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Distressing Symptoms in Children with Cancer in General; During Needle Procedures in Particular
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Women's and Children's Health, Pediatrics.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The main aims of this thesis were to investigate the effect of distraction, midazolam and morphine on fear, distress, and pain during needle procedures, and to longitudinally describe parents’ perceptions of their children’s symptom burden during and after cancer treatment.

The design in Study I-III was that of a randomized controlled trial (RCT) conducted in a medical setting; Studies II-III were placebo controlled. Study IV has a longitudinal design, and data were collected at three times during treatment and three times after the end of successful treatment. Participants in Study I were children aged 1 to 7 (n=28), in Study II children aged 1 to 19 (n=50), in Study III children aged 1 to 19 (n=50), and in Study IV parents (n=160) of children aged 1 to 19.

Blowing soap bubbles or having a heated pillow reduces children’s fear and distress in connection with needle procedures. Low-dose oral midazolam 0.3mg/kg body weight is effective in reducing fear and distress, especially in younger children. Interestingly, oral morphine at a dose of 0.25mg/kg body weight does not reduce fear, distress or pain.

These studies have evaluated interventions that may be of help for the most frightened children during needle procedures. We suggest that the first-line intervention against procedural fear, distress, and/or pain should be standard care (i.e. EMLA) in addition to distraction interventions when needed, and only when this is insufficient to add pharmacological interventions.

According to parents, feeling drowsy, pain, and lack of energy are initially the most prevalent symptoms in their children, whereas less hair than usual is the most prevalent symptom during treatment. Pain, feeling sad, and nausea are initially the most distressing symptoms. Pain is both prevalent and distressing throughout treatment. The child’s symptom burden, as reported by parents, decreases over time. Information about distressing symptoms and when they can be expected may increase acceptance and adaptation in children and parents during and after cancer treatment.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , p. 59
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 772
Keyword [en]
Childhood cancer, pain, RCT, symptoms
National Category
Pediatrics
Research subject
Pediatrics
Identifiers
URN: urn:nbn:se:uu:diva-172905ISBN: 978-91-554-8358-6 (print)OAI: oai:DiVA.org:uu-172905DiVA: diva2:516011
Public defence
2012-06-02, Rosénsalen, Ingång 95-96 NBV, Akademiska barnsjukhuset, Uppsala, 09:15 (Swedish)
Opponent
Supervisors
Available from: 2012-05-10 Created: 2012-04-17 Last updated: 2012-08-01Bibliographically approved
List of papers
1. Randomized interventions for needle procedures in children with cancer
Open this publication in new window or tab >>Randomized interventions for needle procedures in children with cancer
2009 (English)In: European Journal of Cancer Care, ISSN 0961-5423, E-ISSN 1365-2354, Vol. 18, no 4, p. 358-363Article in journal (Refereed) Published
Abstract [en]

The aim of this study was to examine whether children experience less fear, distress and pain connected to a routine needle insertion in an intravenous port when subjected to an intervention: blowing soap bubbles or having a heated pillow vs. standard care. Twenty-eight children, 2-7 years, cared for at a paediatric oncology unit, undergoing a routine needle insertion in an intravenous port were included consecutively. All children were subjected to two needle insertions; at the first they received standard care, and at the second standard care + a randomized intervention. Parents and nurses assessed children's fear, distress and pain on 0-100 mm visual analogue scales. According to parents' report, children experienced less fear when subjected to intervention vs. standard care reported by parents (P < 0.001). Children also experienced less fear (P < 0.05) and distress (P < 0.05) when subjected to standard care + blowing soap bubbles vs. standard care (n = 14), and less fear when subjected to standard care + heated pillow vs. standard care (P < 0.05). Nurses' reports did not show any differences for standard care + intervention vs. standard care. Blowing soap bubbles or having a heated pillow is more effective than standard care in reducing children's fear and distress in needle procedures, according to parents' report.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-100810 (URN)10.1111/j.1365-2354.2008.00939.x (DOI)000267538700006 ()19040458 (PubMedID)
Note
Published Online: 27 Nov 2008Available from: 2009-04-07 Created: 2009-04-07 Last updated: 2017-12-13Bibliographically approved
2. Low-dose oral midazolam reduces fear and distress during needle procedures in children with cancer
Open this publication in new window or tab >>Low-dose oral midazolam reduces fear and distress during needle procedures in children with cancer
2009 (English)In: Pediatric Blood & Cancer, ISSN 1545-5009, E-ISSN 1545-5017, Vol. 53, no 7, p. 1200-1204Article in journal (Refereed) Published
Abstract [en]

BACKGROUND

Children with cancer often mention needle procedures as the most frightening, distressing, and sometimes painful aspect of the disease and treatment. The aim was to investigate whether children experience less fear, distress, and/or pain according to parents, nurses, and children >or=7 years of age when they receive oral midazolam versus placebo before a needle is inserted in a subcutaneously implanted intravenous port.

PROCEDURE

Fifty children 1-18 years of age who were being treated in a pediatric oncology and hematology setting were included consecutively when undergoing routine needle insertion into an intravenous port. All children were subjected to one needle insertion in this randomized, triple-blind, placebo-controlled study in which orally administered midazolam (n = 24) 0.3 mg/kg body weight (maximum 10 mg) was compared with placebo (n = 26). Parents, nurses, and children >or=7 years reported the patients' fear, distress, and pain on 0-100 mm Visual Analogue Scales.

RESULTS

Fear was lower in the midazolam group according to parents (P = 0.001), nurses (P = 0.001), and children (P = 0.015). Parents and nurses also reported lower distress (P = 0.020 and 0.007, respectively). Post hoc analyses indicated that the effects were more pronounced in younger children (<7 years of age).

CONCLUSION

Low-dose oral midazolam was effective in reducing fear and distress in pediatric oncology patients, especially in younger children, undergoing subcutaneous port needle insertion.

Keyword
Cancer, child, oral midazolam, RCT
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-112942 (URN)10.1002/pbc.22233 (DOI)000271363800006 ()19688837 (PubMedID)
Available from: 2010-01-22 Created: 2010-01-22 Last updated: 2017-12-12Bibliographically approved
3. Effect of morphine in needle procedures in children with cancer
Open this publication in new window or tab >>Effect of morphine in needle procedures in children with cancer
2011 (English)In: European Journal of Pain, ISSN 1090-3801, E-ISSN 1532-2149, Vol. 15, no 10, p. 1056-1060Article in journal (Refereed) Published
Abstract [en]

Background: The aim was to investigate whether children experience less fear, distress, and/or pain when they receive oral morphine vs. placebo before a needle is inserted in a subcutaneously implanted intravenous port when combined with topical anesthesia.

Method: Fifty children 1-18 years of age who were treated in a pediatric oncology and hematology setting were included consecutively when undergoing routine needle insertion into an intravenous port. All children were subjected to one needle insertion following topical anesthetic (EMLA) application in this randomized, triple-blind, placebo-controlled study comparing orally administered morphine (n = 26) 0.25 mg/kg body weight with placebo (n = 24). The patients' fear, distress, and pain were reported by parents, nurses and the children themselves (if >= 7 years of age) on 0-100 mm Visual Analogue Scales. In addition, observational methods were used to measure distress and procedure pain.

Results: No differences between the morphine and the placebo group were found with respect to age, weight, height, physical status, sex, weeks from diagnosis, or weeks from latest needle insertion. According to, parents, nurses, and children, oral morphine at a dose of 0.25 mg/kg body weight did not reduce fear, distress or pain compared with placebo.

Conclusion: We could not reject the null hypothesis that there is no difference between the oral morphine and placebo groups assuming an effect size of 15 mm on VAS. Therefore it seems that oral morphine at 0.25 mg/kg does not give any additional reduction of fear, distress or pain compared with placebo when combined with topical anesthesia in pediatric patients undergoing subcutaneous port needle insertion, and would not be expected to be of any advantage for similar procedures such as venipuncture and venous cannulation when topical anesthesia is used.

Keyword
Child, Cancer, RCT, Oral morphine
National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-162464 (URN)10.1016/j.ejpain.2011.05.010 (DOI)000296723300011 ()
Available from: 2011-12-01 Created: 2011-11-30 Last updated: 2017-12-08Bibliographically approved
4. Parents' Perceptions of Their Child's Symptom Burden During and After Cancer Treatment
Open this publication in new window or tab >>Parents' Perceptions of Their Child's Symptom Burden During and After Cancer Treatment
2013 (English)In: Journal of Pain and Symptom Management, ISSN 0885-3924, E-ISSN 1873-6513, Vol. 46, no 3, p. 366-375Article in journal (Refereed) Published
Abstract [en]

Context

Parents’ perceptions of their child’s symptom burden during and after cancer treatment.

Objectives

The aim is to describe parents’ perceptions of their child’s symptom burden during and after cancer treatment and to investigate whether parents’ perceptions vary with child characteristics and parent gender.

Methods

160 parents (49% fathers) of 89 children answered a modified version of the Memorial Assessment Symptom Scale (MSAS) 10-18 at six assessments from one week after the child’s diagnosis (T1) to 12-18 months after the end of successful treatment (T6).

Results

Feeling drowsy, pain, and lack of energy are initially the most prevalent symptoms, and less hair than usual the most prevalent symptom during treatment. Pain, feeling sad, and nausea are initially the most distressing symptoms. Pain is both prevalent and distressing throughout treatment. The child’s symptom burden decreases over time. There is no difference with regard to reported symptom burden between parents of a daughter or a son, or parents of a child over or under 7 years of age. Mothers’ and fathers’ assessments of the symptom number, total MSAS, and the subscales are associated, but mothers’ assessments are often higher than fathers’.

Conclusion

The prevalence and distress of symptoms and symptom burden decrease over time. However, even though the cancer is cured, feeling sad is reported as being prevalent and psychological distress is an issue. A dialogue between staff and the family about distressing symptoms and when they can be expected may increase acceptance and adaptation in children and parents during the disease trajectory.

National Category
Pediatrics
Identifiers
urn:nbn:se:uu:diva-172337 (URN)10.1016/j.jpainsymman.2012.09.012 (DOI)000324026700006 ()23498966 (PubMedID)
Available from: 2012-04-10 Created: 2012-04-04 Last updated: 2017-12-07Bibliographically approved

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