This is part 1 of a 2 part series. Please be sure to listen to part 2!

In this episode, host Jason Woods speaks with Dr. Daniel Tsze and Child Life Specialist Hilary Woodward about how to approach pain in the pediatric patient. This could be pain from the presenting complaint or from the procedure being performed. The discussion focusses primarily on the non-pharmacologic techniques that have been shown to improve the experience for patients, caregivers, and care providers.

Dan and Hilary are both part of the PECARN (Pediatric Emergency Care Applied Research Network) and this episode is published in partnership with the PECARN Dissemination Working Group.

Guests

Hilary Woodward MS, CCLS -New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center

Daniel Tsze MD, MPH – Associate Professor of Pediatrics (Emergency Medicine), New York-Presbyterian Morgan Stanley Children’s Hospital at Columbia University Medical Center

Show Notes

1. Techniques – non pharmacologic
   1. Environment – Remember that the environment can have a huge impact not he patient! (I.e. colors on the walls, pictures/posters, cartoons). The attitude and approach from the caregivers and clinical providers also contributes.
   2. Before procedure
      1. Opportunities for patient to interact (safely) with procedure materials. Can use either (or both) of the techniques below:
         1. Medical play – free play with safe procedure materials, possibly with some child-centered narration as patient manipulates what is provided (i.e. “you’re putting that on the doll’s arm”); helps with desensitization & child-directed understanding (figuring out organically how the materials work) and increases patient’s opportunities for control. 
         2. Developmentally appropriate teaching – practice procedure on stuffed animal/doll etc., while explaining what will happen and clarifying patient’s questions/misconceptions as needed. May consider hand-over-hand techniques to give patients some knowledge/experience with sharps (if caregiver consent provided, safety guidelines in place, patient assessed by clinician to be an appropriate candidate developmentally and in regards to temperament)
      2. Explanation of what you are going to do. How much do you tell a child and how does this change based on 
         1. Can start with “small spoonfuls” of info, focusing on what the patient’s sensory experience will likely be (i.e. how will it feel, what will they see/smell/taste; “some kids say it’s like _______”). Monitor verbal/non-verbal cues to guide when/if/how to share more
         2. Patient and caregiver input is vital – ask what they would like to know more about, and offer choices of coping techniques (consider needs of self-identified “attenders” vs. “distractors”)
      3. Don’t forget the basis like splinting, ice packs, which also have analgesic effects
      4. Positioning for comfort
         1. Chest to chest in a chair for scalp lacs, procedures on extremities
            1. Parent sitting in a chair works well – make sure that patient’s feet are dangling so that they don’t have leverage to push up
            2. Make sure to brace the extremity you are working with (rest extremity on the bed or on a bedside table, ideally at close to a 90 degree angle)
            3. Consider asking a “helper” to hold head or extremity steady
         2. Patient’s back against parent’s chest for facial lacs, procedures on extremities
            1. Have parent lay on stretcher with their whole body (feet included) on the bed; child lays or sits between parent’s legs, with their bottom on the stretcher (NOT on parent’s lap) – then parent can cross their legs over child’s legs
            2. As with chest-to-chest, make sure to use appropriate bracing and a “helper” as needed for steadying
      5. Do you talk with parents about their role in comforting their child, not showing distress etc? 
         1. Strengths-based approach: Reinforce helpful caregiver behaviors, while validating the stress of the situation. “The way you let your child know you will be there for him, and the way you engaged him in telling his favorite story – that was so helpful! It really makes a positive difference when parents show calm and help engage their child. I know you might not be feeling as calm on the inside, but you’re really helping us create a better experience for your son. Thank you!”
         2. If it’s a more challenging scenario, and you are having difficulty identifying a strength, step into the conversation piece by piece. Start with validating: “I can see how upsetting this is for you, and it makes complete sense to feel upset in this situation.” Then read the verbal & non-verbal cues – are you building effective rapport? If so, you might be able to very gently make your big ask (and it can help to label it as such): “I’ve been thinking about how we can help make this experience as smooth as possible for your daughter. I have some ideas, and I know this might be a big ask, but I’m hoping you can help me?” If receptive: “I’m noticing that your daughter seems more tearful & distressed when she sees you get upset. Maybe you could help us distract her? Sometimes, helping distract their child helps parents feel a little better, too.” And when the procedure is over, make sure to validate the parent’s effort and be specific about what went well to both parent & child.
   3. During Procedure
      1. Distraction
         1. Both “techy” (iPad, virtual reality) and “non-techy” (toys, games, songs, conversation, deep breathing, etc.)
      2. “Blinder” and other visual barriers
         1. Any specific dos and dont’s with these?
            1. Generally not worthwhile for kids who become more agitated by the blinder/barrier itself (may include toddlers, patients with sensory challengers, patients who are “attenders” and better able to cope/feel in control when they can see everything that is going on). Patient choice & caregiver input are key.
      3. Parent/family presence? Helpful or harmful?
         1. From Hilary – I would say 98% of the time helpful, but it can be important to give parents the choice whether to be present and/or involved. (This discussion might connect well with the point above about whether or not to talk with parents/caregivers about their role in comforting their child.)

References

1. Tsze DS, Woodward HA. The “Facemask Blinder”: A Technique for Optimizing Anxiolysis in Children Undergoing Facial Laceration Repair. Pediatr Emerg Care. 2019;35(7):e124-e126. doi:10.1097/PEC.0000000000000990
2. Kennedy RM, Luhmann JD. The “ouchless emergency department”. Getting closer: advances in decreasing distress during painful procedures in the emergency department. Pediatr Clin North Am. 1999;46(6):1215-viii. doi:10.1016/s0031-3955(05)70184-x
3. Fein JA, Zempsky WT, Cravero JP; Committee on Pediatric Emergency Medicine and Section on Anesthesiology and Pain Medicine; American Academy of Pediatrics. Relief of pain and anxiety in pediatric patients in emergency medical systems. Pediatrics. 2012;130(5):e1391-e1405. doi:10.1542/peds.2012-2536
4. Cohen LL. Behavioral approaches to anxiety and pain management for pediatric venous access. Pediatrics. 2008;122 Suppl 3:S134-S139. doi:10.1542/peds.2008-1055f
5. Sinha M, Christopher NC, Fenn R, Reeves L. Evaluation of nonpharmacologic methods of pain and anxiety management for laceration repair in the pediatric emergency department. Pediatrics. 2006;117(4):1162-1168. doi:10.1542/peds.2005-1100

Additional resources

1. Koller D, Goldman RD. Distraction techniques for children undergoing procedures: A critical review of pediatric research. J Pediatr Nurs. 2012;27(6):652-681. doi:10.1016/j.pedn.2011.08.001
2. Stephens BK, Barkey ME, Hall HR. Techniques to comfort children during stressful procedures. Accid Emerg Nurs. 1999;7(4):226-236. doi:10.1016/s0965-2302(99)80055-1

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