SUBCUTANEOUS ROUTE IN PAEDIATRIC PALLIATIVE CARE: SCOPE REVIEW

1. TITLE OF THE REVIEW

SUBCUTANEOUS ROUTE IN PAEDIATRIC PALLIATIVE CARE: SCOPE REVIEW

2. QUESTION AND PURPOSE OF THE REVIEW

Question: PCC (Population-concept-context):

Population: Children

Concept: Subcutaneous route

Context: Palliative care

Question: What is the available evidence about the subcutaneous route in pediatric palliative care?

Objective: To explore available evidence on the subcutaneous route in pediatric palliative care.

3. BACKGROUND AND JUSTIFICATION

INTRODUCTION

Pediatric palliative care is essential as it seeks to improve the quality of life of children throughout life-threatening diseases, even in those with curative treatment but with a high probability of failure. They are carried out in a compassionate manner, alleviating suffering and providing comfort through the management of pain and other symptoms, framed by an integral approach in which there is spiritual, physical, and psychosocial support for both the patient and his family (1). Thus, from the perspective of treating unpleasant symptoms, it is important to note that medication is often required, with the oral route being the preferred option (2). However, in a number of situations this alternative may not be feasible. Therefore, in patients receiving palliative care, it is necessary to consider alternative routes, such as subcutaneous (2).

In this context, the administration of drugs and fluids by subcutaneous route has traditionally been studied and used in adult patients due to its multiple benefits based on clinical criteria, viability and patient preference (3). Recently, after years of research and practice, and extrapolating evidence from adults to children, its use in pediatric patients has been re-validated. This fact has generated a growing interest among health professionals, especially because of the need to find less invasive and more comfortable alternatives to this population, mainly those suffering from chronic diseases or who benefit from palliative care (4,5,6,7), in order to increase their quality of life and eliminate their suffering.

However, the use of this route in pediatric patients may present complexities due to factors such as body size, anatomical peculiarities of children and adolescents, stage of development, thickness of adipose tissue, variable pharmacokinetics and patient collaboration. Also, among the most documented incidents are accidental route exit, and local tissue reactions that resolve without additional treatments (8,4,9,5,2,10).

In this way, the subcutaneous route offers a promising alternative that can overcome some of these barriers, although there are challenges that must be adapted to the specific needs of children. The subcutaneous route represents an effective and safe option that improves the care experience in pediatric patients and their families. Provides greater freedom of movement, promoting autonomy and independence for the child, resulting in better adaptation to treatment and fewer psychosocial implications (9,11,10). It also reduces anxiety and discomfort in the child and family, improving their quality of life (9,5,10). It is a feasible route when the oral route is not available, and its ease of use allows caregivers to learn and administer medicines at home (2,8,4,5).

For health personnel, the benefits of this pathway include reduced stress because it is less traumatic to the child, leading to less patient resistance (4,12,13,14). There is also a reduced occurrence of bloodstream infections associated with intravenous puncture (6,2,15); This option is especially viable when there is little patient cooperation for oral drug administration (2,15,10). It is a simple technique that can be used by people with little training, offering gradual, slow and sustained release for prolonged and intermittent therapies, so requires less supervision (8,4,5).

Hence, this scoping review aims to synthesize the available literature to identify techniques, clinical indications, administration methods and care measures related to the subcutaneous route in pediatric palliative care. The results of this review will help inform about the implementation of the subcutaneous route in the field of pediatric palliative care, in order to contribute to the management and treatment of chronic oncological diseases.

METHODOLOGY

The approach of this scoping type review followed the parameters proposed by the Joanna Briggs Institute (JBI) (16) and Khalil et al. (17)through the following phases: 1) Approach to the review question; 2) search and identification of relevant studies; 3) choice of studies; 4) data extraction and synthesis, and 5) presentation of results. Also, to ensure quality, this report was built according to the PRISMA Extension for Scoping Reviews (PRISMA-ScR) (18)

The review question was designed following the PCC structure of the JBI methodology (16): Population of interest (pediatric patients), Concept (subcutaneous route) and Context (areas of care in clinical and ambulatory palliative care). Identification of relevant studies was carried out through the electronic databases Scopus, Medline (via PubMed) and BvS (Lilacs). The search was limited to articles available in English, Spanish and Portuguese, published in the last 10 years (2014-2024), resulting from primary research (qualitative, quantitative and mixed), systematic reviews and literature reviews. The search terms (MeSH and DeCS) were identified in all three languages and defined according to each part of the PCC question: P (Paediatric), C (Infusions, Subcutaneous; Subcutaneous) y C (Palliative Care).

The following inclusion criteria were considered for article selection: 1. The study specifically covers the management of the subcutaneous route to pediatric patients in palliative care; 2. The study addresses phenomena related to techniques, clinical indications, administration methods and care measures related to the subcutaneous route in pediatric palliative care; understanding the subcutaneous route as "administration of liquid or nutrient drugs under the skin, usually in minutes or hours" (19) and 3. The provision of care to pediatric patients described in the study is carried out in any clinical or outpatient setting.

All articles resulting from the search were uploaded to the online platform Rayyan Systems, Inc. (20) , where they were inspected and duplicated and subsequently submitted to a selection process strictly applying the inclusion criteria. Each member of the research team independently read the title, summary and full text of the reports obtained. Doubts in the selection were resolved through a second reading by another team member; identification of new studies by other sources is not carried out. It should be clarified that at this stage no evaluation of the quality of studies was considered, given the focus of such reviews (21).

For data extraction and synthesis, a form was designed in Excel ®, which included the following fields: author(s), year of publication, study country, design, scope, type of patients and clinical care procedures and guidelines. Additionally, in another form, the relevant data to answer the review question was manually extrapolated and analyzed by means of an inductive thematic construction process for scoping reviews, by identifying and classifying the relevant data identified in the texts, which were subsequently organized into themes (22)

CRITERIA FOR INCLUSION

• TYPES OF PARTICIPANTS

Paediatric patients

• CONCEPTS

Subcutaneous route: The administration of liquid drugs or nutrients under the skin, usually in minutes or hours (19).

• Context Palliative care (any type of chronic cancer or non-cancer disease)

• TYPE OF DOCUMENTS OR SOURCES OF INFORMATION

-Primary research articles (qualitative, quantitative, mixed)

-Systematic reviews

• Language

English, Spanish and Portuguese

• Temporality

Last 10 years

6. SEARCH STRATEGY

Includes the design and implementation of the search strategy (definition of descriptors, inclusion criteria for studies, languages) and the identification of relevant studies following a three-stage strategy to increase breadth and completeness:

The first step is a limited search in MEDLINE databases (PUBMED) followed by a choice of words contained in the title, abstract and full-text article.

The second step in which all identified keywords and index terms are used in all included databases: SCOPUS and BVS.

The third stage includes analysis of the reference lists for all reports and articles identified, with a view to identifying additional studies.

7. SELECTION OF STUDIES

Careful selection of studies (title, abstract and full text) that will be part of the review using a team approach and including all levels of evidence considered by JBI.

8. DATA EXTRACTION AND ANALYSIS

Includes the extraction of data from selected studies and documents in tabulation, graphic or narrative format, as appropriate.

9. CONFLICT OF INTEREST

None