733694

research-article2017

CPJXXX10.1177/0009922817733694Clinical PediatricsGates et al

Original Article

Procedural Pain: Systematic Review of Parent Experiences and Information Needs

Clinical Pediatrics 1­–17 © The Author(s) 2017 Reprints and permissions: sagepub.com/journalsPermissions.nav https://doi.org/10.1177/0009922817733694 DOI: 10.1177/0009922817733694 journals.sagepub.com/home/cpj

Allison Gates, PhD1, Kassi Shave, MSc1, Robin Featherstone, MLIS1, Kelli Buckreus, MA1, Samina Ali, MDCM1, Shannon D. Scott, PhD1, and Lisa Hartling, PhD1

Abstract Parents wish to reduce their child’s pain during medical procedures but may not know how to do so. We systematically reviewed the literature on parents’ experiences and information needs related to managing their child’s pain for common medical procedures. Of 2678 records retrieved through database searching, 5 were included. Three additional records were identified by scanning reference lists. Five studies were qualitative, and 3 were quantitative. Most took place in North America or Europe (n = 7) and described neonatal intensive care unit experiences (n = 5). Procedures included needle-related medical procedures (eg, venipuncture, phlebotomy, intravenous insertion), sutures, and wound repair and treatment, among others. Generally, parents desired being present during procedures, wanted to remain stoic for their child, and thought that information would be empowering and relieve stress but felt unsupported in taking an active role. Supporting and educating parents may empower them to lessen pain for their children while undergoing medical procedures. Keywords procedural pain, emergency medicine, information needs, pediatrics, parents, acute care

Introduction Children frequently undergo painful medical procedures when receiving acute care.1,2 The management of resultant procedural pain has been identified as a key health care priority3-6 and is an essential component of familycentered care.7 Procedures regularly carried out in acute care settings, including venipuncture, intravenous insertion, and wound irrigation and repair are among the most common sources of acute pain experienced by children.1 Although evidence for the use of pharmacological (eg, topical anesthetic, sucrose), physical (eg, breastfeeding, nonnutritive sucking, swaddling), and psychological (eg, distraction, hypnosis) interventions to manage procedural pain has been widely advocated in the published literature,8 their implementation in practice is lacking.9 Inadequately managed procedural pain has been associated with significant short- and long-term consequences for children and their parents. In the short term, children often face preventable pain and distress that can complicate and extend hospital visits.10,11 Children who experience inadequately managed procedural pain are

more likely to exhibit altered pain responses, somatic symptoms, anxiety about medical procedures, and health care avoidance behaviors later in life.12,13 Importantly, it can also be very distressing for parents to watch their child experience pain.14 Components of family-centered care include involving parents in decisions about their child’s care whenever possible, incorporating the family’s knowledge and preferences into the child’s treatment plan, and educating the family to facilitate active involvement in the child’s care.7 This approach to care posits that parents and families have an important role to play in the health care of children, including the management of their distress and pain during medical procedures. Nevertheless, many parents do not know how to effectively comfort or distract their child during a medical procedure or do not 1

University of Alberta, Edmonton, AB, Canada

Corresponding Author: Lisa Hartling, Department of Pediatrics, Edmonton Clinic Health Academy 4-472, University of Alberta, 11405-87 Avenue, Edmonton, AB T6G 1C9, Canada. Email: [email protected]

2

Clinical Pediatrics 00(0)

feel confident doing so.15-21 Knowledge translation tools may empower parents to take an active role in managing their child’s procedural pain. Parents of children who visit the emergency department (ED) face exceptional challenges because the procedures are usually unplanned, they are not prepared to see their child in pain, and care teams are constantly changing. A previous study by members of the research team investigated experiences of intravenous insertions and venipuncture among parents who visited the ED at 1 pediatric tertiary care center.22 That small study highlighted parents’ desire for more information about managing procedural pain; however, the findings could not be generalized. To guide the development of knowledge translation tools for parents, we undertook a systematic review to synthesize current knowledge of parents’ experiences and information needs relevant to simple, common medical procedures performed in or relevant to the ED setting. We sought to answer 2 key questions: 1. What are parents’ experiences in managing their child’s pain and distress during medical procedures commonly performed in, or relevant to, the ED setting? 2. What information do parents need to understand and manage their child’s pain and distress during medical procedures commonly performed in, or relevant to, the ED setting?

Materials and Methods The review was carried out between July and November 2016, following an a priori protocol and Preferred Reporting Items for Systematic Reviews and Metaanalyses (PRISMA) reporting standards.23 The review was registered with the International Prospective Register of Systematic Reviews (PROSPERO) on July 28, 2016 (CRD42016043698).

Experiences and Information Needs Experiences and information needs were operationalized for the purposes of this review as follows: A. Parent experiences included how they felt (eg, scared or calm, confident or nervous) and acted (eg, supportive or withdrawn) during and immediately before and after their child underwent a painful medical procedure. Experiences were subjective and personal and could include physical, emotional, and psychological sensations. B. Parent information needs included the content (ie, topic), mode of delivery (eg, electronic, paper-based, verbal), and amount of information that they desired to receive.

Search Strategy The search strategy combined subject headings and keywords for pain, emergency procedures1 and visits, parents, and information needs. Stevens et al1 elucidated the most common painful procedures experienced by children receiving acute care. In collaboration with the research team (which included researchers and clinicians with pain research [SA], methodology [LH], and knowledge translation [SDS] expertise), a medical research librarian (RF) developed and implemented a search strategy that would capture studies reporting on these procedures. The primary search was undertaken in July 2016, including electronic databases: Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid Medline Daily and Ovid Medline (1946 to Present), Ovid PsycINFO (1987 to Present), and CINAHL plus with Full Text via EBSCOhost (1937 to Present). These databases were chosen because they provide broad coverage of health and biomedical sciences, behavioral sciences, psychology, and mental health literature. The reference lists of included full-text records were scanned for articles that were not identified in the database searches. The authors of relevant conference abstracts were contacted via email to inquire as to the availability of related full-text records. Following initial study selection, PubMed via NCBI Entrez (electronic publications only) was searched in September 2016 to identify emergent research. We searched only for records published in the year 2000 or thereafter. The earliest review on procedural pain in children was conducted in 199924 and reported small sample sizes and inconsistent results. Moreover, studies published prior to 2000 may not be reflective of modern pediatric pain management practices, which have evolved since the time of the 1999 review.2,25 The full search strategy is shown in Appendix A.

Study Selection The search results were uploaded to EndNote (v. X7, Clarivate Analytics, Philadelphia, PA), and all duplicates were removed. After transferring the results to an Excel (v. 2016, Microsoft Corporation, Redmond, WA) workbook, 2 independent reviewers (AG, KS) screened the articles for inclusion, first by title and abstract and then by full text. Any disagreements with regard to study inclusion were resolved during a consensus meeting. Detailed inclusion and exclusion criteria are shown in Table 1. Early in the study selection process, the research team convened to refine the inclusion criteria to ensure that the studies selected would contribute to answering the key research questions. As such, the inclusion criteria described

3

Gates et al Table 1.  Inclusion and Exclusion Criteria for Study Selection. Characteristic

Inclusion Criteria

Exclusion Criteria

Study design

•• Primary research •• Qualitative or quantitative study designs

Publication date Language

•• Articles published from January 2000 to present •• Articles published in English

Population

•• Parents of infants, children, or youth aged 0 to 18 years receiving acute medical care •• Human populations

Proceduresd

Mildly (eg, oral and nasal suctioning), moderately (eg, dressing or tape removal, wound irrigation), and severely (eg, venipuncture, phlebotomy, intravenous insertion, lumbar puncture, suprapubic aspiration) painful procedures common to the emergency medicine setting1 Articles describing parent experiences immediately before and/or after, and/or during the painful procedure and their information needs with regard to managing their child’s distress and pain

Outcomes

•• Reviews and overviewsa •• Abstractsb •• Opinion pieces (ie, comments, editorials, letters) •• Articles published prior to January 2000 •• Articles published in any language other than English •• Parents of children with chronic diseases or conditions (eg, cancer, sickle cell anemia)c •• Animal studies Procedures less common to the emergency medicine setting (eg, vaccinations administered in the community), endoscopies, tracheotomies, procedural sedation, epinephrine autoinjectione Articles describing and/or evaluating tools or education programs that parents can use to manage their child’s distress and procedural pain

a

If the topic of a review or overview was relevant, the reference list was checked to identify relevant records for inclusion. The authors of relevant abstracts were contacted via email to inquire as to the availability of related full-text records. c Children with chronic conditions frequently experience painful medical procedures,1 and their parents develop coping mechanisms to deal with procedural pain and distress.26 Studies that focused exclusively on parents of children with chronic conditions were excluded. d Decided in consultation with a pediatric pain research specialist (SA). e Because there exists little time for pain prophylaxis in the event of an anaphylactic reaction,27 experiences associated with epinephrine autoinjectors were not relevant to this review. b

herein differ slightly from the original protocol. Ultimately, it was decided that articles describing parent experiences and information needs related to community-based vaccinations, and those that exclusively reported the experiences of parents whose children were living with chronic conditions would be excluded. Community-based vaccinations are routine and scheduled; thus, parents’ experiences and information needs related to these likely differ from unplanned procedures performed in acute care settings. Likewise, children living with chronic illnesses may frequently experience painful procedures,1 and their parents may develop unique coping skills to deal with this recurrent procedural pain and distress.26 Studies reporting on experiences related to epinephrine autoinjectors were also excluded. In the occurrence of an anaphylactic reaction, rapid treatment is crucial,27 leaving little time for education or pain prophylaxis. We included studies reporting on experiences and information needs relevant to procedures commonly performed in the ED, regardless of clinical setting. Studies examining the efficacy of interventions for reducing children’s distress and pain during acute care procedures have already been reviewed8 and were, therefore, excluded.

Data Extraction and Synthesis Using a form designed by the research team, 1 reviewer (AG) extracted relevant data from each study, including the following: authors, year of publication, study design, participants, clinical setting, painful procedure, outcomes measured, measurement tool or method, and main findings. A second reviewer (KS) verified the data extraction, checking for accuracy and completeness. All disagreements were resolved via discussion. Because this review includes both qualitative and quantitative studies, a tailored approach to data synthesis was used. For quantitative studies, the main findings were summarized descriptively. For qualitative studies, a thematic synthesis approach28 was used to generate analytical themes. Following the recommendations of Thomas and Harden,28 the “Results” or “Findings” section from each study was copied from the record and pasted into 1 Microsoft Office Word (v. 2016, Microsoft Corporation, Redmond, WA) document. One reviewer (KS) used inductive line-by-line coding to assign one or more codes to each line of text within each study.29 These were then synthesized into analytical categories or “themes.”29 To reduce the risk of interpretive bias, a

4

Clinical Pediatrics 00(0)

Figure 1.  Flow diagram of study selection.

second reviewer (AG) reread the text and appraised the coding. The 2 reviewers convened and agreed on the final analytical themes.

Quality of Evidence The methodological quality of each included study was assessed using tools tailored to qualitative and quantitative research designs. For qualitative studies, the Critical Appraisal Skills Programme (CASP) Qualitative Research Checklist30 was used. For quantitative studies, the Newcastle-Ottawa Scale31 was used. Because all the quantitative studies included in this review were crosssectional with a single data collection period, only selection of the study groups and ascertainment of the outcomes were assessed. Each study was awarded an

overall star value, up to a maximum of 4 stars. All appraisals were completed by 1 reviewer (AG) and verified by a second reviewer (KS) for errors and differences in interpretation. Discrepancies were resolved via discussion.

Results A total of 2678 unique records were identified via the search; 41 were selected following title and abstract screening, and 5 met the inclusion criteria following full-text screening. An additional 3 records were identified by scanning the reference lists of included articles. Of the 8 included records, 2 (25%) reported on the results of 1 larger research project. Figure 1 shows the flow of records through the selection process.

Gates et al

Study Characteristics Descriptive characteristics of the included studies are shown in Table 2. Five (62.5%) studies were qualitative, and 3 (37.5%) were quantitative. A variety of qualitative study designs were represented (eg, phenomenology, open-ended surveys); however, all the quantitative studies were cross-sectional surveys. The majority (n = 7; 87.5%) of studies took place in North America or Europe, with 5 (62.5%) in the United States and/or United Kingdom, 1 (12.5%) in Finland, and 1 (12.5%) in Sweden. The remaining (n = 1; 12.5%) study took place in India. In those studies where the data were reported (n = 7; 87.5%), the majority (n = 568/816; 69.6%) of participating parents were mothers. Five (62.5%) of the studies investigated painful procedures in the neonatal intensive care unit (NICU) setting. The remaining 3 studies investigated painful procedures in the pediatric intensive care unit (PICU; n = 1; 12.5%) setting, a general ED (n = 1; 12.5%), and mixed pediatric health care centers (n = 1; 12.5). Two (n = 25.0%) studies specified the painful procedure being investigated (needle-related medical procedures [NRMPs] and wound or injury repair procedures), whereas others investigated a number of painful experiences (including NRMPs, lumbar puncture, urinary catheterization, etc). Across the 8 studies, parents experiences and information needs were measured using a variety of means, including the following: study-specific surveys (n = 2; 25%); unobtrusive observations (n = 2; 25%); interviews (n = 3; 37.5%); focus groups (n = 1; 12.5%); and validated questionnaires (n = 3; 37.5%) including the Parental Stressor Scale, PICU (n = 1; 12.5%); the Parental Stressor Scale, NICU (n = 1; 12.5%); the Spielberger State-Trait Anxiety Inventory (n = 1; 12.5%); and the Parental Attitudes about Infant Nociception (PAIN) questionnaire (n = 2; 25%). Although no mixed-methods designs were identified, half of the studies used more than 1 approach to assess experiences and/or information needs.

Qualitative Findings The thematic synthesis revealed 4 main analytical themes related to parents’ experiences and information needs. The themes—(a) taking an active role, (b) maintaining self-control, (c) needing timely information, and (d) reconciling competing beliefs—were interdependent. For example, some parents’ ability to take an active role in their child’s management of procedural pain was dependent on having adequate information and being supported and encouraged by health care providers (HCPs).

5 Taking an Active Role. Although not universal, taking an active role in helping their child manage procedural pain was important to most parents. Most often, parents acted as their child’s principal support by guiding them through an experience filled with unknowns, sharing the trauma, and confirming their discomfort to provide validation of their experience. Taking on this role was rewarding for parents, who felt they knew their child best and were in the optimal position to provide comfort and distraction. Parents drew on their own experiences to determine what techniques might help their child and interpreted their body language to learn what helped them most. Integral to taking an active role, parents acted as communicators by facilitating their child’s understanding of what would happen through talk and play. Knowing that their child understood what would happen made parents feel more positive. Parents also acted as distractors to focus their child’s attention away from the procedure and as advocates by attempting to be involved in decision making. Although competing priorities (eg, caring for siblings) sometimes interfered with taking an active role, most parents believed that at least 1 parent should always be present during a painful procedure, even if for some reason the other could not. Maintaining Self-control.  Maintaining self-control during their child’s procedure was important for parents and represented a significant source of stress. Some parents tried to withhold their emotions, use positive body language, remain calm, and suppress their own fears for the better of their child. This could be very taxing, especially because few parents were prepared to see their child in pain or watch their child’s painful procedure. Some parents worried that remaining stoic would show their child that it was not okay to cry or to feel pain. Others worried that their child would resent them in the future for having to have undergone the procedure, or for showing little emotion. Conversely, an inability to control one’s body language invoked feelings of insecurity and insufficiency. For some parents, emotions (eg, a fear of needles) interfered with their ability to be present during a procedure, making them feel guilty or that they were not fulfilling their parental role. Losing control and not being able to adequately comfort one’s child could be just as stressful as maintaining self-control and withholding one’s emotions. This left some parents believing that someone else would be better suited to helping their child or that they were getting in the way of the HCPs. Needing Timely Information.  Parents need the right information if they are to feel comfortable and confident supporting their child through a painful procedure. Although most parents could identify which procedures were painful, some felt that they could not recognize when their child

6

Cross-sectional survey

Exploratory descriptive

Franck et al,16 2005

Gale et al,18 2004

Cross-sectional survey

Franck et al,17 2004 n = 257 Parents (71.6% mothers) of infants hospitalized in the NICU

n = 49 Parents (24.4% mothers) of children admitted to the PICU for at least 48 hours, without preexisting psychiatric illness

n = 80 Parents (71.3% mothers) of infants hospitalized in the NICU for >14 days

n = 12 Parents (91.7% mothers) of infants hospitalized in the NICU, or who had been discharged from the NICU in the past 2 years

n = 257 Parents (71.6% mothers) of infants hospitalized in the NICU

n = 34 Parents of children (1-16 years) presenting to the ED with minor injuries

n = 21 Parents (66.7% mothers) of children aged 3-7 years presenting with a nonacute or life-threatening illness

n = 140 Parents (76% mothers) of infants hospitalized in the NICU

Participants

Nine NICUs in the United Kingdom and 2 NICUs in the United States

PICU at a government-funded tertiary care center serving urban and rural critically ill children in India

Two level-IV NICUs at northeastern US hospitals (total 128 beds)

Two NICUs in London (UK)

Nine NICUs in the United Kingdom and 2 NICUs in the United States

Two EDs serving both adults and children in England

Rural and urban health care units: child health care services; pediatric primary care services; pediatric inpatient and outpatient care in Sweden

Four level-III and 3 level-II NICUs at 4 university hospitals in Finland

Setting

Painful procedures in the PICU, including NRMPs, nasogastric tube insertion, urinary catheterization, and other invasive procedures Painful procedures in the NICU

Painful procedures in the NICU

Painful procedures in the NICU, including NRMPs, suction catheters, dressing changes, lumbar puncture, and drainage tubes Painful procedures in the NICU, including NRMPs, eye exams, lumbar puncture

Minor wound and injury repair

NRMPs

Painful procedures in the NICU, including NRMPs

Procedure(s)

Abbreviations: ED, emergency department; NICU, neonatal intensive care unit; NRMPS, needle-related medical procedures; PICU, pediatric intensive care unit. a Articles are ordered from most to least recent within each category (qualitative or quantitative).

Cross-sectional survey

Aamir et al,32 2014

Cross-sectional survey

Not reported

Bentley,15 2005

Quantitative studies Vazquez et al,21 2015

Phenomenology

Cross-sectional survey

Study Design

Karlsson et al,19 2014

Qualitative studies Palomaa et al,20 2016

Author, Year

Table 2.  Characteristics of the Included Studies.a

Parents’ knowledge, selfefficacy and satisfaction regarding their infant’s pain management in the NICU Parental stress score (including personal, family, situational, and environmental stressors) Parents’ views on infant pain care and relations between parents’ experience of their infant’s pain care and parental stress

Parental perceptions of infant pain, how the staff managed their infant’s pain, and how they coped with their infant’s pain

Roles that parents adopt during a visit to the ED and the factors that concern them Parental views on infant pain care and information needs

Parents’ perceptions of factors that influence their participation in pain alleviation in the NICU The meaning of supporting children during NRMPs for parents

Outcome(s) Measured

Parental Stressor Scale: NICU; Spielberger StateTrait Anxiety Inventory; Parental Attitudes about Infant Nociception (PAIN) questionnaire

Hindi version of the Parental Stressor Scale: PICU

Study-specific, 24-item survey

Focus groups and individual interviews

Observations during procedures; face-to-face interviews; telephone follow-up interviews a few days following the procedures Unobtrusive observations in the ED; audiorecorded in-person interviews 1 week following the ED visit 12 Open-ended questions from the Parental Attitudes about Infant Nociception (PAIN) questionnaire

Pilot-tested questionnaires with open-ended questions

Measurement Tool/Method

7

Gates et al was in pain. Furthermore, many parents did not know what their child needed because few received guidance on procedural pain management. Not having the right information to guide their involvement in their child’s procedural pain management represented a serious barrier to their participation. Parents wanted information about pain and pain management and relied on HCPs to provide this information in a calm, supportive environment and without having to ask for it. For example, parents had difficulty absorbing new information during a procedure or in a noisy room with many distractions, and the opportunity to review information at a pace directed by the parent and child was not often provided. Some parents felt hesitant to ask questions or felt that they were getting in the way. Parents wanted information on what was going to happen and when so that they could be prepared and could prepare their child. They wanted to know about the short- and long-term impact of pain, how infants and children perceive pain as compared with adults, what causes pain and how it is measured, and what role they should undertake during the procedure. Knowledge was empowering for parents, facilitated their involvement, and relieved stress. Reconciling Competing Beliefs.  The perceived gap between their beliefs and the HCPs’ stance about the pain their child felt and how it should be managed was a point of contention for some parents. Parents sometimes felt underestimated by HCPs, that they were not invited or allowed to participate, and that they were not informed about procedures; sometimes, they were asked to leave the room. Parents did not want to seem like they were questioning professional judgment but became frustrated by multiple failed procedure attempts or by the perceived disregard by HCPs of their child’s pain. Some parents felt that there was a mismatch between how they perceived their child’s pain and how it was perceived by HCPs. Some parents believed that they were the only ones who could truly understand what their child was going through and expected HCPs to be gentler and more skilled and to acknowledge and appreciate their child’s pain in the same way that they did. Conversely, parents perceived that HCPs expected them to do most of the talking to comfort the child. HCPs need to know when to provide support, but also when to step back and let parents fulfill their desired role. For example, some parents felt more comfortable when the HCP took the lead; because preferences vary, an open line of communication and acceptance of parents’ views can support participation.

Quantitative Findings The findings of the quantitative studies substantiated the analytical themes from the qualitative synthesis and

added further insight into parents’ experiences. In the study by Vazquez et al21 (n = 80), although most parents could tell when their infant was in pain, only 59.6% (n = 34/57) of mothers and 47.8% (n = 11/23) of fathers knew which procedures were painful. Only 30.4% (n = 16/23) of fathers and 61.4% (n = 35/57) of mothers believed that they had the ability to lessen their infant’s pain. The majority (n = 59/76, 77.6%) of parents wanted to be present during painful procedures and thought it would be helpful to receive written information about their infant’s pain (n = 68/80, 85%). The results of the survey by Aamir et al32 (n = 49) showed that not being able to hold one’s child and HCPs using difficult words were the greatest contributors to stress (data not reported). The mean parental stress score was significantly affected by procedures on their children (P = .048).32 The survey by Franck et al17 (n = 257), which investigated parent experiences in the NICU, found that only 4.3% (n = 11/257) of parents received written information about infant pain management, 12% had often been present during painful procedures, 76% were never or not often asked if they wanted to be present during painful procedures, and most (87%) desired greater involvement in their infant’s pain care. Most (57%) desired being present during painful procedures.

Quality Assessment Most qualitative studies performed well on the CASP checklist (ie, n = 4 scored ≥7/10). All but 1 study15 (n = 4; 80%) included a clear statement of the aims or purpose. In all studies, the choice of qualitative methodology was appropriate. Nearly all (n = 4; 80%) studies used an appropriate research design; in 1 study15 (20%), the research design was not specified. In all but 1 study16 (n = 4; 80%), the description of the recruitment strategy was inadequate. Most commonly, a convenience sample was used, and data saturation was not mentioned. In nearly all studies (n = 4; 80%), appropriate data collection methods were used to address the research question; in 1 study15 (20%), the methods were scantily described and inadequately justified. In only 2 studies16,19 (40%) was there a discussion of the positionality and/or the relationship of the researcher to the participants; however, all studies adequately addressed ethical issues related to study participation. The data analysis was sufficiently rigorous in nearly all studies (n = 4; 80%); in 1 study15 (20%), the data analysis was described superficially. All studies included a clear statement of the findings, and all were ranked “very valuable,” with the exception of one15 (20%), which was ranked “somewhat valuable.” All quantitative studies ranked poorly on the Newcastle-Ottawa Scale adapted for cross-sectional

8 studies. No study received stars on participant selection. Potential for selection bias was apparent in all studies. All studies received 1 of a maximum of 3 stars on outcome assessment. Outcomes in all cases were selfreported, and the response rate was either less than 90% or not reported. Overall ratings were 1 out of a total of 4 stars for all studies.

Discussion Our search yielded few studies regarding parent experiences and information needs regarding their child’s pain related to procedures commonly performed in, or relevant to, the ED setting. Although many of the studies took place in NICUs and PICUs, we chose to include them because many of the procedures that neonates and children experience in these acute care settings are identical to those provided during acute care in the ED (eg, NRMPs, wound treatment, urinary catheterization). Furthermore, limiting the information to only the ED clinical setting would have resulted in an extremely small number of studies, given the current limited research in that setting. The small number of studies performed in the ED underscores the need for further research, and precludes definitive conclusions as to parents’ experiences and information needs specific to this context. Nevertheless, the records identified herein provide invaluable data that, when assessed collectively, begin to provide insight with regard to how parents feel and act and what information they desire when faced with the reality that their child will require a common, acutely painful medical procedure. Both parents and HCPs have a role in reducing the distress and pain that children experience during necessary medical procedures. From this review of parent experiences and information needs, it is evident that parents want to be involved in the management of their child’s procedural pain but do not always have the knowledge, experience, or support to do so.15-21 Timely, relevant information empowers parents to adopt a supportive role,15-20 helps them feel in control of the situation,19 and relieves their own stress.18 HCPs, as the main source of information for parents, should be understanding and supportive, take cues from parents’ body language, provide information freely, and invite parents to participate whenever possible.16,18-20 Parents have a need to feel validated in their role as their child’s principal protector.15,19 An inability to fulfill this role often ends in undue distress18,32 for already overwhelmed parents of an acutely ill or injured child. Parents’ expectations of the support and information they will receive from HCPs may not always be consistent with prevalent practices, meaning that those who

Clinical Pediatrics 00(0) expect HCPs to guide them through their child’s painful procedures are often left disappointed.16,19,32 For example, in many acute care contexts, policies and protocols are not in place to manage pediatric procedural pain.33 Evidence practice gaps in pediatric pain management9 could explain much of parents’ frustrations with their child’s treatment and the HCPs who provide it. There exist many reasons why evidence-based practices have not been adopted more universally; in acute care contexts, procedural pain management may not always be a top priority,9 given competing demands placed on HCPs. Specifically, ED nurses cite competing demands on time and limited knowledge as barriers to optimal pain management in pediatric populations.9,33-35 Evaluations of previously developed knowledge translation tools have confirmed that parents are receptive to information and that learning about procedural pain management strategies helps them feel more capable of comforting their child. “It Doesn’t Have to Hurt,” led by the Centre for Pediatric Pain Research (Nova Scotia, Canada), aims to increase parents’ uptake of clinical and academic pediatric pain management knowledge.36 One component of their strategy includes a social media campaign to facilitate discussions of children’s pain via blogs, videos, Twitter, Facebook, and images.36 The Help Eliminate Pain in KIDS (HELPinKIDS) Team, in collaboration with the University of Toronto, Canada, developed an educational pamphlet and 20-minute documentary film to teach parents pain-relieving strategies for vaccine injections.37 Exposure to the tools resulted in significant improvements in knowledge and confidence among participating parents.37 The Commitment to Comfort initiative at the Alberta Children’s Hospital (Alberta, Canada) aims to raise awareness and reduce pain by offering “comfort menus” on the types of pain management options available in the ED and bookmark-sized pain scales for children and parents to effectively describe pain. Anecdotally, the initiative has been effective in reducing dissatisfaction in pain care from 15% to 5%.38 It has been expanded to ~40 EDs provincewide. Preexisting knowledge translation tools provide a starting point for helping parents understand and manage procedural pain; however, these were not always designed for and may not be appropriate for use at the point of care. For example, it is unlikely that a parent will have the opportunity to mindfully watch a 20-minute film while awaiting their child’s painful procedure. Tailoring knowledge translation tools to different learning styles, levels of preexisting knowledge, and the setting in which they are designed to be used will be important if they are to be effective.39 In settings like the ED, visual tools like pamphlets, infographics, videos,

9

Gates et al coloring books, and posters may hold promise, and minimal use of text would make such tools accessible to most literacy levels and overcome the barrier of competing noise.40 Multimodal approaches and portable tools would allow for educational opportunities that could be adapted to many learning styles and environments.37 Information about what types of information would be useful to parents and in which format they would like to receive this information is needed to inform the development of knowledge translation tools. These data were distinctly lacking from the research reviewed herein. Although written information was cited as useful and desirable in 2 studies,16,18 both were published more than 10 years ago. Since this time, the use of smartphones and other portable devices (eg, tablets) has grown markedly.41 A 2015 survey42 found that nearly all parents search for information about their child’s health on the internet and use laptop computers, desktop computers, mobile phones, and tablets in almost equal proportions to do so. Making knowledge translation tools available in multiple formats (eg, digital, paper based) would likely increase accessibility, acceptability, and uptake.

Practice Implications HCPs should take cues from parents, acknowledge their desire to be present during painful procedures, and provide the guidance that they need to support their child. Parents feel a responsibility to protect their child from pain and distress, and HCPs can educate and support them to do so. Training for HCPs may be necessary to increase awareness and implementation of evidenceinformed methods to ease children’s pain and discomfort related to commonly performed medical procedures. Policies and protocols that bring evidence into practice, combined with strategies to empower the involvement of parents, have the potential to significantly reduce the pain that children must endure during necessary medical procedures.

Limitations We identified only 8 records, reporting on 7 studies of parents’ experiences and information needs. The majority of studies took place outside of the ED, investigated the experiences of mothers, and were focused on painful experiences in neonates, so the findings may not be generalizable to parents of older children or to fathers. Nevertheless, the findings are more likely to be generalizable to common painful procedures performed in a variety of contexts and not just the ED. The quantitative studies, though they substantiated the qualitative findings, were all cross-sectional surveys and inadequately

methodologically rigorous alone to inform knowledge translation strategies. The qualitative analysis was prone to subjectivity and interpretive bias; however, the coding was inductive, the researchers remained close to the data, and the analytical themes were confirmed by a second researcher, reducing this likelihood.

Conclusions This review confirms that there is limited literature on parents’ experiences and information needs with regard to managing their child’s distress and pain related to medical procedures commonly performed in, or relevant to, the ED setting. What evidence does exist suggests that knowledge empowers parents to take an active role, eliciting feelings of control and relieving stress. Nevertheless, parents generally feel unsupported in their efforts to comfort their child. Knowledge translation tools and changes to policies and protocols in acute care settings would go a long way toward helping parents take an active role in managing their child’s procedural pain. Tools should be based on comprehensive needs assessments and be evaluated and reported on to support more widespread dissemination of promising practices in this underdeveloped area of research.

Appendix A Search Strategy. Database: Ovid Epub Ahead of Print, In-Process & Other NonIndexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) 1946 to Present Date searched: July 15, 2016 Records retrieved: 2079  1.  Anxiety/  2.  Fear/   3.  exp Pain/   4.  Pain Perception/  5.  Panic/   6.  Stress, Psychological/   7. (afraid* or anxi * or fear* or distress* or pain* or panic* or scare* or scary or stress* or terrif*).tw,kf.   8.  or/1-7 [Combined MeSH & text words for pain]   9.  exp Administration, Intravenous/ 10.  Blood Specimen Collection/ 11.  Casts, Surgical/ 12.  exp Emergency Service, Hospital/ 13.  Fecal Impaction/ 14.  Gynecological Examination/ 15. Injections/ 16.  Injections, Intramuscular/ 17.  Injections, Intravenous/ 18.  exp Injections, Spinal/ 19. Needles/ (continued)

10

Clinical Pediatrics 00(0)

Appendix A (continued)

Appendix A (continued)

Database: Ovid Epub Ahead of Print, In-Process & Other NonIndexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) 1946 to Present

Database: Ovid Epub Ahead of Print, In-Process & Other NonIndexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) 1946 to Present

20. Phlebotomy/ 21. Punctures/ 22.  Spinal Punctures/ 23. Suction/ 24. Sutures/ 25. ((access* or implant* or insert* or remov*) adj3 (intravenous* or IV or line* or port* or tape or tube*)).tw,kf. 26. ((acute care or critical care or emergency or trauma or urgen*) adj2 (cent* or department* or room* or unit* or ward*)).mp. 27.  (blood adj2 (draw* or sampl* or test*)).tw,kf. 28.  (blood work or bloodwork).tw,kf. 29. ((bone* or fracture* or limb*) adj5 (cast* or reduc* or set*)). tw,kf. 30.  capillary sampl*.tw,kf. 31.  (exam* adj3 (gyn* or pelvic or vagina*)).tw,kf. 32. ((extract* or remov*) adj2 (foreign bod* or foreign object*)). tw,kf. 33. ((extract* or peel* or remov*) and (cardiac lead* or chest lead*)).tw,kf. 34. ((faeces or fecal or feces or manual or rectal or rectum) adj2 (dis-impaction or disimpaction or impaction)).tw,kf. 35. injection*.tw,kf. 36.  ((intravenous or IV) adj line?).tw,kf. 37.  (laceration* adj2 repair*).tw,kf. 38.  ((lumbar or spinal) adj2 (puncture* or tap*)).tw,kf. 39. needl*.tw,kf. 40.  ((oral or nasal) adj3 suction*).tw,kf. 41.  (pain* adj2 procedur*).tw,kf. 42. ((pain* or sore or tender) adj3 (ultra-so* or ultraso*)).tw,kf. 43. phlebotom*.tw,kf. 44. procedur*.ti. 45.  procedur*.ab. /freq=2 46. sutur*.tw,kf. 47. stapl*.tw,kf. 48. stitch*.tw,kf. 49.  (veni puncture* or venipuncture*).tw,kf. 50.  (wound* adj2 irrigat*).tw,kf. 51. or/9-50 [Combined MeSH & text words for common ER procedures] 52.  and/8,51 [Combined concepts for painful procedures] 53. Caregivers/ 54. Family/ 55.  Parent-Child Relations/ 56. Parenting/ 57.  exp Parents/ 58. (care giver* or caregiver* or carer* or guardian*).tw,kf. 59. (families* or family* or father* or mother* or parent*).tw,kf. 60. or/53-59 [Combined MeSH & text words for caregivers] 61.  Attitude to Health/ 62.  Caregivers/ed, px 63.  exp Consumer Health Information/ 64.  Decision Making/ 65.  Evidence-Based Practice/

  66.  Focus Groups/   67.  Health Education/   68.  Health Knowledge, Attitudes, Practice/   69.  exp Information Literacy/   70.  Information Seeking Behavior/   71.  Information Services/   72.  Parents/ed, px   73.  exp “Patient Acceptance of Health Care”/   74.  Patient Compliance/   75.  “Patient Education as Topic”/   76.  Patient Participation/   77.  Patient Satisfaction/   78.  Personal Satisfaction/   79.  “Quality of Life”/   80.  “Retention (Psychology)”/   81.  “Surveys and Questionnaires”/  82.  accept*.tw,kf.   83.  (adhere* or nonadhere*).tw,kf.  84.  attitude*.tw,kf.  85.  belie*.tw,kf.   86.  (complian* or comply or noncomplian*).tw,kf.  87.  comprehen*.tw,kf.  88.  concern*.tw,kf.   89.  (co-operat* or cooperat*).tw,kf.   90. (educat* or instruct* or learn* or perform* or train* or teach* or taught*).tw,kf.  91.  experience*.tw,kf.   92.  focus group*.tw,kf.   93.  health litera*.tw,kf.   94.  inform*.ab. /freq=3  95.  inform*.ti,kf.  96.  interview*.tw,kf.   97.  know*.ab. /freq=3  98.  know*.ti,kf.  99.  misconce*.tw,kf. 100. opinion*.tw,kf. 101. participat*.tw,kf. 102. perce*.tw,kf. 103. perspective*.tw,kf. 104. prefer*.tw,kf. 105.  (recall* or remember* or retain* or retention*).tw,kf. 106. satisf*.tw,kf. 107. QoL.tw,kf. 108.  quality of life.tw,kf. 109. questionnaire*.tw,kf. 110. uncertain*.tw,kf. 111. underst*.tw,kf. 112. view*.tw,kf. 113. or/61-112 [Combined MeSH & text words for information needs] 114. and/52,60,113 [Combined concepts for procedural pain, caregivers and information needs] 115.  exp Adolescent/ 116.  exp Child/ 117.  Child Behavior/

(continued)

(continued)

11

Gates et al

Appendix A (continued)

Appendix A (continued)

Database: Ovid Epub Ahead of Print, In-Process & Other NonIndexed Citations, Ovid MEDLINE(R) Daily, and Ovid MEDLINE(R) 1946 to Present

Database: Ovid PsycINFO 1987 to July Week 2, 2016

118.  Hospitals, Pediatric/ 119.  exp Infant/ 120.  exp Minors/ 121.  exp Pediatrics/ 122. (adolescen* or boy* or child* or girl* or preschool* or school age* or schoolchild* or teen* or toddler*).mp. 123. (baby* or babies or infant* or infancy or neonat* or newborn* or postmatur* or prematur* or preterm*).mp. 124.  (paediatric* or peadiatric* or pediatric*).mp. 125. or/115-124 [Combined MeSH & text words for children] 126.  114 and 125 [Child filter] 127.  animals/ not (animals/ and humans/) 128. (animal* or bovine or canine* or cat or cats or dog or dogs or feline* or hamster* or mice or monkey* or mouse or pig or piglet* or pigs or porcine or primate* or rabbit* or rat or rats or rodent or rodents or sheep or swine or swines or zebrafish*).ti. 129.  126 not (127 or 128) [Human filter] 130. (comment or editorial or news or newspaper article).pt. 131.  (letter not (letter and randomized controlled trial)).pt. 132.  129 not (130 or 131) [Opinion pieces excluded] 133.  limit 132 to yr=2000-current 134.  limit 133 to english 135.  135. remove duplicates from 134

Database: Ovid PsycINFO 1987 to July Week 2, 2016 Date searched: July 15, 2016 Records retrieved: 624  1.  Anxiety/  2.  Fear/  3.  Pain/   4.  Pain Perception/   5. (afraid* or anxi * or fear* or distress* or pain* or panic* or scare* or scary or stress* or terrif*).ti,ab.   6.  or/1-5 [Combined headings & text words for pain]   7.  Emergency Services/  8.  Injections/   9.  Intramuscular Injections/ 10.  Intravenous Injections/ 11. ((access* or implant* or insert* or remov*) adj3 (intravenous* or IV or line* or port* or tape or tube*)).ti,ab. 12. ((acute care or critical care or emergency or trauma or urgen*) adj2 (cent* or department* or room* or unit* or ward*)).mp. 13.  (blood adj2 (draw* or sampl* or test*)).ti,ab. 14.  (blood work or bloodwork).ti,ab. 15. ((bone* or fracture* or limb*) adj5 (cast* or reduc* or set*)).ti,ab. 16.  capillary sampl*.ti,ab. 17.  (exam* adj3 (gyn* or pelvic or vagina*)).ti,ab. 18. ((extract* or remov*) adj2 (foreign bod* or foreign object*)). ti,ab. 19. ((faeces or fecal or feces or manual or rectal or rectum) adj2 (dis-impaction or disimpaction or impaction)).ti,ab. 20. injection*.ti,ab. (continued)

21.  ((intravenous or IV) adj line?).ti,ab. 22.  (laceration* adj2 repair*).ti,ab. 23.  ((lumbar or spinal) adj2 (puncture* or tap*)).ti,ab. 24. needl*.ti,ab. 25.  ((oral or nasal) adj3 suction*).ti,ab. 26.  (pain* adj2 procedur*).ti,ab. 27. ((pain* or sore or tender) adj3 (ultra-so* or ultraso*)).ti,ab. 28. phlebotom*.ti,ab. 29. procedur*.ti. 30.  procedur*.ab. /freq=2 31. sutur*.ti,ab. 32. stapl*.ti,ab. 33. stitch*.ti,ab. 34.  (veni puncture* or venipuncture*).ti,ab. 35.  (wound* adj2 irrigat*).ti,ab. 36. or/7-35 [Combined headings & text words for common ER procedures] 37.  and/6,36 [Combined concepts for painful procedures] 38. Caregivers/ 39. Family/ 40.  Parent Child Communication/ 41.  Parent Child Relations/ 42.  Parental Role/ 43.  exp Parenting/ 44.  Parenting Skills/ 45.  exp Parents/ 46.  (care giver* or caregiver* or carer* or guardian*).ti,ab. 47. (families* or family* or father* or mother* or parent*).ti,ab. 48. or/38-47 [Combined headings & text words for caregivers] 49.  Best Practices/ 50.  Client Attitudes/ 51.  Client Education/ 52.  Client Participation/ 53.  Client Satisfaction/ 54.  exp Compliance/ 55.  Consumer Satisfaction/ 56.  Decision Making/ 57.  Evidence Based Practice/ 58.  Health Attitudes/ 59.  Health Education/ 60.  Health Knowledge/ 61.  Health Literacy/ 62.  Health Promotion/ 63. Information/ 64.  Information Dissemination/ 65.  Information Literacy/ 66.  Information Seeking/ 67.  Information Services/ 68.  Knowledge Level/ 69.  Knowledge Transfer/ 70.  Parent Training/ 71.  Procedural Knowledge/ 72.  “Quality of Life”/ 73. Questionnaires/ 74. Satisfaction/ 75.  exp Surveys/ (continued)

12

Appendix A (continued) Database: Ovid PsycINFO 1987 to July Week 2, 2016   76.  exp Retention/  77.  accept*.ti,ab.   78.  (adhere* or nonadhere*).ti,ab.  79.  attitude*.ti,ab.  80.  belie*.ti,ab.   81.  (complian* or comply or noncomplian*).ti,ab.  82.  comprehen*.ti,ab.  83.  concern*.ti,ab.   84.  (co-operat* or cooperat*).ti,ab.   85. (educat* or instruct* or learn* or perform* or train* or teach* or taught*).ti,ab.  86.  experience*.ti,ab.   87.  focus group*.ti,ab.   88.  health litera*.ti,ab.   89.  inform*.ab. /freq=3  90.  inform*.ti.  91.  interview*.ti,ab.   92.  know*.ab. /freq=3  93.  know*.ti.  94.  misconce*.ti,ab.  95.  opinion*.ti,ab.  96.  participat*.ti,ab.  97.  perce*.ti,ab.  98.  perspective*.ti,ab.  99.  prefer*.ti,ab. 100.  (recall* or remember* or retain* or retention*).ti,ab. 101. satisf*.ti,ab. 102. QoL.ti,ab. 103.  quality of life.ti,ab. 104. questionnaire*.ti,ab. 105. uncertain*.ti,ab. 106. underst*.ti,ab. 107. view*.ti,ab. 108. or/49-107 [Combined subject headings & text words for information needs] 109. and/37,48,108 [Combination of procedural pain, caregivers, and information needs] 110. (adolescen* or boy* or child* or girl* or preschool* or school age* or schoolchild* or teen* or toddler*).mp. 111. (baby* or babies or infant* or infancy or neonat* or newborn* or postmatur* or prematur* or preterm*).mp. 112.  (paediatric* or peadiatric* or pediatric*).mp. 113. or/110-112 [Combined MeSH & text words for children] 114.  and/109,113 [Child filter] 115.  animals/ not (animals/ and humans/) 116. (animal* or bovine or canine* or cat or cats or dog or dogs or feline* or hamster* or mice or monkey* or mouse or pig or piglet* or pigs or porcine or primate* or rabbit* or rat or rats or rodent or rodents or sheep or swine or swines or zebrafish*).ti. 117.  114 not (115 or 116) [Human filter] 118. (comment* or correspondence or editorial* or letter*).ti. 119.  117 not 118 [Opinion pieces excluded] 120.  limit 119 to yr=2000-current 121.  limit 120 to english 122.  122. remove duplicates from 121

Clinical Pediatrics 00(0) Database: CINAHL via EBSCOHost (1937 to Present) Date searched: July 15, 2016 Records retrieved: 837   S1. (MH “Anticipatory Anxiety”)   S2. (MH “Anxiety”)   S3. (MH “Fear”)   S4. (MH “Pain”)   S5. (MH “Stress, Psychological”)   S6. (MH “Treatment Related Pain”)   S7. (afraid* or anxi * or fear* or distress* or pain* or panic* or scare* or scary or stress* or terrif*)   S8. S1 OR S2 OR S3 OR S4 OR S5 OR S6 OR S7   S9. (MH “Administration, Intravenous+”) S10. (MH “Blood Specimen Collection+”) S11. (MH “Cast Application”) S12. (MH “Emergency Service+”) S13. (MH “Fecal Impaction Removal”) S14. (MH “Feces, Impacted”) S15. (MH “Gynecologic Examination”) S16. (MH “Injections”) S17. (MH “Injections, Intramuscular+”) S18. (MH “Injections, Intraspinal+”) S19. (MH “Injections, Intravenous”) S20. (MH “Needles”) S21. (MH “Punctures”) S22. (MH “Spinal Puncture”) S23. (MH “Suction+”) S24. (MH “Suture Techniques+”) S25. (MH “Sutures”) S26. (MH “Tube Removal”) S27. (MH “Venipuncture+”) S28. (access* or implant* or insert* or remov*) N3 (intravenous* or IV or line* or port* or tape or tube*) S29. (“acute care” or “critical care” or emergency or trauma or urgen*) N2 (cent* or department* or room* or unit* or ward*) S30. (blood N2 (draw* or sampl* or test*)) S31. (“blood work” or bloodwork) S32. (bone* or fracture* or limb*) N5 (cast* or reduc* or set*) S33. “capillary sampl*” S34. (exam* N3 (gyn* or pelvic or vagina*)) S35. ((extract* or remov*) N2 (“foreign bod*” or “foreign object*”)) S36. ((extract* or peel* or remov*) and (“cardiac lead*” or “chest lead*”)) S37. ((faeces or fecal or feces or manual or rectal or rectum) M2 (dis-impaction or disimpaction or impaction)) S38. injection* S39. ((intravenous or IV) N1 line*) S40. (laceration* N2 repair*) S41. (lumbar or spinal) N2 (puncture* or tap*) S42. needl* S43. ((oral or nasal) N3 suction*) (continued)

13

Gates et al

Appendix A (continued)

Appendix A (continued)

Database: CINAHL via EBSCOHost (1937 to Present)

Database: CINAHL via EBSCOHost (1937 to Present)

S44. (pain* N2 procedur*) S45. ((pain* or sore or tender) N3 (ultra-so* or ultraso*)) S46. phlebotom* S47. stapl* S48. sutur* S48. stapl* S49. stitch* S50. (“veni puncture*” or venipuncture*) S51. (wound* N2 irrigat*) S52. S9 OR S10 OR S11 OR S12 OR S13 OR S14 OR S15 OR S16 OR S17 OR S18 OR S19 OR S20 OR S21 OR S22 OR S23 OR S24 OR S25 OR S26 OR S27 OR S28 OR S29 OR S30 OR S31 OR S32 OR S33 OR S34 OR S35 OR S36 OR S37 OR S38 OR S39 OR S40 OR S41 OR S42 OR S43 OR S44 OR S45 OR S46 OR S47 OR S48 OR S49 OR S50 OR S51 S53. S8 AND S52 S54. (MH “Caregivers”) S55. (MH “Family”) S56. (MH “Fathers”) S57. (MH “Mothers”) S58. (MH “Parent-Child Relations+”) S59. (MH “Parenting”) S60. (MH “Parents”) S61. (“care giver*” or caregiver* or carer* or guardian*) S62. (families* or family* or father* or mother* or parent*) S63. S54 OR S55 OR S56 OR S57 OR S58 OR S59 OR S60 OR S61 OR S62 S64. (MH “Attitude to Health”) S65. (MH “Caregivers/ED/PF”) S66. (MH “Consumer Health Information+”) S67. (MH “Consumer Participation”) S68. (MH “Decision Making, Family”) S69. (MH “Decision Making, Patient”) S70. (MH “Focus Groups”) S71. (MH “Health Education”) S72. (MH “Health Knowledge”) S73. (MH “Interviews+”) S74. (MH “Information Literacy+”) S75. (MH “Information Needs”) S76. (MH “Information Seeking Behavior”) S77. (MH “Information Services”) S78. (MH “Memory”) S79. (MH “Memory, Short Term”) S80. (MH “Parenting Education”) S81. (MH “Parents/ED/PF”) S82. (MH “Patient Compliance”) S83. (MH “Patient Education”) S84. (MH “Patient Satisfaction”) S85. (MH “Personal Satisfaction”) S86. (MH “Professional Practice, Evidence-Based+”) S87. (MH “Quality of Life”)

  S88. (MH “Questionnaires+”)   S89. (MH “Surveys”)   S90. accept*   S91. (adhere* or nonadhere*)   S92. attitude*   S93. belie*   S94. (complian* or comply or noncomplian*)   S95. comprehen*   S96. concern*   S97. (co-operat* or cooperat*)   S98. (educat* or instruct* or learn* or perform* or train* or teach* or taught*)   S99. experienc* S100. “focus group*” S101. “health litera*” S102. inform* S103. interview* S104. know* S105. misconce* S106. opinion* S107. participat* S108. perce* S109. perspective* S110. prefer* S111. (recall* or remember* or retain* or retention*) S112. satisf* S113. QoL S114. “quality of life” S115. questionnaire* S116. uncertain* S117. underst* S118. view* S119. S64 OR S65 OR S66 OR S67 OR S68 OR S69 OR S70 OR S71 OR S72 OR S73 OR S74 OR S75 OR S76 OR S77 OR S78 OR S79 OR S80 OR S81 OR S82 OR S83 OR S84 OR S85 OR S86 OR S87 OR S88 OR S89 OR S90 OR S91 OR S92 OR S93 OR S94 OR S95 OR S96 OR S97 OR S98 OR S99 OR S100 OR S101 OR S102 OR S103 OR S104 OR S105 OR S106 OR S107 OR S108 OR S109 OR S110 OR S111 OR S112 OR S113 OR S114 OR S115 OR S116 OR S117 OR S118 S120. S53 AND S63 AND S119 S121. (MH “Child+”) S122. (MH “Infant+”) S123. (MH “Pediatrics+”) S124. (adolescen* or boy* or child* or girl* or preschool* or “school age*” or schoolchild* or teen* or toddler*) S125. (baby* or babies or infant* or infancy or neonat* or newborn* or postmatur* or prematur* or preterm*) S126. (paediatric* or peadiatric* or pediatric*) S127. S121 OR S122 OR S123 OR S124 OR S125 OR S126 S128. S120 AND S127 S129. ((MH “Vertebrates+”) NOT MH Human)

(continued)

(continued)

14

Clinical Pediatrics 00(0)

Appendix A (continued)

Appendix A (continued)

Database: CINAHL via EBSCOHost (1937 to Present)

Database: PubMed via NCBI Entrez (1946 to Present)

S130. (TI animal* or bovine or canine* or cat or cats or dog or dogs or feline* or hamster* or mice or monkey* or mouse or pig or piglet* or pigs or porcine or primate* or rabbit* or rat or rats or rodent or rodents or sheep or swine or swines or zebrafish*) S131. S128 NOT (S129 OR S130) S132. (TI comment* or editorial* or letter* or news*) S133. S131 NOT S132 S134. S131 NOT S132 Limiters: English Language S135. S131 NOT S132 Limiters: English Language; Publication Date: 20000101-20161231

Date searched: September 12, 2016 Records retrieved: 37 Set 1: Combined MeSH & text words for pain “Anxiety”[mh:noexp] OR “Fear”[mh:noexp] OR “Pain”[mh] OR “Pain Perception”[mh:noexp] OR “Panic”[mh:noexp] OR “Stress, Psychological”[mh:noexp] OR afraid[tiab] OR anxiety[tiab] OR anxious[tiab] OR anxiousness[tiab] OR fear[tiab] OR feared[tiab] OR fearful[tiab] OR fearfulness[tiab] OR fearing[tiab] OR distress[tiab] OR distressed[tiab] OR distressful[tiab] OR distressing[tiab] OR pain[tiab] OR painful[tiab] OR scare[tiab] OR scared[tiab] OR scary[tiab] OR stress[tiab] OR stressed[tiab] OR stressful[tiab] OR terrified[tiab] OR terrify[tiab] OR terrifying[tiab] Set 2: Combined MeSH & text words for common ER procedures “Administration, Intravenous”[mh] OR “Blood Specimen Collection”[mh:noexp] OR “Casts, Surgical”[mh:noexp] OR “Emergency Service, Hospital”[mh] OR “Fecal Impaction”[mh:noexp] OR “Gynecological Examination”[mh:noexp] OR “Injections”[mh:noexp] OR “Injections, Intramuscular”[mh:noexp] OR “Injections, Intravenous”[mh:noexp] OR “Injections, Spinal”[mh] OR “Needles”[mh:noexp] OR “Phlebotomy”[mh:noexp] OR “Punctures”[mh:noexp] OR “Spinal Puncture”[mh:noexp] OR “Suction”[mh:noexp] OR “Sutures”[mh:noexp] OR ((access[tiab] OR accessed[tiab] OR accessing[tiab] OR implant[tiab] OR implanted[tiab] OR implanting[tiab] OR insert[tiab] OR inserted[tiab] OR inserting[tiab] OR insertion[tiab] OR insertions[tiab] OR inserts[tiab] or removal[tiab] OR remove[tiab] OR removed[tiab] OR removes[tiab] OR removing[tiab]) AND (intravenous[tiab] OR intravenously[tiab] OR IV[tiab] OR line[tiab] OR lines[tiab] OR port[tiab] OR ports[tiab] OR tape[tiab] OR taped[tiab] OR tube[tiab] OR tubes[tiab])) OR ((“acute care”[tiab] OR “critical care”[tiab] OR emergency[tiab] OR trauma[tiab] OR urgent[tiab]) AND (center[tiab] OR centers[tiab] OR centre[tiab] OR centres[tiab] OR department[tiab] OR departments[tiab] OR room[tiab] OR rooms[tiab] OR unit[tiab] OR units[tiab] OR ward[tiab] OR wards[tiab])) OR “blood draw”[tiab] OR “blood draws”[tiab] OR “blood sample”[tiab] OR “blood sampling”[tiab] OR “blood test”[tiab] OR “blood testing”[tiab] OR “blood tests”[tiab] OR “blood work”[tiab] OR ((bone[tiab] OR bones[tiab] OR fracture[tiab] OR fractured[tiab] OR fractures[tiab] OR limb[tiab] OR limbs[tiab]) AND (cast[tiab] OR casted[tiab] OR casting[tiab] OR casts[tiab] OR set[tiab] OR sets[tiab])) OR “capillary sampling”[tiab] OR “fecal disimpaction”[tiab] OR “fecal impaction”[tiab] OR

“foreign body extraction”[tiab] OR “foreign body removal”[tiab] OR “foreign object removal”[tiab] OR “gynaecological examination”[tiab] OR “gynaecological examinations”[tiab] OR “gynaecological exam”[tiab] OR “gynaecological exams”[tiab] OR injection[tiab] OR injections[tiab] OR “intravenous line”[tiab] OR “intravenous lines”[tiab] OR “IV line”[tiab] OR “IV lines”[tiab] OR “laceration repair”[tiab] OR “laceration repairs”[tiab] OR “lumbar puncture”[tiab] OR “lumbar punctures”[tiab] OR “nasal suction”[tiab] OR “nasal suctioning”[tiab] OR needle[tiab] OR needles[tiab] OR “oral suction”[tiab] OR “oral suctioning”[tiab] OR “painful procedure”[tiab] OR “painful procedures”[tiab] OR “pelvic examination”[tiab] OR “pelvic examinations”[tiab] OR “pelvic exam”[tiab] OR “pelvic exams”[tiab] OR phlebotomies[tiab] OR phlebotomy[tiab] OR “procedural pain”[tiab] OR “procedure pain”[tiab] OR “spinal puncture”[tiab] OR “spinal punctures”[tiab] OR “spinal tap”[tiab] OR “spinal taps”[tiab] OR suture[tiab] OR sutures[tiab] OR suturing[tiab] OR staple[tiab] OR stapled[tiab] OR staples[tiab] OR stapling[tiab] OR stitch[tiab] OR stitches[tiab] OR stitching[tiab] OR “vaginal examination”[tiab] OR “vaginal examinations”[tiab] OR “vaginal exam”[tiab] OR “vaginal exams”[tiab] OR “veni puncture”[tiab] OR venipuncture[tiab] OR venipunctures[tiab] OR “wound irrigation”[tiab] Set 3: Combined concepts for painful procedures #1 AND #2 Set 4: Combined MeSH & text words for caregivers “Caregivers”[mh:noexp] OR “Family”[mh:noexp] OR “ParentChild Relations”[mh:noexp] OR “Parenting”[mh:noexp] OR “Parents”[mh] OR “care giver”[tiab] OR “care givers”[tiab] OR caregiver[tiab] OR caregivers[tiab] OR carer[tiab] OR carers[tiab] OR guardian[tiab] OR guardians[tiab] OR familial[tiab] OR families[tiab] OR family[tiab] OR father[tiab] OR fathers[tiab] OR mother[tiab] OR mothers[tiab] OR parent[tiab] OR parental[tiab] OR parenting[tiab] OR parents[tiab] Set 5: Combined MeSH & text words for information needs “Attitude to Health”[mh:noexp] OR “Caregivers/education” [Mesh] OR “Caregivers/psychology”[Mesh] OR “Consumer Health Information”[mh] OR “Decision Making”[mh:noexp] OR “EvidenceBased Practice”[mh:noexp] OR “Focus Groups”[mh:noexp] OR “Health Education”[mh:noexp] OR “Health Knowledge, Attitudes, Practice”[mh:noexp] OR “Information Literacy”[mh] OR “Information Seeking Behavior”[mh:noexp] OR “Information Services”[mh:noexp] OR “Parents/education”[Mesh] OR “Parents/psychology”[Mesh] OR “Patient Acceptance of Health Care”[mh] OR “Patient Compliance”[mh:noexp] OR “Patient Education as Topic”[mh:noexp] OR “Patient Participation”[mh:noexp] OR “Patient Satisfaction”[mh:noexp] OR “Personal Satisfaction”[mh:noexp] OR “Quality of Life”[mh:noexp] OR “Retention (Psychology)”[mh:noexp] OR “Surveys and Questionnaires”[mh:noexp] OR accept[tiab] OR acceptance[tiab] OR accepted[tiab] OR accepting[tiab] OR accepts[tiab] OR adhere[tiab] OR adherence[tiab] OR adhered[tiab] OR adhering[tiab] OR adheres[tiab] OR attitude[tiab] OR attitudes[tiab] OR belief[tiab] OR believed[tiab] OR believes[tiab] OR believing[tiab] OR compliance[tiab] OR compliant[tiab] OR complies[tiab] OR comply[tiab] OR comprehend[tiab] OR comprehends[tiab] OR comprehension[tiab] OR concern[tiab] OR concerned[tiab] OR concerning[tiab] OR concerns[tiab] OR cooperate[tiab] OR cooperated[tiab] OR cooperates[tiab] OR cooperation[tiab] OR cooperative[tiab] OR educate[tiab] OR educated[tiab] OR educates[tiab] OR education[tiab] OR experiencing[tiab] OR experience[tiab] OR experienced[tiab] OR experiences[tiab] OR “focus group”[tiab] OR “focus groups”[tiab] OR “health literacies”[tiab] OR “health

(continued)

(continued)

Database: PubMed via NCBI Entrez (1946 to Present)

15

Gates et al

Appendix A (continued)

Appendix A (continued)

Database: PubMed via NCBI Entrez (1946 to Present)

Database: PubMed via NCBI Entrez (1946 to Present)

literacy”[tiab] OR “health literature”[tiab] OR inform[tiab] OR information[tiab] OR informational[tiab] OR informative[tiab] OR informed[tiab] OR informing[tiab] AND informs[tiab] OR instruct[tiab] OR instructed[tiab] OR instructing[tiab] OR instruction[tiab] OR instructive[tiab] OR interview[tiab] OR interviewed[tiab] OR interviewing[tiab] OR know[tiab] OR knowing[tiab] OR knowledge[tiab] OR knowledgeable[tiab] OR learn[tiab] OR learning[tiab] OR learnt[tiab] OR misconceive[tiab] OR misconceived[tiab] OR misconception[tiab] OR misconceptions[tiab] OR misconceiving[tiab] OR nonadherence[tiab] OR opinion[tiab] OR opinions[tiab] OR opinionated[tiab] OR opinioned[tiab] OR participate[tiab] OR participated[tiab] OR participates[tiab] OR participation[tiab] OR participating[tiab] OR perceive[tiab] OR perceived[tiab] OR perceives[tiab] OR perceiving[tiab] OR perform[tiab] OR performed[tiab] OR performs[tiab] OR perspective[tiab] OR perspectives[tiab] OR prefer[tiab] OR preferred[tiab] OR preference[tiab] OR preferences[tiab] OR preferring[tiab] OR QoL[tiab] OR “quality of life”[tiab] OR questionnaire[tiab] OR questionnaires[tiab] OR recall[tiab] OR recalls[tiab] OR remember[tiab] OR remembered[tiab] OR remembering[tiab] OR remembrance[tiab] OR remembers[tiab] OR retain[tiab] OR retained[tiab] OR retains[tiab] OR retention[tiab] OR satisfaction[tiab] OR satisfied[tiab] OR satisfies[tiab] OR satisfy[tiab] OR taught[tiab] OR teach[tiab] OR teaches[tiab] OR teaching[tiab] OR train[tiab] OR trained[tiab] OR training[tiab] OR trains[tiab] OR uncertain[tiab] OR uncertainty[tiab] OR understand[tiab] OR understands[tiab] OR understanding[tiab] OR understood[tiab] OR view[tiab] OR views[tiab] Set 6: Combined concepts for procedural pain, caregivers and information needs #3 AND #4 AND #5 Set 7: Combined MeSH & text words for children “adolescent”[MeSH Terms] OR “child”[MeSH Terms] OR “infant”[MeSH Terms] OR “minors”[MeSH Terms] OR “pediatrics”[MeSH Terms] OR “puberty”[MeSH Terms] OR adolescence[tiab] OR adolescent[tiab] OR adolescents[tiab] OR baby[tiab] OR babies[tiab] OR child[tiab] OR childhood[tiab] OR children[tiab] OR childrens[tiab] OR childs[tiab] OR infancy[tiab] OR infant[tiab] OR infants[tiab] OR neonatal[tiab] OR neonatology[tiab] OR neonate[tiab] OR neonates[tiab] OR “new born”[tiab] OR “new borns”[tiab] OR newborn[tiab] OR newborns[tiab] OR paediatric[tiab] OR paediatrician[tiab] OR paediatricians[tiab] OR peadiatric[tiab] OR pediatric[tiab] OR pediatrician[tiab] OR pediatricians[tiab] OR “pre mature”[tiab] OR premature[tiab] OR “pre term”[tiab] OR preterm[tiab] OR preschool[tiab] OR preschooler[tiab] OR preschoolers[tiab] OR prepubescence[tiab] OR prepubescent[tiab] OR prepubescents[tiab] OR teen[tiab] OR teenaged[tiab] OR teenager[tiab] OR teenagers[tiab] OR teens[tiab] OR toddler[tiab] OR toddlers[tiab] OR youth[tiab] OR youths[tiab] Set 8: Child Filter #6 AND #7 Set 9: Combined MeSH and text words for animal studies ((Animals[MESH] OR Animal Experimentation[MESH] OR “Models, Animal”[ MESH] OR Vertebrates[MESH]) NOT (Humans[MESH] OR Human experimentation[MESH])) OR (((animals[tiab] OR animal model[tiab] OR rat[tiab] OR rats[tiab] OR mouse[tiab] OR mice[tiab] OR rabbit[tiab] OR rabbits[tiab] OR pig[tiab] OR pigs[tiab] OR porcine[tiab] OR swine[tiab] OR dog[tiab] OR dogs[tiab] OR hamster[tiab] OR hamsters[tiab] OR chicken[tiab] OR chickens[tiab] OR sheep[tiab]) AND (publisher[sb] OR inprocess[sb] OR pubmednotmedline[sb])) NOT (human[ti] OR humans[ti] OR people[ti] OR children[ti] OR adults[ti] OR seniors[ti] OR patient[ti] OR patients[ti]))

Set 10: Animal Filter #8 NOT #9 Set 11: Opinion piece publication types comment[pt] OR editorial[pt] OR (letter[pt] NOT (letter[pt] AND “randomized controlled trial”[pt])) OR news[pt] OR “newspaper article”[pt] Set 12: Opinion piece filter #10 NOT #11 Set 13: Limits: English, 2000 – current #10 NOT #11 AND ((“2000/01/01”[PDAT] : “2016/12/31”[PDAT]) AND (English[lang])) Set 14: Electronic Publications ((publisher[sb] NOT pubstatusnihms NOT pubstatuspmcsd NOT pmcbook) OR (pubstatusaheadofprint)) Set 15: E-Pubs Filter #13 AND #14

(continued)

Author Contributions SDS and LH were responsible for the conceptualization/design of the systematic review, acquired funding, and supervised the work. SA provided clinical expertise throughout the study. RF implemented the search strategy. AG and KS drafted the protocol, which all authors reviewed and approved. AG and KS screened the articles, extracted and/or verified the data, synthesized the data, appraised study quality, and drafted the manuscript. RF, KB, SA, SDS, and LH reviewed the manuscript and suggested edits. All authors approved the final version of the manuscript and agreed to be accountable for all aspects of the work.

Declaration of Conflicting Interests The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Network of Centres of Excellence in Knowledge Mobilization, TREKK (TRanslating Emergency Knowledge for Kids) and the Women and Children’s Health Research Institute (Edmonton, Canada). SDS is a Canada Research Chair (Tier II) for Knowledge Translation in Child Health and is supported by an Alberta Innovates Health Solutions Population Health Investigator Award. LH receives salary support through a New Investigator Award from the Canadian Institutes of Health Research. The funders played no role in the design or conduct of the study; the collection, analysis, or interpretation of data; or in the writing of the article and the decision to submit it for publication.

References 1. Stevens BJ, Abbott LK, Yamada J, et al; CIHR Team in Children’s Pain. Epidemiology and management of

16 painful procedures in children in Canadian hospitals. CMAJ. 2011;183:E403-E410. 2. Stinson J, Yamada J, Dickson A, Lamba J, Stevens B. Review of systematic reviews on acute procedural pain in children in the hospital setting. Pain Res Manag. 2008;13:51-57. 3. World Health Organization. WHO Guidelines on the Pharmacological Treatment of Persisting Pain in Children With Medical Illnesses. Geneva, Switzerland: World Health Organization; 2012. 4. Watt-Watson JH, Clark AJ, Finley GA, Watson CPN. Canadian Pain Society position statement on pain relief. Pain Res Manag. 1999;4:75-78. 5. Committee on Fetus and Newborn and Section on Anesthesiology and Pain Medicine. Prevention and management of procedural pain in the neonate: an update. Pediatrics. 2016;137:1-13. 6. American Academy of Pediatrics Committee on Psychosocial Aspects of Child and Family Health; Task Force on Pain in Infants, Children, and Adolescents. The assessment and management of acute pain in infants, children, and adolescents. Pediatrics. 2001;108:793-797. 7. Byczkowski TL, Gillespie GL, Kennebeck SS, Fitzgerald MR, Downing KA, Alessandrini EA. Family-centered pediatric emergency care: a framework for measuring what parents want and value. Acad Pediatr. 2016;16: 327-335. 8. Curtis S, Wingert A, Ali S. The Cochrane Library and procedural pain in children: an overview of reviews. Evid Based Child Health. 2012;7:1363-1399. 9. Ali S, Chambers A, Johnson DW, et al. Reported practice variation in pediatric pain management: a survey of Canadian pediatric emergency physicians. CJEM. 2014;16:352-360. 10. von Baeyer CL, Marche TA, Rocha EM, Salmon K. Children’s memory for pain: overview and implications for practice. J Pain. 2004;5:241-249. 11. Kennedy RM, Luhmann J, Zempsky WT. Clinical implications of unmanaged needle-insertion pain and distress in children. Pediatrics. 2008;122(suppl 3):S130-S133. 12. Young KD. Pediatric procedural pain. Ann Emerg Med. 2005;45:160-171. 13. Buskila D, Neumann L, Zmora E, Feldman M, Bolotin A, Press J. Pain sensitivity in prematurely born adolescents. Arch Pediatr Adolesc Med. 2003;157:1079-1082. 14. Smith RW, Shah V, Goldman RD, Taddio A. Caregivers’ responses to pain in their children in the emergency department. Arch Pediatr Adolesc Med. 2007;161: 578-582. 15. Bentley J. Parents in accident and emergency: roles and concerns. Accid Emerg Nurs. 2005;13:154-159. 16. Franck LS, Allen A, Cox S, Winter I. Parents’ views about infant pain in neonatal intensive care. Clin J Pain. 2005;21:133-139. 17. Franck LS, Cox S, Allen A, Winter I. Parental concern and distress about infant pain. Arch Dis Child Fetal Neonatal Ed. 2004;89:F71-F75.

Clinical Pediatrics 00(0) 18. Gale G, Franck LS, Kools S, Lynch M. Parents’ perceptions of their infant’s pain experience in the NICU. Int J Nurs Stud. 2004;41:51-58. 19. Karlsson K, Englund AC, Enskär K, Rydström I. Parents’ perspectives on supporting children during needle-related medical procedures. Int J Qual Stud Health Well-being. 2014;9:23759. 20. Palomaa AK, Korhonen A, Pölkki T. Factors influencing parental participation in neonatal pain alleviation. J Pediatr Nurs. 2016;31:519-527. 21. Vazquez V, Cong X, DeJong A. Maternal and paternal knowledge and perceptions regarding infant pain in the NICU. Neonatal Netw. 2015;34:337-344. 22. Shave K. Procedural Pain in Children: A Qualitative Study of Caregiver Experiences and Information Needs. Alberta, Canada: University of Alberta; 2016. 23. Moher D, Liberati A, Tetzlaff J, Altman DG; PRISMA Group. Preferred Reporting Items for Systematic Reviews and Meta-analyses: the PRISMA statement. Int J Surg. 2010;8:336-341. 24. Kleiber C, Harper DC. Effects of distraction on children’s pain and distress during medical procedures: a meta-analysis. Nurs Res. 1999;48:44-49. 25. Yamada J, Stinson J, Lamba J, Dickson A, McGrath PJ, Stevens B. A review of systematic reviews on pain interventions in hospitalized infants. Pain Res Manag. 2008;13:413-420. 26. Compas BE, Jaser SS, Dunn MJ, Rodriguez EM. Coping with chronic illness in childhood and adolescence. Annu Rev Clin Psychol. 2012;8:455-480. 27. Muraro A, Roberts G, Clark A, et al; EAACI Task Force on Anaphylaxis in Children. The management of anaphylaxis in childhood: position paper of the European Academy of Allergology and Clinical Immunology. Allergy. 2007;62:857-871. 28. Thomas J, Harden A. Methods for the thematic synthesis of qualitative research in systematic reviews. BMC Med Res Methodol. 2008;8:45. 29. Creswell JW. Data analysis and representation. In: Qualitative Inquiry and Research Design: Choosing Among Five Approaches. Thousand Oaks, CA: Sage; 2007:147-176. 30. Critical Appraisal Skills Program UK. Critical Appraisal Skills Programme: CASP checklists. http://www.casp-uk. net/#!casp-tools-checklists/c18f8. Published March 13, 2017. Accessed May 18, 2017. 31. Wells GA, Shea B, O’Connell D, et al. The NewcastleOttawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. http://www.ohri.ca/ programs/clinical_epidemiology/oxford.asp. Accessed May 18, 2017. 32. Aamir M, Mittal K, Kaushik JS, Kashyap H, Kaur G. Predictors of stress among parents in pediatric intensive care unit: a prospective observational study. Indian J Pediatr. 2014;81:1167-1170.

Gates et al 33. Ali S, Chambers AL, Johnson DW, et al. Paediatric pain management practice and policies across Alberta emergency departments. Paediatr Child Health. 2014;19: 190-194. 34. Czarnecki ML, Simon K, Thompson JJ, et al. Barriers to pediatric pain management: a nursing perspective. Pain Manag Nurs. 2011;12:154-162. 35. Thomas D, Kircher J, Plint AC, et al. Pediatric pain management in the emergency department: the triage nurses’ perspective. J Emerg Nurs. 2015;41:407-413. 36. Centre for Pediatric Pain Research. It doesn’t have to hurt: proven pain control for children. http://itdoesnthavetohurt.ca/. Accessed May 18, 2017. 37. Taddio A, Shah V, Leung E, et al. Knowledge translation of the HELPinKIDS clinical practice guideline for managing childhood vaccination pain: usability and knowledge uptake of educational materials directed to new parents. BMC Pediatr. 2013;13:23.

17 38. Alberta Health Services. New ED pain program debuts at ACH. http://www.albertahealthservices.ca/news/Page12913. aspx. Published January 7, 2016. Accessed May 18, 2017. 39. LaRocca R, Yost J, Dobbins M, Ciliska D, Butt M. The effectiveness of knowledge translation strategies used in public health: a systematic review. BMC Public Health. 2012;12:751. 40. Borges K, Sibbald C, Hussain-Shamsy N, et al. Parental health literacy and outcomes of childhood nephrotic syndrome. Pediatrics. 2017;139:pii: e20161961. 41. Anderson M. Technology device ownership: 2015. http:// www.pewinternet.org/2015/10/29/technology-deviceownership-2015/. Published October 29, 2015. Accessed May 18, 2017. 42. Pehora C, Gajaria N, Stoute M, Fracassa S, SerebaleO’Sullivan R, Matava CT. Are parents getting it right? A survey of parents’ internet use for children’s health care information. Interact J Med Res. 2015;4:e12.

Procedural Pain: Systematic Review of Parent Experiences and Information Needs.

Parents wish to reduce their child's pain during medical procedures but may not know how to do so. We systematically reviewed the literature on parent...
636KB Sizes 1 Downloads 8 Views