(9.30.13)

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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.

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• 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.
Introduction

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• 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.
Methods

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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.

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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).

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• 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.
Results

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• 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.
Comment

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• 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.
Comment

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• 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.
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