Instructions for use of this template:• This PowerPoint was created by child life specialists on the Child Life

Council’s Professional Resources Committee for use by professionals in the field.

• It may be used to educate multidisciplinary team members and students in your practice.

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Our Thanks to:

The Child Life Council’s Professional Resources Committee, who provided a template to help in the creation of this presentation for our audience.

Child Life and Pain Management

What is Child Life?

Child life specialists address the psychosocial concerns that accompany health care

experiences by promoting optimal child development and minimizing adverse effects.

Using play and psychological preparation as primary tools, child life interventions facilitate coping and adjustment under circumstances

that might otherwise be overwhelming.

Certified Child Life Specialist Professional Standards of Practice

• Minimum bachelor’s degree or master’s degree* with specific coursework in human growth and development, family studies, psychology, and related fields*By 2022, all newly Certified Child Life Specialists will be required to hold a master’s degree

• Minimum of 480 hour internship

• National Certification examination

• Professional development hours to maintain certification

• Adherence to the code of ethics and standards established by the Child Life Council

Pain

• Procedural pain is universal to all pediatric patients and needle stick pain is the most common source of pain in hospitalized children (Wong and Baker, 1988)

• Pain is subjective

Wong, D., Baker, C. (1988) Pain in children: comparison of assessment scales. Pediatric Nursing.14 (1): 9-17.

Gate Control Theory of Pain

• Experience of pain can be influenced by thoughts and emotions

• In order to help control the “gate” of pain, other tools can be utilized to distract/“trick” the skin or body to focus on additional sensations, such as cold or vibration, to minimize the sensation of the poke or pain

The gate control theory of pain. (January 01, 1978). British Medical Journal, 2, 6137, 586-7.

How Child Life Can Help• Play

– Therapeutic – Medical

• Diagnosis education• Preparation• Support

– Procedural– Emotional– Family– Coping Plans

Child Life’s Role in Pain Management• Non-pharmacological pain management

– Guided Imagery/Relaxation– Positioning for Comfort– Emotional Support– Distraction– Deep Breathing

• Other pain management techniques– Sucrose Water– Lidocaine (injectable/topical)– Vibration and cold

“CCLSs are often directly involved in the utilization of nonpharmacologic pain management techniques and coaching or supporting patients and families before

and/or during distressing medical procedures.”American Academy of Pediatrics

Brown, C., Ipsan, C., Lostocco, L., Vinocur, C. D., Chitkara, M. B., Percelay, J. M., Betts, J. M., ... Alexander, S. N. (January 01, 2014). Child life services. Pediatrics, 133, 5.)

Guided Imagery

• Guided imagery induces an altered state of consciousness where a patient develops heightened focus on a particular idea for the purpose of relaxation and/or distraction.

• 3 events associated with guided imagery:– Absorption- patient totally involved– Disassociation- separate self from pain– Suggestibility- suggest scenes, patient can agree or

disagree• Patient must be in control to do guided imagery

Guided Imagery

• Guided imagery is most useful for longer procedures or for beside pain management

• It is most effective with older children who are able to use their imagination to follow the script

• Comfort positions allow for good control during a procedure while still allowing the child to receive comfort from the parent

• Helps the parent and child to feel more at ease and in control

• Some positions, like laying on the back, can make children feel very vulnerable

Sparks, L. A., Setlik, J., & Luhman, J. (2007). Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial. Journal of pediatric nursing, 22(6), 440-447. doi: 10.1016/j.pedn.2007.04.010

Positioning for Comfort

Positioning for Comfort: Advantages

• Fewer health care team members needed• Greater immobility of the child• Close physical contact with a caregiver• Caregiver has an active role and can support

the child in a positive way• Creates a sense of control for the child

Stephens, B. K, Barkey, M. E., & Hall, H. R (1999). Techniques to comfort children during stressful procedures. Advances in Mind-Body Medicine, 15, 49-61.

Positioning for Comfort • Children may still cry, but tend to display less stress• Can be initiated as soon as a child has received some

trunk and head control (3-5 months)• Parents/caregivers should not be asked to hold down a

child’s arms or legs; it is important to make sure parents feel comfortable with these positions

• Parents/caregivers can lie next to child on bed for procedures which require supine position

• Compliment parents!• Positions can always be adapted to meet the needs for

each procedure

Examples of Positioning for Comfort

• IV /Blood Draw:P̶ Straddling lap of caregiverP̶ Side-Sitting

Examples of Positioning for Comfort

• IM injection in ThighP̶ Leg is bent over parent’s lap, keeping thigh

muscle relaxed

Lacey, C. M., Finkelstein, M., & Thygeson, M. V. (2008). The impact of positioning on fear during immunizations: Supine versus sitting up. Journal of Pediatric Nursing, 23, 195-200.

Examples of Positioning for Comfort

• Port AccessP̶ Sit forward-facing on parents lapP̶ Parents can cross legs over child’s legs to

prevent kicking

• NG Drop– Hug parent during nasal aspirate– Child can also be held on parents lap facing

outward with parents arms and legs wrapped around the child

Examples of Positioning for Comfort

Examples of Positioning for Comfort

• Urinary Catheterization– Child lies with head in parent’s lap on table

Emotional Support

• Comforting touch• Encouraging words• Developmentally appropriate medical

explanations– Reduces anxiety related to anticipatory pain

Distraction/Planned Alternative Focus

• Does not mean “Hey, look over here so you do not know what is happening!”

• Gives an alternative to focusing on pain• Gives the patient a “job” and promotes sense

of control over an appropriate aspect of the procedure

Items useful for Distraction• Toddler – bubbles, light spinner, cause and effect toys,

toys with lights and sounds, sensory toys, etc.• Preschool – bubbles, light spinner, toys with lights and

sounds, young versions of i-spy books, ViewFinder and cartoon slides, stress ball, pinwheels, whistles, iPad games and activities

• School-age – i-spy books, iPad games and activities, conversation, music, singing, stress balls, pinwheels, whistles, etc.

• Adolescent – iPad games and activities, conversation, MadLibs, music, singing, hangman, Pictionary, stress balls, etc.

Deep Breathing• Deep breathing is a useful coping technique

that can be used in the midst of pain• It can be helpful for both chronic and acute

pain• Tools like whistles, bubbles, and pinwheels can

encourage younger children to take bigger breaths

• Visuals, like birthday candles, can also be beneficial for younger children

• Give parents and patients clear instructions• Rationalize/describe techniques as being

helpful or less threatening; ‘helping you hold still’ or ‘giving you a big hug’

• Involve the parents and include them in what is happening– Decreasing stress level of parents– Parents are the experts of their child

Using Interventions Effectively

Additional Pain Management Techniques

• Cold Spray • Sucrose Water • Pharmacological Numbing Agents • Heat and Cold• Soothing Items

Customize this slide to include more information regarding additional pain management techniques available at your facility (such as JTip, ELMA, LMX, Buzzy, freezy spray, cold spray, SweetEase, pacifiers, hot or cold packs, etc).

Bedside Pain Management

• Sometimes pain can be chronic– Some tools that can be used in the procedure

room can also be used• Bubble blowing• Play with familiar toys• Relaxation

• Teaching and rehearsing coping techniques can also be very beneficial

Developmental Level of Patient Possible Pain Management Technique

Infant Comfort positionEmotional supportSucrose water

Toddler Comfort positionDistraction/Planned alternative focusEmotional support

Pre-school Comfort positionDistraction/Planned alternative focusEmotional supportDeep breathing

School-age Guided imageryDistraction/Planned alternative focusEmotional supportDeep breathing

Adolescent Guided imageryDistraction/Planned alternative focusEmotional supportDeep breathing

RememberChild Life can Help…

• Reduce patient and parental anxiety• Teach techniques to facilitate coping• Offer support during painful procedures• Set clear expectations

Child Life Department

• Insert contact information/unit information

Questions?