Applying the Safe Child® Method for inserting earrings in children’s earlobes

Aplicación del Método Safe Child® para inserción de pendientes en el lóbulo auricular en niños

ABSTRACT

Objective:

To report the experience of applying the Safe Child® Method for inserting earrings in children’s earlobes.

Method:

Experience report. The method is organized in order to explain the procedure’s protocol with three steps: 1) Pre-service guidelines; 2) Perforation of the earlobe; and 3) Post-procedure orientations, carried out exclusively at home, lasting approximately one hour and 30 minutes.

Results:

Earlobe perforation occurs using pharmacological and non-pharmacological relaxation techniques, with the inclusion of the family, to promote care that is free from damage and trauma.

Final considerations:

The method aims to protect the child’s physical and emotional health, providing a pleasant experience for the binomial. The techniques and actions used, based on scientific evidence, allow the practice of humanized care, with the empowerment of nurses and autonomy beyond health services.

Descriptors:
Nursing; Children; Family Health; Pain; Evidence-Based Nursing

RESUMEN

Objetivo:

Relatar experiencia de la aplicación del Método Safe Child® para inserción de pendientes en el lóbulo auricular en niños.

Método:

Discurre de un relato de experiencia. Organizado de manera a explicitar el protocolo del procedimiento con tres pasos: 1) Orientaciones preatención; 2) Perforación del lóbulo auricular; y 3) Orientaciones postprocedimiento, realizado exclusivamente en el domicilio, con duración aproximada de una hora y 30 minutos.

Resultados:

La perforación del lóbulo auricular ocurre mediante el uso de técnicas de relajación, farmacológicas y no farmacológicas, integradas con la inclusión de la familia, para promover un cuidado libre de daños y traumas.

Consideraciones finales:

El método pretende proteger la salud física y emocional del niño, proporcionando una experiencia agradable al binomio. Las técnicas y acciones utilizadas, basadas en evidencias científicas, permiten la práctica del cuidado humanizado, con empoderamiento de la enfermería y autonomía en su actuación para además de los servicios de salud.

Descriptores:
Enfermería; Niños; Salud de la Familia; Dolor; Enfermería Basada en la Evidencia

RESUMO

Objetivo:

Relatar a experiência da aplicação do Método Safe Child® para inserção de brincos no lóbulo auricular em crianças.

Método:

Trata-se de um relato de experiência. O método é organizado de forma a explicitar o protocolo do procedimento com três passos: 1) Orientações pré-atendimento; 2) Perfuração do lóbulo auricular; e 3) Orientações pós-procedimento, realizado exclusivamente no domicílio, com duração aproximada de uma hora e 30 minutos.

Resultados:

A perfuração do lóbulo auricular ocorre mediante o uso de técnicas de relaxamento, farmacológicas e não farmacológicas, integradas com a inclusão da família, para promover um cuidado livre de danos e traumas.

Considerações finais:

O método visa proteger a saúde física e emocional da criança, proporcionando uma experiência agradável ao binômio. As técnicas e ações utilizadas, embasadas em evidências científicas, permitem a prática do cuidado humanizado, com empoderamento da enfermagem e autonomia na sua atuação para além dos serviços de saúde.

Descritores:
Enfermagem; Crianças; Saúde da Família; Dor; Enfermagem Baseada em Evidências

INTRODUCTION

Earlobe perforation for the insertion of earrings is a procedure that symbolizes a unique moment for families, idealized since pregnancy, especially for mothers of girls, as the first jewel represents identification and delicacy. Although it is often considered simple, there is a need for preparation before, during, and after perforation, regarding the location, materials used, professional safety, space, and care for the child and family. The chosen method must be safe, to avoid physical and emotional harm to the child; and earring insertion must be performed by a professional trained in the technique within the current regulations⁽¹⁾.

Traditionally, earlobe perforation was performed exclusively in pharmacies, using a pistol, but the method had disadvantages, such as the potential to cause hearing damage in children. Thus, the Agência Nacional de Vigilância Sanitária (Anvisa) [Brazilian Health Regulatory Agency] released the Resolution of the Collegiate Board (RCB) No. 44, in 2009, which supports and changes previous perforation practices. The resolution directs that the procedure be carried out with a specific device, using a sterile earring as the piercing material, following legislation, be done in an aseptic manner, and documented afterwards⁽¹⁾.

Currently, in addition to pharmacies, the procedure is also performed at home, by other professionals who appropriated the techniques and were authorized to perform the perforation. In the case of nurses, in Brazil, several Regional Nursing Councils (CORENs) support the practice through reasoned guidelines and technical opinions, with autonomy for perforation, as long as the safety of the child is guaranteed and respect for the ethical and legal precepts that govern the profession, such as: harm-free assistance; and practice based on health promotion, prevention, recovery, and rehabilitation are maintained. Nurses must perform the procedure only after training, and technicians and/or nursing assistants can only perform it if supervised by a trained nurse, if it occurs within inpatient hospital units(², ³).

As this is a new area, there are no studies in the international literature that describe the practice of perforating the earlobe for earring insertion. Despite this gap, in clinical practice it is possible to observe the emotional repercussions caused in the family of children who underwent perforations, with a paradigm shift in their ideals due to the lack of preparation and experience of pain and/or aesthetic impacts.

It is known that painful procedures provide long-term repercussions for the child and family. International scientific evidence reports painful experience of hospitalized children, who, during diagnosis and treatment, are subjected to several painful and invasive procedures, such as: venous, arterial, lumbar, heel, and other punctures. These are potential sources of stress and lead to one of the most distressing and difficult experiences of pain for children and suffering for parents(⁴, ⁵), highlighting the fact that, often, neither they nor them are prepared for this.

The preparation of the family and the child becomes essential to reduce anxieties⁽⁴⁾. It is necessary to integrate the shared information with uncomplicated explanations through an accessible language, encouraging collaboration and presence during the procedure. In addition, the professional must be available to clarify any doubts, actions that produce care and safety for the child and are prepared according to their cognitive development, using pharmacological and non-pharmacological measures.

When perforating the earlobe for the insertion of earrings, the professional can schedule this procedure, which allows prior preparation of the binomial, with humanization practices and based on scientific evidence that consider the approach to pain, inflammation, and care with healing. Aiming to change the context of painful and impactful experiences in the perforation of the earlobe, the nurse, with legal support, is a professional with great chance of success in this practice, with entrepre-neurship beyond the health services. With this motivation, the Safe Child® Method was designed to ensure the child’s physical and emotional integrity; and patented in order to ensure the empowerment of nursing as a pioneer in the humanization of this procedure.

OBJECTIVE

To report the experience of applying the Safe Child® Method for inserting earrings in children’s earlobes.

METHODS

This is an experience report, based on the professional experience of more than 20 years of a nurse specialized in pediatrics and neonatology, qualified in neurofunctional auriculotherapy, maternal-infant laser therapy, and breastfeeding consultancy. She is the creator of the Safe Child® Method for perforating the earlobe for earring insertion, patented on April 14, 2020, as per process No. 918042690, NCL class (11)44. An average of 40 to 50 perforations are carried out per month, and courses are offered to train other nurses interested in undertaking this field.

The Safe Child® Method aims to provide a welcoming experience, free from damage and trauma at the time of perforating the earlobe for earring insertion. The practice is based on scientific evidence and on the Family-Centered Care Theory, with techniques and actions aimed at protecting the physical and emotional health of the child who will be subjected to perforation, with direct inclusion of the main caregiver and other family members. It seeks to protect physical health through actions focused on preventing accidents, infections, and cosmetic damage; and emotional health, through the prevention of painful stimuli, respect for the child, its context, and stage of development. In every procedure, there is the inclusion of the caregiver, a safety figure for the child who provides greater acceptance and success in the perforation.

For greater comfort and safety, perforation is performed exclusively at home, by the nurse, lasting approximately one hour and 30 minutes, depending on the child’s age and behavior. The method is divided into three main steps: 1) Pre-service guidelines; 2) Perforation of the earlobe; and 3) Post-procedure orientations. These steps are explained in the results.

As it is an experience report of the authors themselves, there is no need for approval by the Ethics and Research Committee, but the text was based on ethical principles of scientific research and on the legislation that provides for the practice of perforating the earlobe for insertion of earrings(¹, ², ³).

RESULTS

The report was descriptively organized to clarify the procedure protocol, its three main steps, and its application in the nurse’s work practice.

1) Pre-service guidelines

After the initial contact with the mothers, there is a nursing consultation, with a reception and commencement of guidance. A brief exchange of messages and/or a call is carried out, in which the method is exposed, there’s a recognition of the caregiver’s expectations, integrating them to the experience of the person responsible for the procedure; and an anamnesis focused on getting to know the child and identifying whether the conditions are met according to the recommendations for carrying out the perforation, such as: being more than 15 days old; no dermatitis, scaling, or rash in the ear; not being feverish, having the flu, cold, or infections at the time of or before the procedure; not having been vaccinated in the last three days; and not having been hospitalized in the last 15 days. The criteria aim to avoid the association of events and reactions external to the procedure, such as a reaction to the vaccine and hospital infections. Earring insertion in children under 15 days of life can also be performed through an approval of the referral pediatrician.

If the child meets the criteria and the mother is interested, a day is scheduled for the procedure, asking them to contact the reference pediatrician to prescribe the anesthetic ointment (5% lidocaine + 5% prilocaine) that will be used. In addition, they are warned of the importance of contacting them for rescheduling if the child presents any change in health status, hospitalization and/or vaccination.

2) Perforation of the earlobe

Initially, the anesthetic ointment is applied, according to the manufacturer’s instructions and pediatrician’s prescription. During the time it takes to take effect, on average 40 to 50 minutes, there is a moment to clarify the step by step and doubts related to the procedure and other matters brought up by family members, in addition to the interaction with the child.

The interaction aims to: analyze the context of the child and family in order to identify the best guidelines for post-perforation care, identify the best place to perform the procedure, analyze the child’s behavior, and identify possible strategic distraction actions and/or relaxation that can provide comfort and well-being, considering their age and stage of development.

At the end of the period of anesthetic effect, relaxation strategies are applied (Chart 1) based on scientific evidence(⁵, ⁶, ⁷, ⁸, ⁹), chosen alongside family members considering the child’s stage of development.

Chart 1
Relaxation responses to earlobe perforation, 2021, São Paulo, São Paulo, Brazil

Relaxation Technique	Description
Coziness(5)	For this, what is colloquially called as a “tiny cigar” can be used for infants up to 3 months old. The child is wrapped in a sheet, like a cocoon, providing tranquility. Other modes of coziness are: prone position, secure accommodation in bed, crib, sofa, or maternal lap.
Distraction(6)	“White” noises (sound signals that contain all frequencies at the same power) can be used on babies up to 3 months old; and, for infants over 3 months of age, everyday children’s songs, songs, and toys that produce sound.
Nutritious/non-nutritive sucking (7)	Offering the maternal breast, infant formula, or pacifier during piercing.
Auriculotherapy(7, 8)	With the low-frequency laser, a set of points related to anxiety reduction and sleep stimulation can be stimulated. Auriculotherapy is performed in children over 3 months of age, who are sleeping prior to the procedure, with the aim of enhancing sleep and increasing the effectiveness of the method.

Perforation is carried out respecting the biosafety techniques of a clean procedure. The earring used is surgical grade stainless steel plated in 24-karat gold, from Studex Baby System®. The delicate jewelry is chosen according to the right size for the ear.

The procedure is often performed while the child is asleep, maintaining sleep even after the procedure, or when it is distracted. Perforation takes less than a second. There are usually no nonverbal complaints of the newborn and/or infant, with a score of 0 on the Neonatal Infant Pain Scale (NIPS) and on the Face, Legs, Activity, Cry, and Consolability (FLACC) scale. In children, the “no pain” classification on the Faces Scale is considered; and a score of 0 (no pain) on the Verbal Numerical Scale (VNS). There are also no complaints from the family, who are often surprised by the child’s tranquility and comfort.

After inserting the earring, the conjugated low power laser⁽⁹⁾ is also applied, with 1 Joule, using the red and infrared laser together, distributed in three points around the earring, in order to prevent inflammation and assist with the healing process. It is used in only one application, but it can be performed in later meetings in case of complications.

3) Post-procedure orientations

Post-procedural orientations include avoid handling the insertion site; daily cleaning of the earlobe with water and neutral soap during the bath and/or frequent cleaning with aqueous chlorhexidine or saline solution, according to the family’s access to these substances. These orientations are based on the author’s experience: in practice, she noticed that alcohol irritates the skin and can delay the healing process; the ear must be free from moisture (with the aid of flexible swabs) and other sources of infection; the jewelry should only be changed after six or eight weeks. Parents are also informed that the procedure is not without risks and that inflammation may arise from previously undetected allergies. They are also told that, if this occurs, they must contact the nurse responsible for the perforation in order to receive the proper guidance, with the child being monitored by the nurse until regression. Finally, the entire procedure is documented.

DISCUSSION

This study reports the experience of the nurse who devised and patented the Safe Child® Method, organized in three steps, with actions based on scientific evidence, integrated in order to provide the best care for the child and the family during earlobe perforation, with a redefinition of previous negative experiences for an experience free from damage and trauma.

Regarding biosafety, there is a respect for the techniques recommended in a clean procedure⁽¹⁾. Regarding the choice of jewelry, the method uses materials supported by Anvisa’s legislation, with the use of earrings as a piercing material⁽¹⁾. The surgical grade earring uses stainless steel as its agent, a material with low allergenic potential⁽¹⁰⁾, chosen to prevent complications after perforation, such as allergenic dermatitis.

In a cross-sectional study carried out in Brazil, with 144 children aged from 0 to 12 years, it was observed that 4.9% had an allergic reaction to chromium; 9.7% to cobalt; and 20.1% to nickel. These materials are present in several earrings, and children at higher risk of allergic reaction to nickel were those with perforated earlobes (p = 0.031). There is a hypothesis that the perforation, by itself, is not responsible for the dermatitis, but the earrings, such as the low-quality gold ones that contain nickel⁽¹⁰⁾, are. To prevent this complication, guidelines are provided to those responsible for changing the jewelry, from the material that they should be using to the time for changing such material, with the nurse being available after the perforation to assess possible reactions.

Care related to the child’s physical and emotional health is essential. Therefore, the method includes the approach to caring for the pain, inflammation, and healing.

One of the sources of stress for parents and hospitalized children is the experience of painful procedures⁽⁴⁾. To prevent and/or control this source, the Safe Child® Method aims to integrate pain management, also considering that this management is an indicator of the quality of care provided⁽⁶⁾. Although pain assessment in children is a subjective process, standardized scales are used, such as those used by the method, which integrate development, physical, and behavioral factors that represent responses to painful stimuli(⁵, ⁶).

For pain prevention and/or control, pharmacological and non-pharmacological methods present themselves as a significant opportunity(⁵, ⁶). In the case of the Safe Child® Method, there is both the use of the pharmacological method, with topical anesthesia, and the non-pharmacological method, with relaxation responses.

As for prior analgesia, in a systematic review of the literature that aimed to assess the efficacy and safety of topical anesthetics in newborns exposed to invasive procedures involving puncture of the skin and/or other tissues with a needle, it was observed that effects of use are still uncertain and vary by procedure. The authors found that there was a significant reduction in pain for: lumbar puncture (p = 0.004), needle removal during punctures (p < 0.001), venous and arterial puncture, and percutaneous venous catheter insertion (p < 0.05). This action occurs through the reversible blockade of impulse conduction by nerve fibers, stabilizing the neuronal membrane and preventing the initiation and conduction of the painful impulse⁽⁴⁾. Thus, it is worth reflecting that the ointment can be a positive predictor for analgesia, as the earlobe is a less vascularized area and has a smaller number of nerve endings; and for the puncture thrust to last less than a second.

In relation to non-pharmacological measures, there are several possibilities used, depending on the child’s development and condition. In infants, the perforation can be performed while the child is on the maternal lap, as it provides comfort, security, and inclusion of the family in the procedure. In a clinical trial, it was observed that the maternal lap—that is, working with the mother-infant binomial—during the heel puncture led to a lower pain score with a shorter time of crying, compared to babies who were lying on a table (p < 0.05)⁽⁵⁾. In addition, another study has shown that family involvement in painful procedures is a positive predictor of pain reduction in children⁽⁶⁾. In this sense, placing the child in comfortable places, using the “tiny cigar” technique, can be a factor that alleviates pain, as seen in the experience reported here.

Distraction is a method with proven efficacy in studies. In a systematic literature review that aimed to identify effective distraction interventions for pain relief and control in children with cancer when undergoing an invasive procedure (bone marrow punctures or aspiration), it was shown that white noise and music, chosen according to the age group, provide relief from pain, anxiety, anguish, affliction, and fear (p < 0.05), as well as reduce the anguish experienced by parents⁽⁶⁾.

A systematic literature review with meta-analysis⁽⁵⁾ aimed to evaluate the effectiveness of breastfeeding in reducing pain during neonate heel puncture, including randomized or quasi-randomized clinical trials comparing the intervention with: supplemental milk, sucrose, non-nutritive suction, positioning, or no intervention. Breastfeeding was shown to be associated with pain reduction, with fewer changes in physical parameters (heart rate and crying) and with lower scores on standardized pain scales, compared to the interventions mentioned (p < 0.05). This effect may be associated with the bond developed with the security figure, the physical sensation of skin-to-skin contact, the diversion of attention, the sweetness of breast milk, and the presence of tryptophan, a precursor of melatonin, which increases beta-endorphins. It is a natural, available, and risk-free intervention. In the case of children who use formula, the review also points out advantages in reducing pain with its use, with no statistical difference being found when compared to breastfeeding with formula⁽⁵⁾. The author encourages the offer of breast milk at the time of perforation and perceives results like those mentioned in the review.

With regard to auriculotherapy, in an overview investigation with high methodological quality reviews, it was found that the stimulation of the points produces the release of neurotransmitters that regulate the endogenous pain control mechanisms, with the release of endorphins that hinder the propagation and perception of the painful stimulus⁽⁷⁾. Five investigations showed a reduction in tension and anxiety, analgesia, and anti-inflammatory effects (p < 0.05)⁽⁷⁾. In this case, the earlobe perforation may not be felt by the child due to the reduction in stimulus perception. Auriculotherapy is used only for children older than three months, after realizing in practice that the effects are more prominent in this age group, but there are no reports in the literature regarding age restrictions⁽⁷⁾. The points can be stimulated by electrotherapy — for example, with the low-power laser(⁷,⁹), used by the author.

In order to enhance sleep, analgesia, and comfort effects, stimulation of the auriculotherapy points is performed when the child is already asleep. In a quasi-experimental study carried out with auriculotherapy in health professionals, it was found that the intervention was able to improve the dimensions of subjective sleep quality by more than 50% (p = 0.001), habitual efficiency (p = 0.011), sleep duration and reduced sleep disorders (p < 0.001). This improvement is justified by the possibility of regulating neurotransmitters and hormonal factors involved in the sleep and wakefulness process, with the stimulation of the points⁽⁸⁾. Another aspect is that the practice has already obtained results in the first consultation, which can reinforce its use in the Safe Child® Method, which provides only on stimulus prior to the procedure.

In addition to post-perforation analgesia, the use of low-intensity laser reduces the inflammatory reaction and stimulates tissue healing. The effects occur by favoring tissue repair, modulation and oxygenation, cell growth, angiogenesis, reduction of inflammatory cytokines, and nociceptive stimuli. These actions can take place in the first application, which, in some cases, is sufficient⁽⁹⁾.

By way of illustration, in a systematic literature review with meta-analysis, which aimed to list the benefits of laser in chronic nonspecific low back pain, immediate pain reduction effects were observed when compared to placebo (p < 0.05). The review shows that laser is more likely to resolve acute pain⁽⁹⁾, such as in ear lobe perforation. In this report, laser is used after earring insertion, combining red light, which acts on healing, and infrared, which acts on the inflammatory cascade and pain reduction⁽⁹⁾.

It is worth reflecting that the studies cited to elucidate the pharmacological and non-pharmacological practices used in the Safe Child® Method were carried out in procedures that cause severe pain and/or in chronic conditions. Anesthetic ointment⁽⁴⁾, maternal lap, and breastfeeding⁽⁵⁾ were used in punctures in well-vascularized and innervated areas; distraction was used in children with cancer, a state in which more than 70% of patients have severe pain during the procedures⁽⁶⁾; auriculotherapy was performed in the adult population⁽⁸⁾; and low-intensity laser in chronic conditions⁽⁹⁾; however, all studies provided positive and significant effects on analgesia, inflammation, sleep, and healing. Thus, the use of these techniques to perforate the earlobe can be a positive predictor of child comfort.

There is no need of a concomitant use of all the techniques listed, but an association of them, which, in the author’s experience, provides satisfactory and positive effects in the procedure. There is a need for future clinical trials in relation to the methods mentioned here and the perforation of the earlobe.

The experience reported is supported by the nursing practice⁽²⁾ supervisory body, and the author has certifications in previous trainings⁽¹⁾, respects the good practices listed in RCB resolution No. 44/2009⁽¹⁾ as well as the principles listed in Law No. 7,498/1986, in its regulatory decree (Decree 94.406/1987) and in the Code of Ethics for Nursing Professionals⁽²⁾. It is up to the professional interested in working in this area to seek documents from their local regional councils for legal support. If they cannot find them, they should contact the council for clarification based on technical opinions and/or reasoned guidance. In addition, the study exposes the need for legal support from the Federal Council of Nursing to regulate the practice of earlobe perforation.

Study limitations

This is an experience report related to the patented method and requires randomized clinical trials with the interventions used to elucidate the effectiveness of each technique in the reported procedure.

Contributions to the Field

Earlobe perforation, carried out with the Safe Child® Method, proved to be an innovative practice for nursing as it provides a new possibility for nurses to act in the labor market and health services with entrepreneurship and autonomy. Furthermore, it was configured as an innovation in the practice of perforation, as it made it possible to undergo a pleasant experience, free from trauma or suffering, for both the child and family involved in the process.

FINAL CONSIDERATIONS

The Safe Child® Method aims to protect the physical and emotional health of children undergoing earlobe perforation. The techniques and actions used are based on scientific evidence and, in the author’s perception, provide care for both the child and the family, with appreciation and respect for both, making the experience pleasant and allowing nurses to be recognized for their performance excellence, opening new opportunities for their services.

REFERENCES

• ¹
  Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada nº 44, de 17 de agosto de 2009 [Internet]. [Brasília, DF]: Anvisa; 2009[cited 2021 Jul 07]. Available from: https://website.cfo.org.br/wp-content/uploads/2010/02/180809_rdc_44.pdf
  » https://website.cfo.org.br/wp-content/uploads/2010/02/180809_rdc_44.pdf
• ²
  Conselho Regional de Enfermagem de São Paulo. Parecer COREN-SP nº 021/2021 [Internet]. São Paulo: COREN/SP; 2021[cited 2021 Oct 18]. Available from: https://portal.coren-sp.gov.br/wp-content/uploads/2021/10/PARECER_021_2021_Perfuracao_lobulo_auricular_body_piercing.pdf
  » https://portal.coren-sp.gov.br/wp-content/uploads/2021/10/PARECER_021_2021_Perfuracao_lobulo_auricular_body_piercing.pdf
• ³
  Conselho Regional de Enfermagem do Distrito Federal. Parecer técnico nº 07/2019 [Internet]. Brasília, DF: COREN/DF; 2019[cited 2021 Jul 07]. Available from: https://www.coren-df.gov.br/site/wp-content/uploads/2019/06/parecertecnico_n07_2019_legalidadedeperfuracaodelobuloauricular.pdf
  » https://www.coren-df.gov.br/site/wp-content/uploads/2019/06/parecertecnico_n07_2019_legalidadedeperfuracaodelobuloauricular.pdf
• ⁴
  Foster J P, Taylor C, Spence K. Topical anaesthesia for needle-related pain in newborn infants (Review). Cochrane Database Syst Rev. 2017;(2):CD010331. https://doi.org/10.1002/14651858.CD010331.pub2
  » https://doi.org/10.1002/14651858.CD010331.pub2
• ⁵
  Shah PS, Herbozo C, Aliwalas LL, Shah VS. Breastfeeding or breast milk for procedural pain in neonates. Cochrane Database Syst Rev. 2012;(12):CD004950. https://doi.org/10.1002/14651858.CD004950
  » https://doi.org/10.1002/14651858.CD004950
• ⁶
  Ferreira EB, Cruz FOAM, Silveira RCCP, Reis PED. Distraction methods for pain relief of cancer children submitted to painfull procedures: systematic review. Rev Dor. 2015;16(2):146-52. https://doi.org/10.5935/1806-0013.20150028
  » https://doi.org/10.5935/1806-0013.20150028
• ⁷
  Artioli DP, Tavares ALF, Bertolini GRF. Auriculotherapy: neurophysiology, points to choose, indications and results on musculoskeletal pain conditions: a systematic review of reviews. BrJP. 2019;2(4):356-61. https://doi.org/10.5935/2595-0118.20190065
  » https://doi.org/10.5935/2595-0118.20190065
• ⁸
  Melo GAA, Lira Neto JCG, Silva RA, Martins MG, Pereira FGF, Caetano JÁ. Effecgtiveness of auriculoacupuncture on the sleep quality of working nursing professionals during the covid-19 pandemic. Texto Contexto Enferm. 2020;29:e20200392. https://doi.org/10.1590/1980-265X-TCE-2020-0392
  » https://doi.org/10.1590/1980-265X-TCE-2020-0392
• ⁹
  Glazov G, Yelland M, Emery J. Low-level laser therapy for chronic non-specific low back pain: a meta-analysis of randomised controlled trials. Acupunct Med. 2016;34(5):328-41. https://doi.org/10.1136/acupmed-2015-011036
  » https://doi.org/10.1136/acupmed-2015-011036
• ¹⁰
  Brandão MHT, Gotijo B, Girundi MA, Castro MCM. Ear piercing as a risk factor for contact allergy to nickel. J Pediatr (Rio J). 2010;86(2):149-54. https://doi.org/10.2223/JPED.1980
  » https://doi.org/10.2223/JPED.1980

Edited by

EDITOR IN CHIEF: Antonio José de Almeida Filho

ASSOCIATE EDITOR: Ana Fátima Fernandes

Publication Dates

• Publication in this collection
  07 Mar 2022
• Date of issue
  2022

History

• Received
  12 Aug 2021
• Accepted
  11 Nov 2021