Aims

2. Aims To encourage health professionals to use evidence based techniques to support children (and their carer/s) psychologically through painful or distressing procedures. To provide references to enhance practice.

3. Learning Objectives To understand the importance of planning for painful or distressing procedures when working with children To consider developmental stages of each child To be aware of correct positioning and distraction techniques used in paediatric practice

4. What we’ll cover… Planning the procedure Medications to consider pre–procedure Positioning for comfort Age appropriate distraction techniques

5. … think about it … Plan procedure • General approach ‘One Voice’ • Place • Time • Staff involvement ; medical, nursing, Child Life Therapist, parent or carer • Medications +/- fasting times • Equipment

6. ‘One Voice’ Approach Onevoice should be heard during procedures Needfor parent/carer involvement Educateparent/carer before procedure Validatechild with words Offerposition of comfort Individualise your approach Chooseappropriate distraction techniques Eliminateunnecessary people from the room

7. Medications to Consider ‘Emla’ / topical anaesthetic agent Sucrose Oral premedication; analgesia, midazolam, ketamine Nitrous oxide

8. Correct Positioning; promoting comfort Depends on procedure Sitting upright in a ‘hugging hold’ for IV cannula or bloods Lying on side for LP Swaddled/ wrapped (0-3 months)

9. Infants Cuddling/ wrapping for 0-3 month infants promotes self caring and sense of security also prevents limbs from moving if distressed Offer breast feed / sucrose/ non nutritive sucking (dummy) to help minimise stress

10. Toddlers May like to sit upright on a parent’s lap facing the parent or facing the proceduralist whilst being distracted with bubbles, songs, toy or interactive book Hold in a ‘hugging hold’ to contain torso and limbs as parent soothes the child Parent’s free hand stabilises the limb being cannulated

11. Older Children Give choices i.e., which hand can we take blood from today ? Sit upright in a ‘hugging hold’ facing out but head turned away from the procedure Use interactive distraction as much as possible

14. Infant Stresses-parent separation, stranger anxiety • involve a parentor caregiver who can comfort the child • comfort positioning • talking gently before touching; use dummy, consider oral sucrose for non-nutritive sucking • wrap/ swaddle, rhythmic patting, toy

15. 1 – 3 years Separation anxiety, scared of injury or pain • family member support/ (stranger danger) • comfort positioning • give sensory information, talk before touching • provide an alternative focus and involve child as much as possible • play; favourite games, stories, songs, rhymes, own toys

16. 3 – 5 years Separation, fear of blood and needles, perceived punishment, misconception of words • caregiver support/(stranger danger) • gentle concrete preparation/ social stories • give the child choices/ a perceived role/participation • use of play and distraction; iPad, bubbles, counting, own toys • validate throughout • involve Child Life Therapy

17. 6 – 11 years Loss of control, pain, altered body image • explanations and participation/controlwhere possible • be perceptive to child’s cues • give structure • use of guided imagery, relaxation/ controlled breathing, hobbies and interests • validate appropriately

18. Teenagers Loss of body image, control, functions, peer acceptance, death… • include in decision making and give choices where possible • honest explanations about procedure (photos to explain) • coping strategies; music, relaxation, focused breathing, iPad • other teens or caregiver • respect privacy

19. Age related distraction techniques Establish rapport A large part of communication is non-verbal; • get down to their level • use eye contact • Speak in a clear and calm voice

20. Age related distraction techniques • Encourage an alternative focus • stories, books, • songs, music, nursery rhymes • Guided imagery/ relaxation • deep breathing, blowing bubbles, coaching • child’s own interests • TV/ video • iPod, iPad • Toys/ puppets

21. Finally • stay calm • be sensitive to child’s cues and refocus as needed • reinforce coping strategies • validate – ‘you’re doing really well’ / ‘it’s ok to cry’

22. Resources Association of Paediatric Anaesthetists of Great Britain and Ireland. Good Practice in Postoperative and Procedural Pain Management 2nd Edition, 2012. Paediatric Anaesthesia, 22 (Suppl.1),1-79. Breiner, Sandra M. Preparation of the Paediatric Patient for Invasive Procedures. Journal of Infusion Nursing.2009;32(5): 252-256. Crain, William. Theories of Development: Concepts and Applications. Prentice Hall, New Jersey, 2000 (217-294). Fox, S (2012) Paediatric Pain and Distress in the ED; New Management Tips. Paediatrics.130e1391- e1405. RCH Melbourne factsheet; Infant positioning, promoting comfort, 2013 http://www.onevoice4kids.com/index.html Wolheiter, Karen A &Dahlquist, Lynnda M. Interactive versus Passive Distraction for Acute Pain Management in Young Children. J Paediatric Psychology.2013;38(2): 202-212.

23. Resources Sucrose Guidelines http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2006-8241.pdf Procedural sedation guidelines http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2011-9017.pdf Thank you to Fairfield RSL for sponsoring the ‘Being Kind to Kids’ project.