Translational Science Benefits
Summary
Children receiving medical care often experience pain. Unfortunately, this pain frequently goes unnoticed and untreated.1-3 In addition to causing undue discomfort, poor pain management can interfere with medical treatment and lead to long-term consequences, including chronic pain and mental health disorders.4-8 Needle-based procedures are the most common source of pain and anxiety for children.3,9 The burden of needle pain is especially high for children with cancer in low-and middle-income countries (LMICs), who must endure dozens to hundreds of needle pokes throughout their treatment. To avoid these painful procedures, patients sometimes abandon treatment altogether, which negatively impacts their health and ultimately decreases their chances of survival.9
The Children’s Comfort Promise is a quality improvement project designed to reduce the pain and anxiety of needle-based procedures. The project uses a bundle of five interventions to prevent and treat needle pain: applying numbing cream, positioning the child comfortably, using distractions, offering sucrose or breastfeeding for infants, and providing effective communication and praise. Comfort Promise was first implemented in 2018 in one of the largest children’s hospital systems in the United States, where it successfully reduced pain for patients.10 Following this success, the program expanded to additional hospitals in the US and other high-resource countries, increasingly becoming the new standard of care. Unfortunately, these interventions often remained unavailable to children receiving care in low-resource settings.
The Global Comfort Promise is an initiative to reduce needle pain for children worldwide. It adapts the evidence-based interventions from Children’s Comfort Promise for hospitals providing cancer care in low-resource settings. Between July 2021 and July 2023, our team piloted the initiative in four diverse, resource-limited hospitals. At each site, the interventions were successfully implemented and effectively reduced pain.11 In July 2023, we partnered with the Institute for Healthcare Improvement to expand the program to 22 hospitals across 18 different countries. To date, the Global Comfort Promise has been adopted by 52 hospitals and fully implemented in 26. This is an ongoing project, with implementation continually expanding to sites worldwide.
Significance
This initiative has successfully reduced needle pain and anxiety for children with cancer in LMICs. So far, hospitals implementing the Global Comfort Promise interventions have completed more than 10,000 needlestick procedures, decreased pain by 69%, and improved satisfaction for patients, their parents, and the healthcare providers treating them. Importantly, by effectively addressing pain, the program may support better adherence to treatment plans, leading to improved health and survival outcomes for patients. Further, the potential impact of preventing and treating needle pain extends beyond children undergoing cancer treatments. For example, these interventions could facilitate increased adherence to vaccinations and other needle-based procedures. Finally, in addition to reducing pain, our work provides valuable insights for implementing evidence-based interventions in limited-resource settings.
Benefits
Demonstrated benefits are those that have been observed and are verifiable.
Potential benefits are those logically expected with moderate to high confidence.
Provided the supplies necessary to implement Global Comfort Promise interventions, including topical anesthesia and distraction tools. demonstrated.
Clinical
Developed guidelines for implementing interventions to reduce needle pain and anxiety in limited-resource settings. demonstrated.
Clinical
Reduced the pain and anxiety associated with needle-based procedures using the Global Comfort Promise bundle of interventions. demonstrated.
Clinical
Reduce vaccine-preventable disease by increasing adherence to needle-based vaccinations. potential.
Community
Reduce pain and anxiety by providing education on effective interventions to patients, families, and healthcare professionals. potential.
Community
Improve health and survival outcomes for children with cancer in LMICs by increasing adherence to cancer-directed therapy. potential.
Community
Increase adherence to needle-based procedures using evidence-based, cost-effective strategies. potential.
Economic
Reduce the societal and financial cost of vaccine-preventable diseases by increasing adherence to needle-based vaccinations. potential.
Economic
Establish a new standard of care for all needle-based procedures globally. potential.
Policy
This research has clinical, community, economic, and policy implications. The framework for these implications was derived from the Translational Science Benefits Model created by the Institute of Clinical & Translational Sciences at Washington University in St. Louis.12
Clinical
This work has demonstrated clinical benefits. Implementing the Global Comfort Promise bundle improved needle-based procedures for children with cancer in low-resource settings. The 26 hospitals that implemented the interventions were able to reduce pain by 69% and increase satisfaction among patients, parents, and healthcare providers. Our team actively collaborated with global partners to ensure that all sites had the resources needed to successfully deliver each of the five interventions, including educational materials and medical supplies. We also developed guidelines to promote the implementation of evidence-based strategies for reducing needle pain across various resource settings.
Community
Addressing the pain and anxiety associated with needle-based procedures may make it easier for children with cancer to follow treatment plans, greatly improving their life expectancy and quality of life. Additionally, while our efforts so far have focused on reducing pain for children receiving cancer care, this intervention has the potential to improve adherence to all needle-based procedures, including vaccinations, which could significantly prevent and reduce disease.
Economic
This project offers potential economic benefits, including cost-effective cancer care. Treatment abandonment is a major cause of treatment failure and death for children with cancer in LMICs. Research shows that patients sometimes discontinue cancer-directed therapy to avoid painful procedures. Preventing and treating pain could lead to more successful treatment outcomes by improving adherence to treatment plans. The Global Comfort Promise interventions are evidence-based and can be implemented at a relatively low cost compared to their potential impact.
Policy
Our team has demonstrated that the bundle of Comfort Promise interventions can be effectively implemented across a range of resource settings to prevent and treat pain. Based on this success, we believe this program could be used to inform a new global standard of care for needle-based procedures.
Lessons Learned
Enthusiastic engagement from our global partners was essential to the implementation of the Global Comfort Promise. Our collaboration with the Institute for Healthcare Improvement, along with the structured quality improvement curriculum they developed, also played a crucial role in our ability to implement and expand the program. Finally, securing buy-in from institutional leadership to provide material resources, protected time, and ongoing encouragement was a key element in the success of the program.
- International Association for the Study of Pain (IASP). Declaration of Montreal, 2010. Accessed January 6, 2021.
- Birnie KA, Chambers CT, Fernandez CV, et al Hospitalized children continue to report undertreated and preventable pain. Pain Res Manag 2014; 19:198–204.
- Friedrichsdorf SJ, Postier A, Eull D, et al. Pain outcomes in a US Childrenʼs hospital: a prospective cross-sectional survey. Hosp Pediatr 2015; 5:18–26
- Walther-Larsen S, Pedersen MT, Friis SM, et al. Pain prevalence in hospitalized children: a prospective cross-sectional survey in four Danish university hospitals. Acta Anaesthesiol Scand 2017;61:328–37.
- Ammentorp J, Mainz J, Sabroe S. Parents’ priorities and satisfaction with acute pediatric care. Arch Pediatr Adolesc Med. 2005;159(2):127–131.
- Tiedeman ME. Anxiety responses of parents during and after the hospitalization of their 5- to 11-year-old children. J Pediatr Nurs. 1997;12(2):110–119.
- Melnyk BM. Intervention studies involving parents of hospitalized young children: an analysis of the past and future recommendations. J Pediatr Nurs. 2000;15(1):4–13.
- Velazquez Cardona C, Rajah C, Mzoneli YN, et al. An audit of paediatric pain prevalence, intensity, and treatment at a South African tertiary hospital. Pain Rep. 2019 Dec 6;4(6):e789.
- Friedrich P, Lam CG, Kaur G, et al. Determinants of Treatment Abandonment in Childhood Cancer: Results from a Global Survey. PLoS One. 2016 Oct 13;11(10):e0163090.
- Friedrichsdorf SJ, Eull D, Weidner C, et al. A hospital-wide initiative to eliminate or reduce needle pain in children using lean methodology. Pain Rep. 2018 Sep 11;3(Suppl 1):e671.
- McNeil MJ, Garcia Quintero X, Gonzalez M, et al. Preventing and Treating Pain and Anxiety during Needle-Based Procedures in Children with Cancer in Low- and Middle-Income Countries. Cancers (Basel). 2024 Mar 1;16(5):1025.
- Luke DA, Sarli CC, Suiter AM, et al. The Translational Science Benefits Model: A New Framework for Assessing the Health and Societal Benefits of Clinical and Translational Sciences. Clin Transl Sci. 2018;11(1):77-84.