Behavioral techniques to optimize success of in-office pediatric tympanostomy tube placement without sedation.

OBJECTIVE: Tympanostomy tube insertion is the most common pediatric surgery, but it typically requires general anesthesia. To facilitate in-office tube placement without general anesthesia, two complementary technologies have recently been developed comprising an iontophoresis system for delivering local anesthesia and an integrated tube delivery system. The purpose of this study was to evaluate behavioral support techniques used during a clinical study of the new technology for pediatric in-office tube placement without general anesthesia or physical restraints. METHODS: As part of an IRB-approved, prospective, nine-center clinical study, pediatric patients requiring tube insertion underwent in-office treatment using the new procedure. The behavior management techniques included preparation, distraction, coaching, and reinforcement for cooperation. The entire procedure was videotaped and two independent coders used the validated FLACC (Face, Legs, Activity, Cry, Consolability) scale to code behavioral distress across five procedural phases. RESULTS: Seventy pediatric patients aged 8 months to 17 years (M=7.0 years; 51% female) were enrolled in the study and 68 had video recordings available for analysis. Of the 68 recordings analyzed, 63 patients completed the procedure and had tubes placed without sedation. Mean FLACC scores ranged from 0.05 to 2.38 (M=1.25, SD=0.82) and median FLACC scores ranged from 0 to 1 (Mdn=0, IQR=0.05), which indicate "mild" distress. During iontophoresis, eardrum tap (anesthesia assessment), and tube delivery, older children displayed lower distress and girls had higher FLACC scores during the eardrum tap procedural phase. CONCLUSION: When combined with the evidence-based behavioral techniques, office-based local anesthesia and tube delivery resulted in minimal distress, suggesting that the new procedure may be a viable method of conducting tympanostomy tube placement in children without having to use general anesthesia. Clinicaltrials.gov identifier: NCT01496287.

Children's expectations and memories of acute distress: short- and long-term efficacy of pain management interventions.

OBJECTIVE: To examine the effect of psychologic and pharmacologic interventions on children's expectations and 6-month recollections of painful procedures. METHODS: A repeated measures design allowed examination of 22 fourth graders' expectations, experiences, and memories of distress across three conditions (typical care, distraction, topical anesthetic) for a three-injection vaccination series. All participants were African American and from urban, low-income families. RESULTS: Across conditions, children's expectations of distress were significantly higher than their experience of distress. Distress ratings did not differ among conditions prior to or immediately following the injections; however, children later recalled that the treatment conditions were superior to control for distress relief. Analyses of recall accuracy suggest that the interventions buffered the children from forming negative recollections that occurred with typical care. CONCLUSIONS: Children have negative expectations prior to a procedure despite knowing that a distress management intervention will be employed. However, interventions may thwart the development of negative memories of distress.

The Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF): validation of a rating scale for children's and adults' behaviors during painful medical procedures.

This study evaluated the concurrent and construct validity of the Child-Adult Medical Procedure Interaction Scale-Short Form (CAMPIS-SF), a behavior rating scale of children's acute procedural distress and coping, and the coping promoting behaviors and distress promoting behaviors of their parents and the medical personnel who were present in the medical treatment room. Sixty preschool children undergoing immunizations at a county health department served as subjects. Videotapes of the procedures were scored using three observational measures in addition to the CAMPIS-SF. Also, parent, nurse, and child report measures of child distress, fear, pain, and cooperation were obtained. Results indicated that the validity of the CAMPIS-SF codes of Child Coping, Child Distress, Parent Coping Promoting, Parent Distress Promoting, Nurse Coping Promoting, and Nurse Distress Promoting behaviors was supported by multiple significant correlations with the other measures. The interrater reliability of the 5-point CAMPIS-SF scales was good to excellent. The results emphasize that the CAMPIS-SF scales can be used to monitor not only children's acute procedural distress, but also their coping and the various adults' behaviors that significantly influence children's distress. Further, because of the CAMPIS-SF's ease of use, it is likely that the study of the effects of the social environment on children's distress and coping will be facilitated.

Observational assessment of family functioning at mealtime in preschool children with cystic fibrosis.

OBJECTIVE: To examine functioning during a dinner meal in families of a child with a chronic illness that requires dietary treatment recommendations, as compared to families of a child without a chronic illness. METHODS: Ratings of seven dimensions of family functioning on the McMaster Mealtime Family Interaction Coding System (MICS) were obtained on 29 families of children with CF and 29 families of children with no chronic illness, ages 2 to 6 years, during a videotaped dinner meal at home. RESULTS: Ratings of families with a child with CF were significantly lower than those for families of children without a chronic illness on Overall Family Functioning and five of the six MICS dimensions: Communication, Interpersonal Involvement, Affect Management, Behavior Control, and Role Allocation and approached significance on the Task Accomplishment dimension. The ratings of families of a child with CF were in the "clinically significant" range on all subcales, including Task ACCOMPLISHMENT. CONCLUSIONS: This study suggests that family functioning at mealtimes may be different in families of children with CF in which explicit dietary guidelines exist than in families of children with no illness or dietary guidelines. These results are discussed in terms of global family functioning and treatment approaches to dietary treatment recommendations.

Comparative study of distraction versus topical anesthesia for pediatric pain management during immunizations.

This study compared distraction, an anesthetic (eutectic mixture of local anesthetics [EMLA]), and typical care during pediatric immunizations. Participants were 39 4th graders receiving a 3-injection vaccination series over a 6-month period. Children displayed low distress despite reporting moderate anxiety and pain. Distraction resulted in more nurse coaching and child coping and less child distress than did EMLA or typical care on an observational measure. EMLA did not result in increased child coping or decreased distress. In fact, the nurse coached more, and trends suggested that children coped more with typical care than with EMLA. Whereas participant ratings and heart rate did not differ among conditions, all 3 conditions demonstrated improvements over time with these measures. Satisfaction ratings suggested that children preferred the treatments to typical care, whereas the nurse appreciated aspects of each of the conditions. Finally, distraction was more economical than EMLA.

Nurse coaching and cartoon distraction: an effective and practical intervention to reduce child, parent, and nurse distress during immunizations.

Evaluated a low cost and practical intervention designed to decrease children's, parents', and nurses' distress during children's immunizations. The intervention consisted of children viewing a popular cartoon movie and being coached by nurses and parents to attend to the movie. Ninety-two children, 4-6 years of age, and their parents were alternatively assigned to either a nurse coach intervention, a nurse coach plus train parent and child intervention, or a standard medical care condition. Based on previous findings of generalization of adult behaviors during medical procedures, it was hypothesized that training only the nurses to coach the children would cost-effectively reduce all participants levels of distress. Observational measures and subjective ratings were used to assess the following dependent variables: children's coping, distress, pain, and need for restraint; nurses' and parents' coaching behavior; and parents' and nurses' distress. Results indicate that, in the two intervention conditions, children coped more and were less distressed, nurses and parents exhibited more coping promoting behavior and less distress promoting behavior, and parents and nurses were less distressed than in the control condition. Although neither intervention was superior on any of the variables assessed in the study, nurse coach was markedly more practical and cost-effective. Therefore, nurses' coaching of children to watch cartoon movies has great potential for dissemination in pediatric settings.

The Child-Adult Medical Procedure Interaction Scale-Revised: an assessment of validity.

Investigated the validity of the Child-Adult Medical Procedure Interaction Scale-Revised (CAMPIS-R) using multiple concurrent objective and subjective measures of child distress, approach-avoidance behavior, fear, pain, child cooperation, and parents' perceived ability to help their preschool children during routine immunizations. Parents', staffs', and children's behaviors in the treatment room were videotaped and coded. Results indicate that the validity of the CAMPIS-R codes of Child Coping and Distress, Parent Distress Promoting and Coping Promoting, and Staff Distress Promoting and Coping Promoting behavior were supported, with all significant correlations being in the predicted direction. An unanticipated finding was that the child, parent, and staff Neutral behaviors were inversely related to some measures of distress and positively related to some measures of coping. Interobserver reliability was high for each CAMPIS-R code.