Parental cardiac response in the context of pediatric acute pain: current knowledge and future directions

Written by Constantin K, McMurtry CM, Bailey HN

Pain is a complex experience that involves sensory and emotional components. Pain experience and expression are influenced by emotions, with negative emotional states often associated with poor pain outcomes, such as higher levels of reported pain intensity and lower levels of pain tolerance [1]. Pain from needle procedures, such as from immunizations and venipunctures, is common throughout childhood. Children typically report fear of, anxiety about and display distress during these required painful medical procedures [2,3]. [Note: Fear can be defined as a proximal response to perceived threat, anxiety is a future-oriented apprehension; distress is a broad term for unpleasant affect which is commonly applied to capture behaviors observed during medical procedures that are commonly thought to represent a combination of pain and fear [2]. When summarizing previous research, the terms used by the authors are included.] Notably, such negative medical experiences may result in needle fear and anxious avoidance of preventive and medically required healthcare in adulthood [1–3]. In fact, 7–8% of parents and children report needle fear as the primary reason for immunization noncompliance [3]. It follows that identifying the factors that influence children’s experience of procedural pain and fear is necessary to reduce and prevent these adverse consequences.
Given the interpersonal nature of the experience and expression of pain [4], a body of research within the pediatric pain literature has examined how parent behaviors and responses are linked to children’s pain, coping and distress during painful medical procedures. Most of this research has focused on parental self-report and behavioral observations, with minimal attention to parent physiology in pediatric pain contexts. There are a number of distinct benefits to using physiological measures, however. First, they can be recorded while parent and child are preparing for, experiencing and recovering from a painful medical procedure (e.g., vaccination), as opposed to self-report measures that may only capture parents’ experience before or after the procedure and may not be possible to gather throughout the process. Self-report measures also rely on accuracy and insight into one’s cognition, emotion and subjective physiological experience, whereas physiology provides a less subjective index of experience. Finally, physiological measures assess parents’ internal experience of emotion regulation [5]. Behavioral observation provides valuable information about parents’ responses, yet it relies on external cues, which do not always reflect inner experience. Consequently, as a measure of internal experience, physiological measures can complement observable behaviors and self-report responses. Such a multimodal assessment is needed to fully capture parents’ experience of viewing their child in pain.

Various physiological measures are available to assess emotional arousal. For example, electrodermal activity can provide a general index of emotional arousal, whereas heart rate variability (HRV) can inform how an individual is internally managing their emotions during stressful events [6]. Consequently, the physiological measure chosen will vary depending on the nature of the research question. This commentary will highlight parents’ emotional experience and regulatory capacity, which is commonly indexed by HRV [5]. HRV (via the vagus nerve) is a noninvasive, objective measure of cortical systems’ capacity to support regulated emotional responses [5]. The objectives of this commentary are to: highlight parental physiological responding as an additional measure of parental experience underutilized in the literature; describe cardiac responses as common indices of stress and emotional responding; review extant literature examining parental cardiac responses in the pediatric pain context; and outline areas for future investigation.

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