Andrea Messeri

Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study

Background. The induction of anesthesia is one of the most stressful moments for a child who must undergo surgery: it is estimated that 60% of children suffer anxiety in the preoperative period. Preoperative anxiety is characterized by subjective feelings of tension, apprehension, nervousness, and worry. These reactions reflect the child’s fear of separation from parents and home environment, as well as of loss of control, unfamiliar routines, surgical instruments, and hospital procedures. High levels of anxiety have been identified as predictors of postoperative troubles that can persist for 6 months after the procedure. Both behavioral and pharmacologic interventions are available to treat preoperative anxiety in children. Objective. The aim of this study was to investigate the effects of the presence of clowns on a child’s preoperative anxiety during the induction of anesthesia and on the parent who accompanies him/her until he/she is asleep. Methods. The sample was composed of 40 subjects (5–12 years of age) who had to undergo minor day surgery and were assigned randomly to the clown group (N = 20), in which the children were accompanied in the preoperative room by the clowns and a parent, or the control group (N = 20), in which the children were accompanied by only 1 of his/her parents. The anxiety of the children in the preoperative period was measured through the Modified Yale Preoperative Anxiety Scale instrument (observational behavioral checklist to measure the state anxiety of young children), and the anxiety of the parents was measured with the State-Trait Anxiety Inventory (Y-1/Y-2) instrument (self-report anxiety behavioral instrument that measures trait/baseline and state/situational anxiety in adults). In addition, a questionnaire for health professionals was developed to obtain their opinion about the presence of clowns during the induction of anesthesia, and a self-evaluation form was developed to be filled out by the clowns themselves about their interactions with the child. Results. The clown group was significantly less anxious during the induction of anesthesia compared with the control group. In the control group there was an increased level of anxiety in the induction room in comparison to in the waiting room; in the clown group anxiety was not significantly different in the 2 locations. The questionnaire for health professionals indicated that the clowns were a benefit to the child, but the majority of the staff was opposed to continuing the program because of perceived interference with the procedures of the operating room. The correlation between the scores of the form to self-evaluate the effectiveness of the clowns and of the Modified Yale Preoperative Anxiety Scale is significant for both the waiting room and induction room. Conclusions. This study shows that the presence of clowns during the induction of anesthesia, together with the child’s parents, was an effective intervention for managing children’s and parents’ anxiety during the preoperative period. We would encourage the promotion of this form of distraction therapy in the treatment of children requiring surgery, but the resistance of medical personnel make it very difficult to insert this program in the activity of the operating room.

Interactive Music as a Treatment for Pain and Stress in Children During Venipuncture: A Randomized Prospective Study

Objective: The experience of venipuncture is seen by children as one of the most fearful experiences during hospitalization. Children experience anxiety both before and during the procedure. Therefore, any intervention aiming to prevent or reduce distress should focus on the entire experience of the procedure, including waiting, actual preparation, and conclusion. This study was designed to determine whether the presence of musicians, who had attended specific training to work in medical settings, could reduce distress and pain in children undergoing blood tests. Methods: Our sample population was composed of 108 unpremedicated children (4–13 years of age) undergoing blood tests. They were randomly assigned to a music group (n = 54), in which the child underwent the procedure while interacting with the musicians in the presence of a parent or to a control group (n = 54), in which only the parent provided support to the child during the procedure. The distress experienced by the child before, during and after the blood test was assessed with the Amended Form of the Observation Scale of Behavioral Distress, and pain experience with FACES scale (Wong Baker Scale) only after the venipuncture. Results: Our results show that distress and pain intensity was significantly lower (p < .001; p < .05) in the music group compared with the control group before, during, and after blood sampling. Conclusions: This controlled study demonstrates that songs and music, performed by “professional” musicians, have a beneficial effect in reducing distress before, during, and after blood tests. This study shows, moreover, that the presence of musicians has a minor, but yet significant, effect on pain due to needle insertion.

Animal-Assisted Activity at A. Meyer Children's Hospital: A Pilot Study

The authors systematically studied the introduction of animal-assisted activity into a childrens hospital in Italy. This pilot study examined the reactions of children, their parents and the hospital staff and the hospital-wide infection rate before and after the introduction of animals. The SAM (self-assessment manikin), three behavioral scales, analysis of childrens graphic productions, a parent questionnaire and a staff questionnaire were used to evaluate the effectiveness of the intervention. The childrens participation was calculated. The analysis of the hospital infection rate was completed independently by the Hospital Infections Committee. The authors found that the presence of infections in the wards did not increase and the number of children at the meetings with pets in the wards was high (138 children). The study also found that the presence of animals produced some beneficial effects on children: a better perception of the environment and a good interaction with dogs. All parents were in favor of pets in the hospital, and 94% thought that this activity could benefit the child, as did the medical staff, although the staff needed more information about safety. The introduction of pets into the pediatric wards in an Italian childrens hospital was a positive event because of the participation of hospitalized patients, the satisfaction expressed by both parents and medical staff, and the fact that the hospital infection rate did not change and no new infections developed after the introduction of dogs.

End‐of‐life decisions in pediatric intensive care. Recommendations of the Italian Society of Neonatal and Pediatric Anesthesia and Intensive Care (SARNePI)

End‐of‐life decisions represent one of the most complex and challenging issues in pediatric intensive care. These recommendations aim to offer Italian pediatric intensive care unit (PICU) teams a framework for the end‐of‐life decision‐making process. The paper proposes a process based on the principle that the use of a diagnostic or therapeutic tool must comply with a ‘criterion of proportionality’. Appropriately informed parents, as natural interpreters and advocates of the best interests of their child, can contribute in assessing the burdensomeness of the treatment and determining its proportionality. The decision to limit, withdraw or withhold life‐sustaining treatments considered disproportionate represents a clinically and ethically correct choice. This decision should be made (a) collectively by PICU team and the other caregivers, (b) with the explicit involvement of parents, and (c) noting in the patients clinical record the decisions taken and the reasons behind them. The withdrawing or withholding of life support can never entail the abandonment of the patient nor the withdrawal of any therapy aimed at treating any form of suffering. No action aimed at deliberately hastening the death of the patient is ever acceptable. These recommendations advocate a decision as far as possible shared by patient (whenever feasible), parents and caregivers. Ensuring that all involved are kept fully informed and that there is open and timely communication between them is the key to achieving this. It is the physician in charge of the patients care and the head of the unit who bear the main responsibility for the final decision.

Painful procedures in children with cancer: comparison of moderate sedation and general anesthesia for lumbar puncture and bone marrow aspiration.

The study was conducted to compare moderate sedation (MS) with general anesthesia (GA) in the management of frequently performed lumbar puncture or bone marrow aspiration (BMA) during the treatment of childhood cancer.

Thoracentesis in pericardial and pleural effusion caused by central venous catheterization: a less invasive neonatal approach

An 840 g infant developed a rapid onset of shock‐like symptoms. Pericardial and pleural effusions from an indwelling central catheter were diagnosed via echocardiography. A thoracentesis was promptly performed with immediate clinical improvement. The fluid withdrawn from the pleural space was analysed as hyperalimentation. The infant survived because of early diagnosis and aggressive therapeutic intervention. A pericardial effusion should be drained if there is cardiovascular compromise and because pericardiocentesis represents a high risk technique, attempts should be made to rectify the extravasation via thoracentesis.

Use of percutaneous radial artery catheter for peripheral blood progenitor cell collection in pediatric patients.

BACKGROUND : Leukapheresis procedures require adequate flow rates, which in children may frequently involve invasive vascular access placement.

Analgesic efficacy and tolerability of ketoprofen lysine salt vs paracetamol in common paediatric surgery. A randomized, single‐blind, parallel, multicentre trial

Background: In this study, we compared the analgesic efficacy of ketoprofen lysine salt (OKi® suppositories) vs paracetamol, in children undergoing minor surgery. We also studied the side‐effects of the treatment.

Respiratory depression and somnolence in children receiving dimethylsulfoxide and morphine during hematopoietic stem cells transplantation.

Dimethylsulfoxide (DMSO) has been commonly used for the past 20 years as a well-known cryo-protectant agent. It acts by penetrating the cell and binding water molecules; by doing so, it blocks the efflux of water and prevents cellular dehydration, maintains stable pH, intracellular salt