Saul Greenberg

Canadian Acute Respiratory Illness and Flu Scale (CARIFS): Development of a valid measure for childhood respiratory infections

Although acute respiratory infection (ARI) is the most frequent clinical syndrome in childhood, there is no validated measure of its severity. Therefore a parental questionnaire was developed: the Canadian Acute Respiratory Illness Flu Scale (CARIFS). A process of item generation, item reduction, and scale construction resulted in a scale composed of 18 items covering three domains; symptoms (e.g., cough); function (e.g., play), and parental impact (e.g., clinginess). The validity of the scale was evaluated in a study of 220 children with ARI. Construct validity was assessed by comparing the CARIFS score with physician, nurse, and parental assessment of the childs health. Data were available from 206 children (94%). The CARIFS correlated well with measures of the construct (Spearmans correlations between 0.36 and 0.52). Responsiveness was shown, with 90% of children having a CARIFS score less than a quarter of its initial value, by the tenth day.

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.

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.

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.

A Longitudinal Examination of Verbal Reassurance During Infant Immunization: Occurrence and Examination of Emotional Availability as a Potential Moderator

OBJECTIVE This study investigated the associations between caregiver verbal reassurance and infant pain-related distress during immunization over the first year of life. The relationships between verbal reassurance and caregiver emotional availability (EA) were also examined. Finally, EA was investigated as a moderator of the relationship between verbal reassurance and infant pain. METHODS A cross-sectional analysis was conducted with 606 infants (and their parents) at 4 different ages (n = 376 at 2 months, n = 455 at 4 months, n = 484 at 6 months, and n = 407 at 12 months). RESULTS Verbal reassurance was positively associated with infant distress across all four ages. EA was only negatively related to verbal reassurance at 12 months of age. EA was not a significant moderator at any age. CONCLUSION Findings demonstrate consistent but small relationships between verbal reassurance and infant pain over the first year of life.

A cross-sectional examination of the relationships between caregiver proximal soothing and infant pain over the first year of life.

&NA; In a longitudinal cohort of 760 caregiver–infant dyads, earlier infant pain behaviour was a stronger predictor of later infant pain responding than caregiver proximal soothing. &NA; Although previous research has examined the relationships between caregiver proximal soothing and infant pain, there is a paucity of work taking infant age into account, despite the steep developmental trajectory that occurs across the infancy period. Moreover, no studies have differentially examined the relationships between caregiver proximal soothing and initial infant pain reactivity and pain regulation. This study examined how much variance in pain reactivity and pain regulation was accounted for by caregiver proximal soothing at 4 routine immunizations (2, 4, 6, and 12 months) across the first year of life, controlling for preneedle distress. One latent growth model was replicated at each of the 4 infant ages, using a sample of 760 caregiver–infant dyads followed longitudinally. Controlling for preneedle infant distress, caregiver proximal soothing accounted for little to no variance in infant pain reactivity or regulation at all 4 ages. Preneedle distress and pain reactivity accounted for the largest amount of variance in pain regulation, with this increasing after 2 months. It was concluded that within each immunization appointment across the first year of life, earlier infant pain behaviour is a stronger predictor of subsequent infant pain behaviour than caregiver proximal soothing. Given the longer‐term benefits that have been demonstrated for proximal soothing during distressing contexts, caregivers are still encouraged to use proximal soothing during infant immunizations.

Addressing parental concerns about pain during childhood vaccination: is there enough time to include pain management in the ambulatory setting?

Objective:Pain from vaccine injections remains undertreated, despite the availability of numerous pain-relieving strategies. Healthcare providers report lack of time within current office workflows as a major barrier to routine pain management. The objective was to document the total time involved in outpatient vaccine appointments to test the hypothesis that offering pain-relieving strategies can be practically implemented when considering the element of time to vaccine injection. Patients and Methods:Prospective naturalistic study in 8 urban outpatient primary care clinics (4 pediatric and 4 family practice) in Toronto. For 48 to 59 consecutive childhood vaccination appointments at each site, child waiting time from clinic arrival until first vaccine injection was tracked. Results:Altogether, 405 vaccine appointments were included. The median age of the child undergoing vaccination was 12 months. The mean (SD) time from clinic arrival until first vaccine injection was 41.6 minutes (20.9), with a range of 7 to 132 minutes. Linear regression identified a significant (P<0.05) difference according to clinic [ranging from 19.4 min (6.5) to 57.5 min (20.2)] and number of family members in the appointment [ranging from 40.6 min (21.0) for an appointment in the index child only to 50 min (14.3) for an appointment in the index child and 2 other family members]. Conclusions:Contrary to healthcare provider perceptions, the timing of outpatient childhood vaccine appointments allows for the inclusion of pain management interventions. Efforts should now focus on educating healthcare providers and parents about the value of pain management and how to implement evidence-based strategies.

Toy-mediated distraction: Clarifying the role of distraction agent and preneedle distress in toddlers

BACKGROUND Distraction has recently gained attention as a technique that may help reduce acute pain in infants and toddlers; however, results remain equivocal. It appears that these mixed results stem from a variety of methodological differences with regard to how distraction is implemented. OBJECTIVES To offer more definitive conclusions regarding the efficacy and mechanisms of distraction for pain management during infancy. Specifically, the goal was to examine whether the agent of distraction (i.e., the specific person conducting the distraction) and preneedle distress behaviours impact the efficacy of distraction when toddlers were held by parents. METHODS A total of 99 toddlers were randomly assigned to one of three conditions (typical care, research assistant-directed distraction or parent-directed distraction). Toddler distress behaviours were assessed pre- and postneedle. Toddlers were further grouped according to distress behaviours preneedle (low⁄no distress versus high distress). Parental soothing behaviours were also assessed as a manipulation check. RESULTS Toddler postneedle pain did not significantly differ among groups. However, toddlers who were distressed preneedle displayed significantly more pain postneedle, regardless of the treatment group. There were no significant interactions between treatment group and preneedle distress behaviours. CONCLUSIONS These results suggest that, when being held by a parent, distraction using a toy does not result in lower pain scores in the context of immunization, regardless of who offers the distraction. Furthermore, these findings raise the notion that if clinicians ensured toddlers were regulated before attempting an immunization, postneedle pain may be significantly reduced.

Predicting preschool pain-related anticipatory distress: the relative contribution of longitudinal and concurrent factors.

Abstract Anticipatory distress prior to a painful medical procedure can lead to negative sequelae including heightened pain experiences, avoidance of future medical procedures, and potential noncompliance with preventative health care, such as vaccinations. Few studies have examined the longitudinal and concurrent predictors of pain-related anticipatory distress. This article consists of 2 companion studies to examine both the longitudinal factors from infancy as well as concurrent factors from preschool that predict pain-related anticipatory distress at the preschool age. Study 1 examined how well preschool pain-related anticipatory distress was predicted by infant pain response at 2, 4, 6, and 12 months of age. In study 2, using a developmental psychopathology framework, longitudinal analyses examined the predisposing, precipitating, perpetuating, and present factors that led to the development of anticipatory distress during routine preschool vaccinations. A sample of 202 caregiver–child dyads was observed during their infant and preschool vaccinations (the Opportunities to Understand Childhood Hurt cohort) and was used for both studies. In study 1, pain response during infancy was not found to significantly predict pain-related anticipatory distress at preschool. In study 2, a strong explanatory model was created whereby 40% of the variance in preschool anticipatory distress was explained. Parental behaviours from infancy and preschool were the strongest predictors of child anticipatory distress at preschool. Child age positively predicted child anticipatory distress. This strongly suggests that the involvement of parents in pain management interventions during immunization is one of the most critical factors in predicting anticipatory distress to the preschool vaccination.