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Clinical Practice Guidelines

Communicating procedures to children

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  • See also 

    Procedural pain management 

    Autism and developmental disability: Management of distress/agitation

    Key Points

    1. Be honest when explaining the procedure to a child. During the procedure, explain what is occurring and signpost any changes before they occur, especially sensory aspects such as smells, feelings, etc. (eg a change in position, technique, equipment or staff)
    2. Use clear and simple language that is tailored to the child’s developmental level. Use affirmative terms (eg “Keep your arm nice and relaxed”) and avoid negative terms (eg “Don’t move”, “Sting”) and qualifiers (eg “This will hurt a little”). Also be aware of communication devices for children with special needs
    3. Ensure the child is positioned comfortably where they are able to see, hear and/or touch their carer during the procedure
    4. Try to have one person at a time talk to the child

    Background

    • Children who are prepared for medical procedures generally experience less anxiety, less distress and are more cooperative during procedures this in turn empowers the child and builds resilience 
    • A hospital is an unfamiliar environment with many new experiences (equipment, staff, stimuli). Demystifying these unknowns is key to minimising a child’s anxiety.
    • Techniques such as distraction and therapeutic play, paired with timely and appropriate analgesia and/or sedation assist to minimise emotional distress and negative responses to procedures.

    Analgesia, Anaesthesia, Sedation 

    • Consider the use of pre-procedure medications (analgesia, sedatives, anxiolytics)
    • Provide coaching on coping behaviours eg breathing techniques, and plan for how to best support the patient throughout the procedure

    Age specific procedure aides

    Infants

    Children

    Adolescents

    Pre-procedure sucrose
    Feeding
    Skin to skin contact with carer
    Tucking & swaddling
    Pacifiers 

    Comfort teddy/blanket

    Engagement with a Child Life therapist when possible

    Distractions such as toys, books, music

    iPad, phone for music, apps, games, cartoon episodes, YouTube videos

    Engagement with a Child Life therapist when possible or equivalent (eg music therapist)

    Optimisation of privacy
    Encouraging questions & participation in procedure planning when appropriate
    Asking about anxieties alone to avoid embarrassment

    iPad, phone for music, apps, games, cartoon episodes, YouTube videos

    Engagement with a Child Life therapist when possible

    Equipment

    Preparation

    • Do not perform a procedure in the patient’s room where possible, use the procedure room; this allows them to have a ‘safe space’ to return to post procedure
    • Establish the staff who will be completing the procedure, allowing staff the opportunity to meet and develop rapport with the child, where possible
    • Ensure the procedure room has good lighting, pictures or tools for distraction etc.
    • Familiarise the child with the procedure room, staff and equipment to be used
    • Discuss with the family what the plan would be if the procedure is unsuccessful eg another clinician trying the procedure, trying under sedation or an alternative procedure
    • Give the child the opportunity to control elements within the procedure room when possible eg position, the distraction strategy, sounds, lighting. Only offer practical well‐defined options eg ‘Would you like chocolate or strawberry flavour on your breathing mask (for nitrous oxide administration)?’ or ‘Would you like to sit on mum's lap or on the bed when we do the blood test?’  Do not offer a choice when there is not one available or when the answer will most likely be no
    • Ensure a child is positioned comfortably and close to their carer. Allow a child to be positioned with their carer when possible, eg cradled in the carer’s arms with an arm extended for venepuncture
    • Try to have all the equipment set up in a procedure room prior to the child entering to reduce the waiting time

    Procedure

    Child

    1. Find out the child’s likes & dislikes to establish rapport and to help build a procedural support plan eg a favourite song to be played that provides comfort 
    2. Ask the child what they know about the procedure. Correct misconceptions
    3. Assess previous procedural experiences
    4. Ask the child what they would like to bring into the procedure eg a toy/comforter 
    5. Provide options and control during the procedure where possible
    6. Use clear, honest and developmentally appropriate words to explain the procedure (see Appendix 2 below). Avoid confusing detailed explanations and medical jargon
    7. Forecast and explain any sensory changes the child is likely to experience during the procedure, such as the smell of an anaesthetic mask or sounds of observation
    8. Normalise that being anxious or frightened is a common response to a procedure
    9. Speak with the child at their eye level
    10. Children may become withdrawn when distressed; do not mistake a ‘quiet’ child for a non-anxious child
    11. Avoid excessive restraint, especially in pre-verbal children
    12. Check with carers of children with additional needs what is helpful for them in ways of preparation/distraction and/or communication aids/devices that they may use

    Carer

    1. If the caregiver attends the procedure, provide them with a task to help comfort the child. Gauge what a carer is both comfortable and able to do
    2. Discuss common responses children display during a procedure. Toddlers commonly become upset when their movement is restricted and not because of pain or bad behaviour
    3. Discuss positioning that may result in less distress for the child and carer eg having the child sit on the carer’s lap  
    4. Explain the importance of distraction and entrust them with this

    During the procedure

    1. Cluster procedures when able and prepare the child for all of them
    2. Perform the most uncomfortable procedures last to minimise hyperalgesia and more severe pain
    3. Rest, reassess & recover if the procedure attempt is unsuccessful, unexpectedly challenging or to minimise distress

    Special considerations

    • Previous poor procedural experiences
    • Medical conditions including comorbidities that hinder a patient’s ability to communicate
    • High-risk of hyperalgesia (eg very unwell, chronic pain)
    • Children who have different ways of communicating or are non-verbal

    Post procedure care and discharge instructions

    • Debrief the family and child about the procedure and its outcome as early as possible
    • Provide positive reinforcement of what went well during the procedure
    • Ask the child if there is anything they would like to try differently in future
    • Document the child’s response to the procedure and their procedural preferences to help inform subsequent care episodes

    Consider consultation with local paediatric team when

    • A child has a chronic condition that will require multiple procedures; consider developing a ‘procedure plan’
    • The child’s behavioural or emotional distress cannot be well managed with the resources or staff available

    Parent information

    Australian

    Medical Imaging Procedures App

    A child’s guide to hospital

    Comfort kids

    RCH Kids Health Info - Your child’s hospital stay
    RCH Kids Health Info - Reducing your child’s discomfort during procedures 

    The Sydney Children’s Hospital Network - Preparing your child for medical procedures 
    The Sydney Children’s Hospital Network – Preparing your child for a hospital stay

    International

    Association for the Wellbeing of Children in Healthcare 

    Childkind International – Resources Library

    Children’s Hospital of Eastern Ontario – Preparation by age guidelines

    Children’s Hospital of Eastern Ontario – Emergency Care

    Children’s Hospital of Eastern Ontario – Visiting the ED fact sheet

    Stanford Children’s Health - Learning how to manage pain during medical procedures

    The European Association for Children in Hospital – Informing children who come to hospital for a procedure

    Appendix 1: Child friendly explanations for medical equipment

    Equipment

     

    Topical anaesthetic cream

    The cream on your skin helps to make your skin feel numb. Numb means that you can't feel that part of your skin as much or not at all for about an hour

    Bandage

    For a wound or fracture - this helps to protect your sore (name body part).
    For an intravenous catheter - this helps keep the straw in your hand.

    Blood pressure cuff

    This goes around your arm and may feel like a tight hug/squeeze
    It doesn't stay tight for long
    It helps us to know how strong your heart is pumping

    Cardiac monitor leads

    These sticky buttons go on your tummy and chest. The long strings connect to this monitor (which looks like a TV) and helps check how well your heart is beating. Do we need to tell them they need to stay as still as a statue?

     Electrocardiogram (ECG)

    These stickers on your chest, arms and legs connect to the ECG machine and gives us a picture of how your heart is beating
    It is important to keep still while we are taking the picture

    Intravenous Catheter (IVC)

    A small straw or tube that goes into your vein to give your body a drink of medicine/fluid

    Plaster of Paris

    Protects your broken bone until it gets better

    Stethoscope

    Helps us to hear the sounds the inside of your body makes - how your heart is beating, how you are breathing

    Syringe

    A tube with numbers on it - describe its purpose
    eg a helper to give medicine in your mouth 

    Tape

    Special hospital sticky tape to make sure the straw (IVC) stays in your hand

    Tegaderm

    Like big clear sticky tape

    Tourniquet

    Looks like a belt that goes around your arm.  It may feel tight - it's job is to find the best veins

    Appendix 2: Child friendly explanations for procedures

    Procedures

     

    Anaesthetic

    Medicine we give you through the straw in your hand or with a mask that makes you go to sleep so the doctor can (name procedure). You will not feel anything. When it is finished you will wake up

    Blood test

    A tube that goes under the skin to take a small amount of blood. Explain reason for blood test. It tells us information about how to make you better

    Fasting

    You cannot eat or drink anything. Explain reason why in developmentally appropriate terms.

    Flush IVC

    Water goes into the straw with the syringe to make sure it is working 

    Fracture

    Broken bone

    Fracture reduction

    Putting the broken bone back in the right spot so that it can get better

    Infusion

    Medicine that takes a bit of time to go through the straw and into your body. Medicine given slowly through a drinking straw to your body

    Injection

    Medicine that we put into your body with a small needle 

    Lumbar Puncture

    A needle that goes into your back to take a small amount of fluid
    Describe positioning during lumbar puncture. If we curl up into a ball the bones in your back widen to make a good space to take the fluid. Use a Slinky to show how this works 
    Explanation of cerebrospinal fluid and the purpose of the test depends on the age of the child and anxiety level 

    Magnetic resonance imaging(MRI)/Computer tomography scan (CT)

    Takes a picture of the inside of you.  Describe what the child will see, sounds they will hear, how equipment will move, what the child's role is. It is important to stay really still so our pictures aren’t blurry

    MRI has very loud sounds that sound like you are lying next to a construction site with machines. It is a long tunnel that you lie inside of

    CT scan looks like a big doughnut that you lie inside while they take pictures 

    Nitrous Oxide

    Special medicine air that comes out through the mask. You can't see it. We keep the mask on for the whole procedure time
    It helps make the pain go away
    Some children say it makes them have funny dreams
    It is sometimes called laughing gas because it makes some people laugh a lot

    Observations "obs"

    The nurses do "obs" to see how your body is working. "Obs" mean they find out how fast your heart is beating and how quickly you are breathing

    Oxygen Saturation "sats"

    This machine is like a peg that sits on your finger
    It tells us how your lungs are working

    Ondansetron wafer

    A medicine that helps to make your tummy better and stops the vomiting
    It is small and goes on your tongue
    You don't need to swallow it

    Procedure/Treatment room

    A different room to go to for your  "name of procedure". It has everything the doctors and nurses need.  Mum and/or dad (caregiver) can come with you when you go there

    Sedation

    Medicine that helps you to feel more relaxed.  Explain sensation further depending on sedation agent 

    Stool collection

    Use familiar term eg poo. We need to test some of your poo to see what is making you feel sick or have tummy aches

    Suture

    Like a band aid made out of string to hold your skin together so it can heal. Explain steps of procedure if developmentally appropriate. Stitches are a thread that holds to two parts of your cut together while it heals. You may need to explain the cleaning process as well as local anaesthetic if being used

    Going to theatre

    You need to have a special procedure in a different part of the hospital to help you get better. You may meet lots of different people who are all there to help you. Assure the the child that a caregiver will be with them for support. Further explain details of the operation or procedure as developmentally appropriate to the child.. You may wish to describe scrubs so they know they will look different

    This is also the place where you have a special hospital sleep for your operation so you don’t feel anything and they wake you up once it is all finished

    Urine collection/checking urine

    Checking to see how healthy your wee/pee is

     

    Last updated June 2021 

  • Reference List

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