Can presence of a dog reduce pain and distress in children during venipuncture?

The aim of this study was to investigate the effectiveness of animal-assisted intervention as distraction for reducing children's pain and distress before, during, and after standard blood collection procedure. Fifty children (ages 4-11 years) undergoing venipuncture were randomly assigned to the experimental group (EG; n = 25) or to the control group (CG; n = 25). The blood collection procedure was carried on the children in the EG arm in the presence of a dog, whereas no dog was present when venipuncture was conducted on children in CG. In both cases, parents accompanied the child in the procedure room. Distress experienced by the child was measured with the Amended Observation Scale of Behavioral Distress, while perceived pain was measured with a visual analog scale or the Wong Baker Scale (Faces Scale); levels of cortisol in blood also were analyzed. Parental anxiety during the procedure was measured with State Trait Anxiety Inventory. Children assigned to the EG group reacted with less distress than children in the CG arm. Furthermore, cortisol levels were lower in the EG group compared with the CG group. There were no significant differences in pain ratings and in the level of parental anxiety. It appears that the presence of dogs during blood draw procedures reduces distress in children.

Parental presence, clowns or sedative premedication to treat preoperative anxiety in children: what could be the most promising option?

BACKGROUND AND OBJECTIVES: A significant number of children undergo surgery experience high levels of anxiety in the presurgical period. The aim of this study is to investigate which intervention is more effective in reducing preoperative anxiety. METHODS/MATERIALS: The sample was composed of 75 subjects (aged 5-12 years) who had to undergo minor day surgery. Children were randomly assigned to: the Clowns group (N = 25) accompanied to the preoperative room by the clowns and by a parent; Premedication group (N = 25) premedicated with oral midazolam and accompanied to the preoperative room by one parent; or the Control group (N = 25) only accompanied by one parent. Anxiety in the preoperative period was measured by using the Modified Yale Preoperative Anxiety Scale (m-YPAS). Parental anxiety was measured by using the State-Trait Anxiety Inventory (STAI Y-1/Y-2). RESULTS: The Clown group was significantly less anxious during the induction of anesthesia compared with Premedication group and Control group. There were not any significant differences between Control group and Premedication group. There was an increased level of anxiety in the induction room in comparison with the waiting room: this difference was statistically significant for Control group and Premedication group, whereas it was not significant in Clown group. CONCLUSIONS: PPIA+clown intervention is more effective in reducing anxiety in children during the preoperative period than PPIA alone or PPIA+oral midazolam.

Use of non-conventional nurses' attire in a paediatric hospital: a quasi-experimental study.

AIMS: To test the impact of a multi-coloured non-conventional attire on a population of children admitted to a paediatric hospital. DESIGN: Quasi-experimental before-after controlled study. BACKGROUND: It has been suggested that non-conventional nurses' uniforms in paediatric settings may contribute to lowering children's distrust towards healthcare providers and reduce fear. Little formal research has investigated on the impact of nursing attire in a paediatric setting. No study has so far analysed the effects in actual use of a non-conventional, other than the traditional type of uniform, on a paediatric hospitalised population. Design: A quasi-experimental study. METHODS: We introduced multi-coloured nurses' attire in two wards of a paediatric hospital. Using open questions and semantic differential scales (SDS), we evaluated the effects of this non-conventional attire on a group of hospitalised children, compared to sex-and-age-matched controls interviewed before the introduction. Parents were also interviewed. RESULTS: One hundred and twelve hospitalised children and their parents (n = 112) were studied. The percentage of positive words used by children to define their nurse was higher in children interviewed after the introduction of non-conventional uniforms (96.2% vs. 81.8%, p = 0.01). Children's perception of nurses was significantly improved by the use of multi-coloured attire ('bad'-'good' SDS: p = 0.01; 'disagreeable'-'nice' SDS: p = 0.001). Children's perceptions regarding hospital environment did not change. Parents' perception of nurses' uniform adequacy to the role and capability to reassure resulted improved (p < 0.0001, p = 0.0003). CONCLUSIONS: Multi-coloured non-conventional attire were preferred by hospitalised children and their parents. Their introduction improved the perception children have of their nurses. Moreover, the coloured uniforms improve the parents perception about the reliability of the nurse. RELEVANCE TO CLINICAL PRACTICE: The use of non-conventional nurses' attire can contribute to improve the child-nurse relation, which has the potential to ease the discomfort experienced by children due to hospitalisation.

Interactive music as a treatment for pain and stress in children during venipuncture: a randomized prospective study.

OBJECTIVE: The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization. Children experience anxiety both before and during the procedure. Therefore, any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure, including waiting, actual preparation, and conclusion. This study was designed to determine whether the presence of musicians, who had attended specific training to work in medical settings, could reduce distress and pain in children undergoing blood tests. METHODS: Our sample population was composed of 108 unpremedicated children (4-13 years of age) undergoing blood tests. They were randomly assigned to a music group (n=54), in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group (n=54), in which only the parent provided support to the child during the procedure. The distress experienced by the child before, during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress, and pain experience with FACES scale (Wong Baker Scale) only after the venipuncture. RESULTS: Our results show that distress and pain intensity was significantly lower (p<.001; p<.05) in the music group compared with the control group before, during, and after blood sampling. CONCLUSIONS: This controlled study demonstrates that songs and music, performed by "professional" musicians, have a beneficial effect in reducing distress before, during, and after blood tests. This study shows, moreover, that the presence of musicians has a minor, but yet significant, effect on pain due to needle insertion.

Perception of venipuncture pain in children suffering from chronic diseases.

BACKGROUND: Venipuncture pain in children results from a variety of co-factors which increase the intensity of the nociceptive stimulus. Among them, anticipatory anxiety plays an important role. Children with chronic diseases undergo invasive procedures and venipuncture more often than other children. Some healthcare professionals still believe that children who are repeatedly exposed to painful procedures, such as children with chronic diseases, gradually increase their pain tolerance and that, as a result, they have a higher pain threshold than children with no chronic diseases. The purpose of this study was to assess whether a difference exists in the perception of venipuncture pain between children with chronic diseases and children with no previous health problems nor experience of venipuncture. METHODS: A cross-sectional study was carried out using the Wong and numeric pain scales and the Observational Scale of Behavioral Distress (OSBD) for the assessment of behavioral distress. A group of children with chronic diseases and a group of children with no previous health problems nor experience of venipuncture, aged 4 to 12 years, both boys and girls, were observed during a standardized venipuncture procedure. RESULTS: The study included 230 children in total: 82 of them suffered from chronic diseases and had already experienced venipuncture at least once, while the remaining 148 children had no previous experience of venipuncture. The children with chronic diseases reported more pain (median pain score of 8 on the Wong or numeric scales,) and showed more signs of behavioral distress (median score of 27 on the OSBD) than non-chronic children (median pain score of 2 on the Wong/numeric scales, p = 0.00001; median OSBD score 5, p = 0.00001). CONCLUSIONS: Our study suggests that children with chronic diseases have a lower pain threshold than children of the same sex and age who experience venipuncture for the first time.

Cross-sectional study on differences in pain perception and behavioral distress during venipuncture between italian and chinese children.

Venipuncture is perhaps the scariest aspect of hospitalization for children as it causes pain and high levels of behavioral distress. Pain is a complex experience which is also influenced by social factors such as cultural attitudes, beliefs and traditions. Studies focusing on ethnic/cultural differences in pain perception and behavioral distress show controversial results, in particular with regards to children. The aim of this paper is to evaluate differences in pain perception and behavioral manifestations between Italian and Chinese children undergoing a venipuncture, through a cross-sectional study. Behavioral distress and self-reported pain were measured in Chinese and Italian outpatient children during a standardized blood-drawing procedure, using the Observational Scale of Behavioral Distress (OSBD) and pain scales. We observed 332 children: 93 Chinese and 239 Italian. Chinese children scored higher than Italians on pain scales - mean scores 5.3 (95%CI 4.78-5.81) vs. 3.2 (95%CI 2.86-3.53) - but lower mean OSBD scores - mean 4.1 (95%CI 3.04-5.15) vs. 8.1 (95%CI 7.06-9.14). Our data suggest that Chinese children experience higher levels of pain than their Italian peers, although they show more self-control in their behavioral reaction to pain when experiencing venipuncture.

Assessing pain in hospital in-patients: a cross-sectional study in Tuscany, Italy.

Guidelines Towards a Pain-Free Hospital, published in 2001 in Italy, determined an increasing spread of No-Pain Hospital Committees across the country and supported a more effective pain control in hospital. However, few hospitals adopted such protocols. To date, a thorough investigation on quality of pain management documentation is lacking. The present survey aimed to evaluate the quality of pain management documentation reported in medical and hospital discharge records. The study reviewed records of 2,459 patients discharged every Wednesday of November 2006 in 29 Tuscany hospitals. Among 2,459 patients, 51.5 % were males. Patients were aged between 0 and 90 years or above and were mostly (24.93 %) between 70 and 79 years; most of them (47.1 %) were hospitalized in Medicine ward. At hospital admission, less than half of examined records (40.3 %) reported pain-related items, and only 8.1 % reported how it was treated. During hospitalization, 39.6 % of the records reported the use of scales for measuring pain intensity and 49.7 % reported the pharmacological therapy. The present study highlights the lack of an exhaustive documentation of pain recording and management in the hospital setting. Therefore, healthcare providers should pay close attention to this relevant issue, and the quality of such documentation should be constantly monitored.

Animal-Assisted Activity at A. Meyer Children's Hospital: A Pilot Study.

The authors systematically studied the introduction of animal-assisted activity into a children's hospital in Italy. This pilot study examined the reactions of children, their parents and the hospital staff and the hospital-wide infection rate before and after the introduction of animals. The SAM (self-assessment manikin), three behavioral scales, analysis of children's graphic productions, a parent questionnaire and a staff questionnaire were used to evaluate the effectiveness of the intervention. The children's participation was calculated. The analysis of the hospital infection rate was completed independently by the Hospital Infections Committee. The authors found that the presence of infections in the wards did not increase and the number of children at the meetings with pets in the wards was high (138 children). The study also found that the presence of animals produced some beneficial effects on children: a better perception of the environment and a good interaction with dogs. All parents were in favor of pets in the hospital, and 94% thought that this activity could benefit the child, as did the medical staff, although the staff needed more information about safety. The introduction of pets into the pediatric wards in an Italian children's hospital was a positive event because of the participation of hospitalized patients, the satisfaction expressed by both parents and medical staff, and the fact that the hospital infection rate did not change and no new infections developed after the introduction of dogs.

Clown doctors as a treatment for preoperative anxiety in children: a randomized, prospective study.

BACKGROUND: The induction of anesthesia is one of the most stressful moments for a child who must undergo surgery: it is estimated that 60% of children suffer anxiety in the preoperative period. Preoperative anxiety is characterized by subjective feelings of tension, apprehension, nervousness, and worry. These reactions reflect the child's fear of separation from parents and home environment, as well as of loss of control, unfamiliar routines, surgical instruments, and hospital procedures. High levels of anxiety have been identified as predictors of postoperative troubles that can persist for 6 months after the procedure. Both behavioral and pharmacologic interventions are available to treat preoperative anxiety in children. OBJECTIVE: The aim of this study was to investigate the effects of the presence of clowns on a child's preoperative anxiety during the induction of anesthesia and on the parent who accompanies him/her until he/she is asleep. METHODS: The sample was composed of 40 subjects (5-12 years of age) who had to undergo minor day surgery and were assigned randomly to the clown group (N = 20), in which the children were accompanied in the preoperative room by the clowns and a parent, or the control group (N = 20), in which the children were accompanied by only 1 of his/her parents. The anxiety of the children in the preoperative period was measured through the Modified Yale Preoperative Anxiety Scale instrument (observational behavioral checklist to measure the state anxiety of young children), and the anxiety of the parents was measured with the State-Trait Anxiety Inventory (Y-1/Y-2) instrument (self-report anxiety behavioral instrument that measures trait/baseline and state/situational anxiety in adults). In addition, a questionnaire for health professionals was developed to obtain their opinion about the presence of clowns during the induction of anesthesia, and a self-evaluation form was developed to be filled out by the clowns themselves about their interactions with the child. RESULTS: The clown group was significantly less anxious during the induction of anesthesia compared with the control group. In the control group there was an increased level of anxiety in the induction room in comparison to in the waiting room; in the clown group anxiety was not significantly different in the 2 locations. The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of the staff was opposed to continuing the program because of perceived interference with the procedures of the operating room. The correlation between the scores of the form to self-evaluate the effectiveness of the clowns and of the Modified Yale Preoperative Anxiety Scale is significant for both the waiting room and induction room. CONCLUSIONS: This study shows that the presence of clowns during the induction of anesthesia, together with the child's parents, was an effective intervention for managing children's and parents' anxiety during the preoperative period. We would encourage the promotion of this form of distraction therapy in the treatment of children requiring surgery, but the resistance of medical personnel make it very difficult to insert this program in the activity of the operating room.

Painful procedures in children with cancer: comparison of moderate sedation and general anesthesia for lumbar puncture and bone marrow aspiration.

BACKGROUND: The study was conducted to compare moderate sedation (MS) with general anesthesia (GA) in the management of frequently performed lumbar puncture or bone marrow aspiration (BMA) during the treatment of childhood cancer. PROCEDURE: The MS (14 patients for 30 procedures) was managed by non-anesthesiologists (combined nitrous oxide-midazolam +/- non-pharmacological techniques). The GA was managed by anesthesiologists (17 patients for 30 procedures). A neutral observer recorded side effects, use of sedative antagonists, recovery time, oncologist's evaluation, procedure behaviors check list (PBCL); subjective perceptions during the procedure with a questionnaire administered to children (>6 years) and their parents; drugs costs and professional resources. P-values <0.05 were considered significant. RESULTS: We had two inadequate sedations in MS (6.6%) versus 0 in GA. We had no significant differences in side effects (7.10% MS vs. 8.6% in GA), use of antagonists (2.90% GA vs. 0 MS), PBCL, oncologist evaluation and questionnaire data or drugs costs. We observed significant differences in recovery times (MS, mean 43 +/- SD min vs. GA, mean 117 +/- SD min) and professional resources costs. The effects of non-pharmacological techniques on anxiety were perceived very positively by both children and parents (on 0-4 scale, mean scores 3.57 for the children; 3.53 for the parents). CONCLUSIONS: Our study suggests that MS compared favorably to GA with respect to both safety and efficacy. When performed by non-anesthesiologists, MS may be associated with better compliance and cost-effectiveness as it relies on the contribution of non-pharmacological techniques.

Anaesthesia induction in children: a psychological evaluation of the efficiency of parents' presence.

BACKGROUND: The induction of anaesthesia for surgery is a stressful time for both child and parents. To treat preoperative anxiety in children, pharmacological methods (premedication) and behavioural methods (the presence of parents during the induction of anaesthesia) have been used, both independently and in combination. The purpose of this investigation was to study the effect of both premedication and parental presence on preoperative anxiety in a homogeneous population. METHODS: In this study conducted between January and April 2001 in the Meyer Hospital in Florence (Anaesthesia Department and Surgical Department), we studied 39 Italian speaking children aged 2-14 years who were undergoing minor surgery. Before the surgical intervention the State Trait Anxiety Inventory (STAI) questionnaire and a questionnaire for the social-demographic characteristics were given to the parents. The stress of the children was evaluated during induction of anaesthesia. We also studied behavioural areas of both children and parents with two specific questionnaires administered after the surgery. RESULTS: The STAI scores showed that the mothers had a higher level of anxiety compared with the fathers. The induction of anaesthesia for surgery was a stressful time for 23% of children of our sample. The correlation between stress of the child at induction and state (P = 0.034) and trait (P = 0.049) anxiety of parents was statistically significant. The child's loss of consciousness was for the majority of parents (56%) the moment of greatest stress and 97% of parents did feel useful during the induction of anaesthesia. There was a significant difference, P = 0.032, in the presence or absence of stress depending on whether the mother or father accompanied the child to the operating room. There was no significant difference in the presence of stress between children who did and did not receive premedication. CONCLUSIONS: Maternal presence, compared with the father's presence, is fundamental in helping to overcome anxiety in a child receiving anaesthesia. If the parents are present during the induction, the addition of premedication does not offer further benefit. Parents themselves judged their presence during the induction of anaesthesia in their child as a positive event. We also found a statistical significant correlation between anxiety of the parents with the level of the stress of the child during induction of anaesthesia.