JAMA Pediatrics Journal Club Slides: Music in the Pediatric Emergency Department

1. JAMA Pediatrics Journal Club Slides:Music in the Pediatric Emergency Department Hartling L, Newton AS, Liang Y, et al. Music to reduce pain and distress in the pediatric emergency department: a randomized clinical trial. JAMA Pediatr. Published online July 15, 2013. doi:10.1001/jamapediatrics.2013.200.

2. Introduction • Background • Medical procedures for children (eg, venipuncture, intravenous [IV] placement) can cause pain, which can have long-lasting negative effects. • Pain assessment and management in the emergency department setting are often inadequate for children. • Music as a form of distraction may alleviate pain and distress. • Study Objective • To compare music with standard care to manage pain and distress for children undergoing procedures in the pediatric emergency department setting.

3. Methods • Study Design • Two-arm parallel randomized clinical trial with blinded assessment of the primary outcome. • Subjects: Children aged 3 to 11 years attending pediatric emergency department and undergoing IV placement (n = 42). • Must have been conscious, English-speaking (to understand instructions and complete pain assessment). • Excluded if they had hearing impairment, developmental disabilities, or sensory impairment to pain (eg, spina bifida) or if in critical condition. • Intervention: Music was started prior to IV placement, played via ambient speakers in the procedure room until the procedure was completed (n = 21). • Included music of different genres, played in the same order for all children. • Supplemented by standard care (topical anesthetics and soothing techniques including talking, explaining, and using comforting language). • Control: Standard care (n = 21). • Setting • Pediatric emergency department in Edmonton, Alberta, Canada.

4. Methods • Main Outcome • Patient distress • Measured using the Observational Scale of Behavioral Distress–Revised (previously validated in target population). • Includes 8 behaviors, coded by pretrained research assistants viewing video recordings of the procedures for all participating patients. • Music heard by the intervention group was dubbed onto the video of the control group so that the research assistants were blinded to the treatment condition. • Measured during 3 phases: • Preprocedure, during procedure, postprocedure. • Secondary Outcomes • Change in self-reported pain (using Faces Pain Scale) from preprocedure to immediately following initial attempt at IV placement (whether successful or not). • Child heart rate, parent anxiety, parent satisfaction.

5. Results • Primary Outcome: Effect of Music on Objective Measures of Distress • Among all participants, unadjusted for potential confounders: • No difference for intervention vs control. • Among all participants, adjusted for potential confounders: • Less increase in distress from preprocedure to immediately after procedure was observed for music group vs controls (P = .05). • Ethnic minority status was somewhat associated with less increase in distress (P = .06). • Among subgroup of participants (n = 32) who showed some evidence of distress during the procedure: • Substantially less increase in distress among the music group vs controls (P = .02).

6. Results • Secondary Outcomes • Children’s own report of pain (via Faces Scale): • Music group reported no increase in distress from preprocedure to postprocedure. • In contrast, control group reported significant increase in pain score (P = .04). • No significant intervention effect was found for: • Children’s heart rate. • Parent anxiety. • Parent satisfaction.

7. Comment • Overall, exposure to music during IV placement in the emergency department setting for children aged 3 to 11 years was not associated with significantly different objective ratings of distress. • Children’s subjective ratings, however, indicated significant attenuation of procedure-related stress with music exposure. • Among a subgroup of children who experienced distress during the procedure (approximately 75% of this sample), there was a significant attenuation of procedure-related distress through music. • No significant effect of music on physiological or parent measures.

8. Comment • Relationship of objective measures of distress to ethnic minority status warrants further examination. • Choice of music (by a music therapist) was intended to provide a variety of rhythms, instruments, and themes to function as a distractor. • Unknown whether unfamiliar vs familiar music would be more effective in attenuating distress. • Limitations • Unable to blind children, parents, and providers to group assignment (although objective assessment was blinded). • Potential contamination of study groups (ie, some parents in control group sang to their children; would bias to the null). • Parents and children were not allowed to choose music selections.

9. Contact Information • If you have questions, please contact the corresponding author: • Lisa Hartling, PhD, University of Alberta, 4-472 ECHA, 11405-87 Ave, Edmonton, AB T6G 1C9, Canada (hartling@ualberta.ca). Funding/Support • This trial was supported by a grant from the Women and Children’s Health Research Institute in Edmonton, Alberta, Canada. Conflict of Interest Disclosures • Hartling and Newton are supported by New Investigator Salary Awards from the Canadian Institutes of Health Research.