Rebecca Pillai Riddell

Reducing the pain of childhood vaccination: an evidence-based clinical practice guideline (summary)

Injections for vaccinations, the most common source of iatrogenic pain in childhood,[1][1] are administered repeatedly to almost all Canadian children throughout infancy, childhood and adolescence.[2][2] The pain associated with such injections is a source of distress for children, their parents and

Reducing pain during vaccine injections: clinical practice guideline

Pain from vaccine injections is common, and concerns about pain contribute to vaccine hesitancy across the lifespan.[1][1],[2][2] Noncompliance with vaccination compromises the individual and community benefits of immunization by contributing to outbreaks of vaccine-preventable diseases. Individuals

The relationship between caregiver sensitivity and infant pain behaviors across the first year of life.

Summary Previous caregiver sensitivity and infant pain behaviour predict future sensitivity and behaviour in the immunization context, but consistent interrelationships are not seen until 12 months of age. ABSTRACT Recent research has begun to examine discrete caregiver pain management behaviors in the infant immunization context. However, there is a dearth of research exploring more global caregiving constructs, such as emotional availability, which can be used to examine the overall sensitivity of caregiver pain management. The aim of the present study was to examine the relationships between caregiver sensitivity (emotional availability) and infant pain behavior (baseline, immediately post‐needle, 1 min after needle) over the first year of life. Parents and infants were a part of a Canadian longitudinal cohort (the Opportunities to Understand Childhood Hurt or OUCH cohort) followed up during their 2‐, 4‐, 6‐, and 12‐month immunizations (current n = 731). Both within‐age group analyses and over‐age analyses were performed. Results indicated that: (1) over age, previous infant pain behavior predicts future infant pain behavior, but this varied depending on timing of pain response and age of infant; (2) over age, previous caregiver sensitivity strongly predicts future caregiver sensitivity; and (3) the concurrent relationship between caregiver sensitivity and every type of infant pain response is only consistently seen at the 12‐month immunization. Caregiver sensitivity to the infant in pain is predicted most reliably from previous caregiver sensitivity, not infant pain behaviour. The significant concurrent relationship between caregiver sensitivity and infant pain behaviours is not seen until 12 months, replicating patterns in the infant development literature regarding the time at which the attachment relationship between parent and child can be reliably measured. Discussion addresses implications for both researchers and clinicians who work with infants in pain.

Variability in infant acute pain responding meaningfully obscured by averaging pain responses

Summary Stable variability in infant pain responses increases with age, challenging the validity of using a mean infant pain score in pain research. Abstract Given the inherent variability in pain responding, using an “average” pain score may pose serious threats to internal and external validity. Using growth mixture modeling (GMM), this article first examines whether infants can be differentiated into stable groups based on their pain response patterns over a 2‐minute post‐needle period. Secondary analyses, to specifically address the issue of averaging pain scores to represent a sample, qualitatively described clinically meaningful differences between pain scores of the discerned groups and the overall mean (irrespective of groups). Infants were part of Canadian longitudinal cohort naturalistically observed during their 2‐, 4‐, 6‐, and/or 12‐month immunization appointments (N = 458 to 574) at 3 pediatrician clinics between 2007 and 2012. At every age, GMM analyses discerned distinct groups of infants with significantly variable patterns of pain responding over the 2 minutes post‐needle. Our secondary suggested that the overall mean pain score immediately post‐needle reflected most groups well at every age. However, for older infants (6 and 12 months, especially), the overall mean pain responses at 1 and 2 minutes post‐needle significantly over or underestimated groups that contained 48% to 100% of the sample. These results combined highlight the significant variability of infant pain responding patterns between groups of infants and furthermore, calls into question the validity of using an overall mean in research with older infants during the regulatory phase post‐needle.

Far from “just a poke”: common painful needle procedures and the development of needle fear

Background:Vaccine injections are the most common painful needle procedure experienced throughout the lifespan. Many strategies are available to mitigate this pain; however, they are uncommonly utilized, leading to unnecessary pain and suffering. Some individuals develop a high level of fear and subsequent needle procedures are associated with significant distress. Objective:The present work is part of an update and expansion of a 2009 knowledge synthesis to include the management of vaccine-related pain across the lifespan and the treatment of individuals with high levels of needle fear. This article will provide a conceptual foundation for understanding: (a) painful procedures and their role in the development and maintenance of high levels of fear; (b) treatment strategies for preventing or reducing the experience of pain and the development of fear; and (c) interventions for mitigating high levels of fear once they are established. Results:First, the general definitions, lifespan development and functionality, needle procedure-related considerations, and assessment of the following constructs are provided: pain, fear, anxiety, phobia, distress, and vasovagal syncope. Second, the importance of unmitigated pain from needle procedures is highlighted from a developmental perspective. Third, the prevalence, course, etiology, and consequences of high levels of needle fear are described. Finally, the management of needle-related pain and fear are outlined to provide an introduction to the series of systematic reviews in this issue. Discussion:Through the body of work in this supplement, the authors aim to provide guidance in how to treat vaccination-related pain and its sequelae, including high levels of needle fear.

Predicting maternal and behavioral measures of infant pain: The relative contribution of maternal factors

Abstract The Sociocommunication Model of Infant Pain [Craig KD, Pillai Riddell R. Social influences, culture and ethnicity. In: Finley GA, McGrath PJ, editors. Pediatric pain: biological and social context, Seattle: IASP Press; 2003.] theorizes that maternal variables influence the pained infant and that the pained infant reciprocally influences maternal responses to the infant. The current analysis examines the relative predictive utility of maternal behavioral and psychosocial variables for both maternal judgments of her infant’s pain and behavioral measures of infant pain, after infant factors have been controlled. A convenience sample of 75 mother–infant dyads was videotaped during a routine immunization in a pediatrician’s office. Mothers were interviewed on the telephone, within two weeks, to complete a series of questionnaires. Infants were between the ages of 5 and 20 months. Infant pain was measured directly after the immunization using subjective maternal judgments. In addition, both maternal soothing behaviors and infant pain behaviors post‐immunization were measured using objective coding systems. During the telephone interview, mothers were asked to recall infant pain levels for the day after the immunization and were also assessed for level of acculturative stress, perceived social support, general relationship style, feelings towards her infant and endorsed psychopathology. Regression analyses suggested that the role of maternal behavioral and psychosocial variables was highly dependent on the infant pain measure being predicted. These results imply that given the dependence of infants on their primary caregivers, quite often mothers, it is important to understand the dynamic influence of infants’ behavior on maternal judgments of infants’ pain and maternal psychosocial variables on infants’ expression of pain.

Understanding the Psychosocial Profile of Women with Fibromyalgia Syndrome

Fibromyalgia syndrome (FMS) is a disease with a complex etiology characterized by symptoms of widespread pain and fatigue. FMS is more common in women. Both depression and anxiety have been found to be independently associated with the severity of pain in symptoms of FMS. The goal of the present study was to examine the psychosocial profile of women with FMS and to see how the attributions, perceived social support and cognitive biases of women with FMS are related to internalizing ratings of depression and anxiety. The current study included a sample of women with FMS from a local support group and a control group to examine how women with FMS differed from controls with respect to psychosocial variables, and to determine the relationship between these variables. Women with FMS reported a higher external locus of control, lower levels of adaptive cognitive bias, less perceived family support and lower mood than controls. Correlations between these variables were examined within the FMS group, and it was found that an external locus of control was significantly associated with higher ratings of anxiety and depressed mood. These results suggest that beliefs about locus of control and perceived family support of women with FMS may importantly impact their health outcomes, and that treatments related to locus of control and advocating for family support may considerably improve the quality of life of patients with FMS.

Brief Report: Maternal Emotional Availability and Infant Pain-related Distress

OBJECTIVES The current study investigated the relationships between maternal emotional availability and infant pain expressions. METHODS A group of 73 mother-infant dyads were recruited prior to their routine immunization appointment and were subsequently filmed. RESULTS Analyses revealed that maternal non-intrusiveness was related to lower infant pain expressions both immediately and 1 min following needle. In addition, maternal sensitivity and overall emotional availability were related to lower infant pain expressions 1 min after needle. CONCLUSIONS These results suggest that intrusive caregiving behaviors can increase infant pain reactivity and hinder the regulation of pain-related distress. On the other hand, sensitive and emotionally available caregiving help infants to regulate their pain-related distress. The results support that infant pain expressions are related to the quality of maternal caregiving.

Naturalistic parental pain management during immunizations during the first year of life: Observational norms from the OUCH cohort

&NA; Descriptive information about pain management techniques used in infant immunizations is provided. The relationship between these techniques and infant pain is also examined. &NA; No research to date has descriptively catalogued what parents of healthy infants are naturalistically doing to manage their infant’s pain over immunization appointments during the first year of life. This knowledge, in conjunction with an understanding of the relationships different parental techniques have with infant pain‐related distress, would be useful when attempting to target parental pain management strategies in the infant immunization context. This study presents descriptive information about the pain management techniques parents have chosen and examines the relationships these naturalistic techniques have with infant pain‐related distress during the first year of life. A total of 760 parent‐infant dyads were recruited from 3 pediatric clinics in Toronto, ON, Canada, and were naturalistically followed and videotaped longitudinally over 4 immunization appointments during the infant’s first year of life. Infants were full‐term, healthy babies. Videotapes were subsequently coded for infant pain‐related distress behaviors and parental pain management techniques. After controlling for preceding infant pain‐related distress levels, parent pain management techniques accounted for, at most, 13% of the variance in infant pain‐related distress scores. Across all age groups, physical comfort, rocking, and verbal reassurance were the most commonly used nonpharmacological pain management techniques. Pacifying and distraction appeared to be most promising in reducing needle‐related distress in our sample of healthy infants. Parents in this sample seldom used pharmacological pain management techniques. Given the psychological and physical repercussions involved with unmanaged repetitive acute pain and the paucity of work in healthy infants, this paper highlights key areas for improving parental pain management in primary care.

Knowledge translation of the HELPinKIDS clinical practice guideline for managing childhood vaccination pain: usability and knowledge uptake of educational materials directed to new parents

BackgroundAlthough numerous evidence-based and feasible interventions are available to treat pain from childhood vaccine injections, evidence indicates that children are not benefitting from this knowledge. Unrelieved vaccination pain puts children at risk for significant long-term harms including the development of needle fears and subsequent health care avoidance behaviours. Parents report that while they want to mitigate vaccination pain in their children, they lack knowledge about how to do so. An evidence-based clinical practice guideline for managing vaccination pain was recently developed in order to address this knowledge-to-care gap. Educational tools (pamphlet and video) for parents were included to facilitate knowledge transfer at the point of care. The objectives of this study were to evaluate usability and effectiveness in terms of knowledge acquisition from the pamphlet and video in parents of newly born infants.MethodsMixed methods design. Following heuristic usability evaluation of the pamphlet and video, parents of newborn infants reviewed revised versions of both tools and participated in individual and group interviews and individual knowledge testing. The knowledge test comprised of 10 true/false questions about the effectiveness of various pain management interventions, and was administered at three time points: at baseline, after review of the pamphlet, and after review of the video.ResultsThree overarching themes were identified from the interviews regarding usability of these educational tools: receptivity to learning, accessibility to information, and validity of information. Parents’ performance on the knowledge test improved (p≤0.001) from the baseline phase to after review of the pamphlet, and again from the pamphlet review phase to after review of the video.ConclusionsUsing a robust testing process, we demonstrated usability and conceptual knowledge acquisition from a parent-directed educational pamphlet and video about management of vaccination pain. Future studies are planned to determine the impact of these educational tools when introduced in clinical settings on parent behaviors during infant vaccinations.