Received: 17 October 2018 Revised: 10 December 2018 Accepted: 13 December 2018

DOI: 10.1002/pbc.27600

Pediatric
RESEARCH ARTICLE Blood &
The American Society of
Cancer Pediatric Hematology/Oncology

General anesthesia, conscious sedation, or nothing:

Decision-making by children during painful procedures

Karolina Maslak1 Cinzia Favara-Scacco1 Martina Barchitta2 Antonella Agodi2

Marinella Astuto3 Rita Scalisi3 Simona Italia1 Francesco Bellia1
Gregoria Bertuna1 Salvatore D'Amico1 Milena La Spina1 Maria Licciardello1
Luca Lo Nigro1 Piera Samperi1 Vito Miraglia1 Emanuela Cannata1
Mariaclaudia Meli1,4 Federica Puglisi1,4 Giuseppe Fabio Parisi1,4
Giovanna Russo1,4 Andrea Di Cataldo1,4

1 Pediatric Hemato-Oncology Unit, Azienda

Policlinico Vittorio Emanuele, Catania, Italy Abstract

2 Department “GF Ingrassia” University of Cata-
nia, Catania, Italy
3 Intensive Care Unit, Azienda Policlinico Vittorio
Emanuele, Catania, Italy
4 Clinical and Experimental Medicine, University
of Catania, Catania, Italy
Correspondence
Giovanna Russo, Pediatric Hemato-Oncology
Unit, Azienda Policlinico Vittorio Emanuele, Via
Santa Sofia 78, 95123 Catania, Italy.
Email: diberuss@unict.it
Previously published as meeting abstract
1. 45th Congress of the International Society of
Paediatric Oncology, 25–28 September 2013,
Hong Kong, China;
2. XXXVII Congresso Nazionale AIEOP, 20–22
May 2012 Bari, Italy;
3. Submitted to 50th Congress of the Interna-
tional Society of Paediatric Oncology, 16–19
November 2018, Kyoto, Japan
Background: Following diagnosis, children with cancer suddenly find themselves in an unknown
world where unfamiliar adults make all the important decisions. Children typically experience
increasing levels of anxiety with repeated invasive procedures and do not adapt to the discom-
fort. The aim of the present study is to explore the possibility of asking children directly about
their medical support preferences during invasive procedures.
Procedure: Each patient was offered a choice of medical support on the day of the procedure,
specifically general anesthesia (GA), conscious sedation (CS), or nothing. An ad hoc assessment
tool was prepared in order to measure child discomfort before, during, and after each procedure,
and caregiver adequacy was measured. Both instruments were completed at each procedure by
the attending psychologist.
Results: We monitored 247 consecutive invasive procedures in 85 children and found that chil-
dren in the 4 to 7 year age group showed significantly higher distress levels. GA was chosen 66
times (26.7%), CS was chosen 97 times (39.3%), and nothing was chosen 5 times and exclusively
by adolescents. The child did not choose in 79 procedures (32%). The selection of medical support
differed between age groups and distress level was reduced at succeeding procedures.
Conclusions: Offering children the choice of medical support during invasive procedures allows
for tailored support based on individual needs and is an effective modality to return active control
to young patients, limiting the emotional trauma of cancer and treatment.

KEYWORDS
anesthesia, children, pain management, pain, painful procedures, pediatric oncology, psychological
support, sedation

1 INTRODUCTION
A cancer diagnosis can represent a major disruption of everyday life.
Children with cancer suddenly find themselves in a novel rigorous envi-
ronment, in which unfamiliar adults make all the decisions, even the
Abbreviations: BMA, bone marrow aspiration; CS, conscious sedation; GA, general
anesthesia; LP, lumbar puncture; No., number; p, Pearson correlation coefficients; SD,
standard deviation
most negligible ones. Uncertainty becomes a rule for these patients,
the need for a safe space becomes predominant,1–4 and psychologi-
cal assistance aims to create a holding environment containing doubts,
anguish, and fears.5–10 Managing these disturbing emotions is par-
ticularly important during the invasive procedures associated with
diagnosis and treatment.11–19
Researchers report that bone marrow aspiration (BMA) and lumbar
puncture (LP) are perceived as extremely traumatic by children with

Pediatr Blood Cancer. 2019;e27600. wileyonlinelibrary.com/journal/pbc 

c 2019 Wiley Periodicals, Inc. 1 of 8
https://doi.org/10.1002/pbc.27600
2 of 8
cancer.1,3,4,14,20 Although procedure-related pain represents an acute,
short-lived experience, it is accompanied by a great deal of fear and
anxiety and is remembered as traumatic even years after the treat-
ment has completed.4,20,21 Children undergoing cancer treatment
experience an increasing level of anxiety related to repeated inva-
sive procedures and do not adapt to the associated discomfort.22–26
They often develop symptoms such as lack of appetite, insomnia, and
emotional destabilization preceding a hospital visit including these
procedures.27,28 There is a current consensus among professionals
caring for children with cancer that these patients must receive age-
appropriate preparatory information along with adequate psychologi-
cal support around invasive medical procedures.29
These procedures have been performed in the operating room with
the support of general anesthesia (GA) for the last 10 years at our cen-
ter. GA allows for total control over pain and consciousness and has
been considered the preferred solution for painful experiences. How-
ever, we noticed that some patients showed discomfort during GA and
others refused it, presenting extremely high distress levels before and
during the anesthesia induction, and immediately after awakening.30,31
The patients reported disturbing images related to finding them-
selves in fearful places and situations and extra-bodily sensations. We
understood that the fear of the procedure was not neutralized by
GA for some patients and that GA itself was a source of additional
anxiety and discomfort, potentially due to its symbolic association
with death.30–34
The existing literature examines pharmacological versus nonphar-
macological support35–40 and sedation versus no sedation,30,41–50
and describes different ways to prepare children for these
procedures.11,51,52 However, none of these studies included ask-
ing children directly about their preferences for the type of medical
support.
Careful attention to the emotional outcomes of invasive procedures
is often limited, and only 36% of Centers of Pediatric Oncology and
Hematology in Italy reported that they ask children to give an assess-
ment of the pain experienced following the procedure, and only 22%
ask during the procedure.53
The eventual evaluation of pain control efficacy is assigned to either
the operators themselves or the caregivers,54,55 although the child's
perception of the invasiveness of the procedure and the related painful
experience has been confirmed to be poorly understood.56–61
Therefore, we considered that involving children in decision-making
about medical support during the procedure could mitigate some of
their emotional distress.62,63 The primary endpoint of the present
study is to evaluate whether allowing the children to choose among dif-
ferent types of medical support is able to lower their distress.
2 METHODS
All children undergoing invasive procedures in our Pediatric Hema-
tology and Oncology Unit from November 2013 to September 2014
were eligible to participate in this study. All caregivers and children
15 years of age or older provided written informed consent in accor-
dance with the local Ethical Committee requirements. Patients were
MASLAK ET AL .
divided into four age groups: preverbal (0–3 years), elementary school
(4–7 years), preadolescents (8–11 years), and adolescents (≥12 years).
The included procedures were LP, BMA, bone marrow biopsy, and
venous access positioning, since the first investigative procedure prior
to diagnosis as well as in the course of treatment. All procedures
were performed in an operating room equipped for anesthesia and the
team included a psychologist-art therapist, a pediatric oncologist, an
anesthetist, and a nurse. The caregiver could be present in the room
before the procedure, during anesthesia induction, if requested by the
child, and later in the recovery room, but not during the procedure
itself.
We gave children two types of support designated as medical and
psychological support on the day of the procedure. The medical sup-
port is given by the anesthetist during the procedure according to
child's choice of GA, conscious sedation (CS), or nothing. Psychologi-
cal support is given by the psychologist before, during, and after the
procedure.
2.1 Medical support
GA is a drug-induced loss of consciousness from which the patient is
not easily aroused and is unable to respond purposefully to physical
stimulation or verbal command. The drugs used were propofol and/or
sevoflurane and fentanyl, according to the anesthetist's determina-
tion. CS is a medically controlled state of depressed consciousness,
which allows protective reflexes to be maintained and permits volun-
tary responses by the patient to physical stimulation or verbal com-
mands. The drugs used were nitrous oxide and fentanyl as determined
by the anesthetist. Nothing was defined as a state of full consciousness,
with no use of drugs. Local anesthetic cream was applied to the zone of
puncture one hour before the procedure.
2.2 Psychological support before the procedure
The psychologist assisted each patient before the procedure by cre-
ating a listening time during which a comforting and age-appropriate
explanation of the procedure was given to address fearful doubts and
to contain frightening imagination. The methodology used during the
listening time was based on verbal communication as well as various
age-appropriate creative techniques including medical play, drama-
tization, free drawing, coloring, storytelling, and listening to music.
The patient was also asked to recall their “safe place” to stimulate
and increase a sense of comfort. The length of the listening time var-
ied from 10 to 30 minutes depending on the patient's age, physi-
cal/emotional condition, personality, and on their individual recall of
previous procedures.
The patient was then given the opportunity to choose the type
of medical support he or she would receive that day. The patient
was asked to confirm this choice even when the team knew the
patient's previous preference for medical support, and no selection
was described as good or bad. If the patient was unable to express his
or her preference, the medical support was chosen together by the psy-
chologist, the doctors, and the caregiver. The patient was also asked to
choose whether to be accompanied by the caregiver.
MASLAK ET AL . 3 of 8

2.3 Psychological support during the procedure TA B L E 1 Characteristics of the 85 patients (247 procedures)

Patients Procedures
The accompanying psychologist communicated the patient's choice
Characteristic No. (%) No. (%)
of medical support to the team at the entrance to the operating
Age groups
room. Psychological support continued by “focusing visual imagina-
0–3 (preverbal) 21 (24.7) 60 (24.3)
tion” or “freeing visual imagination,” depending on the patient's emo-
4–7 (elementary school) 20 (23.5) 68 (27.5)
tional state.64 “Focusing visual imagination,” such as with a count-
down and regular vocal outcomes, was offered to children with high 8–11 (preadolescents) 21 (24.7) 64 (25.9)

need for control and predictability. The patient's active participation ≥12 (adolescents) 23 (27.1) 55 (22.3)
was necessary in this case. “Freeing visual imagination” was offered to Sex
patients expressing less need for control, and included the following Female 43 (50.6) 124 (50.2)
modalities: Male 42 (49.4) 123 (49.8)
Disease
a. reality-based, in which the patient's active participation alternated
Acute Lymphoblastic Leukemia 45 (52.9) 159 (64.4)
with passive listening, such as recalling pleasant life events;
Myeloid Lymphoblastic Leukemia 7 (8.2) 36 (14.6)
b. fantasy-based, including passive listening and guided imagery, Other Leukemias 4 (4.7) 9 (3.6)
which engaged the patient by placing focus on a pleasant activity,
Non-Hodgkin Lymphoma 4 (4.7) 15 (6.1)
providing distraction from pain, or changing the perception of the
Other solid tumors 4 (4.7) 4 (1.6)
painful experience. The images used were produced during the lis-
Hematological benign disease 3 (3.5) 6 (2.4)
tening time.
Disease suspected, diagnostic phase 18 (21.2) 18 (7.3)
Type of procedure
2.4 Psychological support after the procedure
Bone marrow aspirate 39 (45.9) 101 (40.9)
Once the patient was awake, the psychologist provided the opportu- Lumbar puncture 26 (30.6) 101 (40.9)
nity to elaborate on the experience to help patients regain a sense of Bone marrow aspirate + lumbar puncture 8 (9.4) 28 (11.3)
control and self-assurance while recalling the “safe place.” Bone marrow biopsy 1 (1.2) 1 (0.4)
Venous access 2 (2.4) 3 (1.2)
2.5 Distress checklist Other (combination of above) 9 (10.5) 13 (5.2)
Total 85 (100) 247 (100)
We created an ad hoc assessment tool to measure patient distress
(Supporting Information Table 1S). It consisted of 18 items, drawn
from the literature on pediatric pain/procedures and from our clini-
cal experience19,65–71 and included items referring to both verbal and
physical behaviors. Verbal behaviors included position refusal (e.g., “I 2.7 Statistical analyses
won't stay still”), search for emotional support (e.g., “Mammy stay near
The data were collected in a database, and statistical analyses were
me,” “would you hold my hand?”), and request for termination (e.g.,
performed using SPSS software (IBM Corp. Released 2013. IBM SPSS
“stop now, please,” “I don't want to do it today”).
Statistics for Windows, Version 22.0. Armonk, NY: IBM Corp). Descrip-
Items were scored as 1 if present and 0 if not; therefore, the higher
tive statistics were used to characterize the population using frequen-
the score, the higher the distress level. We measured patient's distress
cies, means, and median values and ranges. Two-tailed 𝜒 2 tests were
before, during, and after each procedure and calculated the average
used for the statistical comparison of proportions, while continuous
score.
variables were evaluated with Student t tests. Correlations between
continuous variables were also evaluated using Pearson correlation
2.6 Caregiver behavior coefficients.

This custom-made tool consisted of four items assessing physical close-

ness, emotional closeness, respect for child's needs, and willingness to
tell the truth about the procedure. For each item, a score of 0 indicated
inadequate behavior and 1 indicated a satisfactory attitude, and each
item was assessed before, during, and after the procedure, leading to a
final score ranging from 0 to 12. For example, if a caregiver remained
near the child and maintained physical contact while saying: “Don't cry,
it's not a big deal,” the behavior would be scored 1 for “physical close-
ness” and 0 for “emotional closeness.” If the caregiver insisted on being
present in the procedure room even if the child wanted to be alone, the
item “respect for child's needs” was scored 0.
3 RESULTS
We performed 247 consecutive painful procedures in 85 children
(Table 1), and patients were homogeneously distributed among the age
and sex groups. The sample ranged in age from 0 to 20 years with a
mean age of 7.6 years. The mean number of procedures observed per
participant was 2.9, ranging from 1 to 10. The most frequent proce-
dures were BMA (n = 101) and LP (n = 101), and the most frequent
diagnosis was acute lymphoblastic leukemia.
4 of 8 MASLAK ET AL .

TA B L E 2 Distress analysis according to age group TA B L E 3 Distress analysis at each procedure, according to the
number of previous procedures
Age group (years) Average distress score
A. 0–3 4.62 Overall number Number of
of procedures procedures Average
B. 4–7 6.24 per child (total = 247) distress score P
C. 8–11 3.88 <2 85 5.48 <0.005
D. ≥12 3.98 ≥2 162 4.33
A vs B P < 0.005. <3 137 5.34 <0.001
B vs C P < 0.001. ≥3 110 3.96
B vs D P < 0.01.
Comparisons between other age groups are not statistically significant <4 175 5.22 <0.001
(P ≥ 0.05). ≥4 72 3.54
<5 200 5.05 <0.001
≥5 47 3.38
<6 220 4.92 <0.005
3.1 Child distress evaluation
≥6 27 3.15
We used the mean value obtained from the scores measured before, <7 233 4.83 <0.05
during, and after each procedure. We found significantly higher dis- ≥7 14 3.07
tress levels in patients aged 4 to 7 years (Table 2).
Females showed significantly higher scores following the procedure
relative to males (0.8 ± 1.1 vs 0.5 ± 1.1, P < 0.05, Cohen d = 0.27),
whereas no significant differences were observed at the entrance to
the procedure room or during the procedure/anesthesia induction.
We compared the distress level, at first procedure, of 21 patients
with no previous experience, with 64 patients, with previous
experience out of this study, and found no significant difference
(mean total sum of distress score 17.57 vs 18.34, respectively).
Finally, we compared the distress across all procedures for single
patients, comparing level at first procedure versus more than first,
first and second versus more than second, etc., and we found that dis-
tress levels diminished across subsequent procedures (Table 3), and
the more procedures the child experienced, the lower the distress level
became.

3.2 Medical support chosen by the child
Figure 1 and Table 4 show that GA was chosen 66 times (26.7%),
mainly by adolescents (32 procedures) and preadolescents (24 proce-
dures). CS was chosen 97 times (39.3%) and was preferred by pread-
olescents (37 procedures) and the elementary school-age group (31
procedures). Nothing was chosen five times and exclusively by adoles-
cents. No choice was made 79 times (32% of the procedures), and chil-
dren who did not make a choice were mainly preverbal (46 procedures)
followed by the elementary school-age group (29 procedures).
3.3 Medical support used
GA was used 167 times, in 66 procedures in which it had been chosen
by the child, in 67 procedures in which the child did not choose and it
was selected by the team, and in 34 procedures in which it was per-
formed after shifting the patient from CS support. The shift was made
during anesthesia induction itself because the child was not able to col-
laborate sufficiently or was uncomfortable.
CS was used in 75 of the 97 procedures in which it was chosen,
because 34 patients were shifted to GA during the anesthesia induc-
F I G U R E 1 The child's choice for medical support vs the medical
support used in 247 procedures
GA, general anesthesia; CS, conscious sedation; nothing, no use of
drugs
tion. In 12 cases, it was selected by the team in cases of no choice by
the patient.
Five patients used “nothing,” and the “no choice” group was
assigned by the team to either GA or CS according to the observed
initial distress level and information obtained during the listening time
(Table 4 and Figure 1).
3.4 Caregiver behavior
The comparison of caregiver behavior showed a more adequate atti-
tude in younger age groups, with a statistically significant differ-
ence between the 0 and 3 year group compared with the 8 to 11
and ≥ 12 year groups (P < 0.03 and P < 0.001, respectively; Table 5).
There was no significant correlation between patient distress level
and caregiver behavior.
MASLAK ET AL . 5 of 8

TA B L E 4 The child's choice of medical support

Medical support chosen

GA CS Nothing No choice Total in age group
Age group (year) No. (%) No. (%) No. (%) No. (%) No. (%)
0–3 2 (3.3) 12 (20.0) 0 46 (76.7) 60 (24.3)
4–7 8 (11.8) 31 (45.6) 0 29 (42.6) 68 (27.5)
8–11 24 (37.5) 37 (57.8) 0 3 (4.7) 64 (25.9)
≥12 32 (58.2) 17 (30.9) 5 (9.1) 1 (1.8) 55 (22.3)
Total in procedures 66 (26.7) 97 (39.3) 5 (2.0) 79 (32.0) 247 (100.0)

TA B L E 5 Caregiver behavior analysis procedural distress. We created a holding environment in which the
Average child had the opportunity to feel empowered. Children shaped their
caregiver own pathways toward self-confidence in facing new experiences in this
behavior score
Age group (year) Number (mean ± SD)
context and were not forced to fit inside a predetermined protocol.
The analysis of the children's selections confirms our background
A. 0–3 60 2.5 ± 1.0
observation that providing GA exclusively may be insufficient. Only
B. 4–7 68 2.2 ± 1.3
66 of 168 participants chose GA, whereas the majority of children who
C. 8–11 64 2.1 ± 1.0
expressed a preference chose CS, 97 of 168. One possible explana-
D. ≥12 55 1.6 ± 1.2
tion is that CS is a modality of support which removes pain without
A vs C P < 0.03. the loss of consciousness and therefore control. Death anguish may be
A vs D P < 0.001.
part of the anesthesia experience and is avoided or at least contained
Differences between other age groups are not statistically significant.
by this modality.80 Each age group appeared to have different prefer-
ences. The youngest were often unable to choose, elementary school
4 DISCUSSION and preadolescents preferred CS over GA, and adolescents preferred
GA (Table 4). Although the reasons why most children in the 0 to3 year
Most children survive their malignancies with modern medical care. age group were unable to express a preference may seem obvious, it is
Long-term survivors have confirmed that painful procedures at diag- interesting to note the “no choice” selection in the elementary school-
nosis and during treatment lead to extremely traumatic memories even age group. This is unlikely to reflect an age-related impediment, but
years after the completion of treatment.21,72 We noticed that GA was rather a difficulty in containing the decision-related emotional burden.
not sufficiently reassuring for all patients despite its total control over “No choice” is therefore a choice itself, expressing the need to have an
pain and consciousness, and that some patients refuse it. Therefore, we adult offer a reassuring emotional containment.74,77,81 This is consis-
decided to let the children participate directly in the pain management tent with the observation of the highest distress level in this age group
process to allow them to experience a sense of control and actively (Table 3).
explore their preferences when facing such an experience. In contrast, preadolescents and adolescents were more capable of
Our results show that patients in the elementary age (4–7 years) expressing their needs at the emotional level. Very few did not choose
group presented significantly higher distress levels than the other (3/64 and 1/55, in the 8–11 and ≥12 age groups, respectively), and
groups (Table 2). One possible explanation is that younger children (0– the preference for GA in adolescents (32/55) indicates an increased
3 years) may be reassured by simpler measures such as physical con- awareness of the disease and its related emotional burden, in that
tact by the caregiver, while older children (8–11 and ≥12) may find patients in this age group needed to lose control completely.64,77
verbal explanation a helpful coping strategy.73–77 Children aged 4 to It is noteworthy that patients chose “nothing” in five procedures.
7 may be vulnerable in that they are not fully dependent on caregivers They completed the procedure as initially chosen in all cases, without
yet also not fully autonomous.77 any pharmacological intervention. This was a minority of cases and all
Despite the fact that the difference between distress levels after in the adolescent age group but is nonetheless particularly significant.
the procedure by gender was statistically significant (Student t tests The reasons for such a selection may stem from the desire to com-
P < 0.05), the effect size (Cohen d = 0.27) was small. As a result, we pletely control both the pain and the procedure, because adolescents
do not suggest that there was practically/clinically important differ- are more aware of their disease severity and have more exposure to
ence between male and female distress scores, although other authors death anguish.
reported that cultural norms encourage females to express their emo- It was a challenge for the care team to accept such a choice. It
tions more freely than males.78,79 required a team effort to have the capability to take the pain away
This study shows that distress levels decrease with the number of without using it, and this effort was guided by respect for the patient's
previously experienced procedures (Table 3). We speculate that the emotional needs.82 The management of complex issues related to the
support modality used in this study was an efficacious remedy for curative process, organizational routine, and patient and caregiver
6 of 8
needs requires a concerted team including a variety of roles, who can
take care of specific aspects of the process and offer support to each
other.83–87
Although our clinical experience suggests that caregiver behavior
can influence the child's experience of the procedure, our study design
failed to show a statistically significant correlation between caregiver
behavior and child distress. It is possible that the observational scale
that we used was not able to uncover a possible correlation, but we can
also speculate that the painful procedure was a traumatic event signif-
icant enough to create a unique emotional condition that temporarily
disrupted the typical supportive exchange between the caregiver and
the child.
Other limitations of the study are the use of a nonvalidated scale
for distress measurement and caregiver behavior, and the lack of col-
lection of parent preferences for medical support.
In conclusion, we found that it is possible to tailor medical
and psychological support to each individual patient during painful
procedures,8,9,15 which can be predominant during cancer treatment.
Patients could not avoid the procedure, but they could regain control
by choosing the type of medical support and lower the distress. We
followed the child, not the protocol.
CONFLICTS OF INTEREST
The authors have no potential conflicts of interest. The authors have
no financial relationships relevant to this article to disclose.
ORCID
Karolina Maslak https://orcid.org/0000-0001-9112-7661
Luca Lo Nigro https://orcid.org/0000-0002-2480-1799
Giovanna Russo https://orcid.org/0000-0001-9369-7473
Andrea Di Cataldo https://orcid.org/0000-0002-4509-3066
REFERENCES
1. Darcy L, Knutsson S, Huus K, et al. The everyday life of the young child
shortly after receiving a cancer diagnosis, from both children's and par-
ent's perspectives. Cancer Nurs. 2014;37:445–456.
2. Coughtrey A, Millington A, Bennett S, et al. The effectiveness of psy-
chosocial interventions for psychological outcomes in pediatric oncol-
ogy: a systematic review. J Pain Symptom Manage. 2018;55:1004–
1017.
3. Mitchell HR, Lu X, Myers RM, et al. Prospective, longitudinal assess-
ment of quality of life in children from diagnosis to 3 months off
treatment for standard risk acute lymphoblastic leukemia: results of
Children's Oncology Group study AALL0331. Int J Cancer.
2016;138:332–339.
4. Kazak AE, Alderfer M, Rourke MT. Posttraumatic stress disorder
(PTSD) and posttraumatic stress symptoms (PTSS) in families of ado-
lescent childhood cancer survivors. J Pediatr Psychol. 2004:211–219.
5. Kazak AE, Abrams AN, Banks J, et al. Psychosocial assessment
as a standard of care in pediatric cancer. Pediatr Blood Cancer.
2015;62:S426–59.
6. Kazak AE, Noll RB. The integration of psychology in pediatric oncology
research and practice: collaboration to improve care and outcomes for
children and families. Am Psychol. 2015;70:146–158.
7. Kazak AE, Rourke MT, Alderfer MA, et al. Evidence-based assess-
ment, intervention and psychosocial care in pediatric oncology: a
MASLAK ET AL .
blueprint for comprehensive services across treatment. J Pediatr Psy-
chol. 2007;32:1099–1110.
8. Thompson AL, Young-Saleme T. Anticipatory guidance and psychoedu-
cation as a standard of care in pediatric oncology. Pediatr Blood Cancer.
2015;62:S684–93.
9. Steele AC, Mullins LL, Mullins AJ, et al. Psychosocial interventions and
therapeutic support as a standard of care in pediatric oncology. Pediatr
Blood Cancer. 2015;62:S585–618.
10. Scialla MA, Canter KS, Chen FF, et al. Implementing the psychosocial
standards in pediatric cancer: current staffing and services available.
Pediatr Blood Cancer. 2017;64:e26634.
11. Schepper F, Schachtschabel S, Christiansen H. Do not worry, it hurts!’-
psychological preparation for medical procedures in pediatric oncol-
ogy. Klin Padiatr. 2012;224:201–206.
12. Salas Arrambide M, Gabaldón Poc O, Mayoral Miravete JL, et al. Psy-
chological intervention for coping with painful medical procedures in
pediatric oncology. An Pediatr (Barc). 2003;59:105–109.
13. Tumino M, Meli C, Farruggia P, et al. Clinical manifestations and man-
agement of four children with Pearson syndrome. Am J Med Genet A.
2011;155:3063–3066.
14. Walco GA, Conte PM, Labay LE, et al. Procedural distress in children
with cancer: self-report, behavioral observations, and physiological
parameters. Clin J Pain. 2005;21:484–490.
15. Wiener L, Kazak AE, Noll RB, et al. Standards for the psychosocial care
of children with cancer and their families: an introduction to the special
issue. Pediatr Blood Cancer. 2015;62:419–424.
16. Wiener L, Viola A, Koretski J, et al. Pediatric psycho-oncology
care: standards, guidelines, and consensus reports. Psychooncology.
2015;24:204–211.
17. Young KD. Pediatric procedural pain. Ann Emerg Med. 2005;45:160–
171.
18. Astuto M, Favara-Scacco C, Crimi E, et al. Pain control during diag-
nostic and/or therapeutic procedures in children. Minerva Anestesiol.
2002;68:695–703.
19. Blount RL, Zempsky WT, Jaaniste T. Management of pain and dis-
tress due to medical procedures. In: Roberts MC, Steele R, eds. Hand-
book of Pediatric Psychology. New York, NY: Guilford Press; 2009:
171–188.
20. Best M, Streisand R, Catania L, et al. Parental distress during pediatric
leukemia and posttraumatic stress symptoms (PTSS) after treatment
ends. J Pediatr Psychol. 2001;26:299–307.
21. Stuber ML, Meeske KA, Leisenring W, et al. Defining medical posttrau-
matic stress among young adult survivors in the Childhood Cancer Sur-
vivor Study. Gen Hosp Psychiatry. 2011;33:347–353.
22. Chen E, Zeltzer LK, Craske MG, et al. Children's memories for painful
cancer treatment procedures: implications for distress. Child Dev.
2000;71:933–947.
23. Hedström M, Haglund K, Skolin I, et al. Distressing events for chil-
dren and adolescents with cancer: child, parent, and nurse perceptions.
J Pediatr Oncol Nurs. 2003;20:120–132.
24. Twycross A, Parker R, Williams A, et al. Cancer-related pain and pain
management: sources, prevalence, and the experiences of children and
parents. J Pediatr Oncol Nurs. 2015;32:369–384.
25. Zeltzer LK, Altman A, Cohen D, et al. American Academy of Pedi-
atrics report of the subcommittee on the management of pain associ-
ated with procedures in children with cancer. Pediatrics. 1990;86:826–
831.
26. Weisman SJ, Bernstein B, Schechter N. Consequences of inadequate
analgesia during painful procedures in children. Arch Pediatr Adolesc
Med. 1998;152:147–149.
MASLAK ET AL .
27. Dupuis LL, Lu X, Mitchell HR, et al. Anxiety, pain, and nausea during the
treatment of standard-risk childhood acute lymphoblastic leukemia: a
prospective, longitudinal study from the Children's Oncology Group.
Cancer. 2014;120:1417–1425.
28. Racine NM, Riddell RR, Khan M, et al. Systematic review: predispos-
ing, precipitating, perpetuating, and present factors predicting antici-
patory distress to painful medical procedures in children. J Pediatr Psy-
chol. 2016;41:159–181.
29. Flowers SR, Birnie KA. Procedural preparation and support as a stan-
dard of care in pediatric oncology. Pediatr Blood Cancer. 2015;62:S668–
S697.
30. Barbi E, Badina L, Marchetti F, et al. Attitudes of children with leukemia
toward repeated deep sedations with propofol. J Pediatr Hematol
Oncol. 2005;27:639–643.
31. Wright KD, Stewart SH, Finley GA, et al. Prevention and interven-
tion strategies to alleviate preoperative anxiety in children: a critical
review. Behav Modif. 2007;31:52–79.
32. Borsook D, George E, Kussman B, et al. Anesthesia and perioperative
stress: consequences on neural networks and postoperative behav-
iors. Prog Neurobiol. 2010;92:601–612.
33. Chorney JM, Kain ZN. Behavioral analysis of children's response to
induction of anesthesia. Anesth Analg. 2009;109:1434–1440.
34. Wennström L, Bergh I. Bodily and verbal expressions of postoperative
symptoms in 3- to 6-year-old boys. J Pediatr Nurs. 2008;23:65–76.
35. Kuppenheimer WG, Brown RT. Painful procedures in pediatric cancer.
A comparison of interventions. Clin Psychol Rev. 2002;22:753–786.
36. Liossi C, White P, Hatira P. A randomized clinical trial of a brief hyp-
nosis intervention to control venepuncture-related pain of paediatric
cancer patients. Pain. 2009;142:255–263.
37. Po’ C, Benini F, Sainati L, et al. The management of procedural pain at
the Italian Centers of Pediatric Hematology-Oncology: state-of-the-
art and future directions. Support Care Cancer. 2012;20:2407–2414.
38. Wall VJ, Womack W. Hypnotic versus active cognitive strategies for
alleviation of procedural distress in pediatric oncology patients. Am J
Clin Hypn. 1989;31:181–191.
39. Wild MR, Espie CA. The efficacy of hypnosis in the reduction of proce-
dural pain and distress in pediatric oncology: a systematic review. J Dev
Behav Pediatr. 2004;25:207–213.
40. Manyande A, Cyna AM, Yip P, et al. Non-pharmacological interven-
tions for assisting the induction of anaesthesia in children. Cochrane
Database Syst Rev. 2015;7:CD006447.
41. Anghelescu DL, Burgoyne LL, Faughnan LG, et al. Prospective random-
ized crossover evaluation of three anesthetic regimens for painful pro-
cedures in children with cancer. J Pediatr. 2013;162:137–141.
42. Chiaretti A, Ruggiero A, Barbi E, et al. Comparison of propofol versus
propofol-ketamine combination in pediatric oncologic procedures per-
formed by non-anesthesiologists. Pediatr Blood Cancer. 2011;57:1163–
1167.
43. Gelen SA, Sarper N, Demirsoy U, et al. The efficacy and safety of proce-
dural sedoanalgesia with midazolam and ketamine in pediatric hema-
tology. Turk J Haematol. 2015;32:351–354.
44. Jayabose S, Levendoglu-Tugal O, Giamelli J, et al. Intravenous anesthe-
sia with propofol for painful procedures in children with cancer. J Pedi-
atr Hematol Oncol. 2001;23:290–293.
45. Kato Y, Maeda M, Aoki Y, et al. Pain management during bone mar-
row aspiration and biopsy in pediatric cancer patients. Pediatr Int.
2014;56:354–359.
46. Nagel K, Willan AR, Lappan J, et al. Pediatric oncology sedation
trial (POST): a double-blind randomized study. Pediatr Blood Cancer.
2008;51:634–638.
7 of 8
47. Po’ C, Agosto C, Farina MI, et al. Procedural pain in children: education
and management. The approach of an Italian pediatric pain center. Eur
J Pediatr. 2012;171:1175–1183.
48. Po’ C, Benini F, Sainati L, et al. Procedural pain management in Italy:
learning from a nationwide survey involving centers of the Italian
Association of Pediatric Hematology-Oncology. Pediatr Rep. 2011;3:
e34.
49. Von Heijne M, Bredlöv B, Söderhäll S, et al. Propofol or propofol–
alfentanil anesthesia for painful procedures in the pediatric oncology
ward. Paediatr Anaesth. 2004;14:670–675.
50. Friedrichsdorf SJ. Nitrous gas analgesia and sedation for lumbar punc-
tures in children: has the time for practice change come? Pediatric Blood
& Cancer. 2017;64.
51. Brown SC, Hart G, Chastain DP, et al. Reducing distress for children
during invasive procedures: randomized clinical trial of effectiveness
of the PediSedate. Paediatr Anaesth. 2009;19:725–731.
52. McCarthy M, Glick R, Green J, et al. Comfort first: an evaluation of a
procedural pain management programme for children with cancer. Psy-
chooncology. 2013;22:775–782.
53. Po’ C, Benini F, Sainati L, et al. The opinion of clinical staff regarding
painfulness of procedures in pediatric hematology-oncology: an Italian
survey. Ital J Pediatr. 2011;37:27.
54. Cechvala MM, Christenson D, Eickhoff JC, et al. Sedative preference of
families for lumbar punctures in children with acute leukemia: propo-
fol alone or propofol and fentanyl. J Pediatr Hematol Oncol. 2008;30:
142–147.
55. Crock C, Olsson C, Phillips R, et al. General anaesthesia or conscious
sedation for painful procedures in childhood cancer: the family‘s per-
spective. Arch Dis Child. 2003;88:253–257.
56. Baeyer von CL. Children's self-report of pain intensity: what we know,
where we are headed. Pain Res Manage. 2009;14:39–45.
57. Ljungman G, Kreuger A, Gordh T, et al. Pain in pediatric oncology: do
the experiences of children and parents differ from those of nurses and
physicians. Ups J Med Sci. 2006;111:87–96.
58. Caes L, Vervoort T, Devos P, et al. Parental distress and catastrophic
thoughts about child pain: implications for parental protective behav-
ior in the context of child leukemia-related medical procedures. Clin J
Pain. 2014;30:787–799.
59. Kazak AE, Boyer BA, Brophy P. Parental perceptions of procedure-
related distress and family adaptation in childhood leukemia. Child
Health Care. 1995;24:143–158.
60. Pöder U, Ljungman G, von Essen L. Parents’ perceptions of their chil-
dren's cancer-related symptoms during treatment: a prospective, lon-
gitudinal study. J Pain Symptom Manage. 2010;40:661–670.
61. Wang Y, Liu Q, Yu JN, et al. Perceptions of parents and paediatri-
cians on pain induced by bone marrow aspiration and lumbar puncture
among children with acute leukaemia: a qualitative study in China. BMJ
Open. 2017;7:e015727.
62. Tan L, Meakin GH. Anaesthesia for the uncooperative child. Contin Educ
Anaesth Crit Care Pain. 2010;10:48–52.
63. Thompson ML. Information-seeking coping and anxiety in school-
age children anticipating surgery. Child Health Care. 1994;23:
87–97.
64. Favara-Scacco C, Smirne G, Schilirò G, et al. Art therapy as support for
children with leukemia during painful procedures. Med Pediatr Oncol.
2001;36:474–480.
65. Blount RL, Piira T, Cohen LL, et al. Pediatric procedural pain. Behav
Modif. 2006;30:24–49.
66. McGrath P, Stevens BJ, Walker SM, et al. Oxford Textbook of Paedi-
atric Pain. New York, NY: Oxford University Press; 2014.
8 of 8
67. Pillai RiddellR, Racine N. Assessing pain in infancy: the caregiver con-
text. Pain Res Manag. 2009;14:27–32.
68. Tucker CL, Slifer KJ, Dahlquist LM. Reliability and validity of the brief
behavioral distress scale: a measure of children's distress during inva-
sive medical procedures. J Pediatr Psychol. 2001;26:513–523.
69. Wong DL, Baker CM. Pain in children: comparison of assessment
scales. Pediatr Nurs. 1988;14:9–17.
70. Blount RL, Cohen LL, Frank NC, et al. The Child-Adult Medical Proce-
dure Interaction Scale-Revised: an assessment of validity. J Pediatr Psy-
chol. 1997;22:73–88.
71. Katz J, Melzack R. Measurement of pain. Surg Clin North Am.
1999;79:231–252.
72. Lown EA, Phillips F, Schwartz LA, et al. Psychosocial follow-up in sur-
vivorship as a standard of care in pediatric oncology. Pediatr Blood Can-
cer. 2015;62:S514–S584.
73. McGrath P, Huff N. What is it?’: findings on preschoolers’ responses to
play with medical equipment. Child Care Health Dev. 2001;27:451–462.
74. Salmela M, Aronen ET, Salanterä S. The experience of hospital-related
fears of 4- to 6-year-old children. Child Care Health Dev. 2011;37:719–
726.
75. Salmela M, Salanterä S, Aronen ET. Coping with hospital-related fears:
experiences of pre-school-aged children. J Adv Nurs. 2010;66:1222–
1231.
76. Koukourikos K, Tzeha L, Pantelidou P, et al. The importance of play dur-
ing hospitalisation of children. Mater Sociomed. 2015;27:438–441.
77. Winnicott DW. Through Paediatrics to Psycho-analysis. London, UK:
Tavistock Publications; 1958.
78. Hechler T, Chalkiadis GA, Hasan C, et al. Sex differences in pain inten-
sity in adolescents suffering from cancer: differences in pain memo-
ries? J Pain. 2009;10:586–593.
79. Boerner KE, Chambers CT, McGrath PJ, et al. The effect of parental
modeling on child pain responses: the role of parent and child sex.
J Pain. 2017;18:702–715.
80. Ljungman G, Gordh T, Sorensen S, et al. Pain in paediatric oncology:
interviews with children, adolescents and their parents. Acta Paediatr.
1999;88:623–630.
MASLAK ET AL .
81. Björk M, Nordström B, Hallström I. Needs of young children with can-
cer during their initial hospitalization: an observational study. J Pediatr
Oncol Nurs. 2006;23:210–219.
82. Finley GA, Franck LS, Grunau RE, et al. Why children's pain matters.
Pain: Clinical Updates. 2005;13:1–6.
83. Franck LS, Bruce E. Putting pain assessment into practice: why is it so
painful? Pain Res Manag. 2009;14:13–20.
84. Giordano J, Abramson K, Boswell MV. Pain assessment: subjec-
tivity, objectivity, and the use of neurotechnology. Pain Physician.
2010;13:305–315.
85. Giordano J, Schatman ME. A crisis in chronic pain care: an ethical anal-
ysis. Part two: proposed structure and function of an ethics of pain
medicine. Pain Physician. 2008;11:589–595.
86. Giordano J, Schatman ME. A crisis in chronic pain care: an ethi-
cal analysis. Part three: toward an integrative, multi-disciplinary pain
medicine built around the needs of the patient. Pain Physician. 2008;11:
775–784.
87. Leroy PL, Schipper DM, Knape HJ. Professional skills and competence
for safe and effective procedural sedation in children: recommenda-
tions based on a systematic review of the literature. Int J Pediatr.
2010;2010:934298.
SUPPORTING INFORMATION
Additional supporting information may be found online in the Support-
ing Information section at the end of the article.
How to cite this article: Maslak K, Favara-Scacco C, Bar-
chitta M, et al. General anesthesia, conscious sedation, or noth-
ing: Decision-making by children during painful procedures.
Pediatr Blood Cancer. 2019;e27600. https://doi.org/10.1002/
pbc.27600