The effectiveness of a medical clowning program on improving emotional status among hospitalized children undergoing cancer treatment: A quasi-experimental study.

PURPOSE: To examine the effectiveness of one-time medical clowning on improving short-term positive emotions among hospitalized children undergoing cancer treatment, and to analyze whether age moderates this effect. DESIGN: In this quasi-experimental research study, we recruited a pooled sample of 96 children who were undergoing cancer treatment in pediatric oncology/hematology wards at three university-affiliated medical centers in Taiwan from June 2018 through April 2020. METHODS: Children's demographic characteristics, symptom distress, quality of life, and pretest emotional status were collected at T1. At T2, we collected only posttest emotional status. We adapted generalized estimating equation models to evaluate the effectiveness of medical clowning on enhancing positive emotions. FINDINGS: Changes in the probabilities of positive emotion were significantly different across groups (51.84% for the experimental group, 15.76% for the control group; Δ = 36.08, p = 0.001), and the change was more than two times larger for the experimental group (effect ratio = 3.28, p < 0.05) than for the control group. When evaluating the moderating effect of age on the intervention, none of the coefficients reached the significant (p < 0.05) levels, suggesting that age may not moderate the intervention effect. CONCLUSION: This study demonstrates the core value of medical clowning in child-friendly health care. Our findings clearly support the benefit of the one-time medical clowning program on enhancing short-term emotional well-being across age groups of children. Medical clowning programs should be strongly encouraged and supported in pediatric oncology wards. CLINICAL RELEVANCE: Medical clowning programs should be widely and continuously implemented in pediatric oncology wards as a routine clinical practice for enhancing emotional well-being among children receiving cancer treatment. Nurses need to be aware of medical clowning's equal effectiveness across age groups, not only or better for younger children.

Visão de familiares sobre o cuidado compartilhado da criança com condição crônica hospitalizada / Visión familiar sobre el cuidado compartido de niños con condición crónica hospitalizada / Family view on the shared care of hospitalized children with chronic condition

Objetivo: compreender a visão dos familiares de criança com condição crônica hospitalizada sobre o cuidado compartilhado com a equipe de enfermagem. Método: estudo transversal, realizado com 231 universitários da área da saúde entre os meses de setembro e outubro de 2020. Aplicou-se o Maslach Burnout Inventory/ Student Survey para avaliar a Síndrome de Burnout e associou-se um questionário para levantamento das variáveis sociodemográficas e acadêmicas. A associação entre variáveis categóricas foi avaliada por meio dos testes Qui-quadrado e Exato de Fisher. Considerou-se nível de significância de 5%. Resultados: identificou-se quatro categorias: Buscando uma definição para cuidado compartilhado; Ajudando e aprendendo durante a hospitalização; Exemplificando as formas de realizar cuidado compartilhado no ambiente hospitalar; Sensações vivenciadas pelos cuidados compartilhados. Considerações Finais: na visão dos cuidadores de crianças em condição crônica, o compartilhamento do cuidado nas hospitalizações é percebido como ajuda dos acompanhantes aos profissionais, e não como parte do cuidado. Foram identificados momentos de troca e aprendizado, porém o cuidado pareceu ser mais compartimentado do que compartilhado.

Objetivo: comprender la visión de los familiares de niños con enfermedades crónicas hospitalizadas sobre la atención compartida con el equipo de enfermería. Método: estudio cualitativo, exploratorio y descriptivo, realizado con diez familiares de niños con enfermedades crónicas hospitalizados en las salas intensivas clínicas, quirúrgicas y pediátricas de un Hospital Universitario de Río de Janeiro, Brasil. La recolección de datos se produjo mediante la aplicación de entrevistas semiestructuradas. Los datos fueron analizados por análisis de contenido. Resultados: se identificaron cuatro categorías: Búsqueda de una definición de atención compartida; Ayudar y aprender durante la hospitalización; Ejemplificar las formas de realizar la atención compartida en el ámbito hospitalario; Sensaciones experimentadas por el cuidado compartido. Consideraciones finales: en opinión de los cuidadores de niños en condiciones crónicas, el reparto de cuidados en las hospitalizaciones se percibe como la ayuda de los acompañantes a los profesionales, y no como parte de los cuidados. Se identificaron momentos de intercambio y aprendizaje, pero el cuidado parecía estar más compartimentado que compartido.

Objective: to understand the view of family members of children with chronic hospitalized conditions about shared care with the nursing team. Method: qualitative, exploratory and descriptive study, conducted with ten relatives of children with chronic conditions hospitalized in the clinical, surgical and pediatric intensive wards of a University Hospital in Rio de Janeiro, Brazil. Data collection occurred through the application of semi-structured interviews. The data were analyzed by content analysis. Results: four categories were identified: Seeking a definition for shared care; Helping and learning during hospitalization; Exemplifying the ways to perform shared care in the hospital environment; Sensations experienced by shared care. Final considerations: in the view of caregivers of children in chronic conditions, the sharing of care in hospitalizations is perceived as the help of companions to professionals, and not as part of care. Moments of exchange and learning were identified, but care seemed to be more compartmentalized than shared.

Intravenous administration of anakinra in children with macrophage activation syndrome.

BACKGROUND: Subcutaneous anakinra is an interleukin-1 inhibitor used to treat juvenile idiopathic arthritis. Recent reports suggest anakinra can be a valuable addition to the treatment of COVID-19 associated cytokine storm syndrome and the related multisystem inflammatory syndrome (MIS-C) in children. Herein, we describe our experience with intravenously administered anakinra. FINDINGS: 19 Patients (9 male) received intravenous (IV) anakinra for treatment of macrophage activation syndrome (MAS) secondary to systemic lupus erythematosus (SLE), systemic JIA (SJIA) or secondary hemophagocytic lymphohistiocytosis (sHLH). In most cases the general trend of the fibrinogen, ferritin, AST, and platelet count (Ravelli criteria) improved after initiation of IV anakinra. There were no reports of anaphylaxis or reactions associated with administration of IV anakinra. CONCLUSION: Intravenous administration of anakinra is an important therapeutic option for critically ill patients with MAS/HLH. It is also beneficial for those with thrombocytopenia, subcutaneous edema, neurological dysfunction, or very young, hospitalized patients who need multiple painful subcutaneous injections.

Objective Sleep Characteristics and Factors Associated With Sleep Duration and Waking During Pediatric Hospitalization.

Importance: Children's sleep may be affected by hospitalization, yet few objective determinations of sleep patterns are reported for children in intensive care or general medicine units. There is limited research on relationships between sleep in hospital and child (eg, age, pain), treatment (eg, medications, nurse presence), or environmental (eg, noise, light, type of unit) factors. Objective: To determine sleep quantity and patterns in hospitalized children and determine factors associated with sleep quantity and nighttime waking for children in hospital. Design, Setting, and Participants: This was a prospective cross-sectional study of children admitted to a general pediatric unit or a pediatric intensive care unit at a pediatric quaternary teaching hospital in Toronto, Ontario, Canada, from October 2007 to July 2008. Participants included children aged 1 to 18 years who were expected to stay in hospital for at least 2 nights. Demographic data, information about the hospital stay and illness, and usual sleep habits were collected. Children wore an actigraph for 1 to 3 consecutive days and nights and completed a sleep diary. Sound and light meters were placed at the bedside. Data analyses took place in April 2009. Main Outcomes and Measures: The primary outcome was the mean number of minutes of child nighttime sleep from 7:30 pm to 7:29 am. Sleep variables were averaged over days and nights recorded (mean [SD] days and nights of wear, 2.54 [0.71]) and examined for associations with sleep quantity and patterns, as well as hazard of waking in the night. Results: Of 124 eligible children approached for inclusion, 69 children consented (35 [51%] female; 20 [29%] aged 1-3 years, 10 [14%] aged 4-7 years, 17 [24%] aged 8-12 years, and 22 [32%] aged 13-18 years; 58 [84%] in the general pediatric unit). Children aged 1 to 3, 4 to 7, 8 to 12, and 13 to 18 years obtained a mean (SD) of 444 (132), 475 (86), 436 (114), and 384 (83) minutes of nighttime sleep, respectively; mean (SD) number of night awakenings was 14 (3), 18 (3), 14 (8), and 12 (6), respectively. Children on general pediatric units slept 258 minutes more per night than children sleeping in the pediatric intensive care unit (95% CI, 165.16-350.56 minutes; P < .001), children admitted for planned surgery slept 123 minutes more than children admitted for exacerbations of chronic illness (95% CI, 49.23-196.01 minutes; P < .01), and children sleeping in rooms with other patients slept 141 minutes fewer than children in private rooms (95% CI, -253.51 to -28.35 minutes; P = .01). Sound events greater than 80 dB were significantly associated with increased risk of instantaneous waking (hazard ratio [HR], 1.35; 95% CI, 1.02-1.80; P = .04), as were light events greater than 150 lux (HR, 1.17; 95% CI, 1.01-1.36; P = .03), receiving a medication that promoted sleep (HR, 1.04; 95% CI, 1.00-1.08; P = .03), and having a nurse in the room for most or all of the night (HR, 1.08; 95% CI, 1.03-1.13; P = .003). Sleeping on the general pediatrics unit was significantly associated with decreased risk of instantaneous waking (HR, 0.81; 95% CI, 0.77-0.85; P < .001), as was being admitted for planned surgery (HR, 0.95; 95% CI, 0.91-0.99; P = .04), receiving a medication that promoted wakefulness (HR, 0.96; 95% CI, 0.93-0.995; P = .02), and sharing a room with another patient (HR, 0.78; 95% CI, 0.72-0.84; P < .001). Conclusions and Relevance: In this cross-sectional study of hospitalized children, children experienced considerable nighttime waking and sleep restriction to levels below national clinical recommendations at a time when they most needed the benefits of sleep. Given light and noise were the greatest contributors to nighttime waking in hospital, clinicians, administrators and hospital design experts should work together for solutions.

Comprensión del trato digno en la hospitalización infantil, según pacientes, padres y profesionales de la salud / Understanding of dignified treatment in child hospitalization, according to patients, parents and health professionals

INTRODUCCIÓN. El trato digno es un concepto de difícil comprensión y con diversas visiones, relevante para entidades nacionales como el MINSAL e internacionales como OMS, como parte de los objetivos de los sistemas de salud. En pediatría resulta un desafío para el entendimiento de las expectativas del paciente. Este estudio busca describir el concepto de trato digno en la hospitalización infantil según padres, pacientes y profesionales de hospitales chilenos. MATERIALES Y MÉTODOS. Estudio cualitativo descriptivo. La muestra incluyó pacientes hospitalizados en unidades de cuidados básicos de establecimientos públicos, de 12 a 15 años, chilenos, a sus padres, enfermeros y pediatras. Se realizaron entrevistas semiestructuradas, análisis de contenido, en base a unidad de análisis "tema". Posteriormente, codificación abierta utilizando software Dedoose®. RESULTADOS. Se logra identificar 8 categorías subyacentes al concepto de trato digno, siendo estas "Resguardo de la intimidad, trato respetuoso, acompañamiento parental, prácticas centradas en la necesidad integral del paciente, comunicación y entrega de información, entorno, equipamiento e infraestructura hospitalaria y autonomía". DISCUSIÓN. Existen elementos transversales del trato digno pediátrico, a pesar de su variabilidad. Los resultados permiten orientar a prestadores de salud hacia un trato digno en pediatría.

INTRODUCTION. Dignified treatment is a concept that is difficult to understand and with different approaches, relevant to national entities such as MINSAL and international entities such as WHO, as part of the objectives of health systems. In pediatrics, it is a challenge to understand patient's expectations. This study seeks to describe the concept of dignified treatment in child hospitalization according to parents, patients and professionals of Chilean hospitals.MATERIALS AND METHODS. Qualitative descriptive study. The sample included patients hospitalized in basic care units of public hospitals, between 12 and 15 years old, Chileans, their parents, nurses and pediatricians. Semi-structured interviews, content analysis, based on the unit of analysis "topic" were conducted. Later, open coding using Dedoose® software.RESULTS. It was possible to identify 8 categories underlying the concept of dignified treatment, these being "Protection of privacy, respectful treatment, parental support, practices focused on the integral need of the patient, communication and delivery of information, environment, equipment and hospital infrastructure autonomy".DISCUSSION. There are cross-cutting elements of dignified pediatric treatment, despite its variability. The results make it possible to guide health providers towards decent treatment in pediatrics.

Percepção da criança hospitalizada acerca do brinquedo terapêutico instrucional na terapia intravenosa / Percepción del niño hospitalizado acerca del juguete terapéutico instructivo en la terapia intravenosa / Perception of the hospitalized child about the instructional therapeutic play in intravenous therapy

Resumo Objetivo analisar a percepção da criança hospitalizada quanto ao uso do brinquedo terapêutico instrucional no preparo para a terapia intravenosa. Método estudo descritivo, com abordagem qualitativa, realizado em um hospital pediátrico público no município de Juazeiro do Norte - Ceará, entre os meses de julho a setembro de 2019. Participaram do estudo 31 crianças em idade pré-escolar e escolar. Os dados foram coletados por meio de uma entrevista semiestruturada e, posteriormente, analisados por meio do software IRAMUTEQ. Resultados diante da percepção das crianças acerca da terapia intravenosa, foi averiguado que elas compreenderam a técnica a partir da utilização do brinquedo terapêutico instrucional. Quando a criança tem a oportunidade de brincar e dramatizar a terapia intravenosa, por meio do brinquedo terapêutico instrucional, a ansiedade, a dor, a angústia, a solidão, o medo e o choro são atenuados. Conclusões e implicações para a prática orientar as crianças quanto à realização da terapia intravenosa favorece sua compreensão quanto aos reais benefícios desta técnica para a sua saúde, possibilitando, ainda, a compreensão do enfermeiro quanto às condições que representam riscos para a criança e intervenha em tempo hábil por meio da utilização de estratégias que favoreçam a recuperação da saúde e a minimização de traumas subsequentes advindos da hospitalização.

Resumen Objetivo Analizar la percepción del niño hospitalizado cuanto al uso del juguete terapéutico instructivo en la preparación para la terapia intravenosa. Método Estudio descriptivo, con enfoque cualitativo, realizado en un hospital pediátrico público de la ciudad de Juazeiro do Norte - Ceará, entre julio y septiembre de 2019. Participaron 31 niños en edad preescolar y escolar. Los datos se recogieron mediante entrevista semiestructurada, posteriormente analizados con el software IRAMUTEQ. Resultados En vista de la percepción de los niños acerca de la terapia intravenosa, se encontró que ellos comprendieron la técnica a partir del uso del juguete terapéutico instructivo. Cuando tienen la oportunidad de jugar y dramatizar la terapia intravenosa, a través del juguete terapéutico instructivo, la ansiedad, el dolor, la angustia, la soledad, el miedo y el llanto son mitigados. Conclusiones e implicaciones para la práctica Orientar a los niños sobre la realización de la terapia intravenosa favorece su comprensión sobre los beneficios reales de esta técnica para su salud, permitiendo además que la enfermera comprenda las condiciones que suponen riesgos para el niño e intervenga de forma oportuna, mediante el uso de estrategias que favorezcan la recuperación de la salud y la minimización de traumas posteriores a la hospitalización.

Abstract Objective to analyze the perception of the hospitalized child regarding the use of the instructional therapeutic play in preparation for intravenous therapy. Method descriptive study, with a qualitative approach, performed in a public pediatric hospital in the city of Juazeiro do Norte - Ceará, between the months of July and September 2019. A total of 31 pre-school and school children participated in the study. The data were collected through a semi-structured interview, and later analyzed through IRAMUTEQ software. Results in view of the children's perception of intravenous therapy, it was found that they understood the technique, from the use of the instructional therapeutic play. When the child has the opportunity to play and dramatize intravenous therapy, through the instructional therapeutic play, the anxiety, the pain, the anguish, the loneliness, the fear and the crying are mitigated. Conclusion and implications for practice Orienting children in the performance of intravenous therapy favors their understanding of the real benefits of this technique for their health, allowing the nurse to understand the conditions that pose risks to the child, and intervene in a timely manner, through the use of strategies that favor the recovery of health and the minimization of subsequent trauma from hospitalization.

Effectiveness of hospital clowns for symptom management in paediatrics: systematic review of randomised and non-randomised controlled trials.

OBJECTIVE: To evaluate evidence from randomised controlled trials and non-randomised controlled trials on the effectiveness of hospital clowns for a range of symptom clusters in children and adolescents admitted to hospital with acute and chronic conditions. DESIGN: Systematic review of randomised and non-randomised controlled trials. DATA SOURCES: Medline, ISI of Knowledge, Cochrane Central Register of Controlled Trials, Science Direct, Scopus, American Psychological Association PsycINFO, Cumulative Index to Nursing and Allied Health Literature, and Latin American and Caribbean Health Sciences Literature. STUDY SELECTION: Randomised and non-randomised controlled trials were peer reviewed using the following eligibility criteria: children and adolescents who were admitted to hospital for acute conditions or chronic disorders, studies comparing use of hospital clowns with standard care, and studies evaluating the effect of hospital clowns on symptom management of inpatient children and adolescents as a primary outcome. DATA EXTRACTION AND SYNTHESIS: Two investigators independently screened studies, extracted data, and appraised the risk of bias. Methodological appraisal was assessed by two investigators independently using the Jadad scale, the revised Cochrane risk-of-bias tool for randomised controlled trials (RoB 2), and the risk of bias in non-randomised studies (ROBINS-I) tool for non-randomised controlled trials. RESULTS: 24 studies (n=1612) met the inclusion criteria for data extraction and analysis. Most studies were randomised controlled trials (n=13). Anxiety was the most frequently analysed symptom (n=13), followed by pain (n=9), psychological and emotional responses and perceived wellbeing (n=4), stress (n=4), cancer related fatigue (n=3), and crying (n=2). Five studies used biomarkers, mainly cortisol, to assess stress or fatigue outcome following hospital clowns. Most of the randomised controlled trials (n=11; 85%) were rated as showing some concerns, and two trials were rated with a high risk of bias. Most non-randomised controlled trials (n=6; 55%) were rated with a moderate risk of bias according to ROBINS-I tool. Studies showed that children and adolescents who were in the presence of hospital clowns, either with or without a parent present, reported significantly less anxiety during a range of medical procedures, as well as improved psychological adjustment (P<0.05). Three studies that evaluated chronic conditions showed favourable results for the intervention of hospital clowns with significant reduction in stress, fatigue, pain, and distress (P<0.05). CONCLUSIONS: These findings suggest that the presence of hospital clowns during medical procedures, induction of anaesthesia in the preoperative room, and as part of routine care for chronic conditions might be a beneficial strategy to manage some symptom clusters. Furthermore, hospital clowns might help improve psychological wellbeing in admitted children and adolescents with acute and chronic disorders, compared with those who received only standard care. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42018107099.

Convivendo com múltiplos sintomas: a experiência de crianças e adolescentes com condição crônica / Living with multiple symptoms: the experience of children and adolescents with chronic condition / Vivir con múltiples síntomas: la experiencia de niños y adolescentes con condición crónica

Objetivo: compreender como é a experiência das crianças/adolescentes de conviver com sintomas de uma condição crônica. Método: abordagem qualitativa, utilizando como referencial a Teoria Fundamentada nos Dados. Os participantes foram 11 crianças e adolescentes de seis a 18 anos incompletos hospitalizados em um hospital estadual universitário. Como instrumentos de coleta de dados, utilizou-se a entrevista semiestruturada e a técnica "draw, write and tell". As entrevistas foram audiogravadas e transcritas, e a análise seguiu os passos do referencial. Resultados: apreendeu-se a categoria "Tendo que conviver com os sintomas", que engloba cinco subcategorias que apresentam sintomas físicos, emocionais e gerais, a convivência com a multiplicidade de sintomas simultâneos e as consequências de se conviver com eles. Conclusão: a convivência com diversos sintomas leva a limitações. A enfermagem precisa favorecer a expressão das vivencias das crianças/adolescentes, minimizando situações de estresse e melhorar o gerenciamento dos sintomas, através do planejamento de estratégias individualizadas.

Objective: to comprehend children's or adolescents' experiences of living with symptoms of a chronic condition. Method: on a qualitative approach, taking Grounded Theory as a frame of reference and 11 children and adolescents aged 6 to 18 years hospitalized in a state university hospital as participants, data were collected by semi-structured interview using the "draw, write, and tell" technique. The interviews were recorded and transcribed, and then analyzed following the steps of Grounded Theory. Results: analysis identified the category "Having to live with symptoms", which comprised 5 subcategories featuring physical, emotional and general symptoms, the experience of living with multiple simultaneous symptoms, and the consequences of living with them. Conclusion: living with several symptoms entails limitations. Nursing needs to favor children's and adolescents' expressions of their experiences in order to minimize stressful situations and improve symptom management by planning individualized strategies.

Objetivo: comprender las experiencias de niños o adolescentes de vivir con síntomas de una enfermedad crónica. Método: con un enfoque cualitativo, tomando como marco de referencia la Teoría Fundamentada y como participantes a 11 niños y adolescentes de 6 a 18 años hospitalizados en un hospital universitario estatal, los datos se recolectaron mediante entrevista semiestructurada utilizando el método "dibujar, escribir y decir "técnica. Las entrevistas fueron grabadas y transcritas, y luego analizadas siguiendo los pasos de Grounded Theory. Resultados: el análisis identificó la categoría "Tener que vivir con síntomas", que comprendía 5 subcategorías que presentaban síntomas físicos, emocionales y generales, la experiencia de vivir con múltiples síntomas simultáneos y las consecuencias de vivir con ellos. Conclusión: vivir con varios síntomas conlleva limitaciones. La enfermería debe favorecer la expresión de las experiencias de los niños y adolescentes para minimizar las situaciones estresantes y mejorar el manejo de los síntomas mediante la planificación de estrategias individualizadas

The Acceptability and Impact of the Xploro Digital Therapeutic Platform to Inform and Prepare Children for Planned Procedures in a Hospital: Before and After Evaluation Study.

BACKGROUND: There is increasing interest in finding novel approaches to improve the preparation of children for hospital procedures such as surgery, x-rays, and blood tests. Well-prepared and informed children have better outcomes (less procedural anxiety and higher satisfaction). A digital therapeutic (DTx) platform (Xploro) was developed with children to provide health information through gamification, serious games, a chatbot, and an augmented reality avatar. OBJECTIVE: This before and after evaluation study aims to assess the acceptability of the Xploro DTx and examine its impact on children and their parent's procedural knowledge, procedural anxiety, and reported experiences when attending a hospital for a planned procedure. METHODS: We used a mixed methods design with quantitative measures and qualitative data collected sequentially from a group of children who received standard hospital information (before group) and a group of children who received the DTx intervention (after group). Participants were children aged between 8 and 14 years and their parents who attended a hospital for a planned clinical procedure at a children's hospital in North West England. Children and their parents completed self-report measures (perceived knowledge, procedural anxiety, procedural satisfaction, and procedural involvement) at baseline, preprocedure, and postprocedure. RESULTS: A total of 80 children (n=40 standard care group and n=40 intervention group) and their parents participated in the study; the children were aged between 8 and 14 years (average 10.4, SD 2.27 years) and were attending a hospital for a range of procedures. The children in the intervention group reported significantly lower levels of procedural anxiety before the procedure than those in the standard group (two-tailed t63.64=2.740; P=.008). The children in the intervention group also felt more involved in their procedure than those in the standard group (t75=-2.238; P=.03). The children in the intervention group also reported significantly higher levels of perceived procedural knowledge preprocedure (t59.98=-4.892; P=.001) than those in the standard group. As for parents, those with access to the Xploro intervention reported significantly lower levels of procedural anxiety preprocedure than those who did not (t68.51=1.985; P=.05). During the semistructured write and tell interviews, children stated that they enjoyed using the intervention, it was fun and easy to use, and they felt that it had positively influenced their experiences of coming to the hospital for a procedure. CONCLUSIONS: This study has shown that the DTx platform, Xploro, has a positive impact on children attending a hospital for a procedure by reducing levels of procedural anxiety. The children and parents in the intervention group described Xploro as improving their experiences and being easy and fun to use.

Effect of a Videoconference-Based Online Group Intervention for Traumatic Stress in Parents of Children With Life-threatening Illness: A Randomized Clinical Trial.

Importance: A substantial proportion of parents whose child is diagnosed with a life-threatening illness experience high levels of distress that can lead to long-term mental health difficulties. This can affect the child's recovery. Objective: To evaluate the efficacy of an acceptance and commitment therapy-based group intervention, delivered using videoconferencing, in reducing posttraumatic stress symptoms (PTSS) in these parents. Design, Setting, and Participants: This study was a randomized clinical trial of an intervention for parents with elevated acute stress symptoms. It was a single-site study conducted in a tertiary pediatric hospital in Australia. Parents of children aged 0 to 18 years admitted for a life-threatening illness or injury to the oncology, cardiology, or pediatric intensive care departments were eligible. Participants were screened for eligibility within the first month after diagnosis or admission and then were randomized to the intervention group or the waiting list control group 4 to 10 months after diagnosis or admission. Recruitment commenced January 2014, and final postintervention follow-up was completed in February 2018. Data analysis was performed from July to September 2018. Interventions: Treatment was a psychological acceptance and commitment therapy-based group therapy program called Take a Breath, which consisted of a 6-session parent-mediated psychological intervention delivered via online videoconferences over the course of 8 weeks. Waiting list control participants received treatment as usual and were offered the intervention 3 months after randomization. Main Outcomes and Measures: The primary outcome was PTSS, as measured by the Posttraumatic Stress Disorder Checklist-Version 5 (total score range, 0-80, with higher scores indicating greater symptom severity). The PTSS was measured both before and immediately after the intervention. Changes in psychological skills taught within the intervention were also evaluated, including acceptance, mindfulness, values-based living, and psychological flexibility. Results: Of 1232 parents who were assessed for eligibility, 313 were randomized; 161 were allocated to the waiting list control group, and 152 were allocated to the intervention group. Of those allocated, 44 parents in the waiting list group and 37 in the intervention group completed the postintervention questionnaire and were analyzed (81 participants total; mean [SD] age, 37.17 [6.43] years). Sixty-five participants (80.2%) were women, 48 participants (59.3%) were married, and 40 participants (49.4%) lived in rural or regional areas, or in a different state. In addition, 24 parents (29.6%) were in the cardiology illness group, 32 parents (39.5%) were in the oncology group, and 25 parents (30.9%) were in the pediatric intensive care unit group. The intervention group demonstrated significantly greater improvements in PTSS compared with the waiting list group (Cohen d = 1.10; 95% CI, 0.61-1.59; P = .03). The mean Posttraumatic Stress Disorder Checklist-Version 5 scores decreased from 31.7 (95% CI, 27.0-36.4) to 26.2 (95% CI, 21.8-30.7) in the waiting list control group and from 23.3 (95% CI, 18.6-28.1) to 17.8 (95% CI, 13.8-21.8) in the intervention group. Conclusions and Relevance: The findings of this study support the use of acceptance and commitment therapy to reduce PTSS in parents of very ill children, regardless of diagnosis. These findings also suggest that a brief, group format using a videoconferencing platform can be used effectively to access hard-to-reach populations, particularly fathers and caregivers living in nonmetropolitan areas. Trial Registration: Australian New Zealand Clinical Trials Registry Identifier: ACTRN12611000090910.

Delirium in hospitalised children.

Delirium is a syndrome characterised by an acute and fluctuating alteration in cognition and awareness. It occurs frequently in children with serious medical illness, and is associated with adverse outcomes such as increased length of hospital stay, duration of mechanical ventilation, hospital costs, and mortality. Delirium-especially the hypoactive subtype-is often overlooked by paediatric practitioners, but can be reduced by mitigating risks and effectively managed if detected early. Non-modifiable risk factors of delirium include young age (age <2 years), cognitive or neurological disabilities, need for invasive mechanical ventilation, severe underlying illness and pre-existing chronic conditions, and poor nutritional status. Routine bedside screening using validated tools can enable early detection of delirium. To reduce delirium in hospitalised children, health-care providers should optimise the hospital environment (eg, by reducing sleep disruption and keeping the child stimulated during the day), improve pain management, and decrease sedation (particularly use of benzodiazepines).

Psycho-art-drama: development and testing a new integrated complementary method of psychiatric treatments for hospitalised children with cancer (a case study).

Objective: Art therapy as a psychotherapy method using art, and psychodrama as a therapeutic method using role play, have different roots, principles, techniques and different effect mechanisms and advantages. Integrated psychotherapies are aimed to maximise each of the component advantages, as well as minimising disadvantages. Therefore, the main objective of this study was to develop a new integrated psychotherapy method, named psycho-art-drama (PAD) for hospitalised children with cancer and testing its effectiveness.Methods: After designing the PAD protocol, five hospitalised children with cancer accompanied with their mothers selected based on inclusion and exclusion criteria to participate in this single-subject study.Results: The results showed that PAD was significantly effective in reducing the bio-psycho-social expressions of incompatibility in the hospital (BPSEIH) in all of the five children.Conclusions: Findings of this study give preliminary support using the PAD model in similar conditions.

Vivências de mães de crianças com câncer em cuidados paliativos mediante diagnóstico, tratamento e apoio familiar / Mothers´ experience of children with cancer under palliative care / Experiencias de madres de niños con cáncer en cuidados paliativos mediante diagnóstico, tratamiento y apoyo familiar

Objetivo: Investigar a vivência de mães de crianças com câncer em cuidados paliativos. Métodos: Trata-se de uma pesquisa de campo de natureza qualitativa realizada em um hospital no estado da Paraíba. A amostra foi composta por 10 mães de crianças com câncer em cuidados paliativos. Para viabilizar a coleta dos dados, foi utilizada entrevista semiestruturada. O material obtido foi analisado por meio da técnica de análise de conteúdo proposta por Bardin. Resultados: Extraíram-se duas categorias temáticas: vivência de mães frente ao diagnóstico e tratamento de criança com câncer; e importância do apoio familiar durante os cuidados à criança hospitalizada com câncer. Conclusão: Mediante o estudo, nota-se que os cuidados paliativos precisam ser inseridos integralmente na assistência às mães de crianças com câncer, haja vista a difícil vivência das genitoras no enfretamento do diagnóstico e tratamento do filho. É, pois, necessário, que os profissionais de saúde criem espaços de diálogos acolhedores

Objective: The study's main purpose has been to investigate the mothers' experiences of bearing-cancer children who were undergoing palliative care concerning the cancer diagnosis, its treatment and family support during hospitalization. Methods: It is a field research with a qualitative approach, which was carried out with 10 (ten) mothers of bearing-cancer children who were undergoing palliative care at a hospital in the Paraíba State. Data collection took place through semi-structured interviews, subsequently, being subjected to the content analysis as proposed by Bardin. Results: After analyzing the empirical material, the following thematic categories were elaborated: Experiences of mothers facing of the diagnosis and treatment of their cancer children undergoing palliative care; Importance of family support during care provision for hospitalized children bearing cancer. Conclusion: Palliative care must be fully integrated with care provision towards cancer children mothers. Furthermore, it is necessary to provide spaces for embracement dialogues by health professionals

Objetivo: Investigar la vivencia de madres de niños con cáncer en cuidados paliativos en cuanto al diagnóstico, tratamiento y apoyo familiar durante la hospitalización. Métodos: investigación exploratoria con abordaje cualitativo, realizada con diez madres de niños con cáncer en cuidados paliativos em un hospital del estado de Paraíba, mediante entrevista semiestructurada y sometida a análisis de contenido propuesto por Bardin. Resultados: se extrajeron dos categorías temáticas: la experiencia de las madres respecto al diagnóstico y tratamiento de un niño con cáncer, destacando el dolor, sufrimiento, angustia ante el diagnóstico del niño; y la importancia del apoyo familiar durante el cuidado de los niños hospitalizados con cáncer, orientado a compartir sentimientos, afrontar condiciones adversas y tomar decisiones difíciles. Conclusión: los cuidados paliativos deben estar plenamente integrados en la atención a las madres de niños con cáncer, y es necessário desarrollar espacios de diálogo de bienvenida por parte de los profesionales de la salud

Meanings assigned by families about children's chronic disease diagnosis / Significados de las familias sobre el diagnóstico de enfermedad crónica en los niños / Significados atribuídos por familiares acerca do diagnóstico de doença crônica na criança

ABSTRACT Objectives: to understand the meanings assigned by family caregivers about children's chronic disease diagnosis. Methods: qualitative study, which used as theoretical framework the Symbolic Interactionism, and methodological, the Grounded Theory. It was held in a pediatric unit in Southern Brazil, in 2016, through interviews submitted to open and axial analysis, with the participation of 20 family caregivers of hospitalized children. Results: relatives, interacting with the nursing/health staff, perceive children's disease at birth. They are diagnosed with chronic disease by the physician and deny it. Subsequently, they accept and seek information on care. Conclusions: the results pointed out the stages that relatives experience by assigning meanings to about children's chronic disease diagnosis. These meanings provide subsidies for nurses' actions, which need to be aware of children's and family's needs in order to offer comprehensive and humanized care.

RESUMEN Objetivos: comprender los significados atribuidos por los cuidadores familiares sobre el diagnóstico de enfermedades crónicas en los niños. Métodos: estudio cualitativo, que utilizó como referencia teórica el interaccionismo simbólico, y metodológico, la Teoría Basada en Datos. Se llevó a cabo en una unidad pediátrica en el sur de Brasil, en 2016, a través de entrevistas sometidas a análisis abiertos y axiales, con la participación de 20 cuidadores familiares de niños hospitalizados. Resultados: los miembros de la familia, cuando interactúan con el equipo de enfermería / salud, perciben la enfermedad del niño al nacer. El médico les diagnostica una enfermedad crónica y lo niegan. Más tarde, lo aceptan y buscan información para recibir atención. Conclusiones: los resultados señalaron las etapas que experimentan los miembros de la familia, atribuyendo significados al diagnóstico de enfermedades crónicas en los niños. Estos significados brindan subsidios para las acciones de las enfermeras, que deben ser conscientes de las necesidades del niño y la familia, a fin de ofrecer una atención integral y humanizada.

RESUMO Objetivos: compreender os significados atribuídos por familiares cuidadores acerca do diagnóstico de doença crônica na criança. Métodos: estudo qualitativo, que utilizou como referencial teórico o Interacionismo Simbólico, e metodológico, a Teoria Fundamentada nos Dados. Realizou-se em uma unidade pediátrica no Sul do Brasil, em 2016, mediante entrevistas submetidas à análise aberta e axial, com a participação de 20 familiares cuidadores de crianças internadas. Resultados: familiares, ao interagirem com a equipe de enfermagem/saúde, percebem a doença da criança ao nascimento. Recebem o diagnóstico de doença crônica pelo médico e o nega. Posteriormente, o aceita e buscam informações para o cuidado. Conclusões: os resultados apontaram os estágios que os familiares vivenciam, ao atribuir significados ao diagnóstico de doença crônica na criança. Esses significados fornecem subsídios para a atuação do enfermeiro, que precisa estar atento às necessidades da criança e da família, tendo em vista o oferecimento de uma assistência integral e humanizada.

Patient safety: perception of family members of hospitalized children / Seguridad del paciente: percepción de la familia del niño hospitalizado / Segurança do paciente: percepção da família da criança hospitalizada

ABSTRACT Objectives: to know the meaning attributed by family members to the health safety of pediatric patients, with attention to the possibilities of their collaboration. Methods: this qualitative study was conducted with eighteen family members of children hospitalized in a pediatric unit, from January to July 2018. Symbolic Interactionism was used as a theoretical framework, and Inductive Content Analysis as method. Results: child hospitalization poses risks to possible incidents and adverse events. Participants and professionals are responsible for patient safety. Thus, their actions focus on error prevention. Therefore, they seek information and observe in a vigil way professional care in classic aspects of safety. They conceive essential and favoring safety the approach centered on children and family members. Final Considerations: family members recognized the chances of errors and care damage, identified themselves as support in minimizing damage and were in partnership with the professional, increasing chances of effecting safety.

RESUMEN Objetivos: conocer el significado atribuido por los familiares a la seguridad de los pacientes pediátricos, con atención a las posibilidades de su colaboración. Métodos: estudio cualitativo, realizado con dieciocho amiliares de niños hospitalizados en una unidad pediátrica, de enero a julio de 2018. El interaccionismo simbólico se utilizó como marco teórico y el análisis de contenido inductivo como método. Resultados: la hospitalización infantil impone riesgos a posibles incidentes y eventos adversos. Los participantes se identifican como corresponsables de la seguridad del paciente junto con los profesionales. Por lo tanto, sus acciones están dirigidas a prevenir errores y, para eso, buscan información y observan la atención de los profesionales en los aspectos clásicos de la seguridad de manera vigilante. El enfoque centrado en la persona del niño y la familia se considera esencial y promueve la seguridad. Consideraciones Finales: los miembros de la familia reconocieron las posibilidades de errores y daños a la atención, se identificaron como apoyo para minimizarlos y vieron en la asociación con profesionales mayores posibilidades de hacer efectiva la seguridad.

RESUMO Objetivos: conhecer o significado atribuído pelos familiares à segurança do paciente pediátrico, com atenção às possibilidades de sua colaboração. Métodos: estudo qualitativo, realizado com dezoito familiares de crianças internadas em unidade pediátrica, de janeiro a julho de 2018. Utilizou-se o Interacionismo Simbólico como referencial teórico, e a Análise de Conteúdo Indutiva como método. Resultados: a hospitalização infantil impõe riscos a possíveis incidentes e eventos adversos. Os participantes se significam enquanto corresponsáveis pela segurança do paciente juntamente aos profissionais. Assim, suas ações voltam-se à prevenção de erros e, para isso, buscam informações e observam de forma vigil o cuidado dos profissionais em aspectos clássicos da segurança. Abordagem centrada na criança e na família é considerada essencial e favorecedora de segurança. Considerações Finais: os familiares reconheceram chances de erros e danos assistenciais, identificam-se como apoio na minimização destes e veêm na parceria com profisisonais chances ampliadas de efetivar a segurança.

Understanding the dramatic therapeutic play session: a contribution to pediatric nursing / Entender la sesión de juego terapéutico dramático: una contribución a la enfermería pediátrica / Compreendendo a sessão de brinquedo terapêutico dramático: contribuição para a enfermagem pediátrica

ABSTRACT Objectives: to understand how the dramatic therapeutic play session occurs within the care of hospitalized children. Methods: qualitative multiple case study, using theoretical references, such as symbolic interactionism and Vygotsky's theory of symbolic play. Twenty play sessions performed with six children from 3 to 10 years old were analyzed, each corresponding to one case. Results: these sessions demonstrated that a dramatic therapeutic play session is a process of four interdependent and complementary steps: bonding, exploring, dramatizing, and play cessation. They also revealed the imaginary situations externalized by the child, the importance of the exploration step for which they manage the imaginary situation and catharsis, and how her higher psychological faculties are articulated during this process. Final Considerations: the results contribute to the understanding of the conduct and analysis of the dramatic therapeutic play session, reinforcing the importance of its use in pediatric nursing care practice.

RESUMEN Objetivos: comprender cómo se lleva a cabo la sesión de juego terapéutico dramático en el cuidado de niños hospitalizados. Métodos: estudio de caso cualitativo múltiple, con referencias teóricas como el interaccionismo simbólico y la teoría del juego simbólico de Vygotsky. Se analizaron veinte sesiones de juguetes, realizadas con seis niños de 3 a 10 años, cada uno correspondiente a un caso. Resultados: se demostró que la sesión de juego terapéutico dramático es un proceso de cuatro pasos interdependientes y complementarios: vinculación, exploración, dramatización y detenimiento del juego. También revelaron las situaciones imaginarias externalizadas por la niña, la importancia de la etapa de exploración para la que maneja la situación imaginaria y la catarsis, y cómo se articulan sus facultades psicológicas superior durante este proceso. Consideraciones Finales: los resultados contribuyen a la comprensión de la conducta y el análisis de la sesión de juguete terapéutico, lo que refuerza la importancia de su uso en la práctica de cuidados de enfermería pediátrica.

RESUMO Objetivos: compreender como transcorre uma sessão de Brinquedo Terapêutico Dramático na assistência à criança hospitalizada. Métodos: estudo de casos múltiplos, qualitativo, sendo referenciais teóricos o Interacionismo Simbólico e a Teoria de Vygotsky sobre a brincadeira simbólica. Analisaram-se vinte sessões de brinquedo, realizadas com seis crianças de 3 a 10 anos de idade, cada uma correspondendo a um caso. Resultados: mostraram que a sessão de Brinquedo Terapêutico Dramático é um processo de quatro etapas interdependentes e complementares: Estabelecendo vínculo, Explorando, Dramatizando e Parando de brincar. Revelaram, também, as situações imaginárias exteriorizadas pela criança, a importância da etapa da exploração para que ela geste a situação imaginária e ocorra a catarse, e como se articulam suas faculdades psicológicas superiores durante esse processo. Consideraç ões Finais: os resultados trazem contribuição à compreensão da condução e análise da sessão de Brinquedo Terapêutico, reforçando a importância de sua utilização na prática assistencial em enfermagem pediátrica.

Rol de los padres en el cuidado del niño gravemente enfermo. Perspectiva de padres y equipo de enfermería / Role of parents in caring for the seriously ill child. Parent and nursing team perspective

CONTEXTO: Actualmente, el rol que cumplen los padres en el cuidado de sus hijos hospitalizados gravemente enfermos en una Unidad de Paciente Crítico Pediátrico (UPCP), dista mucho de ser definido en nuestro medio. Sin embargo, las últimas recomendaciones incluyen a los padres y familia con un papel protagónico en el cuidado del usuario hospitalizado. OBJETIVO: Explorar las creencias de los padres y las expectativas del equipo de enfermería acerca del rol que debe cumplir un cuidador durante la hospitalización de un niño en la UPCP. MÉTODO: Estudio cualitativo fenomenológico. Se entrevista de forma semiestructurada a padres y/o cuidadores de niños que ingresan a UPCP de Hospital Dr. Luis Calvo Mackenna (HLCM) y a los profesionales del equipo de enfermería de la misma unidad. RESULTADO: Se identifican tres dimensiones a partir de las entrevistas realizadas: Elementos que constituyen el rol de padre y/o cuidador de un niño hospitalizado, patrones de cuidado de un niño hospitalizado y estrategias para incorporar a los padres en el cuidado de sus hijos.

CONTEXT: Actually, the role executed by parents taking care of their very seriously sick children in a Paediatric Intensive Care Unit (PICU), is too far to be defined in our context. However, the last recommendations include the parents and family as the protagonist of caring hospitalised users. OBJECTIVE: To explore the parents' beliefs and health care team expectations related to the role which should execute a carer while a child is hospitalised in a PICU. METHOD: Qualitative Phenomenon study. Parents and carers of children, who are admitted to PICU an Hospital in Santiago, Chile are interviewed in a semi-structured style. Also, the heath care team is interviewed. RESULT: Three dimensions are identified from the done interviews. Constitutive elements of the parent or carer role, caring pattern of a hospitalised child and strategies to incorporate the parents in the care of their children.

A percepção do enfermeiro sobre o brincar e o impacto dessa prática na assistência pediátrica / The nurse's perception of playing and the impact of these practices in pediatric assistance / La percepción del enfermero sobre el brincar y el impacto de esta práctica en la asistencia pediátrica

Objetivo: Conhecer a percepção do enfermeiro sobre o brincar e o impacto dessa prática na assistência pediátrica. Método: Trata-se de uma pesquisa descritiva, exploratória e com abordagem qualitativa. A coleta de dados foi realizada após aprovação do Comitê de Ética em Pesquisa, por meio de uma entrevista semiestruturada, durante o período de maio a agosto de 2017. Resultados: Participaram do estudo 10 enfermeiros. A partir das entrevistas com os profissionais foi possível a apreensão de duas categorias: A percepção do enfermeiro sobre o brincar no processo de recuperação infantil e as dificuldades encontradas pela enfermagem na realização de atividades lúdicas. Conclusão: Diante da amplitude que reveste o cuidado à criança, os profissionais afirmam frequentemente, não possuírem tempo suficiente para desenvolver qualquer atividade lúdica. Ressaltaram, assim, a importância de haver um número adequado de profissionais frente a demanda de trabalho, considerando a complexidade da criança

Objective: To know the nurses' perception about playing and the impact of this practice on pediatric care. Method: This is an exploratory descriptive exploratory qualitative approach. The data collection was done after approval of the Research Ethics Committee, through a semistructured interview, during the period from May to August 2017. Results: Ten nurses participated in the study. From the interviews with the professionals it was possible to apprehend two categories: Nurses' perception about playing in the process of child recovery and difficulties encountered by nursing in performing play activities. Conclusion: Given the breadth of care for the child, professionals often say that they do not have enough time to develop any playful activity. They stressed, therefore, the importance of having an adequate number of professionals against the demand of work, considering the complexity of the child

Objetivo: Conocer la percepción del enfermero sobre el juego y el impacto de esta práctica em la asistencia pediátrica. Método: Se trata de una investigación descriptiva exploratoria y con abordaje cualitativo. La recolección de datos fue realizada después de la aprobación del Comité de Ética em Investigación, a través de una entrevista semiestructurada, durante el período de mayo a agosto de 2017. Resultados: Participaron del estudio 10 enfermeros. A partir de las entrevistas com los profesionales fue posible la aprehensión de dos categorías: La percepción del enfermero sobre el jugar en el proceso de recuperación infantil y dificultades encontradas por la enfermería en la realización de actividades lúdicas. Conclusión: Ante la amplitud que reviste el cuidado al niño, los profesionales afirman, frecuentemente, no poseen tiempo suficiente para desarrollar cualquier actividad lúdica. Resaltaron, así, la importancia de haber un número adecuado de profesionales frente a la demanda de trabajo, considerando la complejidad del niño