Note: This guideline is currently under review.

Introduction

Aim 

Definition of terms

Who to contact?

Before, during and after considerations

• Before the procedure
• During the procedure
• After the procedure

Evidence Table 

References

Introduction

Paediatric patients in hospital may experience many different medical procedures (i.e. having observations conducted, blood taking etc). It is our responsibility as healthcare professionals to ensure that every step is taken to protect children from unnecessary healthcare-induced trauma and distress, especially those who will be needing ongoing care [1]. The goal of procedural management at RCH is to minimise anxiety associated with these procedures, particularly in light of potential future procedures (See Figure 1). Planning for procedures is essential for ensuring that the patient’s experience with procedures is a positive one, as poorly managed procedural distress and pain can have long-term negative effects on children and young people [2]. This is best achieved through a multimodal approach incorporating pharmacological and non-pharmacological approaches to reduce distress and improve patient coping with procedures [3]. 

Aim

The aim of this guideline is to provide guidance as well as adequately prepare clinical staff with the knowledge and effective interventions to support the management of procedure-related distress for children and young people receiving health care. 

Definition of terms

Assent: the act of agreeing to or approving of something post thoughtful consideration. This is given by someone who is not of the age to give legal consent

Behaviour Support Profile (BSP): the behavioural support profile is a documentation tool for the non-medical needs of our patients, including their communication preferences/abilities, sensory needs, behaviours of concerns and triggers to name a few. It can be used for any patient with any diagnosis, but is aimed for patients with communication difficulties, behaviours of concern or severe anxiety. For more info click here https://www.rch.org.au/emr-project/learning-resources/Behaviour_Support_Profile/ 

Consent: to give assent or approval given by someone of legal age or considered a mature minor

Procedural Support: Procedural support is a process of preparing and coaching patients and their families before, during and after medical procedures to promote positive coping skills during any interventions 

Procedural Support Plan (PSP): the procedural support plan documents a patient’s preferences for procedures. A general plan can be completed for all procedures, or individual plans for specific procedures can be created. Please refer to the following - Pain / Procedural Support Plan EPIC

Procedural Support Team: A multidisciplinary health professional team working in conjunction with the child’s caregivers form the basis of a procedural support team. The aim of the procedural support team is to promote coping and mastery of medical procedures for the child receiving healthcare.

Who to contact?

Differences between services

• Child Life Therapists are allied Health professionals specialising in child development. They provide medical play, procedure preparation and non-pharmacological procedural support for children.
• Comfort Kids made up of clinical nurse consultants who can advise on sedation agents and pharmacotherapy for procedures as well as provide coordination and planning for procedures and education to staff
• Comfort First are made up of allied health professionals who provide procedural preparation and support to children and adolescents specifically undergoing oncology and Bone Marrow transplant care.

Before, during and after considerations 

A guide to conducing a procedure on a paediatric patient.

Before the procedure

1. Consent & assent

• Informed consent should be sought from a parent or guardian or mature minor for any procedural intervention.
• Verbal consent is adequate for clinical procedures in the ward environment. Signed consent is required for procedures under sedation or general anaesthetic.
• A procedure should not go ahead without parent/guardian consent unless it is in the context of an emergency.
• Where appropriate, assent for the procedure from the child or young person should be sought in conjunction with parental assent.
• Child assent can be verbal or implied through co-operation with the procedure.
• Please refer to the RCH Policies and Procedure: Consent - Informed
• Consent requirements are more complex for medical imaging procedures. Please refer to the document attached:

2. Building a rapport & gaining trust

• It takes a small amount of time to ask the child about their likes and dislikes (pets, siblings, favourite toy, favourite TV show)
• Demonstrating you know something important to the child facilitates trust

3. Assess procedural experience

• Discuss with the patient/family their previous experience of procedures (if any)
• What worked well? What didn't work well? How did the child respond when informed about the procedure? Which part of the procedure might bother the child most?
• Does the child have any coping strategies that they already use

4. Discuss and plan

• Offer choices, where possible, of how the procedure can be completed
  
• Have a staff discussion prior to the procedure, assign roles and consider ‘Plan B’ options
• Consider the use of Buzzy Bee, ice packs or Coolsense.
  
  • See RCH Policies and Procedure: Coolsense and Exocool Pain Numbing Applicators Procedure
    
  • Presentation: Buzzy® Device PowerPoint Presentation
    
• Consider the use and allow adequate time for topical anaesthetic (AnGEL & Emla) as tolerated. LINK COMING SOON.
• Be ready to tailor your practice to the specific needs of the child as your preferred way of practice may need to be adjusted to suit the child.
• Complete or update the Pain/Procedural Support Plan in EMR 
  

5. Prepare the child

• Children vary in the amount of information they want to know about a procedure. Discuss with the parent to assess the best way to communicate the procedure to the child.
• The timing of when you explain the procedure to a child will depend on the child’s age, development and their degree of anxiety, generally:
  • Younger (≤ 7 years) and more anxious children can be told on the day of the medical procedure. Toddlers and Preschool aged children may be best prepared for the procedure just prior to the intervention. 
  • Older ( ≥ 8 years) children can be told the day before or within the week of the medical procedure [4]
• Use soft language and avoid the use of medical words that can be confusing to children (refer to this guideline for more info RCH Clinical Practice Guideline: Communicating procedures to children
  
• Assess the child’s methods and preferences for communication 
  • Children from CALD backgrounds should be assessed for the need for an interpreter, and if required should be booked. See booking information here https://www.rch.org.au/interpreter/booking_an_interpreter/
  • Children who are non-verbal (or who prefer it) should be offered a visual schedule or the procedure should be explained through their preferred communication method. Contact CLT, speech pathology, Comfort Kids or Comfort First to facilitate this
• If called in advance, Child Life Therapists can provide preparation for specific procedures (eg. Modelling an IV insertion on a calico doll, familiarising the child with the “straw” that goes in their arm)
• The RCH has created a number of resources to help prepare children for medical procedures:
  • B positive (A child’s guide to hospital) has videos explaining specific medical procedures for children https://www.rch.org.au/be-positive/Jazz_and_Rocco/A_child_s_guide_to_hospital/
  • 'Okee in Medical Imaging' App to prepare children for medical imaging http://www.rch.org.au/okee/

6. Prepare the parent

• A family member should be encouraged to stay during the procedure to support the child as this can reduce distress [5], but always check parent’s preference.
• Give the parent a clear role, don’t assume the parent knows what to do during the procedure. In most cases this will be to comfort the child, but make sure you explain what they should do in the procedure [6]
• Provide parents with procedural information so they know what to expect as this can reduce parental anxiety and enhance the success of the medical procedure [5,6]

7. Clustering cares/procedures

• Consider if multiple procedures can be done at the same time (eg. Plan to insert an NGT under sedation, can tomorrow’s bloods be brought forward to be completed during the same sedation episode?)
• Is there an upcoming surgery scheduled? Consider clustering procedures together when the child is anaesthetised
• However, a sedation event shouldn’t be relied on to fit every intervention into one sitting, as using nonpharmacological methods for low impact procedures on different occasions can be done effectively
  

8. Consider use of sedation/analgesia

• If the medical procedure is likely to cause discomfort, consider the use of analgesia if appropriate [7].
• Consider procedural sedation if (1) the child has a history of significant procedural distress (2) the child is required to be immobile for a long period of time [8]
• Medication and dosages can be found here RCH Policies and Procedure: Procedural Sedation - Ward and Ambulatory Areas 

9. Environment & setting

• There is evidence to support that modifying the environment a procedure occurs in can positively impact on the child’s perception of pain [7, 9].
• Where possible dim lights and minimize unnecessary equipment in room [8]
• One voice: The person distracting or coaching the patient through the intervention should be the one voice heard through the procedure [10].
• The treatment room is recommended for procedures to help maintain the patient’s bed and room as a safe space [11]. This may be especially true for infants and toddlers who might otherwise begin to perceive a threat every time a staff member enters their room. However, the environment in which the procedure takes place should be negotiated with the patient and their family, therefore giving the patient a sense of control.
• Equipment and staff should be prepared before the child enters the procedural setting and it is recommended that any equipment that may provoke fear be kept out of sight.
• Reduce the number of unnecessary people who are not involved in the procedure to help minimise anticipatory anxiety

10. When to abort the procedure – Having a “Plan B”

• It is important to discuss with the parent and those involved in the procedure in advance what will happen if the procedure fails and when to stop
• Setting clear boundaries for when to abort a procedure in advance makes it easier to stop when things aren’t going to plan
• Discussing a “Plan B” in advance puts less pressure on Plan A being forced if the procedure isn’t working

11. Trouble shooting when you have no time - Consider:

• How important and time sensitive the procedure is?
• Can it wait? If so, challenge those wanting to proceed (even parents) without a plan
• If there is no time to plan and prepare, what is the likelihood of a successful outcome?

12. Refer early to Comfort Kids/First and Child life therapy if the child has a history of:

• Previous high procedural distress
• Trauma
• Developmental delay or intellectual disability or sensory processing syndromes
• Any special needs that you consider may impact on the child’s ability to cope with a medical procedure

Automatic referrals to Child Life Therapy, Comfort Kids and Comfort First can be generated through Nursing Admission navigator on EMR in the wellbeing screening section. Please refer to the following - https://www.rch.org.au/emr-project/learning-resources/Nursing_Admission/

Patients with additional needs

• Including those with neurodevelopmental disorders and developmental disabilities
• These patients may need or already have an individualised support plan such as a PSP & BSP that take into account their specific needs/requirements

13. Pharmacological strategies

Sedation should not be viewed as a last resort and the patient should not be seen to have failed because they need sedation. However, sedation is not an alternative to non-pharmacological techniques. They are used in conjunction. Sedation should be considered if [10]:

• The child displays significant anticipatory anxiety +/- fear related to the procedure
• The medical procedure is considered to cause discomfort beyond the child’s ability to cope
• The procedure is expected to be lengthy and / or the child is expected to be immobile for a long period of time

Refer to the procedure on procedural sedation in ambulatory areas for further information RCH Policies and Procedure: Procedural Sedation - Ward and Ambulatory Areas

During the procedure

14. Non-pharmacological and psychological strategies

• Distraction
• Deep breathing
• Guided Imagery
• Maintaining a calm environment
• Communicating during a procedure
  • Positive language
  • Promoting patient control
  • Step by step explanations
  • Visual schedules
• Use of the buzzy bee and ice
• Breastfeeding / EBM
• Procedural holding

Distraction

Distraction can provide patients with a positive alternative focus which can help to reduce perceptions of pain during an intervention [12]. Distraction should be engaging, interactive and suit the developmental level of the patient. Distraction is best done by one person in the room to help create a calm environment. 

Suggestions:

• Bubbles
• Singing or listening to a favourite song
• Exploring novelty toys
• Books with noisy buttons or find it books.
• Using technology such as phones, tablets or TV can be a motivating distraction for patients.  They may prefer familiar shows, songs or apps.
• Non-procedural talk and humour 
  

Notes:

• Some patients may want to watch the procedure, if that is their preference that is ok.
• Distraction is not meant to trick a patient. It is a tool to help patients cope with medical procedures or interventions.

Deep breathing

Deep breathing techniques can be used as a coping strategy to help a patient regulate their anxiety and perceptions of pain during an intervention [12, 13].

Increasing the supply of oxygen to the brain can reduce the sympathetic nervous system response (fight or flight) and help to calm anxiety by activating the parasympathetic nervous system (relaxation and calm) [14].

Suggestions:

• For younger patients blowing bubbles, blowing a pinwheel or leaning on a parent who is taking slow deep breaths can help prompt deep breathing
• Giving suggestions such as smelling a flower or pretending to blow out birthday candles can help prompt deep breathing
• Getting the patient to place a hand over their tummy and practice 4x4 breathing (inhaling deeply to the count of 4 and exhaling slowly to the count of 4).

Notes: 

These techniques will be more effective if the patient has had time to briefly practice these ideas before the intervention

Guided imagery

Guided imagery can be used and taught to patients to help them deal with a painful or anxiety provoking situation [15]. Guided imagery involves drawing a picture of a place in the patient’s mind that relaxes them. Guided imagery may be elaborate or a simple visualisation.

Suggestions:

• Storytelling
• Meditation
• Progressive muscle relaxation

Note:

These techniques will be more effective if the patient has had time to practice these ideas before the intervention.

Maintaining a calm environment

Procedures and the medical environments in which they occur can be frightening for paediatric patients. A quiet and low stimulus room will reduce the potential for the patient to become overwhelmed.

Suggestions:

• One voice: The person distracting or coaching the patient through the intervention should be the one voice heard through the procedure. 

Note:

The treatment room is recommended for procedures to help maintain the patient’s bed and room as a safe space. This is especially true for infants and toddlers who might otherwise begin to perceive a threat every time a staff member enters their room.

Communicating during a procedure

Positive language

The use of age-appropriate and positive language when supporting patients is integral in aiding coping and cooperation. Communication that creates negative expectations of the procedure will increase reported levels of pain [16].

Suggestions:

• Focus on the positive and use neutral developmentally appropriate language where possible. For example - saying “this may sting/ burn” prior to an IV insertion increases anticipatory anxiety and suggests pain (nocebo effect) [17]. Instead saying “Here comes a push. Let us know how it feels for you” allows the patient to have their own experience.
• Be honest but use language that is developmentally appropriate. For example – Instead of “It’s time for your needle” try “It’s time to get your body ready to have your medicine”.
• Avoid complex or unfamiliar medical terminology as patients may have difficulty interpreting unfamiliar medical words which may cause anxiety and cause worry. For example- Instead of “you need to have a CT to get an accurate diagnosis” you could say “we need to take some pictures to help us see how your body is going”.
• It’s important to acknowledge and validate the patient’s feelings (I can see this feels a bit tricky for you) rather than diminish (that doesn’t hurt, it’s not scary’).
• It’s ok for a patient to cry. This may be how the patient copes or may be a developmentally appropriate response. Consider stopping the procedure and consulting with the procedural team if this response appears beyond a normal coping response

Promoting patient control

Assigning the patient a role can help a patient feel in control and helps them build a sense of mastery. Give the patient-controlled choices to help engage them as active participants in their medical treatment [18]. For example:

• Instead of telling a patient what they need to do (‘be still’), assign them a role “your special job is to keep your arm as still as a statue”. 
  
• Let them choose: Would you like to watch or look away? 
• Create choice wherever there is opportunity to: Would you like to sit up in the chair by yourself or on mum’s lap? or Which arm would you like me to take your blood pressure on?
  
• Offering the patient a way to request a pause or a break in the procedure may help a patient regroup if they are starting to become distressed. “I think you might need a little break? Let’s count to 10 together (or set a timer on phone).”
  
• Identifying things that the patient has done well even if they have found the procedure difficult can help the patient reframe the experience and give them a takeaway to focus on next time. An example of this might be “I could see you tried hard to be still. Well done!”

Step by step explanation

Some patients may want a very simple step by step explanation about what is happening during the procedure. Asking a patient if they want to know what is happening or if they prefer to look at something else can help to give the patient control of how they might want to be involved in the procedure.

Visual schedules

Visual schedules are a set of pictures which show the steps of an activity or intervention. They can help break an intervention down into smaller achievable stages that the patient can see themselves progressing through, which may otherwise seem overwhelming and difficult to begin [19]. Visual schedules are frequently used with patients with autism spectrum disorder and developmental disabilities, but they may also be useful with many other children or CALD patients.

Suggestions:

Visual schedules could be used for many different interventions including nursing observations or IV access.

Note:

RCH Child Life Therapy have a license to use Boardmaker software to create visual schedules for common procedures

Use of the Buzzy and ice

Buzzy is a vibration device that can help to dull or eliminate the pain by confusing the body’s nerves and distracting away from a painful stimulus [20]. Buzzy is recommended to be used in combination with an ice pack if the patient can tolerate the cold sensation (Buzzy® Device PowerPoint Presentation).

Note:

Buzzy is best introduced to the patient prior to the intervention to see if the patient will tolerate the strong vibration sensation. 
Ice packs may also be used without Buzzy if a child prefers for interventions such as immunisations or injections if the patient has found this to be helpful. 

Breastfeeding, sucrose and EBM for procedural pain management

Breastfeeding is preferable when available as parent contact, especially skin to skin provides comfort.  Sucrose is safe and effective at reducing pain during procedures, such as heal lance. Although most effective in neonates less than 28 days, the RCH recommends use for infants up to 18 months. Sucrose is most effective when used in combination of supportive measures, such as swaddling and containment (refer to sucrose guideline). Although EBM is not as effective at reducing pain when compared to sucrose or breastfeeding, it can be considered as an alternative intervention. 

• RCH Nursing Guideline: Sucrose for procedural pain management in infants
• RCH Nursing Guideline: Breastfeeding support and promotion
  

Procedural holding

Procedural holding or ‘Positioning for comfort’ promotes the use of upright positioning and close contact to the parent/guardian. Positioning for comfort facilitates safe access to the part of the body required for the medical procedure without removing the child’s right to freedom of movement. 

Swaddling and facilitated tucking for young infants (0-3 months) may provide comfort [21]. For infants older than 3 months more upright positioning and close contact with parent/carer is recommended.
Sitting upright during a procedure has been demonstrated to reduce fear and distress during medical procedures [3] and enhances the patient’s sense of control over the medical procedure.  The patient can engage in distraction, monitor the progress of the procedure or look away.

Suggestions:

• Encouraging parents to include positive touch during a procedural hold may help build comfort for the patient, this may include stroking, hugging, massage
  

Notes:

• The forcible restraint of children during medical procedures is not recommended at RCH. See RCH Policies and Procedure: Restrictive Interventions
  
• Restraint often causes distress and may effect trust for future interventions [22, 23]
  
• Positioning for comfort also helps to provide minimal handling during health care interventions - https://www.rch.org.au/clinicalguide/guideline_index/Minimal_handling/
  
• Children are human beings and individuals with their own rights https://www.ohchr.org/en/professionalinterest/pages/crc.aspx 
  

When to stop a procedure (Refer to “Plan B” in before section)

• Stop the procedure if the intervention is not urgent and you feel the patient is unable to cooperate and/ or appears too distressed.
  
• Consult with parents or caregivers and discuss other options to help the child settle and potentially proceed. 
  

After the procedure

15. Promote recovery and resilience

Children’s memories of painful experiences are strong predictors of subsequent reports of pain intensity [24]. Therefore, it is integral that any medical procedure is ended in a positive manner for the patient by:

• Reducing the child’s distress before leaving the procedural setting can help to reduce negative associations with treatment spaces. Offer the patient an opportunity for cuddles with the caregiver, provide positive reinforcement of what went well during the procedure and asking them to make choices about what they are doing next may help to promote recovery.
• ‘Bookending’ (positive experiences before and after) a procedure can help to reduce negative associations with medical interventions. 

16. Debrief and follow up with patient and their family

• Get feedback - Find out what worked well and what didn’t
• Ask if there is anything the child would like to try differently next time

17. Documentation

• Document the child’s response to the medical procedure and procedural preferences to help inform subsequent interventions
  • Even if it didn’t go to plan so it can be planned better next time
  •  Patients should have their procedural support plans updated regularly to reflect changes in coping
• Include the following when documenting the procedure:
  • How the procedure went?
  • Was it successful? How many attempts were made?
    • Positioning / restraint used
    • Who was present in the room and their roles
    • Where was the procedure conducted?
    • Forms of non – pharmacological strategies used
    • Detail any specific parent or patient requests
    • Utilise Sedation narrator if warranted or appropriate

• Consider using smart phrases to document this to ensure that all relevant information is included for future procedures

Evidence Table

The evidence table for this procedure management nursing guideline can be accessed here. 

References

• Lewrick, J.L. (2016). Minimizing pediatric healthcare-induced anxiety and trauma. World Journal of Clinical Pediatrics, 5(2); 143-150.
• Young, K., Pediatric Procedural Pain. Annals of Emergency Medicine, 2005. 45(2): p. 160-171.
• Taddio, A., et al., (2015). Reducing pain during vaccine injections: clinical practice guideline. Canadian Medical Association Journal.
• Twycross, A., S. Dowden, and E. Bruce, Managing pain in children: a clinical guide. 2009, Wiley-Blackwell: United Kingdom.
• Loeffen, et al. (2020). Reducing pain and distress related to needle procedures in children with cancer: A clinical practice guideline. European Journal of Cancer, 131, 53–67.
• Srouji, R., S. Ratnapalan, and S. Schneeweiss, Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics, 2010. 2010: p. 11.
• Young, K., Pediatric Procedural Pain. Annals of Emergency Medicine, 2005. 45(2): p. 160-171.
• Krauss B, & Green SM. (2000). Primary care. Sedation and analgesia for procedures in children. New England Journal of Medicine, 342(13), 938–945.
• Pillai Riddell, R., et al., Nonpharmacological management of procedural pain in infants and young children: an abridged Cochrane review. Pain Res Manag, 2011. 16(5): p. 321-30.
• Boles, J. (2013). "Speaking up for children undergoing procedures: the ONE VOICE approach." Pediatric Nursing 39(5): 257-259).
• Fanurik, Debra & Schmitz, Michael & Reach, Kelle & Haynes, Katherine & Leatherman, Isabel. (2000). Hospital Room or Treatment Room for Pediatric Inpatient Procedures: Which Location Do Parents and Children Prefer?. Pain Research and Management. 5. 148-156. 
• Birnie  KA, Noel  M, Chambers  CT, Uman  LS, Parker  JA. Psychological interventions for needle‐related procedural pain and distress in children and adolescents. Cochrane Database of Systematic Reviews 2018, Issue 10.
• Bagheriyan, S., Borhani, F., Abbaszadeh, A., & Ranjbar, H. (2011). The effects of regular breathing exercise and making bubbles on the pain of catheter insertion in school age children. Iranian journal of nursing and midwifery research, 16(2), 174–180.
• Brown, Richard & Gerbarg, Patricia & Muench, Fred. (2013). Breathing Practices for Treatment of Psychiatric and Stress-Related Medical Conditions. The Psychiatric clinics of North America. 36. 121-40. 
• Vagnoli, A Bettini, E Amore, S De Masi, A Messeri, (2019). Relaxation-guided imagery reduces perioperative anxiety and pain in children: a randomized study. European journal of pediatrics, 2019, 178(6), 913‐921).
• Fusco N, Bernard F, Roelants F, Watremez C, Musellec H, Laviolle B, Beloeil H, (2020). Hypnosis and communication reduce pain and anxiety in peripheral intravenous cannulation: effect of Language and Confusion on Pain During Peripheral Intravenous Catheterization (KTHYPE), a multicentre randomised trial. British journal of anaesthesia, 2020, 124(3), 292
• M, Sometti D, Tinazzi M & Fiorio M. (2019). When words hurt: Verbal suggestion prevails over conditioning in inducing the motor nocebo effect. European Journal of Neuroscience, 50, 3311-3326.).
• Harrison, C. 2004. Treatment decisions regarding infants, children and adolescents. Paediatrics & child health, 9(2), 99–114. 
• Mesibov GB, Browder DM, Kirkland C. Using Individualized Schedules as a Component of Positive Behavioral Support for Students with Developmental Disabilities. Journal of Positive Behavior Interventions. 2002;4(2):73-79).
• Taddio, A. B. M. P., et al. (2015). "Procedural and Physical Interventions for Vaccine Injections: Systematic Review of Randomized Controlled Trials and Quasi-Randomized Controlled Trials." Clinical Journal of Pain 31 Supplement (10S): S20-S37).
• Pillai Riddell RR, Racine NM, Turcotte K, et al. 2015. Non-pharmacological management of infant and young child procedural pain. Cochrane Database Syst Rev. 2011;2015 (10).
• McGrath et al (2002).Holding the child down" for treatment in paediatric haematology: the ethical, legal and practice implications. Journal of law and medicine 10(1):84-96.
• Snyder BS. 2004. Preventing treatment interference: Nurses’ and parents’ intervention strategies. Pediatric Nursing 30: 31–40.
• Noel, M., et al., The influence of children's pain memories on subsequent pain experience. Pain, 2012. 153(8): p. 1563-1572.

Please remember to  read the disclaimer. 

The development of this nursing guideline was coordinated by Charmaine Cini, CSN, Koala Wards, and approved by the Nursing Clinical Effectiveness Committee. Updated December 2020.