From Shots to Surgery: Decreasing Fear and Pain

at the Doctor

Nancy McCune, MS, CCLSKaty Tenhulzen, CCLS

• “Children who are calm react with less intensity to negative stimulation than do children who are already upset for other reasons”

• Komer & Thoman, 1972

Children’s Experience in Health Care

Many aspects of healthcare are stressful for young children, whether a routine visit for vaccines, surgery, or being diagnosed with a chronic illness.

Promoting coping and decreasing the experience of pain sets the stage for more positive medical experiences in the future, and gives kids the opportunity to experience mastery over challenges.

Experiences in Health Care

There is a correlation between high pain and fear with medical procedures during childhood and high adult fear, pain, and avoidance of health care.

- Pate, Blount, Cohen et al. Childhood medical experiences and temperament as predictors of adult functioning in medical situations. Children’s Health Care. 1996; 25:281-298

Connection Between Pain & Anxiety

A study appearing in the American Academy of Pediatrics in August 2006 found that “Preoperative anxiety in young children undergoing surgery is associated with a more painful postoperative recovery and higher incidence of sleep and other problems.”

- ‘Preoperative Anxiety, Postoperative Pain, and Behavioral Recovery in Young Children Undergoing Surgery’Zeev N. Kain, MD, Linda C Mayes, MD, Alison A. Caldwell-Andrews, PhD, Daved E. Karas, MD, Brenda C. McClain, MD

Several studies have shown that children tend to have distorted negative recall of pain experienced with procedures, even more so if distressed during procedure.

This causes even greater distress for subsequent procedures.

- Young, K. Pediatric Procedural Pain. Annals of Emergency Medicine. 2005:45:160-168

Developmental Responses to

Hospitalization

Considerations: Infants• Separation from caregivers• Stranger anxiety• Need basic needs met• Learning to trust that caregivers will provide comfort and

safety• Infants begin to demonstrate memory for previous pain:

Full term infants subjected to repeated pokes display greater behavioral pain response to subsequent pokes

• Even babies pick up on a parent’s anxiety

- Taddio A, Shah V, Gilbert-MacLeod C, et al. Conditioning and hyperalgesia in newborns exposed to repeated heel lances. JAMA. 2002; 288:857-861

- McGrath PJ. Annotation: aspects of pain in children and adolescents. J Child Psychol Psychiatry. 199; 36: 717-730

Considerations: Toddlers• Separation from caregivers• Stranger anxiety• Pain• Establishing independence and want control• Children as young as 3 have accurate

memories for details of painful procedures and pain events*

*Merritt KA, Ornstein PA, Spicker B. Children’s memory for a salient medical procedure: implications for testimony. Pediatrics. 1994; 94:17-23

*Zonneveld LN, McGrath PJ, Reid GJ, et al. Accuracy of children’s pain memories. Pain. 1997;71:17-23

Considerations: School Age• Body mutilation/Loss of function• Anesthesia – will I wake up in the

middle of surgery?• Loss of control• Modesty issues

How Can We Address These Concerns?

Psychological Preparation• Explain diagnoses or treatments in words

children & teens can understand • Identify potential stress points• Child will know what to expect before,

during and after • Help children form a plan with the goal of

the image of self coping with a situation

Psychological Preparation Theory -Wolfer

Why prepare?• Preparation – specifically regarding sensations to

expect and information to enhance realistic expectations has shown to decrease distress *

• Reduce fear of the unknown• Build trust• Offer the child choices to give control• Child will know what to expect and will gain

confidence that you will not allow unpleasant ‘surprises’ to happen at future visits

*Chen E, Zeltzer LK, Craske MG, et al. Alteration of memory in the reduction of children’s distress during repeated aversive medical procedures. J Consult Clinical Psychology.1999; 67: 481-490

Preparation Techniques:

• Dialogue/discussions related to anxiety and its sources

• Interactive Play• Photo books, story books, videos,

hospital tours

Language and Communication

• How/when to start talking about it• Why does this need to happen? • Listen/validate/reassure • Avoid words that may create

misconceptions and expectations: “brave,” “special,” “funny”

Identify Stress Points

needles family stress

pain

separation from family members

past negative medical experiences

not knowing what’s going to happen

difficulty coping with new events or experiences

What is stressful for

children?

Identify Coping StylesSensitizers• Anticipatory worrying• Information seeking• Benefits greatly from

preparation• Coping plan• Strong need/desire to watch the procedure

Identify Coping StylesAvoiders• Postpones/avoids acknowledging the events• Evades discussion and/or preparation• Turns head away/does not watch procedure

Coping Techniques• Identify age-appropriate ways of helping

your child cope with procedure • If possible, practice relaxation techniques

prior, while child is calm• Role play to practice coping plan• Equipping a child with ways of coping with

stress, pain, and anxiety gives them a sense of mastery over difficult events

• Pain management – LMX cream

InfantsTips for Supporting them:• Coping techniques will be parent-directed

and focused on comfort• Use distraction – music, light-up toys, rattles• Sucking – pacifier, breastfeeding, sugar water for pain

management and soothing *• Swaddling or in parent’s arms• Change the environment – lights down, security items• Ask questions to prepare yourself and help reduce stress • Be involved with as much care as you feel comfortable with

* Oral Sucrose and Pain Relief for Preterm Infants: Recommendations for Using Sucrose to Provide Pain Relief for Preterm Infants by Anita Mitchell, RN, PhD, Patricia A. Waltman, RNC, EdD, NNP, University of Mississippi Medical School of Nursing, Jackson, Mississippi.)

Toddlers

Tips for Supporting them:• Encourage your kids to participate in care• Offer them choices when possible• Give simple, concrete explanations• Use medical play• Correct misconceptions - i.e., procedure as punishment• Seek info to prepare yourself and advocate for being

w/your child as much as possible• Distraction – bubbles, singing, book, interactive toy• Blowing out “candles”/bubbles to encourage deep breaths,

counting

School AgeTips for Supporting them:• Include your kids in decisions/choices• Practice their coping skills w/them• Be honest and give them specific info• Demonstrate and allow them to manipulate

medical equipment• Distraction – I Spy, pinwheel, Find It, electronic

toys• Relaxation/Pain Coping Techniques

Relaxation/Pain Coping Techniques

• Deep breathing/Red Cloud• Telling a story/imagery• Progressive muscle relaxation• Ice Cube/Magic Glove• The Switch Trick

The clip above is a 15 minute video extract of Dr. Laurence Sugarman from the CD: "Hypnosis in Pediatric Practice" Health Care Applications of Clinical Hypnosis, Volume 2 - authorized by Crown House Publishing Co.Ltd.  (Video1)

Create a Coping Plan• Give a clear title

– “Daniel’s Plan for Vaccines”

• Use child’s language/encourage them to write the plan – “The cold cleaner and the poke are the hard parts for me”

• Child delegates jobs– “My job is to (hold really still, blow ‘bubble’ breaths),– “My mom’s job is to (give me a hug, sing the ABC’s with me)

• Plan for what to do when your child is worried, scared, or hurting, being mindful to match with the chosen strategy

i.e. using distraction with an “avoider” who wants to look away from the procedure– Practice, practice, practice– Especially practice coping techniques when child is not worried or

hurting– Practice ensures child can quickly access coping when they need it

Sarah’s Surgery Plan

• I will bring my "Blankee" & my elephant with me to surgery

• If I have a choice, I would rather have the Mask to go to sleep

• Before surgery, while I wait, I would like to do art work. (Child Life to provide art supplies to family)

• If I have a "pre-med" either my dad or my nurse can give me the medicine in either a cup or a syringe.

• If I am in pain, I know about the "faces chart" (Wong-Baker), and I will tell the nurses if I hurt.

• A few things about Sarah:• My favorite colors are: pink &

purple• I collect unicorns & horses• I love to play w/ barbies &

action figures• I REALLY LOVE TO DO ART

WORK!• I have lots of pets! Sea

monkeys, birds, a dog, a cat, 2 dwarf hamsters, and a fish.

• Connor has severe anxiety, autism, ADHD, and OCD

• Mom reports that he has had a difficult time waking up agitated in recovery – needing to be restrained in the past

• →per mom, being told “no” tends to increase his agitation

• Mom believes that Connor is used to being in pain but thinks he does not cope well w/new pain

• → he is not able to utilize FACES or 0-10 to express pain

• → he often expresses pain through very high volume screaming

• It helps to plan things well in advance and prepare Connor for what to expect. It can also be very

helpful to assign Connor a specific job

• Mom suggests that staff limit the choices they give and avoid trying to negotiate w/Connor

• When Connor has anxiety, he benefits from counting, firm boundaries, black and white statements, with as few words as possible

• Connor likes small sensory objects that he can hold in his hands, watching TV (Phineas & Ferb is his favorite show), cell phones, ring tones, action figures, and small, shiny things

Some Things to Know About Connor

Medical Play/Procedural Play• Allows the child to know how something

will be done, why it is done, and what it will feel like.

• Avoids misconceptions about the procedure.• Maximizes the child’s understanding.• Child gains mastery over situation.

Medical Play/Procedural Play

• Teddy bear clinics in schools or community• Parents can facilitate at home – request

supplies and information from the health care facility

• Use basic toy medical kits for trips to pediatrician, vaccinations/shots

Story books, Hospital tours, Photo books

Introduce new or stress-provoking environment in advance– Use as a guide for sensory information– Can introduce roles of staff– Story books are useful for young children who

frequently are more comfortable hearing about a character’s

experience than their own

Story books, Hospital tours, Photo books

• Request tour of hospital- Desensitize medical

environment

• Creating photo books– Rehearsal/familiarization– Control– Sharing experience with siblings/school

Potential Outcomes of Preparation

• Increase self-concept, self-image• Build confidence• Less emotional distress• More knowledge of the procedure• Better cooperation with treatment• Fewer negative behaviors during hospital

routines & procedures• Fosters trusting relationships with health care

providers• Practice coping techniques when calm

Comfort Positioning• Sometimes it can be difficult for a

child to keep their body still for a painful or scary procedure

• Lying flat is a vulnerable position and often elicits anxiety before anything else has happened

• Hold the child so they feel comforted instead of restrained

Comfort PositionsBenefits for Infant/Toddlers:

Comforted before, during, and immediately after the procedure

Distraction can still be used while holding

Reinforces the child’s sense of control

Permits visualization of parent/caregiver’s face

Benefits for Pre-School/School-Ages:Comforted before, during, immediately after the procedure

Reinforces sense of control and mastery

Allows option to watch procedure or look away

Stephens, Barkey, and Hall 1995 Techniques to comfort children during stressful procedures Advances in Mind-Body Medicine 15: 49-60

Walsh-Sukys, Krug 1997 Procedures in Infants and Children. W.B. Saunders Company, Philadelphia

Schmitz, Martin, Koh, et al. Hospital Room or Treatment Room: Where Should Inpatient Pediatric Procedures Be Performed? Children’s Health Care, 29 (2), 103-111.

During procedure/treatment

• Communicate with health care provider• Facilitate coping techniques/plan• Validate feelings, offer empathy and comfort

while maintaining limits

Following procedure/treatment

• Positive reinforcement• Praise – identify at least one thing they did

well• Pain scale

• Opportunities for expression• Play through experience

Using Incentives• Incentives can be an effective way to

encourage and reward children for doing something that is difficult for them

• Try to use an incentive instead of a bribe →think of bribery as giving or promising a child a

reward AFTER they have begun to behave badly

• Determine rewards ahead of time• Be clear with behavioral expectations• Give reasonable incentives

Schlicher, Erin Bribing Kids vs. Rewarding Kids For Good Behavior: What’s the Difference? Empowering Parents

School • Preschools and Early Childhood programs can

provide medical play supplies/kits for use in classroom/free play

• Teddy bear clinics• Books about going to the doctor• Encourage students to share their

medical experiences• Ask a medical professional to come

talk with the class• Share tips with parents

Medicine Compliance• Age-appropriate explanation regarding

“why” she needs medicine• Make it taste better – mix-ins, Flavor-X,

KidKupz• Use comfort positions• Create a routine• Empower kids by encouraging them to play

a role in taking meds – offer choices• Utilize behavior/sticker chart

Advocacy

YOU are the expert about

your child!

Additional Resources•For further resources on doctor and hospital visits, check out the Child Life Council’s resource page:

http://www.childlife.org/Resource%20Library/ResourcesforCaregivers.cfm

•Follow the link below to view Seattle Children’s tips on preparing for hospital visits:

http://www.seattlechildrens.org/patients-families/

•If you are interested in further support preparing kids for hospital visits or would like to plan a medical play session for your classroom, please feel free to contact the Child Life Department: 206-987-2037

Questions?