The efficacy of hypnosis in the reduction of procedural pain and distress in pediatric oncology: a systematic review

Children who suffer from cancer have to endure regular, painful medical procedures that are associated with a considerable degree of psychosocial distress. Hypnosis has been successfully employed in the management of pain and distress in the adult population, but is not well studied in pediatric populations. This review systematically evaluates the systematic research conducted in the field of procedure-related pain management in pediatric oncology within the context of a nationally agreed framework for the assessment of research evidence. It is concluded that there is not currently enough robust research evidence to recommend that hypnosis should form part of best practice guidelines for the management of procedure-related pain in pediatric oncology. However, there is sufficient evidence to justify larger-scale, appropriately controlled studies. A number of recommendations are made regarding future research.     

Children's Oncology Group's 2013 blueprint for research: Behavioral science

Behavioral science has long played a central role in pediatric oncology clinical service and research. Early work focused on symptom relief related to side effects of chemotherapy and pain management related to invasive medical procedures. As survival rates improved, the focused has shifted to examination of the psychosocial impact, during and after treatment, of pediatric cancer and its treatment on children and their families. The success of the clinical trials networks related to survivorship highlights an even more critical role in numerous domains of psychosocial research and care. Within the cooperative group setting, the field of behavioral science includes psychologists, social workers, physicians, nurses, and parent advisors. The research agenda of this group of experts needs to focus on utilization of psychometrically robust measures to evaluate the impact of treatment on children with cancer and their families during and after treatment ends. Over the next 5 years, the field of behavioral science will need to develop and implement initiatives to expand use of standardized neurocognitive and behavior batteries; increase assessment of neurocognition using technology; early identification of at‐risk children/families; establish standards for evidence‐based psychosocial care; and leverage linkages with the broader behavioral health pediatric oncology community to translate empirically supported research clinical trials care to practice. Pediatr Blood Cancer 2013; 60: 1048–1054. © 2012 Wiley Periodicals, Inc.     

The assessment of pain in children

This article focuses on the methods of pain measurement and assessment in children. The concepts of reliability and validity and the available types of physiologic, self-report, and behavioral measures are addressed. Methods of pain assessment in infants and toddlers, preschoolers, school-aged children, and adolescents are detailed. Finally, some practical suggestions for pediatric pain assessment are provided.     

Children’s exposure to diagnostic medical radiation and cancer risk: epidemiologic and dosimetric considerations

While the etiology of most childhood cancers is largely unknown, epidemiologic studies have consistently found an association between exposure to medical radiation during pregnancy and risk of childhood cancer in offspring. The relation between early life diagnostic radiation exposure and occurrence of pediatric cancer risks is less clear. This review summarizes current and historical estimated doses for common diagnostic radiologic procedures as well as the epidemiologic literature on the role of maternal prenatal, children’s postnatal and parental preconception diagnostic radiologic procedures on subsequent risk of childhood malignancies. Risk estimates are presented according to factors such as the year of birth of the child, trimester and medical indication for the procedure, and the number of films taken. The paper also discusses limitations of the methods employed in epidemiologic studies to assess pediatric cancer risks, the effects on clinical practice of the results reported from the epidemiologic studies, and clinical and public health policy implications of the findings. Gaps in understanding and additional research needs are identified. Important research priorities include nationwide surveys to estimate fetal and childhood radiation doses from common diagnostic procedures, and epidemiologic studies to quantify pediatric and lifetime cancer risks from prenatal and early childhood exposures to diagnostic radiography, CT, and fluoroscopically guided procedures.     

Management of young children's acute pain and anxiety during invasive medical procedures

Acute painful medical procedures frequently engender anxiety reactions in children and sensitize them to future medical interventions. Techniques that reduce pain and anxiety, including behavioral distraction (e.g. bubbles and pop-up books), kinesthetic methods (e.g. rocking), and imaginal methods (e.g. hypnosis), are discussed and described using case examples. Guidelines are provided for the physician's management of children during acute painful procedures. These include methods of engaging the child and the use of ego-supporting suggestions. These pain reduction techniques are synergistic with analgesics and have long-term benefits for pediatric patients.     

The PedsQL in pediatric cancer pain: a prospective longitudinal analysis of pain and emotional distress

The objective of this prospective study was to investigate the cross-sectional and longitudinal associations between pain and emotional distress in children and adolescents with cancer as measured by the Pediatric Quality of Life Inventory (PedsQL) Emotional Functioning and Pain Scales. The PedsQL 1.0 Generic Core Scales are multidimensional scales developed as the generic core measure to be integrated with the PedsQL Disease-Specific Modules. The PedsQL 1.0 Cancer Module was designed to measure pediatric cancer-specific health-related quality of life. The PedsQL Generic Core Scales, Emotional Functioning Scale and Cancer Module Pain Scale, were administered to 69 children and 59 adolescents and their parents at Time 1 and Time 2, which was 6 months on average after Time 1. Prospective hierarchical multiple regression analyses supported a longitudinal predictive model with Time 1 pain predicting Time 2 pain and Time 1 emotional distress predicting Time 2 emotional distress, respectively. Time 1 emotional distress did not predict Time 2 pain, and Time 1 pain did not predict Time 2 emotional distress. The results demonstrate that pediatric cancer pain and emotional distress, although associated cross-sectionally, are differentially predictive in prospective longitudinal analyses. These results suggest that both pain and emotional distress should be targeted for treatment interventions concurrently to enhance long-term health-related quality of life of the pediatric patient with cancer.     

New targets and targeted drugs for the treatment of cancer: an outlook to pediatric oncology

Novel drugs and treatment modalities are urgently needed to further improve survival of children with cancer. In medical oncology, an increased understanding of the molecular basis of cancer is driving the development of new drugs that target relevant signaling pathways in cancer cells and tumor microenvironment. Small-molecule modulators of signal transduction and monoclonal antibodies against various cellular targets have been approved in adult cancers in recent years. These drugs are now starting to be considered for the use in children. Despite the biological differences between adult and pediatric cancers, common cellular pathways have emerged from experimental research. Thus, insights into clinical experience with molecular targeted drugs in adults may help to accelerate progress in pediatric oncology. Here, the authors review molecules and pathways for which drugs are approved for adult cancer treatment and provide links to existing and potential applications in pediatric oncology.     

Effective psychological interventions for coping with painful medical procedures in pediatric oncology: a theoretical review

Children with chronic diseases have to undergo numerous and repeated painful medical procedures. Psychological interventions have produced good results in the treatment of this kind of pediatric pain and, although they have not been routinely incorporated into pediatric practice, they provide an effective complement to physical and pharmacological therapies. The present article reviews research into cognitive-behavioral treatment of the distress, pain and anxiety associated with medical procedures in pediatric oncology. We present the possible benefits of these interventions and suggest uses for cognitive-behavioral techniques when performing painful medical procedures.     

Burden of anxiety disorders in pediatric medical settings: prevalence, phenomenology, and a research agenda

The current review describes the phenomenology of several common anxiety disorders in children and adolescents as they present in medical settings. Anxiety disorders and associated features in children are described, along with epidemiology, functional impairment, common somatic complaints, medical comorbidity, health care utilization, and presentation in general and in specialty pediatric medical settings. Recommendations for clinical management in pediatric settings are presented, and evidence-based interventions and emerging treatments for pediatric anxiety disorders are described. The review concludes with a discussion of future research directions that may lead to increased recognition and improved management of anxiety disorders in pediatric medical settings.     

Clinical implications of unmanaged needle-insertion pain and distress in children

Increasing evidence has demonstrated that pain from venipuncture and intravenous cannulation is an important source of pediatric pain and has a lasting impact. Ascending sensory neural pain pathways are functioning in preterm and term infants, yet descending inhibitory pathways seem to mature postnatally. Consequently, infants may experience pain from the same stimulus more intensely than older children. In addition, painful perinatal procedures such as heel lancing or circumcision have been found to correlate with stronger negative responses to venipuncture and intramuscular vaccinations weeks to months later. Similarly, older children have reported greater pain during follow-up cancer-related procedures if the pain of the initial procedure was poorly controlled, despite improved analgesia during the subsequent procedures. Fortunately, both pharmacologic and nonpharmacologic techniques have been found to reduce children's acute pain and distress and subsequent negative behaviors during venipuncture and intravenous catheter insertion. This review summarizes the evidence for the importance of managing pediatric procedural pain and methods for reducing venous access pain.     

Guidelines for pediatric cancer centers

Since the American Academy of Pediatrics published guidelines for pediatric cancer centers in 1986 and 1997, significant changes in the delivery of health care have prompted a review of the role of tertiary medical centers in the care of pediatric patients. The potential effect of these changes on the treatment and survival rates of children with cancer led to this revision. The intent of this statement is to delineate personnel and facilities that are essential to provide state-of-the-art care for children and adolescents with cancer. This statement emphasizes the importance of board-certified pediatric hematologists/oncologists, pediatric subspecialty consultants, and appropriately qualified pediatric medical subspecialists and pediatric surgical specialists overseeing the care of all pediatric and adolescent cancer patients and the need for facilities available only at a tertiary center as essential for the initial management and much of the follow-up for pediatric and adolescent cancer patients.     

Pain assessment for children: overcoming challenges and optimizing care

There is growing evidence that children have short- and long-term physical, physiological, and psychological effects due to untreated acute pain. Because the majority of children who seek care in an emergency department present with pain or experience pain during the evaluation and treatment in the emergency department, optimal assessment and treatment of pain are paramount for this population. This review will highlight the many complexities of the assessment of pain for the pediatric patient. In addition, a variety of factors that affect the self-report of pain in children will be identified. Optimizing the utility of a pain assessment remains a challenge for the health care provider in the emergency setting. The common goal of a decreased experience of pain for children through improved analgesic administration remains.     

Understanding and managing pain in children with cerebral palsy

Pain in children with cerebral palsy is a common presentation. It is a complex topic with multiple causes, presentations, and effects. This makes assessment and management a huge challenge that requires multidisciplinary input. It can be further complicated by difficulties in communication and thus, expression of pain. Early recognition is vital as pain can impact a child's quality of life and participation in therapy and social activities. This review aims to explore what causes pain in children with cerebral palsy and how it is evaluated. Non-medical, medical, and surgical options for pain are also outlined with reference to side effects and evidence behind their efficacy. This review emphasises the need for further research to create thorough, reliable assessment tools and improve management techniques.     

The assessment and management of acute pain in infants, children, and adolescents

Acute pain is one of the most common adverse stimuli experienced by children, occurring as a result of injury, illness, and necessary medical procedures. It is associated with increased anxiety, avoidance, somatic symptoms, and increased parent distress. Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated. Numerous myths, insufficient knowledge among caregivers, and inadequate application of knowledge contribute to the lack of effective management. The pediatric acute pain experience involves the interaction of physiologic, psychologic, behavioral, developmental, and situational factors. Pain is an inherently subjective multifactorial experience and should be assessed and treated as such. Pediatricians are responsible for eliminating or assuaging pain and suffering in children when possible. To accomplish this, pediatricians need to expand their knowledge, use appropriate assessment tools and techniques, anticipate painful experiences and intervene accordingly, use a multimodal approach to pain management, use a multidisciplinary approach when possible, involve families, and advocate for the use of effective pain management in children.     

Schmerzmanagement bei Kindern in der Schweiz

Objective

Pain in hospitalized children is often undertreated. The aim of the study was to assess the current pain management for children in Switzerland.

Study design

A postal questionnaire was sent to all pediatric units in Switzerland.

Result

A total of 27 of 45 units replied (60% response). Most units used tools for pain assessment (96%) and had a guideline for pain management (78%). Procedural and postoperative pain are always (100%) treated. Premature infants and children in intensive care units often (>?87%) receive analgesics during invasive procedures. However, only 44% of intensive care units have a guideline for this.

Conclusion

Benefits of an effective pain management in children are well established. Many measures have been applied in Switzerland. However, there is still room for improvement, e.g., less than half of all intensive care units rely on guidelines for analgesics during invasive procedures.     

急诊科小儿镇痛和镇静的研究进展

小儿急诊治疗时常伴有外伤或疼痛.在急诊诊治期间,可能有必要进行某些疼痛或令人不适的诊疗操作.临床上需要急诊科医生为小儿提供安全、有效的镇痛和镇静.为此,我们对国外已发表的相关研究结果做一综述,主要包括以下几个方面:确保在急诊时小儿不会经受长时间或额外的疼痛;使用综合评估工具评估疼痛以分诊患儿;选择适当的药物、剂量和途径,在首次疼痛处理时即提供有效镇痛;尽可能选择无痛苦的方式给药(经鼻、调味糖浆)等;经常再次评估疼痛分数以确保有效镇痛,并留有足够时间来等待药物起效,同时使用非药理和药理的模式镇痛;避免"常规"进行一些不必要的致痛的侵入性操作;使用表面麻醉、局部麻醉和区域麻醉连同适当的安全程序镇静,以避免疼痛加剧.     

Current status of palliative care in Israel: a pediatric oncologist's perspective

Pediatric cancer palliative care is characterized by diversity of care delivery models; effect of cancer on the family as the central focus of care and consideration of culture, spirituality, communication, and ethical standards. In Israel, children who are in palliative care are treated by the staff of the centers and about 70 to 80 % of the children are dying in the pediatric Hematology Oncology departments and units. Special efforts are also made in the pediatric departments in order to better treat adolescents in terminal phases. Palliative care education program in Israel was started several years ago together with adult palliative care specialists, the Israeli pediatric oncologists still witness many barriers for treatment amongst parents as well as in medical pediatric teams especially in pain management. During the last years, the Israeli pediatric palliative care teams improved the management of all symptoms in a dying child with special attention to existential, emotional and social demands of the child and the whole family. Education of the medical and nursing team is imperative, training in pharmacology and metabolism of antalgic drugs is also mandatory in order to better manage symptom control of the children at the end of life.     

Symptom management during chemotherapy

Improvements in overall childhood cancer survival over the last four decades have been due to improved multimodal therapeutic regimes and supportive care. Symptoms are related to disease, procedures, treatments such as chemotherapy regimens and the overall experience of cancer. These symptoms are viewed as subjective indicators of distress which impact on the child's quality of life and therefore require a rational approach to management. This review explores the reasons why symptom management during chemotherapy is necessary, assessment of symptoms in children and young people and current approaches to management of common symptoms which are reported by children and professionals as being distressing. These are nausea and vomiting, pain, mucositis and fatigue.     

Managing painful procedures in children with cancer

Children with cancer experience repeated invasive and painful medical procedures. Pain and distress does not decrease with repeated procedures and may worsen if pain is not adequately managed. In 1990, the first recommendations on the management of pain and anxiety associated with procedures for children with cancer were published. Guiding principles described in the recommendations continue to hold true today: maximize comfort and minimize pain, use nonpharmacologic and pharmacologic interventions, prepare the child and family, consider the developmental age of the child, support family and child involvement, assure provider competency in performing procedures and sedation, and use appropriate monitoring to assure safety. This article reviews these key components for managing painful procedures in children and reviews the latest pharmacological and nonpharmacological interventions most effective in minimizing pain and discomfort.