The Use of Non-Pharmacological Therapy in Children

The Use of Non-Pharmacological Therapy in Children
Children’s pain is multidimensional with psychological, physiological and behavioural domains, which presents unique challenges in the assessment and evaluation. These challenges require close consideration of the child’s age, prior pain experiences, developmental, cognitive and communication levels. As nurses are responsible in the assessment of children’s pain, it is appropriate to know all methods, and techniques of alleviating this uncomfortable stimuli, thus presenting the clinical question; in children, how can non-pharmacological (complementary/ alternative) methods be more beneficial in pain management compared to non-pharmacological/conventional medicines? The purpose of this paper is to explore how non-pharmacological methods can be useful in reducing pain. The different variations of non-pharmacological interventions, adverse effects of pharmacological medication, economic factors and knowledge deficits related to nurse education of pain management will be discussed below.
Non-Pharmacological Techniques
Non-pharmacological techniques, or complementary therapies are considered as any intervention used for pain alleviation that are non-analgesics or other kinds of medications and can be used with or without pharmacological aid. To better understand how many of these types of procedures are effective on a cellular level, we must look at “The Gate Control Theory”. This theory proposes inhibitory neurons in the spinal cord regulate pain information to the brain. When these neurons are stimulated through pressure or massage they inhibit the transmission of noxious messages to the brain, and “close the gate” meaning they are unable to be processed (Ball & Bindler, 2008) Non-pharmacological techniques can sometime be included in the broader category of complementary, or alternative medicines and can be classified in 4 groups: * Group 1: Professionally organised alternative therapies, such as acupuncture, herbal medicine, and chiropractic care. * Group 2: Complementary therapies, such as massage, hypnotherapy, meditation, yoga, and reflexology. * Group 3a: Alternative disciplines such as Chinese herbal medicine, naturopathy and Traditional Chinese Medicine. * Group 3b: Other alternative disciplines such as kinesiology, crystal therapy, and radionics.
(Mantle, 2004)
Other types of non-pharmacological techniques include cognitive techniques (breathing exercises, distraction, and imagery), emotional support (presence and comforting measures), and physical intervention (positioning, and thermal regulation) (Gorodzinsky et al., 2012, pp. 1-15). As there is a wide diversity of non-pharmacological therapies, only the most frequent and widely used methods will be examined including the benefits of each.
Distraction
Distraction is said to be the most common technique used in the emergency room in redirecting children’s focus away from painful procedures. Procedures such as venipuncture and I.V catheter insertion are examples in which distraction may be needed to suppress fear and anxiety (Srouji et al., 2010). Distraction is a cognitive based non-pharmacological approach that has been proved to be very effective in pain management and is unfortunately not implemented frequently (Carlson et al., 2000, pp. 75-85). Techniques that can be considered as distraction include listening to music, singing a song, watching television or playing a game (Ball & Bindler, 2008). Research mentioned in Srouji et al. (2010) explains that distraction can also lead to reduction in procedure time, and less staff required for the procedure. Overall, distraction is a practical approach that is useful in helping children feel calm, and relaxed in an otherwise fearful environment.
Massage
Massage is considered another highly popular therapeutic intervention and is often implicated through gently rubbing and kneading painful areas (Ball & Bindler, 2008). According to research conducted in Mantle (2004), there are mixed theories as to how this mechanism acts within the body. One theory states that during massage therapy endorphins begin to react and accelerate causing a natural analgesic effect, and secondly increasing levels of serotonin play an important role. The action of serotonergic is to omit pain, so it would seem believable that the body’s own serotonin levels could mimic this effect. Lastly, as mentioned previously, massage is relevant to the gate theory of pain in that stimulation of nerve fibers located in spine can block painful stimuli from being processed (Mantle, 2004).
In addition, massage has a critical role in reducing anxiety and fear related to painful procedures; this is relevant as anxiety can directly enhance pain levels. A study within Mantle (2004) indicates that massage effectively reduces anxiety cortisol (stress hormone) levels in children. This study was conducted by dividing children into two separate age groups, young and old. One group was massaged by their parents for 20 minutes each night, while the other children participated in relaxation. The results were measured by cortisol levels and anxiety scales, and concluded that younger children positively benefited from massage therapy. What is important to recognize about the technique of massage is its ability to effect the body on a cellular level, by stimulating or inhibiting the release of particular hormones that reduce stress and pain levels. This can be especially beneficial when attempting to soothe young children before or after painful procedures.
Heat and Cold Application
Another resourceful technique is the use of heat and cold application. The use of this therapy is an established method of pain alleviation commonly used amongst physiotherapists (Lane and Latham, 2009, p. 14). Many parents also incorporate this technique in home pain management regimes. As stated in Gorodzinsky et al.(2012), applying ice to a specific pain location rated top 3 in a study investigating non-pharmacological techniques parents used at home for their children’s pain management. To understand how the use of heat and cold effects the body, the physiological effects have to be considered and once again the gate control theory comes into play. When thermo receptors are stimulated within deep tissue from superficial heat/cold application, transmission of the thermal sensation takes over pain impulses and closes the gate. Heat therapy specifically targets the sympathetic nervous system by reducing activity and increasing blood flow through vasodilation, this increased blood flow ‘washes’ pain related neurotransmitters out.
Cold therapy is generally used to reduce inflammation, amount of bleeding, and discourage release of pain conducting irritants (Lane and Latham, 2009, p. 14). Referring to Lane and Latham (2009), a study was conducted in which nurses were educated through teaching sessions provided by pain specialists regarding use and guidelines of heat and cold therapy. Its clinical application was measured in its effectiveness over the span of 18 pediatric beds throughout 14 clinical areas. It was proven that children experiencing mild to moderate pain benefited from this intervention. (Lane and Latham, 2009, p. 14). Due to the fact that this technique is very common, many nurses may overlook or forget its significant ability to reduce pain levels. By knowing the pathophysiology of how heat and cold application acts within the body, a better appreciation for this technique will be gained.
Negative Aspects Associated With Pharmacological Therapy
Negative aspects of pharmacological methods can influence the use of alternative and complementary therapies. Some of these negative aspects include potential harmful side effects from either opioids or conventional medication, the possibility of making medication errors, and cost factors, in that non-pharmacological methods are less expensive to implement.
Adverse Side Effects
When opioids are given over a significant length of time, children may become subjected to physical dependence. Once these drugs are stopped unpleasant withdrawal symptoms may arise. The body systems that are usually affected are the central and sympathetic nervous systems, as well as the gastrointestinal system. Some of the side effects of withdrawal include visual and auditory hallucinations, irritability, diarrhea, tachycardia, increased blood pressure, inability to concentrate and fever (Ball & Bindler, 2008). Parents whom are worried and generally uneasy about side effects from pharmacological methods tend to provide their children with non-pharmacological techniques of pain relief instead (Gorodzinsky et al., 2012). Even if conventional methods are working, parents often turn to complementary and alternative medicine to increase their child’s immune system and prevent any reoccurrences from happening. If pharmacotherapy is non-successful, perhaps due to on-going medical issues that have become resistant to medical intervention, parents will look to any therapy to relieve their child’s suffering, and that most often is non-pharmacological resources. (Schechter et al., 2003).
Medication Error
Medication error is another area of concern related to pharmacological methods that would not exist in non-pharmacological therapy. Medication errors are responsible for deaths, adverse effects, severe consequences such as extended hospital stays, and unnecessary diagnostic tests, as well as unnecessary treatments (Kozer et al., 2002, pp. 737-742). A study was mentioned within Kozer et al. (2002), that notes the frequency of medication errors in Toronto’s Hospital for Sick Children, it states that :
Approximately 50 000 children are treated each year at the Hospital for Sick Children ED. Extrapolating the data from this study to a 1-year period suggests that an estimated 5000 children each year may be subjected to a mediction error and that 2500 may be subjected to significant errors. (Kozer et al., 2002, pp. 737-742) The data also mentions that these errors were most common amongst medical resident trainees. It is very important to consider that these errors are common and very much a reality in the medical field, parents should consider the factor of error before immediatley turning to pharmacological intervention for their children.
Cost Factors
Another factor that may influence the use of non-pharmacologicaltherapy may be the cost of drugs and associated health care resources. Most commonly, children of low income families whom have no health insurance, and are part of ethnic and racial minority groups may experience barriers and cannot afford costly healthcare (Waldman & Perlman, 2013, pp. 1-2).This will dictate the un-likeliness of these children using pharmacological methods to relieve pain symptoms. As noted by Srouji et al. (2010), the technique of distraction has been proven to be more ecomical than using various types of analgesics. Unfortunatley not all children, and families have equal access to health care due to factors mentioned above. A nurse must recognize and be sensitive to these social determinants of health before automatically enouraging pharmacological intervention for families with financial instability. Knowledge Deficits Amongst Nurses The dominant obsticle in the management of pain in children is healthcare professionals inadequate knowledge revolving around pain assessment, management and the philosophy of pain itself. According to He et al.(2010), a review of literature was studied and revealed nurses had poor pain management skills, especially in postoperative care. Nurses did not adequely assess levels of childrens pain, nor did they incorporate any non-pharmacological techniques in their pain management regime. Far too frequently pediatric pain goes untreated, and even with advancements in pain management approximatley “ 81 % of hospitalized children report moderate to severe levels of pain” (Stanley & Pollard, 2013, p. 165). A few barriers that may inhibit proper pain management are; 1) the myth that children experience pain differently then adults, 2) lack of assessment and reassessment of presented pain, and 3) adressing pain in children is a long and lengthy process that requires too much effort .Unfortunatley there are many negative outcomes of inproper pain management, and knowledge deficits amongst nurses, which include increased hospital length of stay and delayed recovery (Stanley & Pollard, 2013, p. 165). There is an obvious need for educational intervention amongst nurses to better enhance knowledge regarding non-pharmacological techniques and their benefits in reducing, and managing children’s pain more effectively. A sudy discussed within Stanley & Pollard (2013),used quasi-experimental one-group pre- and post-test design that included educational intervention regarding emphasis on non-pharmacological methods. Nurses participated in educational resources such as informative literaure, and lectures with discussion. A questionnaire was formulated for the pre-test regarding their use of non-pharmacological methods in the alleviation of childrens pain, and a post- test was conducted 3 months after completeion of education intervention. The results proved that there was a significant increase in nurses’ use of non-pharmacological methods. This study substaniates the need for more education regarding the use of non-pharmacological techniques within nursing practice. If nurses are properly educated, the benefits of these methods could be fully realized. Conclusion In conclusion, upon reviewing the above reseach and data, non-pharmacological methods can be seen as benefical and commendable alternative to pharmacological interventions.The reviewed methods of distraction. massage along with heat and cold application have proven to be valuable and useful in reducing pain symptoms in children, and should be incorporated routinely in pain management. Although pharmacological methods are widely used, individuals need to be aware of the adverse effects and negative economical aspects associated with this type of therapy, and consider more non-invasive procedures. Lastly, education is power,therefore the more educational insight health care providers possess the more effectively pain can be managed in children.

References
Ball, J. & Bindler, R. (2008). Pediatric nursing. Upper Saddle River, N.J.: Pearson/Prentice Hall.
Carlson, K., Broome, M., & Vessey, J. (2000). Using distraction to reduce reported pain, fear, and behavioral distress in children and adolescents: A multisite study. Journal for Specialists in Pediatric Nursing, 5(2), 75-85. Retrieved from http://search.proquest.com/docview/195778085?accountid=40483
Gorodzinsky, A., Bernacki, J., Davies, W., Drendel, A., & Weisman, S. (2012). Community parents' use of Non-Pharmacological Techniques for Childhood Pain Management. Children's Health Care, 41(1), 1-15. Retrieved from http://search.proquest.com/docview/926186244?accountid=40483
He, H., Jahja, R., Lee, T., Ang, E., Sinnappan, R., Vehvil Ainen-Julkunen, K., & Chan, M. (2010). Nurses’ use of non-pharmacological methods in children’s postoperative pain management: Educational intervention study. Journal of Advanced Nursing, 66(11), 2398-2409. Retrieved from http://search.proquest.com/docview/757301282?accountid=40483
Kozer, E., Scolnik, D., Macpherson, A., Keays, T., Shi, K., Luk, T., & Koren, G. (2002). Variables associated with medication errors in pediatric emergency medicine. Pediatrics, 110(4), 737-742. Retrieved from http://search.proquest.com/docview/228371586?accountid=40483
Lane, E. & Latham, T. (2009). Managing pain using heat and cold therapy. Paediatric Nursing, 21(6), 14. Retrieved from http://search.proquest.com/docview/218938958?accountid=40483
Mantle, F. (2004). Complementary and alternative medicine for child and adolescent care. Edinburgh: Butterworth-Heinemann.
Schechter, N., Berde, C. & Yaster, M. (2003). Pain in infants, children, and adolescents. Philadelphia: Lippincott Williams & Wilkins.
Srouji, R., Ratnapalan, S., & Schneeweiss, S. (2010). Pain in children: assessment and nonpharmacological management. International Journal of Pediatrics, 2010doi:10.1155/2010/474838
Stanley, M., & Pollard, D. (2013). Relationship between knowledge, attitudes, and self-efficacy of nurses in the management of pediatric pain. Pediatric Nursing, 39(4), 165. Retrieved from http://search.proquest.com/docview/1440019389?accountid=40483
Waldman, H. & Perlman, S. (2013). Health care costs continue when children with special health care needs become adults. The Exceptional Parent (Online), 43(4), 1-2. Retrieved from http://search.proquest.com/docview/1348648960?accountid=4048

Appendix A

Resource : Name of Article Nurses’ use of non-pharmacological methods in children’s postoperative pain management: educational intervention study | 1. Currency * When was the information published or posted? * Has the information been revised or updated? * Is this a rapidly changing topic area? * Is the information current or out-of date for your topic? * Are all the links on the site current and working, i.e. are there outdated or "dead" links? | * The information was published in 2012 * No information has been revised/updated * The topic is not really a rapidly changing area, non-pharmacological medicine has existed for ages. * The information is current for my topic, only being published in 2010. * There are no links within the journal | 2. Relevance * Does the information relate to the topic or answer your question? * How detailed is the information? * Who is the intended audience? * Have you looked at a variety of sources before determining this is one you will use? * Would you be comfortable using this source for your topic? | * Yes, this information is relevant to my topic as it discusses nurse’s use of non-pharmacological methods in children. * The information is very detailed, including an aim, background, method, results, and conclusion * The intended audience is nurses whom take care of children in postoperative settings * Yes, a variety of sources were considered * I would be comfortable using this article as it directly relates to my topic of interest | 3. Authority * Who is the author/ Are the author's credentials or organizational affiliations given? * What are the author's credentials or organizational affiliations given? * What are the author's qualifications to write on the topic? * Does the author/publisher/source/sponsor have an vested interest or possible bias? * Does the URL reveal anything about the author or source? examples: .com .edu .gov .org .net (websites only) | * The authors are Hong-Gu He, Riawati Jahja, Tat-Leang Lee, Emily Neo Kim Ang, Rajammal Sinnappan, Katri Vehvilainen-Julkunen, and Moon Fai Chan. All authors’ credentials and organizational affiliations are given. * Nearly all authors’ have PhD’s, are RN’s, or are medical doctors * Some authors’ work in children’s hospitals (pain resource nurse), nursing professors, researchers at university’s etc... * No, it does not appear the authors have a possible bias * The journal is a PDF file | 4. Accuracy * Where does the information come from? * Is the information supported by evidence? * Has the information been reviewed or refereed? * Can you verify any of the information in another source or from personal knowledge? * Does the language or tone seem unbiased and free of emotion? * Is the information clear? | * The information comes from Singapore, study was conducted in Singapore hospitals * Yes as there are various in text citations, and a lengthy reference list of credible sources * The information has been reviewed by the “Journal of Advanced Nursing” * From my research, some of the information in this article does overlap with other resources. * Yes, the language is strictly statistical * The information is very clear, and organized in to 5 sections: aim, background, methods,results,and conclusion. | 5. Purpose * What is the purpose of the information? Is it meant to inform? Teach? Or is it meant to entertain? Persuade? Sell a product, an idea, or way of thinking? * Do the authors/sponsors make their intentions or purpose clear? * Is the information fact? opinion? propaganda? * Does the point of view appear objective and impartial? Does it acknowledge other perspectives or conflicting information? * Are there political, ideological, cultural, religious, institutional, or personal biases? | * The purpose of this information is to inform nurses’ educational gaps, and need for educational intervention in the area of non-pharmacological therapy * Yes, they do this by stating the purpose of the paper within the abstract section, under the “aim” section at the beginning of the paper * This information is fact, as it was a study * The journal does not present any other conflicting information, it does acknowledge how future researchers could use different methods and examinations to conduct other meaningful studies * There are no noted biases noted in the information. |

Appendix B

Resource : Name of Article : Community Parents’ Use of Non-Pharmacological Techniques for Childhood Pain Management | 1. Currency * When was the information published or posted? * Has the information been revised or updated? * Is this a rapidly changing topic area? * Is the information current or out-of date for your topic? * Are all the links on the site current and working, i.e. are there outdated or "dead" links? | * The information was published in 2012 * The information has not been revised/updated, it if fairly recent still * The topic is not rapidly changing * The information is current for my topic as it was published in 2012, and has relatable content to this time period * There are no links in this journal | 2. Relevance * Does the information relate to the topic or answer your question? * How detailed is the information? * Who is the intended audience? * Have you looked at a variety of sources before determining this is one you will use? * Would you be comfortable using this source for your topic? | * Yes, the information does relate to my topic as it talks about non-pharmacological techniques for children * The information is fairly detailed including a wide range of relatable sources, looking at various topics such as types of non-pharmacological techniques, reasons why these types of techniques are used, using studies to support literature, ect... * The intended audience is indented for health care providers * Yes, I have looked at variety of sources before choosing this particular one. I feel this has a lot of viable information, useful to the structure of my essay * I am very comfortable using this source due to reasons above | 3. Authority * Who is the author/ Are the author's credentials or organizational affiliations given? * What are the author's credentials or organizational affiliations given? * What are the author's qualifications to write on the topic? * Does the author/publisher/source/sponsor have an vested interest or possible bias? * Does the URL reveal anything about the author or source? examples: .com .edu .gov .org .net (websites only) | * The authors are Aayla Y. Gorodzinskly, Jessica M. Bernacki and W. Hobart Davies of the Department of Psychology, University of Wisconsin-Milwauke, Amy L. Drendel of Department of Pediatrics ,Medical College of Wisconsin, and Steven J. Weisman of Department of Anesthesiology, Medical College of Wisconsin. * The authors all come from educational organizations specializing in psychology, pediatrics, and anesthesiology. All relevant specialties related to pain management in children * There are no noted biases within the journal * This journal is a PDF file | 4. Accuracy * Where does the information come from? * Is the information supported by evidence? * Has the information been reviewed or refereed? * Can you verify any of the information in another source or from personal knowledge? * Does the language or tone seem unbiased and free of emotion? * Is the information clear? | * The information came from Milwaukee, Wisconsin in the United States. * Yes there are a variety on in text citations and credible list of references * Yes, this information can be verified by another source, another source used in my paper is listed in the reference list of this particular article * The language used is unbiased and certainly free of emotional, it is completely statistical and for educational purposes only * The information is very clear, by being neatly organized under appropriate headings | 5. Purpose * What is the purpose of the information? Is it meant to inform? Teach? Or is it meant to entertain? Persuade? Sell a product, an idea, or way of thinking? * Do the authors/sponsors make their intentions or purpose clear? * Is the information fact? opinion? propaganda? * Does the point of view appear objective and impartial? Does it acknowledge other perspectives or conflicting information? * Are there political, ideological, cultural, religious, institutional, or personal biases? | * The purpose of this information is meant to inform health care professionals of the non-pharmacological pain alleviating techniques used by parents in the community, and a need to evaluate the effectiveness of these techniques * Yes, the author does this in the abstract on the first page where they state what exactly the paper will be talking about * The information is factual orientated * The journal does present some limitations to the study they chose to examine that could be seen as conflicting, or different perspective * There are no noted biases relating to political, cultural, religion ect.. |

Appendix C

Resource : Name of Article Managing pain using heat and cold therapy | 1. Currency * When was the information published or posted? * Has the information been revised or updated? * Is this a rapidly changing topic area? * Is the information current or out-of date for your topic? * Are all the links on the site current and working, i.e. are there outdated or "dead" links? | * The information was published in 2009 * The information has not been updated/revised * This is not a rapidly changing topic, heat and cold therapy is very common, and a fairly universal technique * The information is current enough to include in my paper, as it was only released a few years ago * There are no links included within this journal | 2. Relevance * Does the information relate to the topic or answer your question? * How detailed is the information? * Who is the intended audience? * Have you looked at a variety of sources before determining this is one you will use? * Would you be comfortable using this source for your topic? | * The information is very relevant to my topic as it examines a non-pharmacological technique of interest * The information is fairly detailed, includes a good amount of evidence-based research on information relating to heat and cold therapy * The intended audience is for paediatric nurses * I have looked at a variety of sources and found this article to be suitable to the purpose of my paper, as it examines a very specific technique of interest * I am comfortable using this source for the above reasons, and credibility of the authors | 3. Authority * Who is the author/ Are the author's credentials or organizational affiliations given? * What are the author's credentials or organizational affiliations given? * What are the author's qualifications to write on the topic? * Does the author/publisher/source/sponsor have an vested interest or possible bias? * Does the URL reveal anything about the author or source? examples: .com .edu .gov .org .net (websites only) | * The authors are Elaine Lane- Clinical nurse specialist, children’s pain service, Leeds Teaching Hospitals NHS trust and Tracy Latham- Clinical educator, children’s surgery, Leeds Teaching Hospitals NHS trust * The authors credentials and organizational affiliation are given * Both authors specialize in children’s pain, and surgery services * There are no noted biases * There are no websites, journal is a PDF document | 4. Accuracy * Where does the information come from? * Is the information supported by evidence? * Has the information been reviewed or refereed? * Can you verify any of the information in another source or from personal knowledge? * Does the language or tone seem unbiased and free of emotion? * Is the information clear? | * The information comes from England, from Leeds Teaching Hospitals * Yes the information is supported by evidence by use of in text citations linked to credible sources listed in references * Yes I can verify the information from my anatomy text books, and also personal experience relating to heat and cold therapy * The language is appropriate, unbiased and free of emotion. Information is strictly statistical and factual information * The information is very clear and easy to read with appropriate use of headings, and language to help readers follow the content, and understand it | 5. Purpose * What is the purpose of the information? Is it meant to inform? Teach? Or is it meant to entertain? Persuade? Sell a product, an idea, or way of thinking? * Do the authors/sponsors make their intentions or purpose clear? * Is the information fact? opinion? propaganda? * Does the point of view appear objective and impartial? Does it acknowledge other perspectives or conflicting information? * Are there political, ideological, cultural, religious, institutional, or personal biases? | * The purpose of the information is meant to inform ,and teach nurses of the benefits of non-pharmacological technique of heat and cold therapy, and how to minimize pain for children at hospitals * Yes, the authors made it clear that they wanted to discuss best practice related to equipment, safety, and infection control and the benefits of heat and cold therapy has on children * The journal does acknowledge some conflicting perspectives such as including a section titled “ General contradictions for heat and cold therapy” * There are no noted biases |