Assessment and treatment of pediatric behavioral sleep disorders in Canada.

OBJECTIVES/BACKGROUND: This paper outlines the current state of Canadian training, clinical services, research, and advocacy initiatives related to non-respiratory sleep disorders, with a specific focus on insomnia, the most common sleep problem in children. METHODS: Information for this narrative review was collected from peer-reviewed publications, web-resources, and personal communications and experiences. RESULTS: It is estimated that approximately one-third of Canadian children and youth present with insomnia, and that this is impacting their physical and mental health, as well as learning in school. Training in pediatric sleep is limited and highly inconsistent within and across disciplines. While there are some publicly and privately funded pediatric sleep services available, these are mostly focused on respiratory sleep problems and are not equally accessible across the country. CONCLUSIONS: Pediatric assessment and treatment services for non-respiratory sleep disorders needs to be more integrated into the Canadian health care system.

Insomnias of childhood and adolescence.

Childhood insomnias (CI) are a diverse group of sleep-related problems that present across the first 2 decades of life, ranging widely in severity. Little is understood about the origins of CI which are likely heterogeneous. Nevertheless, effective treatments for younger children have been shown to be efficacious. Defined within a development framework, this article reviews common correlates and causes of CI during the first two decades. A practical approach to the evaluation and treatment of insomnias among children and youth is presented.

How to obtain excellent response rates when surveying physicians.

This paper outlines ways to maximize response rates to surveys by summarizing the most relevant literature to date and demonstrating how these techniques have resulted in consistently high rates of return in family practice research. We describe the methodology used in recent surveys of physicians conducted by the Centre for Studies in Family Medicine through its Thames Valley Family Practice Research Unit, located in London, Ontario, Canada and funded by the Ontario Ministry of Health and Long-Term Care. The identification and implementation of these techniques to maximize response rates is critical, as primary health care researchers often rely on information gathered through questionnaires to study physicians' practice profiles, experiences and attitudes. Four separate and distinct mailed surveys of physicians using a modified Dillman approach were conducted from 2001 to 2004. The sampling strategies, topics, types of questions and response formats of these surveys varied. The first survey did not use any incentives or recorded delivery/registered mail and received a response rate of 48%. In sharp contrast, the other three surveys obtained responses rates of 76%, 74%, 74%, respectively, achieved through the use of gift certificates and recorded delivery/registered mail. Sending a survey by recorded delivery/registered mail tends to result in the survey package being given priority in the physicians' incoming mail at the practice. Gift certificates partially compensate physicians for time spent completing the survey and recognition of the time required is appreciated. The response rates achieved provide strong evidence to support the use of monetary incentives and recorded delivery/registered mail (along with the Dillman approach) in survey research. It is anticipated that this evidence will be used by other researchers to justify requests for funding to cover the costs associated with incentives and recorded delivery/registered mail. We recommend the use of these strategies to maximize response rates and improve the quality of this type of primary health care research.

Subepithelial apoptosis in normal caecal biopsy specimens is primarily an age-related phenomenon.

AIMS: To determine whether prominent subepithelial apoptosis in otherwise normal caecal endoscopic biopsy specimens has any clinical significance. METHODS AND RESULTS: Calculating the average number of subepithelial apoptotic bodies per intercrypt space [i.e. a subepithelial apoptotic index (SAI)] was found to reflect accurately and reproducibly the density of subepithelial apoptosis in a colonic biopsy specimen. The SAIs of 124 histologically normal caecal biopsy specimens from adult patients showed a positively skewed normal distribution without bimodality. The clinical details of patients with specimens in the top quartile of this distribution were compared with those of patients in the bottom quartile. Patients in the top quartile were found to be older and more likely to suffer with ulcerative colitis than those in the bottom quartile. However, controlling for age removed the association between SAI and ulcerative colitis. The SAIs of 144 caecal biopsy specimens (including 20 paediatric cases) showed a positive correlation with patient age. CONCLUSIONS: Subepithelial apoptosis in normal caecal biopsy specimens appears to be an age-related phenomenon with no demonstrable clinical significance.

Facial expression of children receiving immunizations: a principal components analysis of the child facial coding system.

OBJECTIVE: To identify the structure of facial reaction to procedural pain and to determine the subset of facial actions that best describe the response. DESIGN: Observational. SETTING: Five rural and five urban physicians' offices. PATIENTS: One hundred twenty-three children aged 4 to 5 years undergoing routine diphtheria, pertussis, tetanus, and polio immunization. OUTCOME MEASURES: The Child Facial Coding System, comprising 13 discrete facial actions, was used to code each second of five 10-second phases from videotape: baseline, preneedle, needle, postneedle, and posthandling. Parents and a technician provided visual analog scale ratings of children's pain. Children provided a self-report using a Faces Pain Scale, and parents and nurses rated the children's pain and anxiety using visual analog scales. RESULTS: A "pain face" similar to that reported in adults emerged with the onset of pain. Principal component analyses revealed the frequency and intensity of facial action during the needle phase could be represented by components reflecting pain sensation, a "brave face," and the children's expectations for pain. Children's Faces Pain Scale and adult visual analog scale ratings were best predicted by components reflecting pain sensation and expectations of high pain. CONCLUSIONS: These results provide a preliminary indication that the Child Facial Coding System can be reduced to components that reflect several aspects of children's acute pain experience and predict self-reports and observer reports of children's pain.

A randomized double-blind, placebo-controlled trial of the EMLA patch for the reduction of pain associated with intramuscular injection in four to six-year-old children.

UNLABELLED: The effectiveness of a eutectic mixture lidocaine-prilocaine topical anaesthetic cream (EMLA) patch compared with a placebo patch in the reduction of pain associated with intramuscular immunization was evaluated. As part of the study, 161 children (aged 4-6-y) undergoing routine diphtheria, pertussis, tetanus and polio (DPTP) immunization in five urban and five rural private office settings were randomly assigned to an EMLA patch (n = 83) or a placebo patch control group (n = 78). Pain measurements included: child's self-report on a Faces Pain Scale; facial action on the Child Facial Coding System; the Children's Hospital of Eastern Ontario Pain Scale and parent and technician ratings on a Visual Analogue Scale. Parents also rated their own and their child's immunization-related anxiety on a Visual Analogue Scale. The EMLA patch group had significantly less pain on all four pain measures compared with the placebo group. Of the children in the placebo group, 43% had clinically significant pain, compared with 17% of children in the EMLA patch group. No severe adverse symptoms occurred as a result of either EMLA or placebo patch application. CONCLUSION: The EMLA patch reduced immunization pain in 4 to 6-y-old children during needle injection.

Comparison of infrared spectroscopic and fluorescence depolarization assays for fetal lung maturity.

OBJECTIVE: Infrared spectroscopic analysis of amniotic fluid was recently shown to be a potential useful method for the determination of fetal lung maturity. Those studies used thin-layer chromatography as a reference method for the calibration of the infrared-based technique. However, thin-layer chromatography is compromised by large intra-assay and interlaboratory coefficients of variation. Therefore in this study we have used a reference method that is based on fluorescence depolarization, the TDx FLM II assay, to verify the sensitivity and precision of infrared spectroscopy for assessment of fetal lung maturity status. STUDY DESIGN: Samples of amniotic fluid were obtained by amniocentesis from 101 patients between the 24th and 40th weeks of pregnancy. Small volumes (35 microL) of amniotic fluid specimens were dried, and the infrared spectra were measured with a commercial infrared spectrometer. The fetal lung surfactant/albumin ratio was determined separately for each specimen with the TDx FLM II assay. The proposed infrared method was then calibrated and tested with a partial least-squares regression analysis to quantitatively correlate the infrared spectra with the surfactant/albumin ratios provided by the TDx FLM II assays. RESULTS: A total of 144 training spectra were used to build the partial least-squares calibration model. The correlation coefficient for the training set was excellent (r = 0.92), with an SE between infrared-predicted and reference surfactant/albumin ratios of 17 mg/g. The model was then validated on a set of 69 test spectra and yielded an SE of 14 mg/g (r = 0.86). The final partial least-squares model included the 900- to 1500-cm(-1) and 2800- to 3200-cm(-1) spectral ranges and 6 partial least-squares factors. CONCLUSION: Because the infrared-based fetal lung maturity measurements correlated well with assays from both of the current standard clinical techniques (thin-layer chromatography and fluorescence depolarization) and the procedure is less labor and training intensive, we concluded that infrared spectroscopy has the potential to emerge as the method of choice for prediction of fetal lung maturity from amniotic fluid analysis.

Placental expression of glucose transporter proteins 1 and 3 in growth-restricted fetal rats.

OBJECTIVE: The purpose of this study was to determine the effect of intrauterine growth restriction on the placental expression of glucose transporter proteins. STUDY DESIGN: Intrauterine growth restriction was induced by bilateral uterine artery ligation in the pregnant rat at a gestational age of 19 days (term is 21.5 days). Maternal rats were killed and fetuses were delivered by hysterotomy on gestational days 20 and 21. Control fetuses from mothers that had been subjected to a sham operation were studied simultaneously. Glucose transporter protein 1 and glucose transporter protein 3 messenger ribonucleic acid was quantified by reverse transcriptase-polymerase chain reaction amplification. Glucose transporter protein 1 and glucose transporter protein 3 densities in placental membranes were also assessed by Western blotting and by immunohistochemical analysis. RESULTS: Glucose transporter protein 1 messenger ribonucleic acid, expressed as a multiple of the matched sham control value, was unchanged on both days 20 and 21 of gestation. Glucose transporter protein 3 messenger ribonucleic acid was also unchanged. Western blotting demonstrated no change in expression of glucose transporter protein 1 or glucose transporter protein 3 on either day 20 or 21 of gestation. Immunohistochemical staining patterns for glucose transporter protein 1 and glucose transporter protein 3 on the syncytiotrophoblastic membranes were similar between the growth-restricted group and the sham control group. CONCLUSION: Placental expression of glucose transporter proteins in the pregnant rat is unchanged with uteroplacental insufficiency.

The Pain Coping Questionnaire: preliminary validation.

A new measure of coping, the Pain Coping Questionnaire (PCQ), is presented and validated in two studies of children and adolescents. Factor analyses of data from healthy children and adolescents supported eight hypothesized subscales (information seeking, problem solving, seeking social support, positive self-statements, behavioral distraction, cognitive distraction, externalizing, internalizing/catastrophizing) and three higher-order scales (approach, problem-focused avoidance, emotion-focused avoidance). The subscales and higher-order scales were internally consistent. The pain coping scales were correlated in the expected directions with children's appraisals of pain controllability, self-rated coping effectiveness, emotional distress when in pain, and among high school students, pain thresholds and functional disability. The structure and internal consistency of the PCQ were replicated in a sample of children and adolescents experiencing recurrent pain (headache, arthritis), and their parents. Relations between child- and parent-ratings of children's coping were moderate (median r=0.34). Higher levels of emotion-focused avoidance were related to more emotional distress (both samples), less coping effectiveness (headache sample), and higher levels of pain (arthritis sample). Higher levels of approach coping were related to less disability (headache sample). Other relations between approach and distraction coping and the outcome variables were generally not significant. The PCQ is a promising instrument for assessing children's pain coping strategies. The items are simple and relatively few, making it useful for assessing coping across a wide age range. It can be administered to children as young as 8 years of age in approximately 15 min.

Differences in heartbeat awareness among males with higher and lower levels of systolic blood pressure.

Recent empirical findings related to the baroreceptor hypothesis indicate that elevated heart rate, pulse pressure, and blood pressure may dampen exteroception and interoception. We thus predicted that persons with elevated systolic blood pressure would be less able to accurately perceive their heartbeats and profit from feedback training. This study examined the plausibility of this hypothesis by exposing 57 male students (11 with elevated SBP levels and 46 with normotensive SBP levels) to the Whitehead heartbeat perception task with, and without, feedback training. Results indicated that participants with elevated SBP levels were more able to accurately perceive their heartbeats prior to, and after, feedback training. Participants with elevated SBP levels also showed a significant increase in heartbeat perception accuracy when they were provided with feedback training while participants with normotensive blood pressure levels did not show a significant response to feedback training. These findings are interpreted in terms of the ballistic perception model of cardiac awareness.

Agreement between child and parent reports of pain.

OBJECTIVE: Parents are often the primary source of information regarding their children's pain in both research and clinical practice. However, parent-child agreement on pain ratings has not been well established. The objective of the present study was to examine agreement between child- and parent-rated pain following minor surgery. SETTING: Tertiary care children's hospital. PARTICIPANTS: A total of 110 children (56.4% male) aged 7-12 years undergoing surgery and their parents. OUTCOME MEASURES: Parents and children independently rated pain intensity by using a 7-point Faces Pain Scale on the day of the child's surgery and the following 2 days. RESULTS: Correlations (both Pearson's and intraclass correlation coefficients) indicated a highly significant relationship between child and parent ratings. However, kappa statistics indicated only poor to fair agreement beyond chance. Parents tended to underestimate their children's pain on the day of surgery and the following day, but not on the second day following surgery. When children's and parents' pain ratings for each of the 3 days were collapsed into a no-pain/low-pain group or a clinically significant pain group, kappa statistics indicated fair to good agreement. Parents demonstrated low levels of sensitivity in identifying when their children were experiencing clinically significant pain. CONCLUSIONS: Correlations between parent and child pain reports do not accurately represent the relationship between these ratings and in fact overestimate the strength of the relationship. Parents' underestimation of their child's pain may contribute to inadequate pain control.

Accuracy of children's pain memories.

Despite its importance in clinical practice, little research has examined memory for pain in children. This prospective study tried to justify the use of children's pain recall in clinical practice. The purpose of this study was to (a) investigate the accuracy of children's recall of their worst and average pain intensity when controlling for the effects of repeated pain measurement and (b) examine the influence of children's anxiety, age, general memory ability and pain coping strategies on this accuracy. The accuracy of children's recalled pain intensities was studied in 55 inpatients aged 5-16 years by comparing the level of recorded pain intensity with the level of recalled pain intensity 1 day and 1 week after recording using Bieri's Faces Pain Scale. The accuracy of children's recalled pain intensities was high and showed little decrement over 1 week. Older children had more accurate recall of their worst pain intensity. Anxiety, general memory ability and pain coping strategies were not related to accuracy of recalled pain intensities.

Self-administration of over-the-counter medication for pain among adolescents.

OBJECTIVE: To examine over-the-counter (OTC) medication use and self-administration of medication among adolescents. DESIGN: In-person survey. SETTINGS: Three public junior high schools in Halifax, Nova Scotia. PARTICIPANTS: Six hundred fifty-one junior high school students (7th, 8th, and 9th grades). MAIN OUTCOME MEASURES: A questionnaire regarding OTC medication use and self-administration for head: stomach; ear and throat; muscle, joint, and back; and menstrual pains. RESULTS: Of those who reported taking medication, many adolescents (58.7%-95.9%) reported taking OTC medications for each pain. Medications and knowledge about medications were obtained from a variety of sources, primarily parents. Self-administration was widespread; 58.3% to 75.9% of adolescents reported taking an OTC medication for pain without first checking with an adult in the previous 3 months. Self-administration of medication without the knowledge of adults increased significantly from grades 7 to 9 for all types of pain. Girls tended to self-administer medication more than boys. Higher levels of pain frequency and intensity were related to higher levels of self-administration for all pains except muscle, joint, and back pain. Adolescents reported that they began to self-administer medication between the ages of 11 and 12 years. CONCLUSIONS: Although a relatively responsible picture of self-administration of medication emerges, some adolescents engaged in inappropriate OTC medication use (eg, the common use of aspirin), highlighting the importance of providing adolescents with correct information about these medications.

Primary juvenile fibromyalgia: psychological adjustment, family functioning, coping, and functional disability.

OBJECTIVES: 1) To determine the importance of psychological adjustment and family functioning in primary juvenile fibromyalgia by assessing these factors in children with fibromyalgia and in their parents, compared with children with juvenile rheumatoid arthritis (JRA) and with pain-free control children and their parents. 2) To examine which of these factors predict functional disability. METHODS: Fifteen children in each of the 3 study groups, and their parents, completed self-report questionnaires and pain diaries. A medical evaluation of each child was performed, including assessment of tender points by palpation and by dolorimetry. RESULTS: All children in the fibromyalgia group met the Yunus and Masi criteria for fibromyalgia, and 11 met the American College of Rheumatology criteria. There were almost no significant group differences in the children's or parents' psychological adjustment, ratings of family functioning, or coping strategies. Significant group differences in functional disability, pain, fatigue, tender point threshold, and control point tolerance were found. A number of the psychological adjustment, pain, fatigue, and coping variables were significantly associated with functional disability. CONCLUSION: The notion that fibromyalgia is a psychogenic condition is not supported by these results. Fibromyalgia is associated with disability of a magnitude comparable to that of other chronic pain conditions. Disability among children with fibromyalgia or JRA is a function of the children's psychological adjustment and physical state, and of the parents' physical state and method of coping with pain.

Coping with pain and surgery: children's and parents' perspectives.

This article examines relations between coping with general and postoperative pain. Children's and parent's coping ratings, and the contribution of temperament and coping to postoperative adjustment. Before and after day surgery, 7-to 12-year-olds (n = 124) rated their coping with pain. Parents rated their child's coping and temperament pain and distress were rated on the day of and 2 days following surgery. Coping with general and postoperative pain were moderately correlated (median r = .48). Except for distraction, all types of coping strategies were used more frequently for general than postoperative pain. Correlations between child and parent coping ratings were moderate (median r = .36). After controlling for emotionality and medications, lower levels of emotion-focused avoidance and higher levels of distraction were related to lower pain and distress. After controlling for a priori surgical group (no-low pain; moderate-high pain), emotionality, and medications, lower levels of emotion-focused avoidance were related to lower pain and distress but distraction was no longer significant in a number of the regressions. Coping with pain has trait-like qualities but differences in the nature and context of pain create differences in strategy use. Level of pain appears to influence the type of coping strategies used. Interventions should target children's use of distraction and minimize us of emotion-focused avoidance.

Development and preliminary validation of a postoperative pain measure for parents.

Parents are now primarily responsible for the at home assessment and treatment of their children's pain following minor surgery. Although some research has suggested that parents underestimate their children's pain following surgery, no behavioral measure exists to assist parents in pain assessment. The Postoperative Pain Measure for Parents was developed based on cues parents reported using to assess their children's pain (e.g. changes in appetite, activity level). The purpose of the present study was to develop and validate this measure by examining the relation between parent-report of child behaviors and child-rated pain. Subjects were 110 children (56.4% male) aged 7-12 years undergoing day surgery at a tertiary-care children's hospital and their parents. Parents and children completed a pain diary for the 2 days following surgery. Children rated their pain and emotional distress and parents rated the presence or absence of specific behaviors from a checklist. Correlations were conducted between each of the 29 behavioral items and child-rated pain on Day 1; 14 items with correlations less than 0.30 were dropped. The remaining 15 items were subjected to a principal axis factor analysis. A one-factor solution was the best fit for the data. The items were then summed to yield a total score out of 15. Internal consistency reliabilities for the measure and correlations with child-rated pain were high on both days following surgery. Child-rated pain and emotional distress were moderately correlated. The Postoperative Pain Measure for Parents was also positively correlated with child-rated emotional distress on both days following surgery. As child-rated pain decreased from Day 1 to Day 2, so did scores on the behavioral measure. The Postoperative Pain Measure for Parents was successful in discriminating between children who had undergone no/low pain surgeries and children who had undergone moderate to high pain surgeries. There were no significant differences in scores on the behavioral measure for child age or sex. Using a cut-off score of six out of 15, the measure showed excellent sensitivity (> 80%) and specificity (> 80%) in selecting children who reported clinically significant levels of pain. This study provides preliminary evidence for the use of the Postoperative Pain Measure for Parents as a valid assessment tool with children between the ages of 7-12 years following day surgery. It is internally consistent and strongly related to child-rated pain. Future research should explore the use of this measure with a younger sample and children with developmental delays.

Psychological treatments for migraine.

Psychological and behavioral treatments for migraine are described and evidence for their efficacy is reviewed. Treatments for children, adolescents, and the elderly, and for menstrual migraine are then discussed. Biofeedback, relaxation, and stress-coping treatments have all demonstrated effectiveness. These treatments are effective for the majority of migraine sufferers and treatment effects are reliably maintained for periods of at least one year. Little is known about the mechanism behind the efficacy of psychological treatments. Suggestions for future research on treatment mechanisms, enhancement of treatment effectiveness, and increasing the acceptance of psychological treatments are provided.

Cues parents use to assess postoperative pain in their children.

OBJECTIVE: Very little is known about the cues parents use to assess pain in their children. This study has described the cues (verbal and nonverbal) parents reported using to determine how their children felt following surgery. DESIGN AND SUBJECTS: The subjects were 176 parents of children undergoing short-stay or day surgery. Using pain diaries, parents were asked to provide written responses to the question "Did your child give you any clues on how they were feeling?" for the day of surgery and 2 days after their children's surgery. Parents also provided ratings of their children's pain five times per day using a visual analogue scale. SETTING: The study was conducted at a tertiary care children's hospital. RESULTS AND CONCLUSIONS: Parents frequently cited using verbal report and appetite as cues to how their children were feeling. A variety of other cue types were also reported by parents, including activity level, sleep quality, visible/audible discomfort, and physiological observations. Cue types were not significantly related to the child's gender, and only one cue type was significantly related to the child's age (appetite was used more often for older children than younger children). The presence or absence of illness behavior cues (e.g., protective behavior, visible/audible discomfort) as well as disruptions to normal behavior pattern cues (e.g., sleep, level of activity) was related, in the expected direction, to the pain intensity ratings. This study provides insights into the cues parents use to assess pain in their children and serves as a foundation for future studies on parents' assessment of children's pain.

A trial of pulsatile versus continuous oxytocin administration for the induction of labor.

The objective of this study was to compare the efficacy and complications of intermittently pulsed oxytocin administration with continuous infusion in the induction of labor. Patients undergoing scheduled induction of labor at term were randomized to a pulsatile group in which oxytocin was infused in boluses every 8 minutes or to a control group in which oxytocin was administered through a conventional continuous intravenous infusion. A total of 38 patients were studied. The groups were similar with respect to parity, gestational age, indication for induction, preinduction Bishop's score, and the use of prostaglandin gel for cervical ripening. The average induction-to-delivery interval was similar in both groups (14 hours). The frequency of uterine hyperstimulation was similar in both groups, as was the frequency of uterine of decreases in the rate of oxytocin infusion for any reason. The rate of cesarean delivery was similar (three in each group). The frequency of failed induction was similar with three in the pulsatile group and none in the continuous group. Pulsatile infusion of oxytocin was as efficacious as continuous infusion. However, it seems to offer no clinical advantage in this situation.