Sleep in infants and young children: Part one: normal sleep

The importance of sleep to overall health and well-being is becoming increasingly appreciated; however, clinicians may not have a sound understanding of the fundamentals of sleep. This review of normal pediatric sleep is meant to provide a foundation for the pediatric nurse practitioner to develop and use in clinical practice. Key concepts such as normal sleep physiology including biological rhythms and stages of sleep are discussed. Developmental changes in sleep seen in the transition from infancy to young childhood are highlighted, and strategies for instituting and maintaining normal sleep behaviors are recommended. Part 2 of this series will address common sleep problems experienced by young children.

Parent stress and coping in NICU and PICU

The purpose of this study was to identify and compare parental perceptions of their stress and coping experiences with children in pediatric intensive care units (PICU) and the neonatal intensive care units (NICU). The sample consisted of 31 NICU and 20 PICU parents. Parents in both units experienced the most stress from alteration in their parenting role and in their infants' behavior and appearance. Parents of children in PICU found assistance with parenting role more helpful than parents of children in NICU. Parents with children in the PICU perceived problems-focused coping more helpful than parents with children in the NICU; parents of children in NICU found emotion-focused coping more helpful than parents of children in PICU. Parents in both units considered problem-focused coping more helpful than appraisal- or emotion-focused coping.

Opioid and benzodiazepine withdrawal symptoms in paediatric intensive care patients

The purposes of this prospective repeated measures study were to: (a) describe the occurrence of withdrawal symptoms with the use of a standardised protocol to slowly taper opioids and benzodiazepines; and (b) to test the predictive validity of an opioid and benzodiazepine withdrawal assessment scoring tool in critically ill infants and young children after prolonged opioid and benzodiazepine therapy. Fifteen children (6 weeks-28 months of age) with complex congenital heart disease and/or respiratory failure who received opioids and benzodiazepines for 4 days or greater were evaluated for withdrawal symptoms using a standardized assessment tool. Thirteen children showed moderate to severe withdrawal symptoms a median 3 days after commencement of tapering. Symptom intensity was not related to prior opioid or benzodiazepine exposure, extracorporeal membrane oxygenation (ECMO) therapy or length of tapering. Children who received fentanyl in addition to morphine more often exhibited signs of withdrawal. This study demonstrated that significant withdrawal symptoms occur in critically ill children even with the use of a standardised assessment tool and tapering management protocol. The predictive validity and utility of the Opioid and Benzodiazepine Withdrawal Score (OBWS) was adequate for clinical use, but areas for further improvement of the tool were identified. Problems with the clinical withdrawal prevention and management guidelines were also identified. More research is needed to establish the optimal methods for prevention and management of iatrogenic opioid and benzodiazepine withdrawal in paediatric critical care.

Validation of the Pain Assessment in Neonates (PAIN) scale with the Neonatal Infant Pain Scale (NIPS)

PURPOSE

To establish the validity and clinical usefulness of a modified pain assessment scale, the Pain Assessment in Neonates (PAIN) scale.

DESIGN

Correlational design to compare scores obtained on the PAIN with scores obtained on the Neonatal Infant Pain Scale (NIPS).

SAMPLE

A convenience sample of 196 neonates from an NICU and a step-down unit with gestational ages of 26 to 47 weeks.

METHOD

Bedside nurses observed the neonates for two minutes and then scored their responses on both scales. The scales were scored sequentially and in a randomized order.

MAIN OUTCOME VARIABLE

Correlation of individual item scores and total scores on the PAIN and the NIPS.

RESULTS

The scores for individual items on the PAIN were significantly associated with scores obtained on the NIPS. Overall correlation between the scales was 0.93. These associations suggest that the PAIN is a valid scale for assessment of neonatal pain.

Children's participation in the decision-making process during hospitalization: an observational study

Twenty-four children (aged 5 months to 18 years) who were admitted to a university hospital were observed for a total of 135 hours with the aim of describing their degree of participation in decisions concerning their own care. Grading of their participation was made by using a 5-point scale. An assessment was also made of what was considered as optimal participation in each situation. The results indicate that children are not always allowed to participate in decision making to the extent that is considered optimal. In no case was it judged that a child participated in or was forced to make a decision that was too difficult for the child. The interactions between children, parents and staff were also described in connection with discussions and decision-making processes. This showed that parents do not always support their children in difficult situations and that health care staff often inform children about what is going to happen without presenting alternatives or asking for their views. Staff may, however, find themselves facing an ethical conflict in deciding between supporting a child's view or following hospital routine. It is of great importance that children are looked upon as potentially autonomous individuals and that staff members realize that one of their core duties is to facilitate children's participation in decision making concerning their health care.

Pain assessment in children with cognitive impairment. An exploration of self-report skills

Prior to surgery, 47 children (ages 8 to 17) with borderline to profound cognitive impairment were administered tasks to evaluate their understanding of the concepts of magnitude and ordinal position and their abilities to use a 0 to 5 numerical scale to rate pain levels in schematic faces. Of the 111 children (ages 4 to 14) without cognitive impairment, were administered the same tasks. Nurses conducting preoperative evaluations predicted whether children would understand the numerical scale. Fifty percent (n = 3) of children with borderline and 35% (n = 7) of children with mild cognitive impairment (and all children 8 years and older nonimpaired) correctly used the scale. Half of the children with cognitive impairment demonstrated skills (magnitude and ordinal position) that may allow them to use simpler pain rating methods. Nurses overestimated the abilities of cognitively impaired children (and younger children without cognitive impairment) to use the rating scale.

Children's drawings as facilitators of communication: a meta-analysis

In an attempt to explore new methods for accessing children's voices, this meta-analysis explores the facilitative effects of offering children the opportunity to draw as an interview strategy as compared with a traditional directed interview. Based on this analysis, introducing the opportunity to draw appears to be a relatively robust interview strategy with a large overall effect size (d = .95). Both research and clinical implications are discussed.

Hospitalized children's descriptions of their experiences with postsurgical pain relieving methods

The purpose of this study was to describe children's (aged 8-12 yr) experiences with postsurgical pain relieving methods, and their suggestions to nurses and parents concerning the implementation of pain relief measures in the hospital. The data were collected by interviewing children (N = 52) who were inpatients on a pediatric surgical ward in the university hospital of Finland. Content analysis was used to analyze the data. The children rated the intensity of pain on a visual analogue scale. The results indicated that all of the children used at least one self-initiated pain relieving method (e.g. distraction, resting/sleeping), in addition to receiving assistance in pain relief from nurses (e.g. giving pain killers, helping with daily activities) and parents (e.g. distraction, presence). The children also provided suggestions, especially as it relates to nurses (e.g. creating a more comfortable environment), regarding the implementation of effective surgical pain relief. However, some cognitive-behavioral and physical methods were identified that should be implemented more frequently in clinical practice. Furthermore, most children reported their worst pain to be severe or moderate, which indicates that pain management in hospitalized children should be more aggressive.

Nonpharmacological methods in relieving children's postoperative pain: a survey on hospital nurses in Finland

AIM OF THE STUDY

The aim of this study was to describe nurses' use of selected nonpharmacological methods in relieving 8-12-year-old children's postoperative pain in hospital.

METHODS

The convenience sample consisted of 162 nurses working on the paediatric surgical wards in the five Finnish university hospitals. An extensive questionnaire, including a five-point Likert-scale, on the nurses' use of selected nonpharmacological methods and demographic data was used as a method of data collection. The response rate was 99%. Descriptive statistics as well as nonparametric Kruskall-Wallis ANOVA and the chi-squared test were used as statistical methods.

RESULTS

The study indicates that emotional support, helping with daily activities and creating a comfortable environment were reported to be used routinely, whereas the cognitive-behavioural and physical methods included some less frequently used and less well known strategies. The results also show that attributes, such as the nurses' age, education, and work experience, the number of children the nurses had, the nurses' experiences of hospitalization of their children as well as the hospital and the place of work, were significantly related to the use of some nonpharmacological methods.

CONCLUSIONS

The nurses used versatile nonpharmacological methods in children's postoperative pain relief, although some defects could be observed. More research is needed on the methods used by nurses to relieve children's pain in different patient groups and the factors which hinder or promote nurses' use of pain alleviation methods in the clinical practice.

Pain assessment in nonverbal children with severe cognitive impairments: the Individualized Numeric Rating Scale (INRS)

Children's Hospital Boston began a major pain assessment and management initiative 3 years ago: Pain assessment and management are considered one of the institution's primary standards of care. The initiative included State of the Science meetings with internationally renowned nursing pain researchers and clinicians. These meetings generated nursing staff interest in specific applications of what is known about pain; how evidence-based knowledge can be used to ask population-specific clinical questions; and how an evidence-based approach can be applied to systematically develop, implement, and assess interventions that suit a population's clinical needs. This article is an example of an evidence-based pain assessment project at Children's Hospital Boston that focused on nonverbal children with cognitive impairments. After developing a clinical question, the authors did a literature review and a benchmarking analysis of best practice. The pilot of an adapted, existing pain assessment tool is described in this article.

Puberty-timing is everything!

Puberty is a dynamic period of physical growth, sexual maturation, and psychosocial achievement that generally begins between age 8 and 14 years. The age of onset varies as a function of sex, ethnicity, health status, genetics, nutrition, and activity level. Puberty is initiated by hormonal changes triggered by the hypothalamus. Children with variants of normal pubertal development--both early and late puberty--are common in pediatric practice. Recognizing when variations are normal and when referral for further evaluation is indicated is an important skill.

An analysis of a behavioral intervention for children undergoing venipuncture

An examination of factors was conducted to determine the effectiveness of the distraction component of a behavioral intervention (use of a party blower). In one condition, parents were instructed to coach children in the use of a party blower and to praise child cooperation. In a second condition, nurses were instructed to assist parents in coaching the child. Parents used the coaching skills they learned and got their children to use the distraction technique. Use of the distraction technique was associated with less crying. Encouragement from a health care professional and intervention early in the procedure did not enhance the intervention's effectiveness. Older children and children who were less distressed during the initial phase of the procedure were less likely to reject the intervention.

Relieving children's pain: nurses' abilities and analgesic administration practices

A primary purpose of this study was to examine relationships among nurses' knowledge and attitudes about children' pain relief, nurses' abilities to overcome barriers to optimal pain management, nurses' analgesic practices, and pain levels of hospitalized children. Significant positive relationships were found between nurses' (N = 67) analgesic administration and children's pain, and between nurses' years of practice with children and nurses' abilities to overcome barriers to optimal pain management. The children's (N = 132) mean pain level was 1.63 (scale of 0 to 5), with one half of the children reporting moderate to severe pain. Of the 117 children who reported pain, 74% received analgesia. Nurses administered a mean of 37.9% of available morphine and means of 36% to 54% of recommended amounts of morphine, acetaminophen, and codeine.

Partnership nursing: influences on involvement of informal carers

Factors influencing family involvement in the care of children in hospital were explored in a survey of 243 inpatients in two hospitals. Eighty-five per cent of the children were receiving some or all of their care from a family member, usually the mother. Significant influences on the amount and type of involvement included acuity, type of illness, length of stay and the language spoken by the family. Other social factors, such as distance from the hospital, number of dependent siblings, social class and ethnicity were not significant influencing factors in this population. The influence of language on involvement, and conclusions from related literature, suggest that characteristics of the interaction such as communication and nursing style are more significant than social structural factors. A typology of nursing approaches to informal carers is proposed which could apply beyond the paediatric context. Further work is needed to test the hypothesis that such approaches are characterized by nurses excluding the carer, or permitting, making assumptions about, or negotiating carer involvement.

Decision-making and paediatric pain: a review

The aim of this paper is to present an overview of the literature on the factors influencing decision-making in the nursing care of children in pain. To that effect published and unpublished references were reviewed. The most frequently cited factors influencing the assessment and management of pain in children are summarized and discussed. Finally recommendations are made where further research is warranted.

Using the Braden Q Scale to Predict Pressure Ulcer Risk in pediatric patients

The Braden Q Scale for Predicting Pediatric Pressure Ulcer Risk (Braden Q Scale) is a widely used, valid, and reliable pediatric-specific pressure ulcer risk assessment tool. Since its original publication, requests for clarification on how best to use the tool across the wide spectrum of pediatric patients commonly cared for in health care systems have been received. Common clarifications focus on using the Braden Q Scale as originally designed; specifically, not using untested derivations of the tool, and not using the Braden Q Scale to predict medical device-related pressure damage. The purpose of this article is to provide practical information on how best to use the Braden Q Scale and how to score a pediatric patient's risk for pressure ulcers. Accurate assessment of patient risk for pressure ulcers is the first step in guiding appropriate nursing interventions that prevent pressure ulcers. Patient assessment, scoring, and common clinical scenarios are presented.

Comparison of 1- versus 2-person bag-valve-mask techniques for manikin ventilation of infants and children

STUDY OBJECTIVE

We compare the mean tidal volumes per weight and peak pressures generated by the 1- and 2-person techniques of bag-valve-mask ventilation in a pediatric model.

METHODS

This was a prospective, descriptive study in which postgraduate year 1, postgraduate year 2, and postgraduate year 3 pediatric residents, postgraduate year 2 emergency medicine residents, pediatric emergency department nurses, transport personnel, and paramedics were asked to perform 1- and 2-person bag-valve-mask ventilation on infant and child manikins. Participants were randomly assigned a partner and performed both techniques. Tidal volume and peak pressure were recorded every 15 seconds for 3 minutes by a blinded assistant.

RESULTS

Seventy participants, 10 in each group, completed the study. Overall, for the infant- and child-manikin groups, the 2-person technique generated higher mean tidal volume per weight than the 1-person technique (infant: 7.2 versus 5.9; child: 8.8 versus 6.1). Overall, the 2-person technique generated higher mean peak pressures than the 1-person technique (infant: 27.4 versus 22.0; child: 27.2 versus 21.8). Similar results were found among all provider groups. Paramedics were the only providers able to generate a recommended median tidal volume per weight of 10 mL/kg in the child manikin group when using either technique and were the only providers, when using the 2-person technique, to generate a mean tidal volume per weight of 10 mL/kg in the infant group.

CONCLUSION

Two-person bag-valve-mask ventilation provided greater mean tidal volumes per weight and peak pressures in the infant- and child-manikin model compared with the 1-person technique.

The world of the child: a world of play even in the hospital

Play is an integral part of a child's life. Working with children in the hospital is based on the worldly view that claims that the patient is first and foremost a child. Investing in his mental well-being will assist him and his parents to better cope with his illness and hospitalization. From this point of view, many activities have been developed at Schneider Children's Medical Center of Israel (SCMCI), where the focus is on play. It is vital that the nurses work in cooperation with the educational staff and also integrate components of play during routine activity, in preparing children for surgeries and invasive procedures, and during painful or uncomfortable interventions.

Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth

Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth.

Preparing parents for their child's transfer from the PICU to the pediatric floor

The experimental study described here was conducted to examine a nursing intervention intended to diminish the anxiety level of parents of children being transferred from a pediatric intensive care unit (PICU) to a general pediatric floor. The convenience sample included 50 parents of patients in a PICU at a southeastern U.S. tertiary medical center. The sample was randomly assigned to control and experimental groups. All subjects' anxiety levels were measured using Spielberger's State-Trait Anxiety Inventory (STAI) 24 to 48 hours prior to the child's impending transfer. The experimental group subsequently was given a transfer-preparation letter along with a verbal explanation. Finally, both groups were retested using the STAI immediately prior to the child's transfer. After controlling for trait anxiety, the analysis of covariant results showed significantly lower anxiety levels among the subjects who received the transfer-preparation letter than among those who did not, F(1,47) = 18.65, p < .0005. The study concludes that effective transfer preparation can significantly reduce the anxiety experienced by parents who are facing the imminent transfer of their child out of the PICU.

Witnessing family violence: the children's experience

A phenomenological study was conducted in order to describe the experience of children as they accompany their mothers who are leaving abusive relationships. Thirteen children were interviewed. The children describe their experience as having three components: living with violence, living in transition and living with Mom. Themes within these components are identified, and implications for nursing practice are discussed.

Measurement of behavioral, affective, and somatic responses to pediatric bone marrow transplantation: development of the BASES scale

A new measure to assess behavioral, affective and somatic outcomes in the acute phase of bone marrow transplant is described. The Behavioral Affective and Somatic Experiences Scale (BASES) is a 38 item nurse-report instrument, with five subscales labeled Somatic distress, Compliance, Mood/Behavior, Interactions, and Activity. A series of pilot studies were conducted to refine the content of the BASES scale and to establish its psychometric properties in terms of internal consistency, inter-rater reliability, and validity. Internal consistency (Chronbach's alpha) for the subscales ranged from .742 to .902. Inter-rater reliability was good, with a median correlation between paired nurse observations of .866. A parent report version of the BASES scale has also been developed, and the finding of significant parent-nurse correlations provides preliminary evidence of the validity of the measure. Potential uses of the BASES scale in the pediatric BMT setting are discussed.