Anxiolysis for laceration repair in children: a survey of pediatric emergency providers in Canada

Objectives: Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers’ practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption. Methods: We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics. Results: The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that \u3e 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%). Conclusions: Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit

Pain management practices surrounding lumbar punctures in children: A survey of Canadian emergency physicians.

OBJECTIVES: Lumbar punctures (LPs) are painful for children, and analgesia is recommended by academic societies. However, less than one-third of pediatric emergency physicians (EPs) adhere to recommendations. We assessed the willingness to provide analgesia among pediatric and general EPs and explored patient and provider-specific barriers. METHODS: We surveyed physicians in the Pediatric Emergency Research Canada (PERC) or Canadian Association of Emergency Physicians (CAEP) databases from May 1 to August 1, 2016, regarding hypothetical scenarios for a 3-week-old infant, a 3-year-old child, and a 16-year-old child requiring an LP. The primary outcome was the willingness to provide analgesia. Secondary outcomes included the type of analgesia, reasons for withholding analgesia, and their perceived competence performing LPs. RESULTS: For a 3-week old infant, 123/144 (85.4%) pediatric EPs and 231/262 (88.2%) general EPs reported a willingness to provide analgesia. In contrast, the willingness to provide analgesia was almost universal for a 16-year-old (144/144 [100%] of pediatric EPs and 261/262 [99.6%] of general EPs) and a 3-year-old (142/144 [98.6%] of pediatric EPs and 256/262 [97.7%] of general EPs). For an infant, the most common barrier cited by pediatric EPs was the perception that it produced additional discomfort (13/21, 61.9%). The same reason was cited by general EPs (12/31, 38.7%), along with unfamiliarity surrounding analgesic options (13/31, 41.9%). CONCLUSION: Compared to a preschool child and adolescent, the willingness to provide analgesia for an LP in a young infant is suboptimal among pediatric and general EPs. Misconceptions and the lack of awareness of analgesic options should be targets for practice-changing strategies

Corrigendum: Pain management practices surrounding lumbar punctures in children: A survey of Canadian emergency physicians (Canadian Journal of Emergency Medicine (2018) DOI: 10.1017/cem.2018.382)

In the original publication of this article, Pediatric Emergency Research Canada (PERC) was not listed as an author. The authors regret this error. The original version has been updated

Knowledge, attitudes and practices of Canadian pediatric emergency physicians regarding short-term opioid use: a descriptive, cross-sectional survey

BACKGROUND: In the midst of the current opioid crisis, physicians are caught between balancing children\u27s optimal pain management and the risks of opioid therapy. This study describes pediatric emergency physicians\u27 practice patterns for prescribing, knowledge and attitudes regarding, and perceived barriers to and facilitators of short-term use of opioids. METHODS: We created a survey tool using published methodology guidelines and distributed it from October to December 2017 to all physicians in the Pediatric Emergency Research Canada database using Dillman\u27s tailored design method for mixed-mode surveys. We performed bivariable binomial logistic regressions to ascertain the effects of clinically significant variables (e.g., training, age, sex, degree of worry regarding severe adverse events) on use of opioids as a first-line treatment for moderate pain in the emergency department, and prescription of opioids for moderate or severe pain for at-home use in children. RESULTS: Of the 224 physicians in the database, 136 (60.7%) completed the survey (60/111 [54.1%] women; median age 44 yr). Of the 136, 74 (54.4%) had subspecialty training. Intranasally administered fentanyl was the most commonly selected opioid for first-line treatment of moderate (47 respondents [34.6%]) and severe (82 [60.3%]) pain due to musculoskeletal injury. On a scale of 0 (not worried) to 100 (extremely worried), physicians\u27 median score for worry regarding physical dependence was 6.0 (25th percentile 0.0, 75th percentile 16.0), for worry regarding addiction 10.0 (25th percentile 2.0, 75th percentile 20.0) and for worry regarding diversion of opioids 24.5 (25th percentile 14.0, 75th percentile 52.0). On a scale of 0 (not at all) to 100 (extremely), the median score for influence of the opioid crisis on willingness to prescribe opioids was 22.0 (25th percentile 8.0, 75th percentile 49.0). The top 3 reported barriers to prescribing opioids were parental reluctance (57 [41.9%]), lack of clear guidelines for pediatric opioid use (35 [25.7%]) and concern about adverse effects (33 [24.3%]). Binomial logistic regression did not identify any statistically significant variables affecting use of opioids in the emergency department or prescribed for use at home. INTERPRETATION: Emergency department physicians appeared minimally concerned about physical dependence, addiction risk and the current opioid crisis when prescribing opioids to children. Evidence-based development of guidelines and protocols for use of opioids in children may improve physicians\u27 ability to manage pain in children responsibly and adequately

Oral Morphine Versus Ibuprofen Administered at Home for Postoperative Orthopedic Pain in Children: a Randomized Controlled Trial

BACKGROUND: Oral morphine for postoperative pain after minor pediatric surgery, while increasingly popular, is not supported by evidence. We evaluated whether oral morphine was superior to ibuprofen for at-home management of children\u27s postoperative pain. METHODS: We conducted a randomized superiority trial comparing oral morphine (0.5 mg/kg) with ibuprofen (10 mg/kg) in children 5 to 17 years of age who had undergone minor outpatient orthopedic surgery (June 2013 to September 2016). Participants took up to 8 doses of the intervention drug every 6 hours as needed for pain at home. The primary outcome was pain, according to the Faces Pain Scale - Revised, for the first dose. Secondary outcomes included additional analgesic requirements, adverse effects, unplanned health care visits and pain scores for doses 2 to 8. RESULTS: We analyzed data for 77 participants in each of the morphine and ibuprofen groups. Both interventions decreased pain scores with no difference in efficacy. The median difference in pain score before and after the first dose of medication was 1 (interquartile range 0-1) for both morphine and ibuprofen ( INTERPRETATION: Morphine was not superior to ibuprofen, and both drugs decreased pain with no apparent difference in efficacy. Morphine was associated with significantly more adverse effects, which suggests that ibuprofen is a better first-line option after minor surgery. TRIAL REGISTRATION: ClinicalTrials.gov, no. NCT01686802

Study protocol for two complementary trials of non-steroidal or opioid analgesia use for children aged 6 to 17 years with musculoskeletal injuries (the No OUCH study)

Introduction Musculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children\u27s pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference. Methods and analysis Using a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019. Ethics and dissemination This study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant. Trial registration number NCT03767933, first registered on 07 December 2018

A novel preference-informed complementary trial (PICT) design for clinical trial research influenced by strong patient preferences

Background: Patients and their families often have preferences for medical care that relate to wider considerations beyond the clinical effectiveness of the proposed interventions. Traditionally, these preferences have not been adequately considered in research. Research questions where patients and families have strong preferences may not be appropriate for traditional randomized controlled trials (RCTs) due to threats to internal and external validity, as there may be high levels of drop-out and non-adherence or recruitment of a sample that is not representative of the treatment population. Several preference-informed designs have been developed to address problems with traditional RCTs, but these designs have their own limitations and may not be suitable for many research questions where strong preferences and opinions are present. Methods: In this paper, we propose a novel and innovative preference-informed complementary trial (PICT) design which addresses key weaknesses with both traditional RCTs and available preference-informed designs. In the PICT design, complementary trials would be operated within a single study, and patients and/or families would be given the opportunity to choose between a trial with all treatment options available and a trial with treatment options that exclude the option which is subject to strong preferences. This approach would allow those with strong preferences to take part in research and would improve external validity through recruiting more representative populations and internal validity. Here we discuss the strengths and limitations of the PICT design and considerations for analysis and present a motivating example for the design based on the use of opioids for pain management for children with musculoskeletal injuries. Conclusions: PICTs provide a novel and innovative design for clinical trials with more than two arms, which can address problems with existing preference-informed trial designs and enhance the ability of researchers to reflect shared decision-making in research as well as improving the validity of trials of topics with strong preferences

Bringing It All Together: A Review of the Challenges in Measuring Children’s Satisfaction as a Key Component of Acute Pain Management

In 2008, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) published a consensus statement that recognized the dearth of research surrounding the topic of children’s satisfaction with acute pain management. This review of published literature will summarize what is known about the topic of children’s satisfaction with pain management, identify current gaps in the knowledge, and provide direction for future research in this critical area. Including children in the decision-making process as soon as they are developmentally able is a concept that is the fundamental basis for seeking assent and more active roles within healthcare decisions for children. It is the responsibility of adults to provide them with increasing opportunities for self-evaluation and more independent management of their healthcare, encouraging the development of children into adults. As clinicians and researchers, it is our prerogative to support the maturation of children by building effective methods to communicate their satisfaction with acute pain treatment and healthcare. Children’s satisfaction with acute pain management is not well studied and further research is needed for the development of inclusive, developmentally appropriate measures of satisfaction for our pediatric patients

Longitudinal Assessment of Acute Concussion Outcomes Through SMS Text (ConText Study)

Objective Mild traumatic brain injury (mTBI), or concussion, is a common health problem that has seen a recent increase in US adolescents. This study uses SMS text messaging (a mobile health [mHealth] tool) to report patient symptoms. We aim to better characterize mTBI recovery and hypothesize that this mHealth tool will have high retention rates and correlate with a conventional means of assessing symptoms, the Post-Concussion Symptom Inventory (PCSI). Methods A prospective observational cohort pilot study. Thirty-one pediatric patients with acute mTBI were recruited to characterize their injury and report their symptoms via text messaging. Patients reported symptoms once every 3 days for the first 21 days, then once a week for 6 weeks. Results There was a strong and positive correlation between the PCSI and the mHealth tool (rs = 0.875, P \u3c 0.000, n = 22). Retention was 74% until symptom resolution and 42% until study completion. Patients with balance deficits had a significantly higher somatization score than those with normal balance (6.53 ± 3.25 vs 2.56 ± 2.30, t(22) = 3.211, P \u3c 0.01). Conclusions This pilot study demonstrates that this tool is a valid and easy-to-use method of reporting pediatric mTBI symptoms—it replicates and identifies novel findings. Our results suggest that there may be a relationship between balance and the manifestation of somatic symptoms. Retention rates were lower than predicted, indicating that text messaging may not be the ideal format in this population. Text messaging may still have other applications for short-term communication/symptom measurement