The efficacy of socially assistive robots in improving children's pain and negative affectivity during needle-based invasive treatment: A systematic review and meta-analysis.

BACKGROUND: The ability of socially assistive robots (SARs) to treat dementia and Alzheimer's disease has been verified. Currently, to increase the range of their application, there is an increasing amount of interest in using SARs to relieve pain and negative emotions among children in routine medical settings. However, there is little consensus regarding the use of these robots. OBJECTIVE: This study aimed to evaluate the effect of SARs on pain and negative affectivity among children undergoing invasive needle-based procedures. DESIGN: This study was a systematic review and meta-analysis of randomized controlled trials that was conducted in accordance with the Cochrane Handbook guidelines. METHODS: The PubMed, CINAHL, Web of Science, Cochrane Library, Embase, CNKI, and WanFang databases were searched from inception to January 2024 to identify relevant randomized controlled trials (RCTs). We used the Cochrane Risk of Bias tool 2.0 (RoB2.0) to assess the risk of bias among the included studies, and we used RevMan 5.4 software to conduct the meta-analysis. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework was used to assess the quality of the evidence. RESULTS: Ten RCTs involving 815 pediatric subjects were selected for this review and reported outcomes related to pain and emotions during IV placement, port needle insertion, flu vaccination, blood sampling, and dental treatment. Children undergoing needle-related procedures with SARs reported less anxiety (SMD= -0.36; 95% CI= -0.64, -0.09) and fewer distressed avoidance behaviors (SMD= -0.67; 95% CI= -1.04, -0.30) than did those receiving typical care. There were nonsignificant differences between these groups in terms of in pain (SMD = -0.02; 95% CI = - 0.81, 0.78) and fear (SMD = 0.38; 95% CI= -0.06, 0.82). The results of exploratory subgroup analyses revealed no statistically significant differences based on the intervention type of robots or anesthetic use. CONCLUSIONS: The use of SARs is a promising intervention method for alleviating anxiety and distress among children undergoing needle-related procedures. However, additional high-quality randomized controlled trials are needed to further validate these conclusions. TRIAL REGISTRATION: The protocol of this study has been registered in the database PROSPERO (registration ID: CRD42023413279).

Impact of virtual reality on the perception of procedural pain in paediatric oncology.

INTRODUCTION: Virtual reality is being used more and more in the healthcare field, particularly during treatment. In the context of pain management, the question arises as to the effectiveness of using virtual reality during care in reducing the perception of procedural pain. AIM: To study the impact of using virtual reality on the perception of procedural pain and on the course of care in pediatric oncology. METHODS: A quasi-experimental, matched-case-control study conducted at the pediatric oncology unit of the Tunis Children's Hospital over a three-month period. Each child had two nursing care : with and without the use of virtual reality. RESULTS: Thirty-two children were enrolled. The sex ratio was 0.88. The edia nage was 96 ± 49 months. The care provided was peripheral venous line insertion (53%), blood sampling (32%) and port-a-catheter puncture (15%). The use of virtual reality significantly reduced heart rate (p<0.0001), respiratory rate (p<0.0001) and pain perception (p<0.0001). Workload was reduced, as evidenced by a drop in the duration of nursing care (p<0.0001) and in the number of people needed to carry out care (p<0.0001). CONCLUSIONS: Virtual reality is a good non-pharmacological alternative for procedural pain control in a pediatric oncology unit.

Factors associated with pain sensation in patients with ultrasound-guided prostate biopsy.

Introduction: TRUS-guided prostate biopsy is a current method used to obtain the histopathological material necessary to make a definitive diagnosis of prostate cancer. Objective: To investigate patient-related variables affecting the level of pain felt during prostate biopsy to determine what can be done to minimize pain. Methods: The study included 241 patients scheduled for prostate biopsy. Four patients who did not meet the criteria were excluded. Local anesthesia was administered intrarectally 10 minutes before the biopsy to 237 patients, and a conventional 12-core biopsy was performed. The level of pain felt by all patients during the biopsy was measured using the Visual Analog Scale (VAS) score. Pain scores were compared by forming groups according to the selected parameters. Results: The mean age of the 237 included patients was 66.0±7.8 years, the mean serum PSA level was 33.7±197.5 ng/dL, and the mean prostate volume was 33.7±197.5 ml. The mean VAS score was 4.3±1.9. The pain score was higher in patients with positive digital rectal examination findings and lower in patients using 5-alpha reductase inhibitors(5-ARI). At the same time, no significant difference was found in patients with positive tumor pathology, perineural invasion, alpha-blockers, or combination therapy. Conclusion: Some patient parameters may affect the level of pain felt during TRUS-guided prostate biopsy.

Introducción: La biopsia de próstata guiada por ecografía transrectal (TRUS) es un método utilizado para obtener el material histopatológico necesario para realizar un diagnóstico definitivo de cáncer de próstata. Objetivo: Investigar las variables relacionadas con el paciente que afectan al nivel de dolor sentido durante la biopsia de próstata para para tratar de minimizar el dolor durante el procedimiento. Métodos: El estudio incluyó a 241 pacientes programados para biopsia de próstata. Se excluyeron cuatro pacientes que no cumplieron los criterios. Se administró anestesia local por vía intrarrectal 10 minutos antes de la biopsia a 237 pacientes y se realizó una biopsia convencional de 12 núcleos. El nivel de dolor sentido por todos los pacientes durante la biopsia se midió mediante la puntuación de la Escala Visual Analógica (EVA). Se compararon las puntuaciones de dolor formando grupos según los parámetros seleccionados. Resultados: La edad media de los 237 pacientes fue de 66.0±7.8 años, el nivel sérico medio de PSA fue de 33.7±197.5 ng/dL y el volumen prostático fue de 33.7±197.5 ml. La puntuación media de la EAV fue de 4.3±1.9. La puntuación del dolor fue mayor en los pacientes con resultados positivos del tacto rectal y menor en los pacientes que utilizaban inhibidores de la 5-alfa reductasa (5-ARI). Al mismo tiempo, no se encontraron diferencias significativas en los pacientes con patología tumoral positiva, invasión peri neural, alfa bloqueantes o terapia combinada. Conclusiones: Algunos parámetros del paciente pueden afectar al nivel de dolor sentido durante la biopsia de próstata guiada por TRUS.

Inhaled methoxyflurane (Penthrox®) as a novel pain relief for outpatient hysteroscopy and other gynaecological procedures.

OBJECTIVE: Penthrox® (methoxyflurane) is a convenient, portable, self-administered disposable single-use handheld inhaler licenced as an emergency, rapid-onset, short-acting, analgesic in adult trauma patients. Outpatient hysteroscopy is one of the commonest procedures in contemporary gynecology but it can be associated with significant pain leading to poor patient experience and failed procedures. We evaluated the feasibility and acceptability of Penthrox® in women undergoing outpatient hysteroscopic procedures and its potential efficacy to reduce pain and improve patient experience. STUDY DESIGN: We conducted a prospective observational cohort study on women undergoing hysteroscopy or other intrauterine procedures, such as coil fitting, endometrial biopsy, polypectomy, endometrial ablation and manual vacuum aspiration in an outpatient setting. Women were offered Penthrox® inhalers for pain control, instructed how to use it and asked to record the intra-procedural pain they expected and actually experienced using a 10 cm Visual Analogue Scale. The acceptability, side effects and ease of use of the Penthrox® device were also recorded. RESULTS: 122/146 (83.6 %) women chose to use Penthrox®. 116 out of the 122 (95.1 %) underwent an intrauterine procedure, including 59 hysteroscopic polypectomies and 34 global endometrial ablations. The average pain expected during the procedure was 6.0 (SD = 2.8) and the pain experienced during the procedure was 5.1 (SD = 2.8). The intended procedure was completed in 117 (96 %) women. Penthrox® was considered easy to use by 118 (97 %) women and 111 (91 %) would use it again, although 22 (18 %) women would prefer general anaesthesia in the future. No adverse events occurred but 88 (72 %) women reported mild, self-limiting side effects. CONCLUSION: Penthrox® appears safe, feasible and acceptable as a pain relief option during outpatient hysteroscopy and other intrauterine procedures. The effectiveness of Penthrox® should be evaluated against conventional pain control in an adequately powered multicentre randomised controlled trial.

Pain management associated with arteriovenous fistula cannulation among children undergoing haemodialysis: Systematic review.

Objective: To evaluate studies related to pain management associated with arteriovenous fistula cannulation among children. METHODS: The systematic review comprised literature search on Embase, ProQuest, Science Direct, Scopus, SpringerLink and Wiley Online databases for studies published in English between 1998 and 2021. The search used key words, including pain management OR analgesia AND child OR paediatric AND haemodialysis OR dialysis AND arteriovenous fistula OR arteriovenous fistula cannulation OR fistula needle OR arteriovenous fistula insertion OR needle insertion. The quality of the studies was evaluated using the Joana Briggs Institute checklist. General characteristics of the and pain outcomes were noted. RESULTS: Of the 2,877 studies initially identified, 8(0.27%) were analysed; 7(87.5%) quasi-experimental and 1(12.5%) randomised controlled trial. Overall, there were 283 participants aged 6-18 years. The strategies used for reducing arteriovenous fistula puncture-related pain among children undergoing haemodialysis included cryotherapy, lidocaine agents, virtual reality (VR), guided visualisation, balloon inflation, aromatherapy, and other programmed distractions. The strategies had a positive effect on reducing arteriovenous fistula cannulation-related pain among children. Conclusion: Non-pharmacological pain management is an easier, simpler, inexpensive and more effective method of atraumatic care among children undergoing haemodialysis.

Comparative analysis of artificial intelligence and expert assessments in detecting neonatal procedural pain.

Assessing pain in newborns in the NICU is crucial due to their frequent exposure to painful stimuli, yet it's challenging due to the subjective nature of current methods. This study aimed to evaluate the effectiveness of an AI system designed for automatic facial recognition by comparing its performance with the expert opinion of health care provider. This is a secondary analysis from an eye-tracking study, assessing neonatal pain evaluations by healthcare professionals. The performance of AI software, FaceReader 9, was compared to experts' evaluations using a visual-analog scale, focusing on identifying specific facial action units associated with different pain levels. The study found significant differences in AI-generated metrics-arousal and valence-across three stimulus types: non-noxious thermal, short-noxious, and prolonged-noxious, with p-values below 0.001. A strong correlation (r = 0.84, p ≤ .001) was observed between AI metrics and expert ratings. Eleven facial action units were identified as relevant to describe neonatal pain. The findings highlight the AI system's potential in accurately detecting and analyzing newborn facial expressions in response to varying pain intensities, demonstrating a significant correlation with healthcare professionals' assessments. This suggests that AI technology could enhance objective pain assessment in neonates.

Pediatric Procedural Sedation.

Pediatric procedural sedation (PPS), formerly known as conscious sedation, is often used outside the operating room for various procedures. Twenty years ago, nearly all cases of PPS were performed by pediatric intensivists, dentists, emergency medicine physicians, and anesthesiologists, due to the urgent nature of procedures in their settings. However, with the emergence of pediatric hospital medicine as a board-certified subspecialty, many children's hospitals have created dedicated PPS teams. These teams, composed of highly trained physicians and ancillary staff, are well-suited for procedures, quality measures, and multidisciplinary care. The wider availability of sedation outside the operating room allows other pediatric subspecialties, such as surgery and oncology, to use PPS in ensuring safe and timely interventions for their patients. This article will cover PPS as an alternative to anesthesia for otherwise healthy children and aim to answer frequent questions that arise regarding medications, risks, and candidacy for PPS. [Pediatr Ann. 2024;53(9):e324-e329.].

Efficacy of music therapy for pain control of extracorporeal shock wave lithotripsy: A meta-analysis of randomized controlled studies.

INTRODUCTION: Music therapy may have some potential in the pain control of extracorporeal shock wave lithotripsy, and this meta-analysis aims to study the analgesic efficacy of music therapy for extracorporeal shock wave lithotripsy. METHODS: We have searched several databases including PubMed, EMbase, Web of Science, EBSCO and Cochrane Library databases, and selected the randomized controlled trials (RCTs) comparing the efficacy of music therapy for pain control of extracorporeal shock wave lithotripsy. This meta-analysis was conducted using the random-effect or fixed-effect model based on the heterogeneity. RESULTS: Ten RCTs and 879 patients were included in this meta-analysis. Compared with routine care for extracorporeal shockwave lithotripsy, music therapy was associated with substantially reduced pain scores (standard mean difference [SMD] = -1.00; 95% CI = -1.57 to -0.42; P = .0007), improved patient satisfaction (SMD = 1.61; 95% CI = 0.45 to 2.77; P = .006) and willingness to repeat (SMD = 2.06; 95% CI = 0.40 to 3.72; P = .01), but had no influence on analgesic consumption (SMD = -3.11; 95% CI = -7.07 to 0.85; P = .12) or adverse events (OR = 1.66; 95% CI = 0.20 to 14.10; P = .64). CONCLUSIONS: Music therapy was effective to control the pain of extracorporeal shock wave lithotripsy.

[Virtual reality in the outpatient: reducing anxiety and fear in venous puncture]. / Realidad virtual en el paciente ambulatorio: reduciendo la ansiedad y el miedo en la punción de vías venosas.

Up to 80% of children admitted to a hospital experience pain, mainly associated with venipuncture. OBJECTIVE: To analyze whether the use of virtual reality (VR) headsets during venipuncture can modify the perception of pain, anxiety, and fear in pediatrics. PATIENTS AND METHOD: Open label, randomized clinical trial. The presence of intellectual, visual, or hearing impairment were considered exclusion criteria. Two anxiety and fear scales were administered before and after the procedure, and the Wong-Baker face pain scale at the end. The following were recorded: number of venipuncture attempts, duration of the procedure, and side effects. RESULTS: 78 patients were included, 38 males and a mean age of 9.63 years. In the intervention group, the mean pain value was 2.87, with a mean difference (MD) of -0.85 compared with the control one (95% confidence interval (CI) -2.02 to 0.33). There was a significant reduction in the level of anxiety and fear, with MDs of -2.59 (95%CI: -3.92 to -1.26) and -0.85 points (95%CI: -1.45 to -0.24), respectively. CONCLUSIONS: the use of VR headsets in venipuncture in hospital daytime care decreases the level of anxiety and fear in children and seems to reduce pain, without adverse effects. The venipuncture procedure has the same success rate and does not increase its duration.

The use of intranasal sufentanil and/or s-ketamine for treatment of procedural pain in children in an ambulatory setting: A retrospective observational study.

BACKGROUND: Minor but painful medical procedures are often handled at the operating room. If safe and effective treatment options are available many procedures may be performed outside of the operating room. OBJECTIVE(S): The objective of this study is to assess the adverse events of intranasal s-ketamine and/or sufentanil alone or as part of a multimodal analgesic regime for medical procedures outside of the operating room. Secondary outcomes included analgesic effect, doses and indications for use. DESIGN: Retrospective observational study. SETTING: Tertiary care paediatric hospital. PATIENTS: Children 1 year up till 18 years. INTERVENTION(S): Intranasal (IN) sufentanil (S), intranasal s-ketamine (K) or the free combination of the two drugs (SK). MAIN OUTCOME MEASURE(S): The frequency of adverse events including serious adverse events reported by intervention. RESULTS: Between 2004 and 2014, 2185 medical procedures were registered, including 652 procedures with IN SK, 1469 procedures with IN S and 64 procedures with IN K. The children's median age was 5.6 years (range 1.0-17.9). Medical procedures with at least one adverse event were 18% with IN SK, 25% with IN K and 18% with IN S. Common adverse events included episodes of vomiting (9%), nausea (8%) and dizziness (3%). In two patients receiving IN S, serious adverse events occurred. One patient had respiratory depression and bronchospasm and another patient with cerebral palsy had a seizure. Both were handled immediately and did not result in any sequelae. The median doses of intranasal sufentanil were 38% lower when combined with s-ketamine (IN SK free combination: sufentanil dose 0.5 µg/kg (range 0.2-1.3) and s-ketamine dose 0.5 mg/kg (range 0.2-1.5). IN S monotherapy, sufentanil dose 0.8 µg/kg (range 0.2-2.7)). Similar analgesic effect was reported for S and SK. CONCLUSIONS: Intranasal sufentanil and/or s-ketamine are feasible for the treatment of procedural pain in an ambulatory setting with appropriate per- and post-procedural observations and trained staff.

Effectiveness of pharmacological procedural sedation in children with autism spectrum disorder: A systematic review and meta-analysis.

AIM: Management of primary healthcare and routine minor procedures for children with autism spectrum disorder (ASD) can be challenging; therefore, when behavioural strategies fail, sedative medications are often employed. We evaluated the effectiveness of the current pharmacological strategies for managing children with ASD. METHODS: We performed a systematic review and meta-analysis of the current approaches for procedural sedation in children with ASD. RESULTS: Twenty studies met inclusion criteria. Dexmedetomidine, midazolam, propofol and chloral hydrate were the most efficient agents for successful procedures, while propofol had the highest number of adverse events. The most frequently used agents were dexmedetomidine and midazolam or a combination of the two, and the effectiveness of dexmedetomidine plus midazolam was superior to dexmedetomidine alone. CONCLUSION: Multiple effective drug regimens exist for procedural sedation in children with ASD. These results could support the development of specific guidelines for procedural sedation in children with ASD.

[Effects of enriched environments on behavioral development at toddler period of preterm experienced early repeated procedural pain].

Objective: To investigate the effects of enriched environments on behavioral development at toddler period of preterm who had experienced early repeated operative pain. Methods: A cross-sectional study was conducted. A total of 80 high-risk preterm children of 2 years of age, who had experienced repeated pain stimuli in the neonatal intensive care unit (NICU), were enrolled as preterm group from the High-risk Children Clinic of Children's Hospital of Nanjing Medical University from October 2016 to March 2021. Furthermore, 39 full-term healthy children, aged 2 years, who were undergoing routine check-ups during the same period, were selected as the full-term group. The preterm group was further divided into preterm intervention group and preterm non-intervention group based on the implementation of enriched environment interventions. Data of neonatal characteristics from 3 groups were collected. Growth and development indicators at the age of 2 years were measured. Neuropsychological development evaluated by Gesell developmental scale. Behavioral development evaluated by child behavior check list. The salivary cortisol levels in response to novelty (baseline, task, end) were collected. The family environment, including maternal parenting pressure, were evaluated through a survey questionnaire. One-way ANOVA and least significant difference (LSD) tests were used to compare physical development, maternal parenting stress, Gesell neuropsychological development, and behavioral problems among the 3 groups. A repeated-ANOVA and LSD tests were employed to compare the patterns of salivary cortisol secretion. Pearson correlation analysis was used to explore the influencing factors related to neuropsychological and behavioral development and cortisol level. Results: There were 44 cases in the preterm intervention group (17 males, gestational age of (31.3±2.8) weeks), and 36 in the preterm non-intervention group (29 males, gestational age of (32.5±2.6) weeks). The full-term group consisted of 39 children (23 males, gestational age of (39.3±2.1) weeks). At 2 years of age, the height, weight, and head circumference of the preterm intervention group and non-intervention group were all lower than those of the full-term group (all P<0.05).The Gesell developmental schedule showed that the preterm non-intervention group scored all lower in gross motor, fine motor, adaptive, language and personal-social domains compared to the full-term group (91±7 vs. 97±6, 88±9 vs. 94±6, 89±8 vs. 99±8, 84±10 vs. 100±15, 89±7 vs. 95±6), with statistical significance (all P<0.01). The preterm intervention group scored all higher than the preterm non-intervention group in gross motor, fine motor, adaptive and language domains (all P<0.05), with no significant difference compared to the full-term group (all P>0.05). The number of needle painful procedures during hospitalization in NICU of the non-intervention group was negatively correlated to the adaptive development quotient (r=-0.48, P<0.05). Furthermore, the preterm non-intervention group exhibited higher scores in social withdrawal, depression, somatic complaints, aggression, and destructive behaviors compare to the full-term group and preterm intervention group (F=8.07, 5.67, 7.72, 7.90, 7.06; all P<0.05); while the preterm intervention group showed no significant difference compared to full-term group (all P>0.05). Behavioral problems (social withdrawal and depression) in the preterm non-intervention group were positively correlated with maternal parenting stress (r=0.66, 0.50; both P<0.05). In response to novel visual stimuli and cognitive challenges, the preterm non-intervention group had significantly higher salivary cortisol levels compared to the full-term group (P=0.006), which were negatively correlated with the frequency of early painful procedures (r=-0.83, -0.80; both P<0.01). There was no significant difference in cortisol secretion pattern between the intervention group and the full-term group (P=0.772). Conclusion: Enriched environmental interventions can improve neuropsychological development, decrease behavioral problems, and down-regulate consistent high cortisol response to task in preterm infants who have experienced repeated procedural pain in the NICU by the age of 2 years.

Impact of virtual reality on peri-interventional pain, anxiety and distress in a pediatric oncology outpatient clinic: a randomized controlled trial.

PURPOSE: Pain and anxiety-inducing interventions have a major impact on pediatric patients. Pain reduction by virtual reality (VR) during port and vein punctures is well studied. This study investigates peri-interventional reduction of pain, anxiety and distress using VR compared to the standard of care (SOC) in a pediatric oncology outpatient clinic. METHODS: In a randomized, controlled cross-over design, patients aged 6-18 years experience potentially painful interventions accompanied by VR. Observational instruments include NRS, FPS-r, BAADS, mYPAS-SF, PedsQL and SSKJ3-8R. All patients undergo two observations: SOC (A) and VR (B) in a randomized order. In addition, parents and staff are interviewed. Specific conditions for VR in an outpatient clinic setting derived from interprofessional focus group discussion are being explored. RESULTS: Between July 2021 and December 2022 57 eligible patients were included and randomized to the orders A/B (n = 28) and B/A (n = 29). Thirty-eight patients completed both observations. Characteristics in both groups did not differ significantly. More than half of the patients had no previous experience with VR, 5% decided to discontinue VR prematurely. Peri-interventional pain, anxiety and distress were significantly reduced by VR compared with SOC. 71% of patients and 76% of parents perceived punctures with VR to be more relaxed than previous ones. 95% of patients perceived fun with VR goggles. Detailed questionnaires on individual stress and anxiety were returned from 26 of 38 patients. Focus group discussion with staff yielded evidence for successful implementation of VR in an outpatient clinic. CONCLUSIONS: The present study shows that VR can be used for peri-interventional reduction of pain, anxiety, and distress in the special environment of a pediatric outpatient clinic. Specific conditions must be met for successful implementation. Further studies are needed to identify particularly susceptible patients and to illuminate alternatives for distraction that are feasible to implement with limited resources. TRIAL REGISTRATION NUMBER: (ClinicalTrials.gov ID): NCT06235723; 01/02/2024; retrospectively registered. This study adheres to the standard checklist of CONSORT guidelines.

Intranasal midazolam for procedural distress in children in the emergency department: a systematic review and meta-analysis.

OBJECTIVES: Intranasal (IN) midazolam is the most common anxiolytic for children in the emergency department (ED), but evidence of benefit is conflicting. We synthesized the evidence on IN midazolam for procedural distress in children undergoing ED painful procedures. METHODS: We included trials involving painful ED procedures in children 0-18 years involving IN midazolam. Primary outcome was procedural distress. We summarized results using Tricco et al.'s classification of "neutral" (p ≥ 0.05), "favorable," and "unfavorable" (p < 0.05), supporting IN midazolam or comparator, respectively, or "indeterminate" (unable to judge). Where possible, we pooled results using meta-analysis. Methodologic quality of evidence was evaluated using Cochrane Collaboration's risk of bias tool and GRADE system. RESULTS: We included 41 trials (n = 2973 participants). Thirty trials involved intravenous insertion. IN midazolam was superior to placebo (RR = 7.2; 95% CI: 3.43, 15.25; 3 trials; I2 = 0%). However, 56-90% of the IN midazolam group resisted the procedure. Focusing on the three trials that used validated measures, IN midazolam was "neutral" versus IN ketamine and either "neutral" or "unfavorable" versus IN dexmedetomidine. There was no difference in the proportion of children with a satisfactory distress score between IN midazolam and oral midazolam (RR = 1.1; 95% CI: 0.74, 1.73; 2 trials; I2 = 53%), IN ketamine (RR = 1.1; 95% CI: 0.91, 1.25; 6 trials; I2 = 0%), or IN dexmedetomidine (RR = 0.4; 95% CI: 0.17, 1.05; 3 trials; I2 = 84%). Ten trials involved laceration repair. IN midazolam was "favorable" versus placebo; however, both groups scored in the anxious range. There was no difference in distress between IN midazolam and oral midazolam (SMD = 0.01; 95% CI:-0.32, 0.34; 2 trials; I2 = 0%) (Fig. 3E) [64,65]. Using validated instruments, IN midazolam was "unfavorable" versus IN dexmedetomidine but "favorable" versus oral diazepam and placebo. CONCLUSIONS: There is limited methodologically rigorous evidence that IN midazolam is better than placebo for IV insertion and laceration repair. At the doses studied, preliminary evidence suggests that IN dexmedetomidine may be superior to IN midazolam for both IV insertion and laceration repair.

ABSTRAIT: OBJECTIFS: Le midazolam intranasal (IN) est l'anxiolytique le plus courant chez les enfants du service des urgences (DE), mais les preuves des avantages sont contradictoires. Nous avons synthétisé les preuves sur l'IN midazolam pour la détresse procédurale chez les enfants subissant des procédures douloureuses d'urgence. MéTHODES: Nous avons inclus des essais impliquant des procédures douloureuses d'urgence chez les enfants de 0 à 18 ans impliquant IN midazolam. Le résultat principal était la détresse procédurale. Nous avons résumé les résultats en utilisant la classification de Tricco et coll. de « neutre ¼ (p 0,05), « favorable ¼, « défavorable ¼ (p < 0,05), à l'appui du midazolam IN ou du comparateur, respectivement, ou « indéterminé ¼ (incapable de juger). Dans la mesure du possible, nous avons regroupé les résultats en utilisant la méta-analyse. La qualité méthodologique des preuves a été évaluée à l'aide de l'outil de risque de biais de Cochrane Collaboration et du système GRADE. RéSULTATS: Nous avons inclus 41 essais (n = 2973 participants). Trente essais portaient sur l'insertion intraveineuse. L'IN midazolam était supérieur au placebo (RR = 7,2; IC à 95 % : 3,43,15,25; 3 essais; I2 = 0 %). Cependant, 56 à 90 % du groupe IN midazolam a résisté à la procédure. En se concentrant sur les trois essais qui ont utilisé des mesures validées, IN midazolam était « neutre ¼ par rapport à IN kétamine et « neutre ¼ ou « défavorable ¼ par rapport à IN dexmedetomidine. Il n'y avait pas de différence dans la proportion d'enfants ayant un score de détresse satisfaisant entre IN midazolam et midazolam oral (RR = 1,1; IC à 95 % : 0,74,1,73; 2 essais; I2 = 53 %), IN kétamine (RR = 1,1; IC à 95 % : 0,91,1,25; 6 essais; I2 = 0 %) ou IN dexmedetomidine (RR = 0,4; IC à 95 % : 0,17,1,05; 3 essais; I2 = 84 %). Dix essais portaient sur la réparation de la lacération. L'IN midazolam était « favorable ¼ par rapport au placebo, mais les deux groupes ont obtenu des résultats dans la fourchette de l'anxiété. Il n'y avait pas de différence de détresse entre le midazolam IN et le midazolam oral (SMD = 0,01; IC à 95 %:-0,32,0,34; 2 essais; I2 = 0 %) (figure 3E)64,65. À l'aide d'instruments validés, l'IN midazolam était « défavorable ¼ par rapport à l'IN dexmedetomidine, mais « favorable ¼ par rapport au diazépam oral et au placebo. CONCLUSION: Il y a peu de preuves méthodologiques rigoureuses que l'IN midazolam est meilleur que le placebo pour l'insertion IV et la réparation de lacération. Aux doses étudiées, des preuves préliminaires suggèrent que l'IN dexmedetomidine peut être supérieure à l'IN midazolam pour l'insertion IV et la réparation de lacération.

Distracting children with virtual reality during otomicroscopy: A randomised control trial.

OBJECTIVES: Virtual Reality (VR) is a successful distraction method for reducing procedure-related pain in children, though it has never been studied during otomicroscopy. Therefore, we investigated the efficacy of VR as a distraction method during otomicroscopy. METHODS: This Randomised Control Trial (RCT) included 60 children aged 4-15 years. The patients were randomised to receive distraction by VR, tablet, or no distraction. Procedure-related pain was scored by patients and compared with previous examinations. RESULTS: Patients' experience with otomicroscopy was significantly improved with VR compared to tablet (p < 0.05) and no distraction (p < 0.01). Pain scores did not differ significantly between groups. CONCLUSION: VR did not reduce pain scores, but it improved the children's experience with otomicroscopy without causing significant adverse outcomes.

The Effect of Swaddling and Oropharyngeal Colostrum During Endotracheal Suctioning on Procedural Pain and Comfort in Premature Neonates: A Randomized Controlled Trial.

BACKGROUND: Endotracheal suctioning (ES) is a painful procedure frequently performed in the neonatal intensive care unit. This procedure negatively affects the comfort level of premature neonates. PURPOSE: To determine the effect of 2 nonpharmacologic methods, swaddling and the administration of oropharyngeal colostrum, on the pain and comfort levels of preterm neonates during ES. METHODS: This randomized controlled experimental study comprised 48 intubated premature neonates (swaddling group n = 16; oropharyngeal colostrum group n = 16; and control group n = 16) at 26 to 37 weeks of gestation. The neonates were swaddled with a white soft cotton cloth or administered 0.4 mL of oropharyngeal colostrum 2 minutes before ES, according to the group in which they were included. Two observers evaluated the pain levels (Premature Infant Pain Profile-Revize [PIPP-R]) and comfort (Newborn Comfort Behavior Scale [COMFORTneo]) of the infants by observing video recordings of before, during, and after the procedure. FINDINGS/RESULTS: A significantly lower mean PIPP-R score was found in the swaddling group during ES compared with the control group ( P = .002). The mean COMFORTneo scores of the swaddling and oropharyngeal colostrum groups during ES ( P < .01, P = .002) and the mean PIPP-R and COMFORTneo scores immediately after ES and 5, 10, and 15 minutes later were significantly lower than the control group ( P < .005). IMPLICATIONS FOR PRACTICE AND RESEARCH: Swaddling was effective both during and after the procedure, while oropharyngeal colostrum was effective only after the procedure in reducing ES-related pain in premature neonates. Swaddling and oropharyngeal colostrum were effective in increasing comfort both during and after the procedure.

Gel instillation sonohysterography (GIS) using Endosgel versus ExEmgel, comparison of pain and image quality and cost benefit analysis: A double blind randomised controlled trial. GISPAIN trial.

INTRODUCTION: Pain experience, physical reaction, image quality and adverse events during Gel Instillation Sonohysterography (GIS) can differ using gels with different compositions. As a result, patient satisfaction can also be affected. The effect of two instillation gels, Endosgel versus ExEmgel, using both the Visual Analogue Scale (VAS) and a Continuous Pain Score Meter (CPSM) was therefore compared. METHODS: This single centre double blind randomised controlled trial included 80 women planned for outpatient GIS, diagnosed with abnormal intrauterine bleeding or fertility disorders and suspicion on an intrauterine abnormality. Patients were randomly allocated to the instillation of Endosgel containing chlorhexidine or ExEmgel without chlorhexidine. Primary outcome was reported pain during the procedure using VAS. Secondary outcomes included pain score measured using CPSM, satisfaction to the procedure and preference at 3 weeks and 3 months after the procedure and image quality. A cost benefit analysis was also performed. RESULTS: The reported median VAS concerning pain during gel instillation was comparable in the Endosgel and ExEmgel group, 2.50 (IQR 0.00-5.00) and 2.00 (IQR 0.00-5.75) respectively (p = 0.69). The median VAS of the entire procedure was also similar: both 2.00 (IQR 0.00-5.00) (p = 0.86). CPSM-scores were not significantly different either. Both groups were similar in image quality (p = 0.83) and patient's satisfaction (p = 0.36). CONCLUSION: Concerning the pain experienced during a GIS procedure and patients' satisfaction, the ExEmgel was not proven to be superior to the Endosgel. Our advice is to use the gel that is available at the lowest costs, as the image quality is the same for both Endosgel and ExEmgel.

Effectiveness of ShotBlocker application on reducing the pain of needle-related procedures in children: A systematic review and meta-analysis.

PROBLEM: Needle-related procedures are quite common throughout life, especially during childhood. Pain caused by these procedures is the most common complication. ShotBlocker is an alternative non-pharmacological method to reduce pain during injection-related procedures. However, the effectiveness of the ShotBlocker application in children for reducing pain needle-related procedures remains unclear. This review aimed to evaluate the effectiveness of ShotBlocker application on pain during needle-related procedures in children from Randomized Controlled Trials. ELIGIBILITY CRITERIA: Eight electronic databases were searched until November 2023 for articles published in English. The methodological quality and evidence strength were appraised using the Cochrane Risk of Bias 2 tool and the GRADE approach. A random-effects model was used to determine the effect of the ShotBlocker application on pain levels. The review included results involving assessments from the child, parents, and an observer in pain evaluation. SAMPLE: A total of nine studies with 1205 children patients were included. RESULTS: The evaluation data showed that ShotBlocker application significantly reduced the pain caused by needle-related procedures in children. The Cochrane GRADE approach showed moderate level evidence for the effect of ShotBlocker application on pain during needle procedures. CONCLUSIONS: As a result of the studies included in this meta-analysis, it was determined that ShotBlocker application significantly reduced the pain caused by needle-related procedures in children. IMPLICATIONS: ShotBlocker, a non-pharmacological method, can be used by pediatric nurses to reduce pain during needle-related procedures in children. Randomized controlled studies with well-designed methods are needed to create strong evidence in this field.

Optimizing pediatric periprocedural pain management part II-Adjunct therapies to support the use of infiltrative anesthetics.

Pediatric procedure-related pain management is often incompletely understood, inadequately addressed, and critical in influencing a child's lifelong relationship with the larger healthcare community. We present a comprehensive review of infiltrative anesthetics, including a comparison of their mechanisms of action and relative safety and efficacy data to help guide clinical selection. We also describe the multimodal utilization of adjunct therapies-in series and in parallel-to support the optimization of pediatric periprocedural pain management, enhance the patient experience, and provide alternatives to sedation medication and general anesthesia.