections for GTPS did not provide greater pain relief or reduction in functional limitations than DN. Our data suggest that DN is a noninferior treatment alternative to cortisone injections in this patient population. Level of Evidence Therapy, level 1b. Registered December 2, 2015 at www.clinicaltrials.gov (NCT02639039). J Orthop Sports Phys Ther 2017;47(4):232-239. Epub 3 Mar 2017. doi:10.2519/jospt.2017.6994.
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Olsen MF, Bjerre E, Hansen MD, Hilden J, Landler NE, Tendal B, Hróbjartsson A. Pain relief that matters to patients: systematic review of empirical studies assessing the minimum clinically important difference in acute pain. BMC Med 2017; 15:35. [PMID: 28215182 PMCID: PMC5317055 DOI: 10.1186/s12916-016-0775-3] [Citation(s) in RCA: 261] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 12/23/2016] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND The minimum clinically important difference (MCID) is used to interpret the clinical relevance of results reported by trials and meta-analyses as well as to plan sample sizes in new studies. However, there is a lack of consensus about the size of MCID in acute pain, which is a core symptom affecting patients across many clinical conditions. METHODS We identified and systematically reviewed empirical studies of MCID in acute pain. We searched PubMed, EMBASE and Cochrane Library, and included prospective studies determining MCID using a patient-reported anchor and a one-dimensional pain scale (e.g. 100 mm visual analogue scale). We summarised results and explored reasons for heterogeneity applying meta-regression, subgroup analyses and individual patient data meta-analyses. RESULTS We included 37 studies (8479 patients). Thirty-five studies used a mean change approach, i.e. MCID was assessed as the mean difference in pain score among patients who reported a minimum degree of improvement, while seven studies used a threshold approach, i.e. MCID was assessed as the threshold in pain reduction associated with the best accuracy (sensitivity and specificity) for identifying improved patients. Meta-analyses found considerable heterogeneity between studies (absolute MCID: I2 = 93%, relative MCID: I2 = 75%) and results were therefore presented qualitatively, while analyses focused on exploring reasons for heterogeneity. The reported absolute MCID values ranged widely from 8 to 40 mm (standardised to a 100 mm scale) and the relative MCID values from 13% to 85%. From analyses of individual patient data (seven studies, 918 patients), we found baseline pain strongly associated with absolute, but not relative, MCID as patients with higher baseline pain needed larger pain reduction to perceive relief. Subgroup analyses showed that the definition of improved patients (one or several categories improvement or meaningful change) and the design of studies (single or multiple measurements) also influenced MCID values. CONCLUSIONS The MCID in acute pain varied greatly between studies and was influenced by baseline pain, definitions of improved patients and study design. MCID is context-specific and potentially misguiding if determined, applied or interpreted inappropriately. Explicit and conscientious reflections on the choice of a reference value are required when using MCID to classify research results as clinically important or trivial.
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Affiliation(s)
- Mette Frahm Olsen
- Nordic Cochrane Centre, Rigshospitalet, Blegdamsvej 9, Department 7811, 2100, Copenhagen Ø, Denmark
| | - Eik Bjerre
- University Hospitals' Centre for Health Research (UCSF), Rigshospitalet, Blegdamsvej 9, Department 9701, 2100, Copenhagen Ø, Denmark
| | | | - Jørgen Hilden
- Section of Biostatistics, University of Copenhagen, Østre Farigmagsgade 5, 114, Copenhagen Ø, Denmark
| | - Nino Emanuel Landler
- Department of Cardiology, Herlev-Gentofte Hospital, Kildegårdsvej 28, 2900, Hellerup, Denmark
| | - Britta Tendal
- Nordic Cochrane Centre, Rigshospitalet, Blegdamsvej 9, Department 7811, 2100, Copenhagen Ø, Denmark
| | - Asbjørn Hróbjartsson
- Centre for Evidence-Based Medicine, University of Southern Denmark & Odense University Hospital, Sdr. Boulevard 29, Gate 50 (Videncenteret), 5000, Odense C, Denmark.
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Smith D, Cheek H, Denson B, Pruitt CM. Lidocaine Pretreatment Reduces the Discomfort of Intranasal Midazolam Administration: A Randomized, Double-blind, Placebo-controlled Trial. Acad Emerg Med 2017; 24:161-167. [PMID: 27739142 DOI: 10.1111/acem.13115] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/03/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Intranasal (IN) midazolam is a commonly prescribed medication for pediatric sedation and anxiolysis. One of its most frequently encountered adverse effects is discomfort with administration. While it has been proposed that premedicating with lidocaine reduces this undesirable consequence, this combination has not been thoroughly researched. The objective of our study was to assess whether topical lidocaine lessens the discomfort associated with IN midazolam administration. METHODS This was a double-blind, randomized, placebo-controlled trial performed in an urban, academic pediatric emergency department. Children 6-12 years of age who were receiving IN midazolam for procedural sedation received either 4% lidocaine or 0.9% saline (placebo) via mucosal atomizer. Subjects were subsequently given IN midazolam in a similar fashion and then rated their discomfort using the Wong-Baker FACES Pain Rating Scale (WBS). The primary endpoint of WBS score was analyzed with a two-tailed Mann-Whitney U-test, with p < 0.05 considered statistically significant. RESULTS Seventy-seven patients were enrolled over a consecutive 8-month period. One child was excluded from analysis due to a discrepancy in recording the drug identification number. Study groups were similar in regard to demographic information and indication for sedation. Subjects who received IN lidocaine reported less discomfort with IN midazolam administration (median WBS = 3, interquartile range [IQR] = 0-6) than those who received placebo (median WBS = 8, IQR = 2-9; p = 0.006). CONCLUSIONS Premedication with topical lidocaine reduces the discomfort associated with administration of IN midazolam (ClinicalTrials.gov, NCT02396537).
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Affiliation(s)
- David Smith
- Department of Pediatrics University of Alabama at Birmingham Birmingham AL
| | - Hugh Cheek
- Department of Pediatrics University of Alabama at Birmingham Birmingham AL
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Saps M, van Tilburg MAL, Lavigne JV, Miranda A, Benninga MA, Taminiau JA, Di Lorenzo C. Recommendations for pharmacological clinical trials in children with irritable bowel syndrome: the Rome foundation pediatric subcommittee on clinical trials. Neurogastroenterol Motil 2016; 28:1619-1631. [PMID: 27477090 DOI: 10.1111/nmo.12896] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Accepted: 05/30/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND There is little published evidence of efficacy for the most commonly used treatments. Thus, there is an urgent need to conduct clinical trials on existing and novel therapies. PURPOSE In order to address these issues the Rome Foundation and members of the Pediatric Committee of the European Medicines Agency formed a subcommittee on clinical trials to develop guidelines for the design of clinical trials in children with irritable bowel syndrome (IBS). The following recommendations are based on evidence from published data when available and expert opinion. KEY RECOMMENDATIONS The subcommittee recommends randomized, double-blind, placebo-controlled, parallel-group, clinical trials to assess the efficacy of new drugs. The combined endpoints for abdominal pain are a decrease in intensity of at least 30% compared with baseline and to meet or exceed the Reliable Change Index (RCI) for the sample. Stool consistency is measured with the Bristol Stool Scale Form (BSFS). The subcommittee recommends as entry criteria for abdominal pain a weekly average of worst abdominal pain in past 24 h of at least 3.0 on a 0-10 point scale or at least 30 mm in 100 mm Visual Analog Scale. For stool endpoints the committee recommends an average stool consistency lower than 3 in the BSFS during the run-in period for clinical trials on IBS-C and an average stool consistency greater than 5 in the BSFS during the run-in period for clinical trials on IBS-D. Changes in stool consistency are the primary endpoints for both IBS with diarrhea (IBS-D) and IBS with constipation (IBS-C).
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Affiliation(s)
- M Saps
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA.
| | - M A L van Tilburg
- Division of Gastroenterology and Hepatology, Center for Functional Gastrointestinal and Motility Disorders, University of North Carolina, Chapel Hill, NC, USA
| | - J V Lavigne
- Department of Child and Adolescent Psychiatry, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.,Mary Ann and J. Milburn Smith Child Health Research Program, Chicago, IL, USA.,Children's Hospital of Chicago Research Center, Chicago, IL, USA
| | - A Miranda
- Division of Pediatric Gastroenterology Hepatology & Nutrition, Medical College of Wisconsin, Milwaukee, WI, USA
| | - M A Benninga
- Department of Pediatric Gastroenterology and Nutrition, Emma Children's Hospital/Academic Medical Center, Amsterdam, The Netherlands
| | - J A Taminiau
- Member of the Pediatric Committee (PDCO) European Medicines Agency, London, UK
| | - C Di Lorenzo
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Nationwide Children's Hospital, Columbus, OH, USA
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Reynolds SL, Studnek JR, Bryant K, VanderHave K, Grossman E, Moore CG, Young J, Hogg M, Runyon MS. Study protocol of a randomised controlled trial of intranasal ketamine compared with intranasal fentanyl for analgesia in children with suspected, isolated extremity fractures in the paediatric emergency department. BMJ Open 2016; 6:e012190. [PMID: 27609854 PMCID: PMC5020878 DOI: 10.1136/bmjopen-2016-012190] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Fentanyl is the most widely studied intranasal (IN) analgesic in children. IN subdissociative (INSD) ketamine may offer a safe and efficacious alternative to IN fentanyl and may decrease overall opioid use during the emergency department (ED) stay. This study examines the feasibility of a larger, multicentre clinical trial comparing the safety and efficacy of INSD ketamine to IN fentanyl and the potential role for INSD ketamine in reducing total opioid medication usage. METHODS AND ANALYSIS This double-blind, randomised controlled, pilot trial will compare INSD ketamine (1 mg/kg) to IN fentanyl (1.5 μg/kg) for analgesia in 80 children aged 4-17 years with acute pain from a suspected, single extremity fracture. The primary safety outcome for this pilot trial will be the frequency of cumulative side effects and adverse events at 60 min after drug administration. The primary efficacy outcome will be exploratory and will be the mean reduction of pain scale scores at 20 min. The study is not powered to examine efficacy. Secondary outcome measures will include the total dose of opioid pain medication in morphine equivalents/kg/hour (excluding study drug) required during the ED stay, number and reason for screen failures, time to consent, and the number and type of protocol deviations. Patients may receive up to 2 doses of study drug. ETHICS AND DISSEMINATION This study was approved by the US Food and Drug Administration, the local institutional review board and the study data safety monitoring board. This study data will be submitted for publication regardless of results and will be used to establish feasibility for a multicentre, non-inferiority trial. TRIAL REGISTRATION NUMBER NCT02521415.
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Affiliation(s)
- Stacy L Reynolds
- Division of Pediatric Emergency Medicine, Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | | | - Kathleen Bryant
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Kelly VanderHave
- Department of Orthopedics, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Eric Grossman
- Department of Pediatric Surgery, Levine Children's Hospital, Concord, North Carolina, USA
| | - Charity G Moore
- Dickson Advanced Analytics, Carolinas Healthcare System, Charlotte, North Carolina, USA
| | - James Young
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Melanie Hogg
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
| | - Michael S Runyon
- Department of Emergency Medicine, Carolinas Medical Center, Charlotte, North Carolina, USA
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Davidson F, Snow S, Hayden JA, Chorney J. Psychological interventions in managing postoperative pain in children: a systematic review. Pain 2016; 157:1872-1886. [PMID: 27355184 DOI: 10.1097/j.pain.0000000000000636] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Pediatric surgeries are common and painful for children. Postoperative pain is commonly managed with analgesics; however, pain is often still problematic. Despite evidence for psychological interventions for procedural pain, there is currently no evidence synthesis for psychological interventions in managing postoperative pain in children. The purpose of this review was to assess the efficacy of psychological interventions for postoperative pain in youth. Psychological interventions included Preparation/education, distraction/imagery, and mixed. Four databases (PsycINFO, PubMed, EMBASE, and Certified Index to Nursing and Allied Health Literature) were searched to July 2015 for published articles and dissertations. We screened 1401 citations and included 20 studies of youth aged 2 to 18 years undergoing surgery. Two reviewers independently screened articles, extracted data, and assessed risk of bias. Standardized mean differences (SMDs) and 95% confidence intervals (CIs) were calculated using RevMan 5.3. Fourteen studies (1096 participants) were included in meta-analyses. Primary outcome was pain intensity (0-10 metric). Results indicated that psychological interventions as a whole were effective in reducing children's self-reported pain in the short term (SMD = -0.47, 95% CI = -0.76 to -0.18). Subgroup analysis indicated that distraction/imagery interventions were effective in reducing self-reported pain in the short term (24 hours, SMD = -0.63, 95% CI = -1.04 to -0.23), whereas preparation/education interventions were not effective (SMD = -0.27, 95% CI = -0.61 to 0.08). Data on the effects of interventions on longer term pain outcomes were limited. Psychological interventions may be effective in reducing short-term postoperative pain intensity in children, as well as longer term pain and other outcomes (eg, adverse events) require further study.
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Affiliation(s)
- Fiona Davidson
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
| | - Stephanie Snow
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Centre for Pediatric Pain Research, IWK Health Centre
| | - Jill A Hayden
- Departments of Community Health and Epidemiology and
| | - Jill Chorney
- Department of Psychology and Neuroscience, Dalhousie University, Halifax, NS, Canada
- Centre for Pediatric Pain Research, IWK Health Centre
- Anesthesia, Pain Management and Perioperative Medicine, Dalhousie University, Halifax, NS, Canada
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Gornitzky AL, Flynn JM, Muhly WT, Sankar WN. A Rapid Recovery Pathway for Adolescent Idiopathic Scoliosis That Improves Pain Control and Reduces Time to Inpatient Recovery After Posterior Spinal Fusion. Spine Deform 2016; 4:288-295. [PMID: 27927519 DOI: 10.1016/j.jspd.2016.01.001] [Citation(s) in RCA: 100] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Revised: 01/05/2016] [Accepted: 01/09/2016] [Indexed: 11/28/2022]
Abstract
STUDY DESIGN Retrospective comparative cohort. OBJECTIVES To determine if a standardized multimodal analgesic and rehabilitation protocol (rapid recovery pathway [RRP]) in adolescent idiopathic scoliosis (AIS) patients undergoing posterior spinal fusion (PSF) could improve pain control, reduce opioid-related complications, and expedite early mobilization. BACKGROUND Several reports have described postoperative recovery pathways for AIS patients undergoing PSF that shorten length of stay (LOS) without reporting the impact such pathways might have on patients' pain or quality of recovery. METHODS We compared two high-volume surgeons' patients managed on our conventional pathway (CP) or our RRP. The CP analgesia consisted of intraoperative methadone and postoperative patient-controlled analgesia (PCA) until tolerating oral analgesics, with adjunctive diazepam. Analgesia on the RRP includes intraoperative methadone and postoperative PCA; patients also receive preoperative gabapentin and acetaminophen, intraoperative intravenous acetaminophen, and postoperative diazepam, gabapentin, acetaminophen, and ketorolac. Ambulation and full diet are permitted beginning postoperative day 1. The primary outcome was mean daily pain scores. Secondary outcomes were LOS, time to pathway milestone completions, and frequency of opioid-related side effects requiring treatment. RESULTS There were 58 patients in the RRP group and 80 patients in the CP group. Patients on RRP had improved mean daily pain scores on postoperative days 0 (p = .027), 1 (p < .001) and 2 (p = .004). RRP patients were discharged home 31% earlier, discontinued from PCA 34% earlier and had their urinary catheters removed 26% earlier. Total opioid consumption decreased on postoperative day 0 (p < .001), but not postoperative day 1 (p = .773) or 2 (p = .343). Fewer patients on the RRP required medication for opioid-induced pruritus (p = .001), but there was no difference in the frequency of odansetron administration (p = .566). There were no differences in 30-day rates of readmission (p = .407). CONCLUSION Implementation of standardized RRP resulted in reduced pain, faster mobilization, reduced frequency of opioid-related side-effects, and earlier discharge.
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Affiliation(s)
- Alex L Gornitzky
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - John M Flynn
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| | - Wallis T Muhly
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Wudbhav N Sankar
- Division of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center Boulevard, Philadelphia, PA, 19104, USA
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Welsh JT. Assessing Pain in the ED Including the Use of Pain Scales (Such as OSBD, FLACC, VRS, NRS, CRS, and Oucher). CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2016. [DOI: 10.1007/s40138-016-0091-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lavigne JV. Systematic Review: Issues in Measuring Clinically Meaningful Change in Self-Reported Chronic Pediatric Pain Intensity. J Pediatr Psychol 2016; 41:715-34. [DOI: 10.1093/jpepsy/jsv161] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2015] [Accepted: 12/01/2015] [Indexed: 11/12/2022] Open
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Sun T, West N, Ansermino JM, Montgomery CJ, Myers D, Dunsmuir D, Lauder GR, von Baeyer CL. A smartphone version of the Faces Pain Scale-Revised and the Color Analog Scale for postoperative pain assessment in children. Paediatr Anaesth 2015; 25:1264-73. [PMID: 26507916 DOI: 10.1111/pan.12790] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/03/2015] [Indexed: 12/11/2022]
Abstract
BACKGROUND Effective pain assessment is essential during postoperative recovery. Extensive validation data are published supporting the Faces Pain Scale-Revised (FPS-R) and the Color Analog Scale (CAS) in children. Panda is a smartphone-based application containing electronic versions of these scales. OBJECTIVES To evaluate agreement between Panda and original paper/plastic versions of the FPS-R and CAS and to determine children's preference for either Panda or original versions of these scales. METHODS ASA I-III children, 4-18 years, undergoing surgery were assessed using both Panda and original versions of either the FPS-R or CAS. Pain assessments were conducted within 10 min of waking from anesthesia and 30 min later. RESULTS Sixty-two participants, median (range) age 7.5 (4-12) years, participated in the FPS-R trial; Panda scores correlated strongly with the original scores at both time points (Pearson's r > 0.93) with limits of agreement within clinical significance (80% CI). Sixty-six participants, age 13 (5-18) years, participated in the CAS trial. Panda scores correlated strongly with the original scores at both time points (Pearson's r > 0.87); mean pain scores were higher (up to +0.47 out of 10) with Panda than with the original tool, representing a small systematic bias, but limits of agreement were within clinical significance. Most participants who expressed a preference preferred Panda over the original tool (81% of FPS-R, 76% of CAS participants). CONCLUSION The Panda smartphone application can be used in lieu of the original FPS-R and CAS for assessment of pain in children. Children's preference for Panda may translate to improved cooperation with self-report of pain.
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Affiliation(s)
- Terri Sun
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Nicholas West
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - J Mark Ansermino
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Carolyne J Montgomery
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dorothy Myers
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Dustin Dunsmuir
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Gillian R Lauder
- Department of Pediatric Anesthesia, BC Children's Hospital, Vancouver, BC, Canada.,Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Carl L von Baeyer
- Departments of Psychology and Pediatrics, University of Saskatchewan, Saskatoon, SK, Canada.,Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Abstract
Quantitative sensory testing (QST), a set of noninvasive methods used to assess sensory and pain perception, has been used for three decades. The precision of the instruments and the uninvasiveness encouraged many QST-based trials. The developments made have benefited multiple disciplines. QST relies on analysis of an individual's response to external stimuli, reflecting the integrity of the PNS and the sensory pathway. The sensory pathway cannot be assessed in isolation from the affective and cognitive characteristics of patients or testers. Many variables potentially affect the reliability and reproducibility of QST, which after all, is designed for the testing of individuals by other individuals. Several decades of QST research have yielded exciting contributions, but the future of QST cannot be fully known.
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Affiliation(s)
- Carlos J Roldan
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
- Department of Emergency Medicine, University of Texas Health Science Center at Houston, Houston, TX 77030, USA
- Department of Emergency Medicine Memorial Hermann Hospital, Houston, TX 77030, USA
- Department of Emergency Medicine Lyndon B Johnson Hospital, Houston, TX 77026, USA
| | - Salahadin Abdi
- Department of Pain Medicine, University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
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