Intrapyloric Botulinum Toxin Injection for Refractory Nausea and Vomiting in Pediatric Patients.

OBJECTIVES: Chronic nausea and vomiting may be associated with gastroparesis or other conditions. Poor mechanistic understanding of symptoms often precludes targeted therapy. Numerous case series suggest that intrapyloric botulinum toxin injection (IPBI) may be beneficial in treating gastroparesis and dyspepsia in children. We hypothesized that nausea, vomiting, and other symptoms, independent of gastroparesis, may improve with IPBI. We sought to identify gastric emptying (GE) and manometric patterns in IPBI responders versus nonresponders. METHODS: Electronic records of 25 pediatric patients who received IPBI for refractory nausea, vomiting, or both were retrospectively reviewed. We assessed symptom improvement post-IPBI and compared symptoms, GE, and antroduodenal manometry (ADM) findings between IPBI responders and nonresponders. RESULTS: At least one major symptom improved in 19 patients (76%) after IPBI. Of 22 patients completing a GE study, 14 had delayed GE with no significant difference between IPBI responders and nonresponders. Of 22 patients who underwent ADM, 18 had normal fasting peristalsis, 5 had postprandial antral hypomotility, 4 had neuropathic findings, and 19 had pylorospasm. IPBI responders, compared to nonresponders, demonstrated higher antral pressures with feeding ( P < 0.0001) and shorter duration of pylorospasm ( P = 0.0036). Antral pressures did not differ significantly with fasting or following motilin agonists. CONCLUSIONS: Our findings suggest that IPBI may have therapeutic benefit in pediatric patients with chronic nausea and/or vomiting, independent of gastroparesis. ADM findings of intact antral peristalsis and elevated antral pressures, in conjunction with efficacy of IPBI, support pyloric non-relaxation as a potential contributor to nausea and/or vomiting in pediatric patients.

Impact of Sleep Disturbance on Fatigue, Nausea, and Pain: Mediating Role of Depressive Symptoms Among Youth With Disorders of Gut-Brain Interaction.

OBJECTIVES: A high degree of sleep disturbance is reported among youth with disorders of gut-brain interaction (DGBIs). Given that sleep quality impacts a range of pediatric health outcomes including somatic sensations (eg, pain) and depressive mood occurs relatively frequently among youth with DGBIs, there is a dire need to disentangle the unique contributions of sleep and depressive mood on the somatic sensations experienced by youth with DGBIs. We aimed to examine whether depressive mood mediates the relations among sleep disturbance and pain intensity, nausea, and fatigue among youth with DGBIs. METHODS: One hundred eighteen patients aged 8-17 years ( Mage = 14.05, SD = 2.88; 70.34% female), 83.05% White/non-Hispanic recruited at a pediatric neurogastroenterology clinic completed measures of sleep disturbance, nausea, fatigue, pain intensity, and depressive mood. Three mediation models examined the effect of sleep disturbance on nausea, fatigue, and pain, with depressive mood as a mediator. RESULTS: Participants reported moderate sleep disturbance. Depressive mood partially mediated the significant, respective relations between greater sleep disturbance and more severe nausea and fatigue. Sleep disturbance was significantly associated with higher pain intensity; however, depressive mood was not a significant mediator of this relation. CONCLUSIONS: Sleep quality is a major concern among youth with DGBIs. Low sleep quality may worsen nausea and fatigue via co-occurring increases in depressive mood symptoms. In contrast, sleep disturbance may directly increase pain, regardless of youths' depressive mood symptoms. Future research should explore these relations through prospective studies leveraging a combination of subjective and objective assessment approaches.

Association of Multimodal Pain Control with Patient-Reported Outcomes in Children Undergoing Surgery.

INTRODUCTION: Our aim was to describe practices in multimodal pain management at US children's hospitals and evaluate the association between non-opioid pain management strategies and pediatric patient-reported outcomes (PROs). METHODS: Data were collected as part of the 18-hospital ENhanced Recovery In CHildren Undergoing Surgery (ENRICH-US) clinical trial. Non-opioid pain management strategies included use of preoperative and postoperative non-opioid analgesics, regional anesthetic blocks, and a biobehavioral intervention. PROs included perioperative nervousness, pain-related functional disability, health-related quality of life (HRQoL). Associations were analyzed using multinomial logistic regression models. RESULTS: Among 186 patients, 62 (33%) received preoperative analgesics, 186 (100%) postoperative analgesics, 81 (44%) regional anesthetic block, and 135 (73%) used a biobehavioral intervention. Patients were less likely to report worsened as compared to stable nervousness following regional anesthetic block (relative risk ratio [RRR]:0.31, 95% confidence interval [CI]:0.11-0.85), use of a biobehavioral technique (RRR:0.26, 95% CI:0.10-0.70), and both in combination (RRR:0.08, 95% CI:0.02-0.34). There were no associations of non-opioid pain control modalities with pain-related functional disability or HRQoL. CONCLUSION: Use of postoperative non-opioid analgesics have been largely adopted, while preoperative non-opioid analgesics and regional anesthetic blocks are used less frequently. Regional anesthetic blocks and biobehavioral interventions may mitigate postoperative nervousness in children. LEVEL OF EVIDENCE: III.

Virtual Reality in the Pediatric Intensive Care Unit: Patient Emotional and Physiologic Responses.

Context: Patients in the Pediatric Intensive Care Unit (PICU) are limited in their ability to engage in developmentally typical activity. Long-term hospitalization, especially with minimal interpersonal engagement, is associated with risk for delirium and delayed recovery. Virtual reality (VR) has growing evidence as a safe, efficacious, and acceptable intervention for pain and distress management in the context of uncomfortable healthcare procedures, and for enhancing engagement in, and improving outcomes of rehabilitation therapy. Hypothesis: Critically ill children may experience high levels of engagement and physiologic effects while engaging with VR. Methods and Models: This cross-sectional study of 3-17-year-old children admitted to a PICU used a VR headset to deliver 360-degree immersive experiences. This study had a mixed-method approach, including standardized behavioral coding, participant and parent surveys, and participant physiologic responses. Investigators noted comments the child made about VR, observed emotional responses, and documented an engagement score. To determine physiologic response to VR, integer heart rate variability (HRVi) was collected 30 min before, during, and 30 min after VR. Results: One hundred fifteen participants were enrolled from 6/18 to 10/19, and they interacted with VR for a median of 10 min (interquartile range 7-17). Most children enjoyed the experience; 83% of participants smiled and 36% laughed while using VR. Seventy-two percent made positive comments while using VR. The strongest age-related pattern regarding comments was that the youngest children were more likely to share the experience with others. Seventy-nine percent of participants were highly engaged with VR. Ninety-two percent of parents reported that VR calmed their child, and 78% of participants felt that VR was calming. HRVi Minimum scores were significantly higher during VR than pre- (p < 0.001) or post-VR (p < 0.001). There was no significant difference between pre-and post-VR (p = 0.387); therefore, children returned to their pre-intervention state following VR. Interpretations and Conclusions: Children admitted to the PICU are highly engaged with and consistently enjoyed using VR. Both participants and parents found VR to be calming, consistent with intra-intervention physiologic improvements in HRVi. VR is an immersive tool that can augment the hospital environment for children.

An Innovative Virtual Reality Experience in the PICU: A Pilot Study.

OBJECTIVES: Patients in the PICU frequently have limitations that impede independent interactions with their environment. Virtual reality is an immersive experience that may improve outcomes in critically ill children. The objective of this study was to assess feasibility and satisfaction with virtual reality. DESIGN: Cross-sectional, single-arm pilot study. SETTING: PICU. PATIENTS: Convenience sample of 3- to 17-year-old patients. INTERVENTIONS: Three-hundred sixty degree immersions were delivered using a simple virtual reality headset and smartphone videos. Each participant was given a choice of developmentally appropriate virtual reality experiences. Following the short (< 15 min) virtual reality experience, participants, and parents completed a brief survey. MEASUREMENTS AND MAIN RESULTS: One-hundred percent of participants enjoyed using virtual reality, and 84% reported preference to use virtual reality for a longer duration. One-hundred percent of parents agreed that their child enjoyed using virtual reality, and 100% enjoyed watching their child use virtual reality. Eighty-two percent of parents reported that virtual reality calmed their child. CONCLUSIONS: Virtual reality is an innovative, easily administered, and enjoyable tool that subjectively calms PICU patients in an otherwise chaotic environment.

A developmental analysis of the factorial validity of the parent-report version of the Adult Responses to Children's Symptoms in children versus adolescents with chronic pain or pain-related chronic illness.

UNLABELLED: The widely used Adult Responses to Children's Symptoms measures parental responses to child symptom complaints among youth aged 7 to 18 years with recurrent/chronic pain. Given developmental differences between children and adolescents and the impact of developmental stage on parenting, the factorial validity of the parent-report version of the Adult Responses to Children's Symptoms with a pain-specific stem was examined separately in 743 parents of 281 children (7-11 years) and 462 adolescents (12-18 years) with chronic pain or pain-related chronic illness. Factor structures of the Adult Responses to Children's Symptoms beyond the original 3-factor model were also examined. Exploratory factor analysis with oblique rotation was conducted on a randomly chosen half of the sample of children and adolescents as well as the 2 groups combined to assess underlying factor structure. Confirmatory factor analysis was conducted on the other randomly chosen half of the sample to cross-validate factor structure revealed by exploratory factor analyses and compare it to other model variants. Poor loading and high cross-loading items were removed. A 4-factor model (Protect, Minimize, Monitor, and Distract) for children and the combined (child and adolescent) sample and a 5-factor model (Protect, Minimize, Monitor, Distract, and Solicitousness) for adolescents was superior to the 3-factor model proposed in previous literature. Future research should examine the validity of derived subscales and developmental differences in their relationships with parent and child functioning. PERSPECTIVE: This article examined developmental differences in the structure of a widely used measure of caregiver responses to chronic pain or pain-related chronic illness in youth. Results suggest that revised structures that differ across developmental groups can be used with youth with a range of clinical pain-related conditions.

Examination of the Factor Structure of the Adolescent Sleep-Wake Scale (ASWS).

This study examined the factor structure of the Adolescent Sleep-Wake Scale (ASWS) among 491 adolescents (12-18 years) with and without pediatric health conditions. Exploratory factor analyses were conducted using iterated principal axis factoring with varimax rotation. Highly cross-loading items were systematically removed and analyses were rerun until a clean solution was attained. The final solution explained 57.1% of the total model variance, including 10 items and three factors: Falling Asleep and Reinitiating Sleep-Revised, returning to Wakefulness-Revised, and Going to Bed-Revised. Internal consistency reliability scores were acceptable to good, with the exception of the Going to Bed-Revised subscale for the healthy sample. Adolescents with chronic pain reported significantly poorer overall sleep quality and more problems in falling asleep, reinitiating sleep, and returning to wakefulness as compared to healthy adolescents, providing preliminary evidence for construct validity of the new factors. The resulting ASWS version is a concise assessment tool with empirically derived, distinct behavioral sleep dimensions that can be used for clinical and research purposes.

Adaptation of Problem-Solving Skills Training (PSST) for Parent Caregivers of Youth with Chronic Pain.

Research on the experience of parents caring for a child with chronic pain indicates that high levels of parental role stress, feelings of frustration over an inability to help, and psychological distress are common. Moreover, parental distress adversely influences child adjustment to chronic pain. Therefore, intervening with parents of youth with chronic pain may, in turn, result in positive outcomes for children in their ability to engage in positive coping strategies, reduce their own distress, and to function competently in their normal daily lives. Our aim was to adapt an intervention, Problem-Solving Skills Training, previously proven effective in reducing parental distress in other pediatric illness conditions to the population of caregivers of youth with chronic pain. In the first phase, the intervention was adapted based on expert review of the literature and review of parent responses on a measure of pain-related family impact. In the second phase, the intervention was tested in a small group of parents to evaluate feasibility, determined by response to treatment content, ratings of acceptability, and ability to enroll and deliver the treatment visits. This phase included piloting the PSST intervention and all outcome measures at pre-treatment and immediately post-treatment. In an exploratory manner we examined change in parent distress and child physical function and depression from pre- to post-treatment. Findings from this feasibility study suggest that PSST can be implemented with parents of youth with chronic pain, and they find the treatment acceptable.

The economic costs of chronic pain among a cohort of treatment-seeking adolescents in the United States.

UNLABELLED: The aim of this study was to assess the economic cost of chronic pain among adolescents receiving interdisciplinary pain treatment. Information was gathered from 149 adolescents (ages 10-17) presenting for evaluation and treatment at interdisciplinary pain clinics in the United States. Parents completed a validated measure of family economic attributes, the Client Service Receipt Inventory, to report on health service use and productivity losses due to their child's chronic pain retrospectively over 12 months. Health care costs were calculated by multiplying reported utilization estimates by unit visit costs from the 2010 Medical Expenditure Panel Survey. The estimated mean and median costs per participant were $11,787 and $6,770, respectively. Costs were concentrated in a small group of participants; the top 5% of those patients incurring the highest costs accounted for 30% of total costs, whereas the lower 75% of participants accounted for only 34% of costs. Total costs to society for adolescents with moderate to severe chronic pain were extrapolated to $19.5 billion annually in the United States. The cost of adolescent chronic pain presents a substantial economic burden to families and society. Future research should focus on predictors of increased health services use and costs in adolescents with chronic pain. PERSPECTIVE: This cost of illness study comprehensively estimates the economic costs of chronic pain in a cohort of treatment-seeking adolescents. The primary driver of costs was direct medical costs followed by productivity losses. Because of its economic impact, policy makers should invest resources in the prevention, diagnosis, and treatment of chronic pediatric pain.

The influence of condition parameters and internalizing symptoms on social outcomes in youth with spina bifida.

OBJECTIVE: To test a model of social competence in youth with spina bifida (SB). Involvement in social activities was expected to mediate associations between SB-related condition parameters (pain, body mass index, and motor function) and social competence. Internalizing symptoms were predicted to amplify the negative impact of condition parameters on social activity involvement. METHODS: 108 youth with SB, their caregivers, peers, and teachers participated in a multimethod study that included cognitive testing, questionnaires, and observational interaction tasks. RESULTS: Social activity involvement partially mediated the relation between pain and lower social competence. Internalizing symptoms had a significant indirect effect on social competence via decreased involvement in social activities. CONCLUSIONS: Pain and internalizing symptoms interfere with social activity involvement, which is, in turn, important for social competence development in youth with SB. Assessing and treating these condition parameters and activity factors may be important areas of focus in clinical practice and research with these youth.

When helping hurts: miscarried helping in families of youth with chronic pain.

OBJECTIVE: To examine "miscarried helping" as a maladaptive dyadic process in families of youth with chronic pain using the Actor-Partner Interdependence Model. METHODS: 210 adolescents with chronic pain (mean = 14.23 years; 73.9% female) and their parents participating in a multicenter study completed measures assessing pain characteristics, miscarried helping, family functioning, parental protectiveness, and child depressive symptoms. RESULTS: Multilevel modeling revealed significant actor effects of miscarried helping on family functioning for both parents and teens, but not partner effects. Individual-level factors, including child pain characteristics, depressive symptoms, and parental protectiveness, uniquely contributed to miscarried helping. CONCLUSIONS: Higher perceptions of miscarried helping contribute to worse family functioning and may be a useful target for psychological intervention in parents of children with chronic pain. Parents who exhibit more protective responses to pain and youth with more depressive symptoms may be at increased risk for a miscarried helping process to develop.

A camp-based psychosocialiIntervention to promote independence and social function in individuals with spina bifida: moderators of treatment effectiveness.

PURPOSE: To replicate and extend O'Mahar and colleagues' (O'Mahar, K., Holmbeck, G. N., Jandasek, B., & Zuckerman, J. [2010]. A camp-based intervention targeting independence among individuals with spina bifida. Journal of Pediatric Psychology, 35, 848-856) findings in a new and larger sample of youth and young adults with spina bifida who participated in a modified camp-based intervention targeting independence and social skills. Moderators of intervention effectiveness and clinical significance were examined. METHOD: In all, 119 campers aged 7-41 years participated in an intervention that included goal setting and interactive workshops. Campers and parents completed measures of campers' goal attainment, independence, and social functioning at preintervention and postintervention; counselors reported on campers' goal attainment daily throughout the intervention. RESULTS: Parents and campers reported improvements in campers' goal attainment, management of health-related self-care, and independence. Although benefits were found for most campers, cognitive functioning and family income moderated some outcomes. Campers who improved most on their social goals perceived the intervention to be more effective. CONCLUSIONS: Further support is provided for the effectiveness of a camp-based intervention targeting independence and social skills for individuals with spina bifida. More attention should be directed toward those with cognitive difficulties and low-income backgrounds.

Mother-adolescent agreement regarding decision-making autonomy: a longitudinal comparison of families of adolescents with and without spina bifida.

OBJECTIVE: Longitudinal comparison of mother and adolescent agreement regarding decision-making autonomy for adolescents with and without spina bifida (SB). METHODS: Forty-two mother-adolescent dyads of adolescents with SB and 55 comparison dyads reported on who was responsible for decision-making across five waves of data collection, beginning at age 8 or 9 years through age 16 or 17 years. RESULTS: The proportion of tasks that dyads agreed were decided by adolescents increased over time for both samples beginning at age 12 or 13 years, but appeared to be delayed by roughly two years for youth with SB and was lower for youth with SB from lower socioeconomic (SES) backgrounds. Mothers and adolescents with low SES demonstrated higher proportions of tasks that dyads agreed were decided by mothers. CONCLUSIONS: SB and low SES are risk factors for lower levels of agreed-upon decision-making autonomy. Future studies should examine how parent-adolescent agreement regarding autonomy relates to psychosocial outcomes.

The impact of family, peer, and school contexts on depressive symptoms in adolescents with spina bifida.

OBJECTIVE: Based on social ecological theory, this study examined the joint relations among adolescents' family, peer, and school contexts and depressive symptoms in youth with spina bifida using cumulative, protective, and specific effects models. METHOD: Sixty families of adolescents with spina bifida and 65 comparison families reported on adolescents' positive experiences within these contexts and on depressive symptoms when youth were 14-15 and 16-17 years old. RESULTS: Adolescents with spina bifida had fewer total positive contexts and less positive experience within peer and school contexts, as compared to typically developing adolescents. Greater total number of positive contexts and higher levels of positive experiences within family and school contexts were associated with fewer depressive symptoms for both groups; peer positive experiences were related to lower depressive symptoms for typically developing adolescents only. CONCLUSION: Adolescents with spina bifida have fewer positive contexts, which may place them at risk for higher levels of depressive symptoms.

Trajectories of psychosocial adjustment in adolescents with spina bifida: a 6-year, four-wave longitudinal follow-up.

OBJECTIVE: As a follow-up to an earlier cross-sectional study (Holmbeck et al., 2003), the current multimethod, multi-informant investigation examined individual growth in psychosocial adjustment across the adolescent transition in 2 samples: young adolescents with spina bifida (SB) and typically developing adolescents (N = 68 in both groups at Time 1). METHOD: Growth curve modeling procedures were used to describe the developmental course of psychosocial adjustment across 4 waves of data collection from ages 8 to 15. Child gender was included in the models as a moderator of associations between illness status and adjustment trajectories. RESULTS AND CONCLUSIONS: Findings revealed that preadolescent differences between groups were maintained for several adjustment variables, indicating that adolescents with SB have enduring academic and attention problems and difficulties with social development (e.g., fewer friends and less influence during family interactions). For other outcomes, trajectories of adjustment levels for adolescents with SB converged on levels observed in comparison adolescents, indicating some areas of resilience. Girls with SB were at risk for increasing levels of social difficulties and negative perceptions of their physical appearance. Clinical implications are discussed.