1. Copyright restrictions may apply 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. Copyright restrictions may apply 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

3. Copyright restrictions may apply 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

4. Copyright restrictions may apply 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. Copyright restrictions may apply 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. Copyright restrictions may apply 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

7. Copyright restrictions may apply 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

8. Copyright restrictions may apply 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

9. Copyright restrictions may apply 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. Contact Information