Key points

Introduction

One of the most satisfying parts of medicine is improving an acute or painful problem. Procedures in the outpatient setting provide an opportunity for immediate resolution of the problem, such as reducing subluxed radial heads or repairing lacerations. When a painful procedure is not approached correctly, however, short-term and long-term consequences follow. Poorly controlled procedural pain can prolong treatment times, drain staff resources, dissatisfy parents, and leave patients with a lasting fear of medical treatment. When anxiety or motion prevent successful completion, an additional trip to the emergency department may be necessary. With the correct approach to pediatric distress and proper pain management, many office procedures can be accomplished with minimal discomfort and distress, and improved office flow.

Introduction

One of the most satisfying parts of medicine is improving an acute or painful problem. Procedures in the outpatient setting provide an opportunity for immediate resolution of the problem, such as reducing subluxed radial heads or repairing lacerations. When a painful procedure is not approached correctly, however, short-term and long-term consequences follow. Poorly controlled procedural pain can prolong treatment times, drain staff resources, dissatisfy parents, and leave patients with a lasting fear of medical treatment. When anxiety or motion prevent successful completion, an additional trip to the emergency department may be necessary. With the correct approach to pediatric distress and proper pain management, many office procedures can be accomplished with minimal discomfort and distress, and improved office flow.

Rationale for pediatric pain management

Before 1987, the prevailing teaching was that children were born incapable of experiencing pain in a meaningful way. Anand and colleagues demonstrated that withholding analgesia for procedures resulted in poorer outcomes in preterm patent ductus arteriosus ligation patients, including bradycardia, hypotension, and even intraventricular hemorrhage. An increased awareness of adverse long-term consequences from oligoanalgesia (whether in cases of circumcision, venipuncture, lumbar puncture [LP], or acute multisystem trauma ) has led the American Academy of Pediatrics to recommend adequate procedural pain management, even for venipuncture.

Common objections to pain management

A primary barrier to effective acute pain management in children includes the inability to assess pain in younger children, as well as a fear of overmedicating. Parents, as well as clinicians, fear using opioid medication. In one postoperative tonsillectomy study, despite having access to acetaminophen with codeine, 99% of home doses were for acetaminophen alone. Procedural pain control is limited by more operational issues, primarily perceived lack of time and inconvenient access to medications. In addition, early experiences with lidocaine-prilocaine cream for intravenous (IV) access left the perception that topical pain relief decreases procedural success. In fact, addressing IV pain has been found to significantly decrease time and increase first-attempt success.

Nature of pediatric procedural distress

Procedural distress in children and, to a lesser extent, adults, combines behavioral components (fear, lack of control, temperament) with physical pain and how focused they are on the procedure ( Fig. 1 ). Patient and family assessment is critical to determine the amount and type of nonpharmacologic management to best support a family during procedures.

Procedural distress for a child includes the level of fear, how much attention is focused on the procedure versus something comforting or neutral, and how much pain is involved.

(Copyright © Baxter. Used with permission.)

Fear

Lack of knowledge of what to expect, lack of control over the procedure, and physical vulnerability all contribute to a sense of fear. Fear is highly correlated with reported pain and has implications for future memory of painful experiences. Because the contribution of parental anxiety accounts for 50% of a child’s distress and is predictive of children’s reported pain, awareness and addressing the parent and child as a unit can improve procedural success.

Recent research evaluated serum beta-endorphin, a stress and pain biomarker. Higher preoperative levels in adults correlated with increased postoperative pain. Compared with nonsurgical hospitalized patients, neonates had a moderate elevation and preschool children had an “explicitly high” elevation in endorphins, indicating a significant presence of presurgical anxiety ( P <.0005). Interestingly, before and after an operation, infants had low biomarker levels and did not differ from nonsurgical hospitalized patients. This suggests that the conditioned responses of neonates (who may have had more previous procedural interventions), and preschool children “who exhibit increased emotional perception” are more susceptible to the effects of fear. Preschool children may benefit the most from fear-reducing preparation and intraprocedural interventions.

Preparation

Preparation should include a brief age-appropriate explanation of the ensuing sequential procedural steps presented in a calm, confident manner. Ideally, incorporate gentle touch at a location distant to a painful area and include descriptions of any sounds, sights, or physical sensations that the patient may experience. Allowing patients and their parents to ask questions may alleviate any fears or inaccurate expectations. Preparation should include guidance toward appropriate coping skills, such as relaxation techniques (eg, deep breathing, muscle relaxation) or distraction. “A lot of kids find it helps when they blow out on a pinwheel, or find things in my picture book, or play on my iPad. Let’s make a plan for what you would like to do.” Although certain language increases fear and pain ( Table 1 ), focused mental and physical distraction provided by the parent can improve the experience. In addition, assigning both patient and parent a distraction or restraint responsibility during a procedure is an anchoring point to return to if either becomes distressed. “OK, remember, your job is to hold really still. We said you’d take a huge breath and hold it like a statue if you got nervous, so go ahead now and take that breath.”

Table 1

Language and pediatric distress

	Neutral or Reduces Distress	Increases Distress
Language	Pressure, tight squeeze Bother, uncomfortable Push Metal tube, squirter	Shot, sting, pinch Hurt “I’m sorry” Needle, syringe
Behaviors	Redirecting Nonprocedural discussion Talk before touch Firm, warm confidence Humor	Empathizing Apologizing Punishing Allowing the child to delay Multiple adults talking

Sinha and colleagues found distraction to be effective for all children by parent-report, although self-report only differed for older children. In contrast, a smaller study by Gursky and colleagues found that extensive preparation and active distraction was extremely effective, even in a younger cohort. Gursky and colleagues used a 15-minute protocol that included modeling the procedure to the patient on dolls and allowing the patient to feel the suture material. Although this extensive level of preparation may be excessive for many primary care settings, explaining the procedure while a topical anesthetic is placed on the child may mitigate fear even without using anxiolytic medications.

A good resource incorporating multiple aspects of preparation can be found at http://www.youtube.com/watch?v=T2f7G6zMdXA .

Restraint

Lying supine is the most vulnerable position for humans, particularly when physically restrained with a papoose board or by adults. In contrast to preparation (tell-show-do) being the most helpful technique to allay anxiety for pediatric dentistry, the papoose board and physical restraint were the most detrimental. Techniques to restrain without physical force or use of papoose boards include sheet wrapping and insertion of a child’s arms behind them into a pillowcase on which to recline ( Fig. 2 ). To reduce further the anxiety caused by lying supine, a parent can sit next to a child or sit on the table with the child in his or her lap ( Fig. 3 ). Placing an arm around the child’s shoulder, the parent can tuck one of the child’s arms behind the parent’s back, using a shoulder to restrain gently the child’s other arm, or use one arm to control the forearm ( Figs. 4 and 5 ). This position-of-comfort approach significantly reduced distress when used for IV placement ( Figs. 6 and 7 ). An excellent video demonstrating multiple examples is available at http://www.youtube.com/watch?v=VOqIVIFN5Bo . A PDF is available at http://ministryhealth.org/SaintJosephsChildrensHospital/ChildLifeProgram/Positioning_for_Comfort_2007.pdf .

To use the pillowcase restraint, have the child place arms into a pillowcase located behind their back ( A ), then lie down on the case ( B ). This allows limited movement of the arms without jeopardizing a sterile field.

( Courtesy of Amy Baxter, MD, Augusta, GA.)

Security is enhanced by having the child sit on the parent’s lap for laceration repair. The mother is in a good position to control the patient’s upper arm in case of forgetful movement or distress. The anxiety is further reduced before the procedure by the father’s use of distraction cards.

( Courtesy of Amy Baxter, MD, Augusta, GA.)

The child is sitting upright, with the mother able to secure his arms from either side. He is engaged in active distraction with a tablet game.

( Courtesy of Amy Baxter, MD, Augusta, GA.)

Note that with a position of comfort, distraction, and a good digital block, the patient can be allowed to be distracted further and rewarded with a popsicle because eating is not a concern with nonpharmacologic interventions. The father’s hand is in a position to restrain the forearm during this thumb nailbed repair.

( Courtesy of Amy Baxter, MD, Augusta, GA.)

For a child who wants to watch, allow sitting on the parent’s lap facing the procedure. Note that the father’s left hand should move up past the bear and gently secure the forearm during the procedure.

( Courtesy of Heidi Giese, BS, CCLS, CTRS, CIMI, Child Life Manager, Saint Joseph’s Children’s Hospital, Marshfield Clinic Children’s, Marshfield, Wisconsin.)

To secure a child who is less cooperative, have them face their parent and secure the arm for an IV on a gurney at just below axilla height. Ideally, the father’s left arm would be above the patient’s shoulder to secure the arm further.

( Courtesy of Heidi Giese, BS, CCLS, CTRS, CIMI, Child Life Manager, Saint Joseph’s Children’s Hospital, Marshfield Clinic Children’s, Marshfield, Wisconsin.)

Environment

Although literature on environmental factors such as ambient temperature, light, and sound is scarce for in-office procedures, both preanesthesia and dental literature offer some support beyond a common sense approach to children. Without parental preparation, parental presence alone is the least effective way of decreasing anxiety. In addition to preparation and a position of comfort, decreasing the amount of noise and chaos can lower the anxiety preprocedure. One randomized, controlled trial of 70 children preanesthesia found significantly decreased anxiety with a three-pronged approach: dimming operating room lights, playing Bach’s Air on a G String , and having only one person, the attending anesthesiologist, interact with the child. Keeping lights low and using only the ceiling spotlight for suturing can minimize stimulation ( Fig. 8 ).

With the use of LET and naptime, this child could be sutured completely without sedation. He was allowed to fall asleep on his mother. During the procedure, she restrained his head with her right arm under the drape and controlled his shoulders with her left hand. This also illustrates draping for retaining vision for an awake, anxious child.

Music and dimmed lights may be difficult to provide; however, “One Voice,” which is only one person speaking during the intervention, is a simple technique available at http://www.onevoice4kids.com/learning.html . This method designates one person to provide information and distraction during the procedure to reduce chaos and give the child more control. A YouTube video is available at https://www.mededportal.org/icollaborative/resource/546 .

Humor, normalizing discussion, and calm redirection are powerful tools to reduce anxiety. Often, when words such as pain, hurt, shot, or medical jargon are used, fear increases. Ironically, empathy and reassurance (“I know, honey, it’s okay”) also increase distress in children.

Pharmacologic anxiolysis

The fast-acting benzodiazepine midazolam as a single agent is by far the most studied anxiolytic for procedural sedation ( Box 1 , Table 2 ). Oral doses of 0.5 to 0.7 mg/kg, with a maximum of 15 mg, result in mild sedation within 15 to 30 minutes. Recently, Klein and colleagues described 0.5 mg/kg aerosolized buccal administration of the IV formulation having improved efficacy to oral, with less distress than when administered intranasally.

The IV form of midazolam can be administered at a dose of 0.3 to 0.4 mg/kg intranasally, yielding effective sedation in 5 to 15 minutes. To improve absorption, use a mucosal atomizer device (approximately $1.00) and divide the dose between the nares. Because the pH of the IV formulation is 3.3, pretreatment with lidocaine 10 mg per puff in the nares, or an oral drop of cherry syrup afterwards may make the administration more tolerated. The duration of sedation from oral midazolam is between 20 and 40 minutes. Intranasal administration had an average of 23.1 minutes duration of sedation.