The foreground question I sought to answer was In pediatric patients with asthma does hypnosis or music lead to greater stress reduction? The most important concept in this question is maximizing the amount of stress reduction. My final working set was the search ((((((((Adolescent[MeSH Terms]) AND Child[MeSH Terms]) NOT Adult[MeSH Terms]) AND hypnosis) or music) AND “stress reduction”)). I searched for the MeSH terms adolescent and Child to select for studies that specifically concerned people under the age of 18.
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I wanted to eliminate any studies that were primarily about people above the age of 18, so I used the MeSH term adult and the Boolean term Not to remove any studies with the MeSH tag. I further selected for articles containing either Hypnosis or music and the phrase stress reduction. The study titled, Feasibility of Music and Hypnotic Suggestion to Manage Chronic Pain is a cohort study, and was chosen because it directly studied patients and was conducted recently, while the other study Beyond the drugs: nonpharmacologic strategies to optimize procedural care in children is a meta-analysis and was chosen because it offers a condensed overview of existing literature.
The study Feasibility of Music and Hypnotic Suggestion to Manage Chronic Pain is a cohort study, published 24 August, 2017. 1 The study was conducted between January 2016 through May 2016 and used the inclusion criteria: (a) age 18 years or older; (b) diagnosed with cancer or other serious illness; (c) English or Spanish speaking; and (d) a pain rating of ?‰? 4 on an 11-point numerical rating scale.1 After gaining informed consent they determined each participant’s baseline then explained the intervention, approximately five minutes of hypnotic suggestions (did not include a formal hypnotic induction) for pain relief, reduced pain perception, focused attention, pleasantness, and relaxation followed by 15 minutes of string orchestra music (Fantasia on a Theme of Thomas Tallis by Ralph Vaughn Williams).1 The participant rated their pain upon waking over two weeks, at the end of which they completed an endpoint measurement. They study found that the average pain lever decreased from the baseline and decreased pre and post intervention. Further they found average anxiety decreased from the baseline, as did their overall distress. They noted that the effect of both hypnotic suggestion and music therapy when used together produced a stronger effect than individually, although the study did not test either individually. As the study was a relatively small sample size, the generalizability is low. Further, as all the participants were above the age of 35, applicability to a pediatric population may be limited. Because the participants suffered from a variety of chronic conditions, and all participants demonstrated reduced anxiety, it is likely that an asthma sufferer would also be benefitted by the intervention. Another limitation to note is the poor demographic distribution, with 9 of the 10 participants being Caucasian. Finally the researchers noted that during the exit interviews it was noted that the participants may have seen greater reductions in anxiety if they had been able to make their own music selection. Choice in music selection may be especially important when attempting any of these techniques on children, and special consideration to their individual, culture and ethnic preferences is highly important.
The study Beyond the drugs: nonpharmacologic strategies to optimize procedural care in children is a meta-analysis, published 1 March 2016.2 The researchers presented evidence from other studies and reviews in a narrative fashion. They noted a number of nonpharmacologic strategies (NPS) to manage pain and anxiety in children and categorized specific techniques into larger categories. Regarding hypnosis specifically they note There is an increasing body of evidence showing the positive effects of (self) hypnosis’ on procedural comfort, particularly in children beyond the age of 4 years [24,30,72“74]. Hypnosis has been defined as a state of highly focused attention and a heightened responsiveness to social cues . Hypnosis is known to facilitate relaxation and analgesia.2 Music was addressed both as part of a comfort menu2 and as part of various distraction techniques but did not provide quantitative measure of how much stress or anxiety were reduced. The study notes that in the vast majority of studies, researchers used quantitative measures that may not adequately reflect a patient’s feelings and that qualitative measures may be more beneficial. This study was specifically related to dentistry which allows for direct applicability to my patient. Further they provide guidance regarding a holistic approach to stress and anxiety reduction that includes the environment of the office, techniques for the parents, and the dental professionals. They note the importance of NPS in any procedure and that the most effective technique is one that is tailored specifically to the individual and that not all techniques will be equally effective in all patients.2
In treating Sophia, if we assume that neither I or any members of the staff are competent to relieve Sophia of her language brokering responsibilities, it would be best to have a translator on-call or on staff. If Sophia is the only person available to translate then every effort must be taken to ensure that the process is as low-stress as possible. Further, it must be ascertained if Sophia’s grandmother is an authorized guardian or if her parents must be contacted in order to obtain consent. Assuming the grandmother can provide consent, then the exam can begin. At all times it is important to maintain a non-threatening, professional environment.2 It would be best to apply a number of NPS techniques, particularly explaining what I will be doing prior to beginning, and then continue to talk to her and tell her what I am doing and the visit progresses.2 Using music, unless at a very low background volume may prove to be a stressor if it makes understanding difficult between us or between her and her grandmother. Speaking slowly, softly, and using language that is appropriate for her developmental level will reduce some of the stress she may experience.2 finally, asking for feedback and assessing her pain and anxiety levels throughout the procedure will be important to a successful visit and help alleviate any anxiety about future visits.2
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