Management of Pediatric Pain and Distress Due to Medical ...

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176 II. CROSS-CUTTING ISSUESment for cooperation (Elliott & Olson, 1983), training parents to coach their childrento use coping behaviors (Blount et aI., 1994), and having nurses prompt children towatch cartoon videos (Cohen et aI., 1997). These CBT procedures led to increased useof coping skills, parents' and medical staff members' coaching the children, and reducedpain and distress. Some investigations that included comparisons with pharmacologicalagents found CBT to be as effective as, or more effective than, such agents as diazepam(Valium) (Jay et aI., 1987) or EMLA cream (discussed later) (Cohen et aI., 1999). Also,the combination of CBT with midazolam (Versed) was better than midazolam alone onsome outcome variables (Kazak et aI., 1996). Powers (1999) concluded that CBT metcriteria to be considered as a "well-established treatment" for procedural pain in childrenand adolescents.The beneficial effects of distraction have also been supported in a meta-analysis(Kleiber & Harper, 1999). Furthermore, in a Cochrane Database review, Uman, Chambers,McGrath, and Kisely (2006) studied psychosocial interventions for 2- to 19-yearoldsundergoing needle procedures. The largest effect sizes for treatment versus controlconditions existed for distraction and multicomponent CBT interventions, with hypnosisbeing promising. Promising evidence was also found for other interventions, includinginformation/preparation procedures and nurse coaching to promote child distraction.It is encouraging that the data converge to support the effectiveness of distractionin particular, as well as multicomponent CBT interventions.Virtual reality (VR) is a novel technique for promoting distraction. VR equipmenttypically consists of a head-mounted visual display with auditory input. In a review,Lange, Williams, and Fulton (2006) concluded that the evidence for the use of VR wasstrongest for burns. As an intervention for the pain caused by treating burn injuries,Hoffman, Doctor, Patterson, Carrougher, and Furness (2000) designed Snow World, inwhich a patient moves through an ice world with a video-game-like atmosphere. Painwas reduced in several studies (see www.hitl.washington.edu/projects/vrpain; Hoffmanet aI., 2000). Some limitations of VR include the cost and technical expertise required;the necessity of proper head orientation, which makes it difficult for patients in pronepositions to use; and possible impaired communication with the patient.Effective Use of Distraction ProceduresRegardless of the techniques for promoting distraction, the stimuli or activity should behighly engaging, should be easily performed, and should require an observable response.Observable responses confirm that the coping behavior is being performed. In addition,prompts by adults can help facilitate children's coping and redirect their attention asneeded away from compelling painful or frightening medical procedures. There is someevidence that coping/distracting activities should be matched to the demands of differentmedical phases (Blount et aI., 1990). For example, in one study, distracting conversationsor toy play helped to lower anticipatory distress, but these techniques werereplaced with prompted use of a party blower during painful LPs (Blount et aI., 1994).Using a party blower is simple, is distracting, and requires less thought by the childthan nonprocedural talk during painful LPs would require. During painful procedures,simple distraction techniques that do not exceed a patient's limited attentional capacityat that time are probably more effective.
11. Management of Pediatric Pain/Distress177HypnosisHypnosis involves a state of increased suggestibility, attention, and relaxation. Althoughthe exact mechanism of its action is not well understood, neuroimaging techniquesshow that hypnosis is associated with activation of brain areas consistent with decreasedarousal, visual imagery, and possible reinterpretation of perceptual experiences (Wood& Bioy, 2008). Hypnosis has been used with children experiencing BMAs (Liossi &Hatira, 2003), fracture pain (Iserson, 1999), and postoperative pain and anxiety (Lambert,1996). Uman and colleagues (2006) found hypnosis to be a promising interventionfor self-reported pain in children and adolescents. However, hypnosis may be lesseffective for children under 5 years of age, and some people are not easily hypnotized(Liossi, White, & Hatira, 2006). Challenges in the area include the lack of agreementover operational definitions of hypnosis, as well as the heterogeneity of techniques thathave been used (hypnotherapy, guided imagery, imagery). Future r~search should establishstandardized treatment manuals and should attempt to understand efficacy as afunction of child age and pain type.Combining Information Provision and Attention ManipulationA revised version of our prescriptive model of medical and coping interventions by phaseof medical procedure (Blount et aI., 2003) is presented in Table 11.1. Information provisionincluding both sensory and procedural components should be presented to bothchild and parent during Phase 1, the time prior to the procedure. Most studies indicatethat preparation should occur about a week to several days before the procedure, atleast for older children (Jaaniste et aI., 2007b; Kain et aI., 1996). This duration mayallow a child to mentally prepare for the event or give time for anxiety to diminish viaprolonged exposure to the information. Preparation is also a time for training parents incoping promoting skills and training children to use coping behaviors before and duringmedical treatments. Home practice can also be incorporated.During Phase 2, the child and parent are in the medical setting anticipating the procedure.Rather than introducing new information or dwelling on the upcoming event,playful nonprocedural activities and conversation should be used. These activities helpto lower the child's fear and anxiety before the procedure, and therefore predisposehim or her to lower distress during the next phase (Blount et aI., 1990). As the procedurebecomes imminent and preprocedural instructions are given (e.g., "Climb on thetable"), parents and staff should continue to provide distracting prompts, albeit allowingfor necessary procedural comments (e.g., "a little stick").Phase 3 includes encounter with the painful procedure. Active coaching shouldcontinue. For less painful procedures, distraction techniques such as a continuation ofPhase 2's use of interactive cartoon viewing (Cohen et aI., 1999) may suffice. For morepainful procedures, such as LPs, prompted use of simple coping behaviors that requirelittle cognitive processing (e.g., deep breathing or use of distracting party blowers) maybe preferable. If so, practice during the preparation phase may be necessary to facilitatea child's performance of the desired behaviors. Alternatively, if a trained therapist isavailable, hypnosis may be used (Uman et aI., 2006).
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