The importance of supporting children through clinical procedures cannot be overstated. In my last article, I looked at the procedures children are likely to have, why children need extra support through procedures and the long-term effects that fear and anxiety from childhood procedures can have on patients. Now that we know why it is so crucial to get this right, what are some techniques that we can use in the clinical setting?
The use of topical local analgesia, such as Emla or Angel cream has been shown to be helpful in both venepuncture and cannulisation. Multiple studies have found no real difference in the success of cannulisation when comparing either Angel or Emla so personal choice, availability, cost and time of the procedure should be considered. Angel tends to have a quicker onset than Emla and is a vasodilator rather than a vasoconstrictor.
Distraction therapy is hugely successful and has widely documented success. Used early and consistently it can help both the child and family deal with procedures.
Tips for distraction:
- Start early and use specific toys.
Use toys that are not in the playroom and that the child hasn’t played with before. Bubbles are great! Just beware of slippery floors. I often use apps on my phone and it may be a real treat for the child to use their parent’s smartphone or tablet, so ask if that may be appropriate.
- Explain to the parents and get them involved.
There is often more than one parent/carer present. While one cuddles/holds the child, the other can read a book, blow bubbles or sing a song. Some parents may be reluctant and I’ve sometimes heard statements like, “It’s not going to work on her, there’s no point in trying.” I explain the rationale behind it and the suggest we give it a go. They are often pleasantly surprised. Distraction also gives the parents something to do when they feel helpless.
- Allow the child some degree of choice.
This is not: “Which hand do you want a cannula in?” This is: “Do you want to sit on mummy’s lap or on the chair? Do you want to look or look away? Which book shall we read?”
- Consider when you tell the child of an upcoming procedure
Preparation is important and good clear explanations are helpful. Give some notice but not too far in advance as this may increase anxiety. Prepare trolleys out of sight and bring them in at the last minute.
- Be patient and follow through.
If you say you are going to blow bubbles, do it! Consistency is important to gain trust and help out the next nurse who comes along and needs to carry out a procedure.
- Reward the child.
Certificates or stickers are great.
- Platitudes have been shown to be unhelpful, instead talk about something else
Every time you say “you’re doing really well” or “it’s nearly done” you are re-focusing the child on the procedure. Talking about school, sport or a favourite movie completely distracts.
Options for Infants
For infants, non-pharmacological solutions such as sucrose/breastfeeding have been shown to help. Sucrose given two minutes before the procedure and throughout the procedure is useful and has documented success. This is usually more appropriate in younger babies (from neonates to 4 months), but there has been some suggestion that sucrose may be helpful even up to the age of 18 months. Young babies also love swaddling, but older infants hate being wrapped and will struggle before you’ve even begun to do anything.
The Importance of Holding
Holding is not restraining. Research has shown that being held flat produces greater distress for the child. Being restrained (held down) flat by multiple people is scary. You essentially have a fearful, struggling child before the procedure has even begun.
Holding discourages a child from performing an act. Restraint uses the degree of force necessary to prevent a child performing an act.
So what exactly is holding? Lambrenos et al provide this definition: “Positioning a child so that a procedure can be carried out in a safe and controlled manner, wherever possible with the consent of the child and parent/carer.” Holding discourages a child from performing an act. Restraint uses the degree of force necessary to prevent a child performing an act.
Often the instinct is to hold as tightly as possible or even wrap a child in a sheet to keep them still in order to complete the procedure quickly. It may seem like the easiest option, but we know this is not in the best interest of the child or their family. A bad experience can have a lasting negative effect on the child. We know that children can become fearful of clinicians and when the next nurse comes in just to take some vital signs, the child may be afraid. Our first choice should always be holding.
Below are two ‘comfort positions’ that you can use in conjunction with the child’s caregivers.
The Bear Hug
For the bear hug hold the child sits on the carers lap with his arms and legs facing backwards. Because the hands and feet are free, cannulas can be inserted and bloods can be taken. Remember distraction therapy too! A nurse can hold the arm still while another person blows bubbles.
In the seatbelt hold the child faces forward on the carers lap and the carer’s arm goes across the child’s body. This hold is popular and gives the clinician lots of room to utilise equipment.
Sparks at al have noted that “Parental holding and upright positioning decrease IV distress in young children, increase parental satisfaction and DOES NOT significantly impact IV success.” It’s not easier, but it certainly is not harder if you are practised in it and have a good ‘holder’. The more you do it, the better you get. Parents may need support with holding and procedures for children often take multiple clinicians to lend a hand.
Of course, pharmacological solutions could be necessary and should be used as required. Sedation most definitely has its place but when doing simple procedures, being able to do so without the need for sedation is the most appropriate course of action for both patients and clinicians.
Some Final Points
Every effort should be made to keep the bedside as a ‘safe place’. If at all possible the child should be removed from the bedside and taken to a treatment room for procedures. This means that the child need not be fearful when in bed and can relax, making it so much easier for the next clinician who may just need to take a temperature or listen to a chest.
Two health professionals should agree that the procedure is necessary. It should be documented in the chart. Children have the right to refuse or consent to treatment in some areas. When considering refusal of treatment, ascertaining whether the child is ‘Gillick’ competent (sometimes referred to as Marion’s Case in Australia) is vital. This should be done by the most senior clinician and in conjunction with the Department of Communities or Child Advocacy Service. Under the guardianship act, clinicians can commence emergency treatment (for example when loss of life may occur) without consent.
It is important to note that in the case of an emergency waiting for Emla or Angel to work or carrying out distraction therapy is not always appropriate. Emergency treatment should commence immediately. Although in the case of scared children with a threatened airway, such as in croup, keeping the child calm is vital so even basic techniques can be utilised. I have been known to blow bubbles in resus!