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Corresponding author: Department of Pediatric Oncology/Hematology,Beatrix Children’s Hospital PO Box 30.001 9700 RB Groningen University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.. Fax: +31 50 36 14 235.
University of Groningen, University Medical Center Groningen, Beatrix Children’s Hospital, Department of Pediatric Oncology/Hematology, Groningen, the Netherlands
Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the NetherlandsPrincess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the NetherlandsPrincess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, CanadaDepartment of Pharmacy and Research Institute, The Hospital for Sick Children, Toronto, Canada
Department of Pediatric Oncology, Emma Children’s Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, the NetherlandsPrincess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
Leslie Dan Faculty of Pharmacy, University of Toronto, Toronto, ON, CanadaDepartment of Pharmacy and Research Institute, The Hospital for Sick Children, Toronto, Canada
1 F.C. Campbell and W.J.E. Tissing contributed equally to this work.
Wim J.E. Tissing
Footnotes
1 F.C. Campbell and W.J.E. Tissing contributed equally to this work.
Affiliations
University of Groningen, University Medical Center Groningen, Beatrix Children’s Hospital, Department of Pediatric Oncology/Hematology, Groningen, the NetherlandsPrincess Máxima Center for Pediatric Oncology, Utrecht, the Netherlands
Children with cancer are often confronted with procedure-related pain and distress.
•
This clinical practice guideline provides recommendations to manage this.
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Both pharmacological and psychological management strategies are discussed.
•
The international interdisciplinary panel adhered to Grading of Recommendations Assessment, Development and Evaluation methodology.
Abstract
Background
Children with cancer often undergo long treatment trajectories involving repeated needle procedures that potentially cause pain and distress. As part of a comprehensive effort to develop clinical practice guidelines (CPGs) to address pain prevention and management in children with cancer, we aimed to provide recommendations on the pharmacological and psychological management of procedure-related pain and distress.
Methods
Of the international inter-disciplinary CPG development panel (44 individuals), two working groups including 13 healthcare professionals focused on procedural pain and distress. Grading of Recommendations Assessment, Development and Evaluation methodology was used, including the use of systematic literature reviews to inform recommendations and the use of evidence to decision frameworks. At an in-person meeting in February 2018, the guideline panel discussed these frameworks and formulated recommendations which were then discussed with a patient-parent panel consisting of 4 survivors and 5 parents.
Results
The systematic reviews led to the inclusion of 48 randomised controlled trials (total number of participants = 2271). Quality of evidence supporting the recommendations ranged from very low to moderate. Strong recommendations were made for the use of topical anesthetics in all needle procedures, for offering deep sedation (DS)/general anesthesia (GA) to all children undergoing lumbar puncture, for the use of DS/ GA in major procedures in children of all ages, for the use of hypnosis in all needle procedures and for the use of active distraction in all needle procedures.
Conclusion
In this CPG, an evidence-based approach to manage procedure-related pain and distress in children with cancer is presented. As children with cancer often undergo repeated needle procedures during treatment, prevention and alleviation of procedure-related pain and distress is of the utmost importance to increase quality of life in these children and their families.
With the introduction of intensive treatment protocols, survival rates for childhood cancer in developed countries have now increased from 40% in the 1970s to over 80% [
]. The drawback of these intensive and prolonged treatments is that they are often associated with significant morbidity. Of these side-effects, pain is a key area for which healthcare professionals seek guidance [
In contrast to adult patients with cancer, in whom pain is mostly tumor related, pain in children with cancer is mostly related to treatment or procedures [
]. Children with cancer undergo various potentially painful and/or distressing needle procedures, such as accessing the central venous access port or bone marrow punctures. It is increasingly acknowledged that children are at risk of long-term sequelae from inadequate pain management during needle procedures, for example, increased levels of anxiety and non-compliance with care [
]. The lack of attention to pain management practices may negatively influence health outcomes for children with cancer.
In this clinical practice guideline (CPG), we provide recommendations regarding pharmacological and psychological interventions for reducing pain and distress related to needle procedures in children with cancer. This CPG is targeted to healthcare professionals who care for children with cancer undergoing painful medical procedures, including pediatric oncologists, nurses, anesthesiologists and child life specialists. This CPG is the first of a series of CPGs focusing on pain in children and adolescents with cancer.
2. Methods
The full methodology for this guideline development project has been published separately [
The CPG development panel comprised 44 international panel members and was divided into six working groups. Two working groups focused on pharmacological and psychological interventions to reduce pain related to needle procedures and included three pediatric oncologists, two pediatric oncology nurses, two clinical psychologists and a pediatric anesthesiologist, academic pharmacist, pediatric intensivist, child life specialist, pediatric oncology researcher and pediatric surgeon. A core group of eight individuals with experience in CPG development supervised the process and provided methodological expertise.
2.2 Scope, definitions and clinical questions
For the purposes of this CPG, needle procedures were categorised as minor procedures (blood sampling, peripheral intravenous access and access to central venous access port), lumbar puncture procedures (LPs) and major procedures (bone marrow aspiration (BMA), bone marrow puncture (BMP), combined LP with BMA/BMP, bone biopsy, organ biopsy and echo-/radiographically guided punctures). Levels of sedation were defined according to the American Society of Anesthesiologists: no sedation, minimal sedation, moderate sedation, deep sedation (DS) and general anesthesia (GA) [
Refer Table 1 for a full list of clinical questions that were included. Clinical outcomes for these questions were prioritised using a simple voting procedure, in accordance with the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology [
For 22 clinical questions, systematic literature searches were performed (last update March 13th 2018). Randomised controlled trials (RCTs) studying children and adolescents with cancer were eligible for inclusion. Study selection, quality appraisal (Cochrane risk of bias tool and GRADE) and data extraction were performed independently by two reviewers [
When formulating recommendations, the CPG development panel prioritised the perspective of the patient and his/her family as most important when formulating recommendations. Evidence summaries were disseminated and used to complete evidence to decision (EtD) frameworks [
GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines.
]. These frameworks facilitate formulation of recommendations in a systematic and transparent manner by considering the balance between benefits and harms of an intervention and also other factors such as costs, feasibility and acceptability. In February 2018, the results of the systematic review and the EtD frameworks were discussed during an in-person guideline panel meeting in Amsterdam attended by 36 members (80%) including 11 of the 13 members (85%) of the procedural pain working groups. Decisions were made through group discussion and consensus; final recommendations had to be supported unanimously. For questions where the evidence was deemed insufficient to formulate a recommendation, an approach to identify non-RCT and indirect evidence including evidence syntheses was established. Draft recommendations were refined and finalised using repeated group conversations through email and telephone.
In accordance with GRADE methodology, good practice statements were formulated to address practice points for which studies were not possible or feasible but that according to the panel underpin a comprehensive guideline. Good practice statements were ‘ungraded’ because no formal grading of evidence can be performed [
The draft recommendations were reviewed in an in-person group meeting by a patient-parent panel (four survivors, five parents) to consider the values and preferences of children and families. Participants received a short training session on CPG development and contributed to the decisions regarding the direction and strength of recommendations and to implementation considerations (refer Supplemental Material S1).
2.6 CPG update cycle
This CPG will be updated in five years (March 2024) or earlier should novel studies or insights warrant an earlier update.
3. Results
We retrieved 11.159 citations. Refer Fig.1 for a flowchart of the selection process. In all, 48 primary studies were included (total number of participants = 2.271); 33 studies (n = 1.602) and 15 studies (n = 669) focused on pharmacological or psychological interventions, respectively.
Fig. 1Flowchart of the selection process. Working groups are indicated using their working group number; 2C for pharmacological management of procedure-related pain, 3B for psychological management of procedure related pain.
In Table 2, the conclusions of included studies are presented. The formulated recommendations (arranged per type) and the ungraded good practice statements are presented in Table 3, Table 4, respectively. Refer Supplemental Materials S2 and S3 for the full evidence summaries and Supplemental Materials S4 and S5 for the EtD frameworks. For a flowchart to guide clinical care, refer Fig.2.
Table 2Conclusions of evidence.
Topical anesthetics
Minor procedures
Quality of evidence
Reduced self-rated pain intensity with lidocaine-prilocaine 5% (60 min) vs. placebo
⊕⊕◯◯ LOW(18)
Reduced proxy-rated distress with lidocaine-prilocaine 5% (60 min) vs. placebo
⊕⊕◯◯ LOW(18)
No significant difference in adverse effects with lidocaine-prilocaine 5% (60 min) vs. placebo
⊕⊕◯◯ LOW(18)
Reduced self-rated pain intensity with lidocaine-prilocaine 5% (60 min) vs. lidocaine-prilocaine 5% (40 min)
⊕⊕◯◯ LOW(17)
No significant difference in proxy-rated distress with lidocaine-prilocaine 5% (60 min) vs. lidocaine-prilocaine 5% (40 min)
⊕⊕◯◯ LOW(17)
No significant difference in self-rated pain intensity with lidocaine-prilocaine 5% (60 min) vs amethocaine gel (30 min)
⊕◯◯◯ VERY LOW(19)
No significant difference in proxy-rated distress with lidocaine-prilocaine 5% (60 min) vs amethocaine gel (30 min)
⊕◯◯◯ VERY LOW(19)
No significant difference in adverse effects with lidocaine-prilocaine 5% (60 min) vs amethocaine gel (30 min)
⊕◯◯◯ VERY LOW(19)
No significant difference in success of procedure with lidocaine-prilocaine 5% (60 min) vs amethocaine gel (30 min)
⊕◯◯◯ VERY LOW(19)
Lumbar puncture procedures
Quality of evidence
Varying results (benefit in 2 studies, no significant difference in 1 study) with lidocaine-prilocaine 5% vs. placebo
⊕⊕◯◯ LOW(20–22)
Reduced proxy rated distress with lidocaine-prilocaine 5% vs. placebo
⊕⊕◯◯ LOW(20–22)
No significant difference in success of procedure with lidocaine-prilocaine 5% vs. placebo
⊕⊕◯◯ LOW(20–22)
Oral analgesics
Minor procedures
Quality of evidence
No significant difference in self-rated pain intensity with paracetamol vs. placebo
⊕⊕⊕◯ MODERATE (36)
Reduced self-rated distress with paracetamol vs. placebo
⊕⊕⊕◯ MODERATE (36)
Reduced behavioral distress with paracetamol vs. placebo
⊕⊕⊕◯ MODERATE (36)
No significant difference in self-rated pain intensity with morphine vs. placebo
⊕⊕⊕◯ MODERATE (35)
Increased self-rated distress with morphine vs. placebo
⊕⊕⊕◯ MODERATE (35)
Use of sedation
Minor procedures
Quality of evidence
No significant difference in self-rated pain intensity with midazolam vs. placebo
⊕⊕◯◯ LOW(33.34)
No significant difference in self-rated distress (distress, needle discomfort) with midazolam vs. placebo
⊕⊕◯◯ LOW(33.34)
Reduced self-rated distress (fear) with midazolam vs. placebo
⊕⊕◯◯ LOW(33)
Reduced behavioral distress with midazolam vs. placebo
⊕⊕◯◯ LOW(33)
Increased adverse effects with midazolam vs. placebo
⊕⊕◯◯ LOW(33)
Lumbar puncture procedures
Quality of evidence
No significant difference in self-rated distress with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(30)
No significant difference in adverse effects with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(30)
No significant difference in success of procedure with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(30)
No significant difference in duration of procedure with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(30)
Major procedures
Quality of evidence
No significant difference in self-rated pain intensity with general anesthesia vs. no sedation
⊕◯◯◯ VERY LOW(25)
No significant difference in self-rated distress with general anesthesia vs. no sedation
⊕◯◯◯ VERY LOW(25)
Reduced behavioral distress with general anesthesia vs. no sedation
⊕◯◯◯ VERY LOW(25)
No significant difference in self-rated pain intensity with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(26)
No significant difference in self-rated distress with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(26)
No significant difference in behavioral distress with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(26)
No significant difference in adverse effects with general anesthesia vs. deep sedation
⊕⊕◯◯ LOW(26)
Hypnosis
Minor procedures
Quality of evidence
Reduced self-rated pain intensity with hypnosis vs. standard care
⊕⊕⊕◯ MODERATE (38–41)
Reduced self-rated distress with hypnosis vs. standard care
⊕⊕⊕◯ MODERATE (38–41)
Reduced behavioral distress with hypnosis vs. standard care
⊕⊕⊕◯ MODERATE (38–41)
Reduced fear of future medical procedures with hypnosis vs. standard care
⊕⊕⊕◯ MODERATE (40.41)
Reduced self-reported distress in parents with hypnosis vs. standard care
⊕⊕⊕◯ MODERATE (41)
Active distraction
Minor procedures
Quality of evidence
No significant difference in self-rated pain intensity with active distraction vs. standard care
⊕⊕◯◯ LOW(44.45)
No significant difference in self-rated distress with active distraction vs. standard care
⊕⊕◯◯ LOW(44.45)
Reduced behavioral distress with hypnosis vs. standard care
⊕⊕◯◯ LOW(45)
No significant difference in proxy-rated distress with active distraction vs. standard care
⊕⊕◯◯ LOW(43.45)
Passive distraction
Lumbar puncture procedures
Quality of evidence
Reduced self-rated pain intensity during and after procedure with passive distraction vs. standard care
⊕⊕◯◯ LOW(47)
No significant difference in self-rated pain intensity before procedure with passive distraction vs. standard care
⊕⊕◯◯ LOW(47)
No significant difference in self-rated pain intensity with passive distraction vs. standard care
⊕◯◯◯ VERY LOW(48)
Reduced self-rated distress with passive distraction vs. standard care
⊕⊕◯◯ LOW(47)
Combining modalities
Major procedures
Quality of evidence
Reduced self-rated pain intensity post-intervention with combining strategies vs. single procedure
⊕⊕◯◯ LOW(49)
No significant difference in self-rated pain intensity pre-intervention with combining strategies vs. single procedure
⊕⊕◯◯ LOW(49)
Reduced self-rated distress pre-intervention with combining strategies vs. single procedure
⊕⊕◯◯ LOW(49)
No significant difference in self-rated distress post-intervention with combining strategies vs. single procedure
⊕⊕◯◯ LOW(49)
Varying results (with no formal testing) with hypnosis vs. non-hypnotic attention techniques
⊕◯◯◯ VERY LOW(50)
Reduced behavioral distress post-intervention with combining strategies vs. single procedure
⊕⊕◯◯ LOW(49)
No significant difference behavioral distress pre-intervention with combining strategies vs. single procedure
Selection of approach should be based on the developmental stage and preferences of the patient, availability of resources and the patient’s prior experience with the interventions and the procedure. Pharmacological interventions should be dosed appropriately. All interventions should be administered by appropriate, qualified providers according to local legislation and medical regulations.
Strong and weak recommendations have different implications. A strong recommendation implies that most patients in that situation would want the recommended course of action and only a small proportion would not. For clinicians this implies that most patients should receive the recommended course of action (which however does not omit the need for discussing options). A weak recommendation (sometimes called conditional, discretionary, or qualified) implies that most patients in that situation would want the recommended course of action, but many would not. For clinicians this implies that they should recognize that different choices will be appropriate for different patients and that one must help each patient to arrive at a management decision consistent with her or his values and preferences [15].
Definitions: minor procedures = blood sampling, peripheral intravenous access, and access to central venous access port. Lumbar puncture procedures = lumbar puncture procedures only (not combined procedures). Major procedures = bone marrow aspiration (BMA), bone marrow puncture (BMP), combined LP with BMA/BMP, bone biopsy, organ biopsy, and echo-/radiographically guided puncture.
1
We recommend the use of a topical anesthetic for all needle procedures
Strong
Low
4
We suggest that sedatives not be used routinely for minor procedures
Weak
Low
5
We suggest that oral analgesics not be used for minor procedures
Weak
Low
6
We recommend the use of hypnosis for all needle procedures
Strong
Moderate
7
We recommend the use of active distraction for all needle procedures
Strong
Low
8
We suggest the use of passive distraction for all needle procedures
Weak
Very low
10
We recommend combining psychological interventions with pharmacological interventions during all needle procedures
Definitions: minor procedures = blood sampling, peripheral intravenous access, and access to central venous access port. Lumbar puncture procedures = lumbar puncture procedures only (not combined procedures). Major procedures = bone marrow aspiration (BMA), bone marrow puncture (BMP), combined LP with BMA/BMP, bone biopsy, organ biopsy, and echo-/radiographically guided puncture.
1
We recommend the use of a topical anesthetic for all needle procedures
Strong
Low
3
We recommend that the use of deep sedation or general anesthesia be offered to all children undergoing lumbar punctures
The panel acknowledges that there are children who may prefer not to receive deep sedation or general anesthesia for lumbar puncture, but instead prefer to receive no, minimal or moderate sedation and/or psychological interventions [31,32]. A strong recommendation was made to emphasize 1) the need to determine each patient’s needs and preferences and 2) the requirement that all levels of sedation be readily accessible and available to all patients. When the success of the procedure is not likely to be compromised, patients preferences should be honored.
Strong
Very low
6
We recommend the use of hypnosis for all needle procedures
Strong
Moderate
7
We recommend the use of active distraction for all needle procedures
Strong
Low
8
We suggest the use of passive distraction for all needle procedures
Weak
Very low
10
We recommend combining psychological interventions with pharmacological interventions during all needle procedures
Definitions: minor procedures = blood sampling, peripheral intravenous access, and access to central venous access port. Lumbar puncture procedures = lumbar puncture procedures only (not combined procedures). Major procedures = bone marrow aspiration (BMA), bone marrow puncture (BMP), combined LP with BMA/BMP, bone biopsy, organ biopsy, and echo-/radiographically guided puncture.
1
We recommend the use of a topical anesthetic for all needle procedures
Strong
Low
2
We recommend the use of deep sedation or anesthesia for major procedures
Strong
Very low
6
We recommend the use of hypnosis for all needle procedures
Strong
Moderate
7
We recommend the use of active distraction for all needle procedures
Strong
Low
8
We suggest the use of passive distraction for all needle procedures
Weak
Very low
10
We recommend combining psychological interventions with pharmacological interventions during all needle procedures
Strong
Very low
∗ Selection of approach should be based on the developmental stage and preferences of the patient, availability of resources and the patient’s prior experience with the interventions and the procedure. Pharmacological interventions should be dosed appropriately. All interventions should be administered by appropriate, qualified providers according to local legislation and medical regulations.
∗∗ The panel acknowledges that there are children who may prefer not to receive deep sedation or general anesthesia for lumbar puncture, but instead prefer to receive no, minimal or moderate sedation and/or psychological interventions [
]. A strong recommendation was made to emphasize 1) the need to determine each patient’s needs and preferences and 2) the requirement that all levels of sedation be readily accessible and available to all patients. When the success of the procedure is not likely to be compromised, patients preferences should be honored.
† Definitions: minor procedures = blood sampling, peripheral intravenous access, and access to central venous access port. Lumbar puncture procedures = lumbar puncture procedures only (not combined procedures). Major procedures = bone marrow aspiration (BMA), bone marrow puncture (BMP), combined LP with BMA/BMP, bone biopsy, organ biopsy, and echo-/radiographically guided puncture.
‡ Strong and weak recommendations have different implications. A strong recommendation implies that most patients in that situation would want the recommended course of action and only a small proportion would not. For clinicians this implies that most patients should receive the recommended course of action (which however does not omit the need for discussing options). A weak recommendation (sometimes called conditional, discretionary, or qualified) implies that most patients in that situation would want the recommended course of action, but many would not. For clinicians this implies that they should recognize that different choices will be appropriate for different patients and that one must help each patient to arrive at a management decision consistent with her or his values and preferences [
GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines.
Prior to all needle procedures, healthcare providers, children and parents should be educated and prepared regarding needle procedures and interventions to reduce pain and distress.
The child and his/her family should always be consulted in determining the appropriate management strategy to reduce procedure-related pain and distress.
Healthcare professionals should offer parents the option to be present during their child's needle procedures if the child wishes to.
Throughout the course of treatment, children should have ongoing assessments and re-assessments of pain and distress and the appropriateness of interventions should be re-assessed to determine the continued effectiveness of strategies to reduce procedural pain and distress.
The clinical questions regarding the use of pharmacological interventions are presented in Table 1. Critical outcomes for all these questions included self-rated pain intensity, self-rated distress, adverse effects and behavioral distress. For clinical questions regarding LPs, success of the procedure was also a critical outcome.
3.1.1 Topical anesthetics
We recommend the use of a topical anesthetic for all needle procedures (strong recommendation, low quality of evidence).
3.1.1.1 Evidence
A total of six studies (minor procedures: 3 studies (n = 173); LPs: 3 studies (n = 46)) informed this recommendation [
]. All studies compared lidocaine-prilocaine 5% (Eutectic Mixture of Local Anesthetics; EMLA®) cream to either a placebo or another topical anesthetic each with a 60 min application time in needle insertion into a subcutaneous intravenous port. Lidocaine-prilocaine 5% reduced self-rated pain intensity in four studies (no significant difference in 2 studies) and reduced proxy-rated distress in 3 studies (no significant difference in three studies). Adverse effects were addressed in two studies; there were no significant differences between groups. Given the low number of included RCTs, additional evidence was sought and two general pediatrics evidence syntheses (dermal laceration repair, vaccine injection pain) were included [
]. Both syntheses concluded that topical anesthetics are effective in reducing pain.
3.1.1.2 Evidence to decision
The panel concluded that the desirable consequences of topical anesthetics clearly outweigh the undesirable consequences (i.e. possible erythema, itchiness). Required resources are small relative to the benefits, and topical anesthetics are acceptable to key stakeholders and feasible to implement.
3.1.1.3 Implementation considerations
Topical anesthetics used in included studies were lidocaine-prilocaine 5% cream or patch (e.g. EMLA®) and amethocaine 4% gel (e.g. Ametop™). The required application time relative to the procedure (e.g. for lidocaine-prilocaine 5% at least 60 min before procedure) is feasible in pediatric oncology as most procedures are planned procedures. Healthcare providers, patients and parents should be educated regarding application timing (e.g. when leaving for the hospital or coming early to apply) and patch removal technique to minimise distress. Topical anesthetics should be introduced as early in the treatment trajectory as possible.
3.1.2 Sedation in major procedures
We recommend the use of DS or anesthesia for major procedures (strong recommendation, very low quality evidence).
3.1.2.1 Evidence
Twelve studies evaluating a wide spectrum of sedative drugs were included. Of these, two compared different sedation levels [
]. GA reduced behavioral distress compared with no sedation, with no significant differences in self-rated pain intensity and distress (1 study, n = 18)[
The panel concluded that the desirable consequences of DS or GA probably outweigh the undesirable consequences. The panel judged that the vast majority of patients would want to undergo a major procedure with DS or GA. Also the panel judged that clinicians would prefer to perform these procedures with DS or GA. The patient-parent panel supported this recommendation unanimously. In fact, patients who had not receive DS or GA for major procedures stated explicitly that they would have wanted so had they had the choice. Although the required resources are substantial, the panel deemed the option feasible to implement and acceptable for institutions caring for children with cancer.
3.1.2.3 Implementation considerations
We realise the stratification of the sedation spectrum established by the ASA is relatively artificial [
Guidelines for monitoring and management of pediatricpatients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016.
]. Therefore this recommendation should be seen in the light of the overarching aim of this CPG: optimal patient comfort, absence of restraint and successful performance of the procedure.
The CPG panel recognised that some of the agents evaluated in the studies informing this recommendation differ from modern practice with respect to the provision of DS and GA. The CPG panel therefore directs users of this CPG to current evidence-based guidance on this topic such as the American Academy of Pediatrics guideline on using sedation for diagnostic and therapeutic procedures in pediatric patients [
American Academy of Pediatrics; American Academy of Pediatric Dentirstry Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures.
To safely implement this recommendation, the facilities to provide DS/GA should be readily available, including the presence of an expert to administer the anesthetic drugs and monitor the patient. At minimum, patient monitoring requirements should comply with local laws and regulations or the American Academy of Pediatrics guideline on monitoring of sedation in children may be consulted [
Guidelines for monitoring and management of pediatricpatients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016.
] and the other study (n = 22) observed no differences between GA and DS with respect to self-rated distress, success of procedure or adverse effects [
Overall the panel concluded that the desirable consequences probably outweigh the undesirable consequences and that the option is feasible to implement. Furthermore, the panel took into account the need for motion control in LPs and the body of evidence for major procedures (several studies focused on combined BMAs/LPs) that favored higher levels of sedation.
Motion control is critical to the successful performance of LPs and is often difficult to achieve without sedation, especially in younger children. However, both the guideline development panel and the patient-parent panel acknowledged that there are children who may prefer not to receive DS or GA for lumbar puncture, and for whom no, minimal or moderate sedation and/or psychological interventions will suffice to establish a successful and comfortable LP [
]. A strong recommendation was made to emphasise (1) the need to determine each patient's needs and preferences and (2) the requirement that all levels of sedation be readily accessible and available to all patients. When the success of the procedure is not likely to be compromised, the patient preferences should be honored.
3.1.3.3 Implementation considerations
Refer implementation considerations presented for the use of DS or GA for major procedures.
3.1.4 Sedation for minor procedures
We suggest that sedatives not be used routinely for minor procedures (weak recommendation, low quality evidence).
3.1.4.1 Evidence
Two studies (n = 93) compared midazolam to placebo in needle insertion into a subcutaneous intravenous port [
Appraising the limited evidence, the panel concluded that the desirable consequences of the use of sedatives probably do not outweigh the undesirable consequences. In addition, the panel judged that sedative use is not acceptable to key stakeholders nor is it feasible to implement. Information regarding other sedatives was lacking.
3.1.4.3 Implementation considerations
There may be a subset of children who are extremely anxious before and/or during minor procedures for whom sedation might be beneficial [
American Academy of Pediatrics; American Academy of Pediatric Dentirstry Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures.
We suggest that oral analgesics not be used for minor procedures (weak recommendation, low quality evidence).
3.1.5.1 Evidence
Two placebo-controlled studies (n = 101) were included, one focusing on oral acetaminophen (paracetamol) and one on oral morphine. Both found no significant differences in self-rated pain intensity [
In the systematic search for general pediatrics evidence syntheses, one vaccine pain CPG was included. This CPG recommended against acetaminophen use due to a lack of evidence [
In formulating this recommendation, the CPG panel considered both the included evidence and the wide between-patient variability of analgesic bioavailability and time to maximum effect. Thus, coordinating the procedure with the peak analgesic effect would be logistically difficult. Overall, the panel concluded that the undesirable consequences of analgesics outweigh their uncertain desirable effects.
3.2 Psychological interventions
The included clinical questions on psychological interventions focused on hypnosis, active distraction and passive distraction (reer Table 1). Critical outcomes for all these questions were self-rated pain intensity, self-rated distress, proxy-rated distress, behavioral distress, fear of future medical procedures, adverse effects and, for the questions on distraction, global judgement of satisfaction with treatment.
Hypnosis was defined as a trance-like state awareness, where a child is highly focused on (suggested or self-created) images or ideas. Active distraction was defined as distraction in which a child actively participates, for example, completing a puzzle or playing a computer game. Passive distraction was defined as distraction in which a child does not actively participate, for example, listening to music or watching a movie.
It should be noted that in procedures where DS or GA is used, the use of psychological interventions is limited to the preparation phase.
3.2.1 Hypnosis
We recommend the use of hypnosis for all needle procedures (strong recommendation, moderate quality evidence).
3.2.1.1 Evidence
Four studies (n = 120), all from one study group, compared the use of hypnosis to standard care during minor procedures, LPs and major procedures [
Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-hypnosis in the management of pediatric procedure-related pain.
Heal psychol [internet].2006; 25 (Washington, District of Columbia: American psychological association): 307-315
]. In all studies, hypnosis reduced self-rated pain intensity, self-rated distress and behavioral distress; in two studies, hypnosis reduced fear of future medical procedures.
3.2.1.2 Evidence to decision
The panel concluded that the desirable consequences of hypnosis clearly outweigh the undesirable consequences. In addition, hypnosis is feasible to implement (although formal training is required) and acceptable to stakeholders. Thus, the CPG panel made a strong recommendation based on the consistent demonstration of benefit of hypnosis and the low likelihood of harm. This recommendation was unanimously supported by the patient-parent panel.
3.2.1.3 Implementation considerations
The patient-parent panel emphasised the need to eliminate misconceptions about hypnosis through education. To implement hypnosis, professionals need to be trained to use this technique. They could then perform hypnosis or train patients to perform self-hypnosis.
3.2.2 Active distraction
We recommend the use of active distraction for all needle procedures (strong recommendation, low quality evidence).
3.2.2.1 Evidence
Five studies (n = 171) evaluated the use of active distraction compared with standard care during minor procedures [
]. Although several critical outcomes were not reported in sufficient detail to extract data, active distraction reduced behavioral distress (one study), with no significant differences for self-rated pain intensity (one study), and self- and proxy-rated distress (two studies).
3.2.2.2 Evidence to decision
As there is a low likelihood that distraction causes harm, even small benefits can be of value, and the panel thus concluded that the desirable consequences probably outweigh the undesirable consequences (if any). Distraction interventions can be of low cost and therefore accessible in nearly all settings. The parent-patient panel unanimously underlined the strong recommendation.
3.2.2.3 Implementation considerations
The parent-patient panel emphasised the need to take the time, together with the child, to select the preferred distraction. In addition, from the literature (and from the experience of our patient-parent panel), we know that there are people who benefit from knowing and seeing what is going on and therefore prefer not to be distracted [
The panel concluded that the desirable consequences probably outweigh the undesirable consequences, with the option being feasible and acceptable. However, given the very low overall quality of the evidence and the focus of the included studies on LPs only, the panel preferred active distraction over passive distraction and thus categorised this recommendation as weak.
3.2.3.3 Implementation considerations
Refer the implementation considerations paragraph of active distraction. As no person is needed to interact with the child, passive distraction might be more simple to implement than active distraction.
3.3 Combining intervention modalities
We recommend combining psychological interventions with pharmacological interventions during all needle procedures (strong recommendation, very low quality evidence).
3.3.1 Evidence
Two studies (n = 175) compared combined interventions (valium and cognitive behavioral therapy in one study, midazolam/morphine and play/guided imagery in the other) to single interventions in major procedures [
A randomized controlled prospective outcome study of a psychological and pharmacological intervention protocol for procedural distress in pediatric leukemia.
]. In one study, combining intervention modalities reduced self-rated pain intensity post-intervention (but not pre-intervention), self-rated distress pre-intervention (but not post-intervention) and behavioral distress post-intervention (but not pre-intervention) [
Given the available evidence and the previous strong recommendations for several single interventions among different modalities, the panel judged a strong recommendation for combining appropriate interventions as justifiable. Combining psychological and pharmacological interventions is generally feasible and acceptable to key stakeholders. This recommendation was also based on the included studies on psychological interventions that included pharmacological interventions as part of standard care.
3.3.3 Implementation considerations
Other than situations where combining modalities is not applicable (e.g. during DS), the panel judged that clinicians should always strive to combine recommended pharmacological interventions (e.g. topical anesthetics) with recommended psychological interventions (e.g. active distraction) to optimise pain/distress management.
3.4 Ungraded good practice statements
3.4.1 Education and preparation
Before all needle procedures, healthcare providers, children and parents should be educated and prepared regarding needle procedures and interventions to reduce pain and distress (ungraded good practice statement).
Both the CPG panel and the patient-parent panel deemed education and preparation (starting as early as possible in the treatment process) to be critical to the provision of high-quality, patient-centered care of children undergoing procedures. This might be partly covered in the process of gaining informed consent. Children and parents should be informed about the meaning and process of each procedure and about what measures can be taken to reduce pain and distress. This can effectively decrease distress and increase coping and compliance during a variety of medical procedures [
]. In addition, healthcare providers need to be trained on effective procedural pain and distress management strategies.
3.4.2 Empowerment
The child and his/her family should always be consulted in determining the appropriate management strategy to reduce procedure-related pain and distress (ungraded good practice statement).
Healthcare providers should always engage a child and their parents in the selection of effective interventions to reduce procedural pain and distress. Developmental age, personality, gender and cultural factors may all play a role in the success of an intervention. An informed decision on the preferred strategy should be made together. The patient-parent panel emphasised the autonomy of the child by saying: put the child in charge. Several projects are being undertaken that contribute to this aim, for instance, the Comfort, Ask, Relax, Distract (CARD) project in which patient empowerment is combined with education, for patients as well as healthcare providers [
Healthcare professionals should offer parents the option to be present during their child's needle procedures if the child wishes to (ungraded good practice statement).
Parental presence might facilitate patient distraction and/or comfort and if desired the parents can act as a coach for their child. During preparation and education, parents should be informed about what behaviors and techniques are helpful to decrease distress and increase coping.
3.4.4 Ongoing pain assessments
Throughout the course of treatment, children should have ongoing assessments and re-assessments of pain and distress and the appropriateness of interventions should be re-assessed to determine the continued effectiveness of strategies to reduce procedural pain and distress (ungraded good practice statement).
Intervention effectiveness may vary over the course of a child's cancer treatment, and their preferences and capabilities might change. A child's willingness to accept certain interventions is among other things influenced by the pain and distress experienced during past procedures. This may not have a linear trajectory. For instance, a negative procedure experience (e.g. more distressing, multiple attempts before success) can provoke increased levels of fear, which may call for a different approach with regard to managing procedural pain and distress in the future.
3.5 Recommendations for research
The panel identified several evidence gaps (refer Supplemental Materials S4 and S5). Overall, the panel calls for large, multicenter RCTs that evaluate the critical outcomes defined in this guideline. In particular, head-to-head intervention comparison trials and cost-effectiveness trials for sedation drugs, use of nitrous oxide, virtual reality for distraction and trials in which different combinations of treatment modalities are compared are needed. Developing specific guidance for children with developmental disorders would also be of interest.
Future studies should take into account the long treatment trajectories with repeated procedures that children with cancer often undergo. Most current studies focus on one procedure. However, an intervention can be effective for one procedure but ineffective over time due to increases in pain and/or distress. Therefore, longitudinal design studies taking into account pain and distress over multiple procedures and other relevant outcomes such as psychological sequelae, compliance behavior and quality of life are needed.
The patient-parent panel emphasised that attention should be placed on identifying optimal ways to put the child in charge of their own procedure experience. Children should be fully and optimally facilitated to explore possibilities and formulate their own approach to pharmacological and psychological management of procedure-related pain and distress, within the boundaries of what is clinically possible and appropriate.
4. Discussion
Throughout the course of treatment, children with cancer undergo frequent, repeated procedures that are associated with high levels of pain and distress [
]. In this CPG, we have formulated recommendations to reduce pain and distress during these procedures to improve health-related quality of life for children with cancer and their families.
This CPG endeavor benefited from an international and interprofessional CPG development panel. We believe this contributed significantly to the international applicability of the recommendations. However, we included only one healthcare professional from a non–high-income country. Although some of the recommendations are feasible in lower income settings (e.g. use of distraction), this may not be the case for all recommendations. We have provided detailed evidence summaries, accompanying EtD frameworks, transparent reports of the justification for each recommendation and implementation considerations to facilitate local adaptation of the recommendations.
Use of the rigorous methodology of the GRADE working group increases the credibility of our recommendations [
]. Inclusion of patients and parents in the recommendation formulation process and integrating their perspective increased the applicability and usefulness of our recommendations. The panel placed high value on using a patient-centered approach, as is also increasingly promoted [
Evaluating patient-centered outcomes in clinical trials of procedural sedation, Part 1 efficacy: sedation consortium on endpoints and procedures for treatment, education, and research recommendations.
This CPG is limited by the scarcity of direct evidence available to address our clinical questions. Few high-quality studies have been performed that focus on alleviating procedural pain in children with cancer. The GRADE group acknowledges the frustration of clinicians when a CPG does not succeed in providing guidance, and therefore encourages guideline developers to attempt to formulate recommendations even when confidence in the effect estimate is low [
]. The scarcity of direct evidence calls for high-quality RCTs to be conducted in this field.
In addition, there might be subgroups of patients for whom these recommendations might not be applicable and who could benefit from recommendations tailored to their specific situation. For example, this might be true for children with severe procedural distress/needle phobia.
Pain and distress from repeated procedures is often a great burden for children with cancer and their families. Our group has formulated recommendations to guide healthcare professionals in daily practice, aimed at reducing this suffering. It is critical that clinicians recognise the great between-patient variability in the severity of procedural pain and distress. Therefore, tailoring our recommendations to the individual child is of utmost importance. This approach will result in improved care for children with cancer undergoing painful procedures, thereby reducing suffering and potentially enhancing health-related quality of life.
Disclaimer
The views expressed in the submitted article are those of the authors and might not reflect the official position of their institution or the funding source.
Funding source
The project ‘Towards evidence-based guidelines for supportive care in childhood oncology’ is supported by the Alped’HuZes foundation/Dutch Cancer Society (RUG 2013–6345). The funding source had no role in the study design, in the preparation of the manuscript or in the decision to submit the manuscript for publication.
Financial disclosure
The authors have no financial relationships relevant to this article to disclose.
Conflict of interest statement
The authors have no conflicts of interest relevant to this article to disclose.
Acknowledgements
The authors thank the Dutch pediatric oncology patient and parent association ‘VerenigingOuders, Kinderen en Kanker’ for playing an active role in the recruitment of parent representatives. In addition, the authors thank Edith Leclercq (passed away in 2018) and Cochrane Childhood Cancer for assistance in designing and commencing the literature searches. Lastly, the authors thank the iPOG network for helping in member recruitment and providing the international network to learn and benefit from one another in developing and implementing childhood cancer supportive care guidelines.
Appendix A. Supplementary data
The following are the Supplementary data to this article:
GRADE Evidence to Decision (EtD) frameworks: a systematic and transparent approach to making well informed healthcare choices. 2: Clinical practice guidelines.
Guidelines for monitoring and management of pediatricpatients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016.
Randomized clinical trial of local anesthetic versus a combination of local anesthetic with self-hypnosis in the management of pediatric procedure-related pain.
Heal psychol [internet].2006; 25 (Washington, District of Columbia: American psychological association): 307-315
A randomized controlled prospective outcome study of a psychological and pharmacological intervention protocol for procedural distress in pediatric leukemia.
Evaluating patient-centered outcomes in clinical trials of procedural sedation, Part 1 efficacy: sedation consortium on endpoints and procedures for treatment, education, and research recommendations.
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