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Never alone again

Most children will have to endure, during their childhood, a medical test, an examination, some kind of medical procedure for diagnostic purposes, such as a taking a blood sample or having an intravenous catheter, taking a urine sample, stitches, an X-ray, an ultrasound or another examination for diagnosis, a minor surgery operation with the use of local anesthesia, taking urine with the use of a urinary catheter or a needle, injection of drugs, a lumbar puncture etc. These actions might take place into a delivery room, a hospital, a private clinic. Even a simple examination to a pediatrician’s office can be a painful and traumatic experience for a child, and that is why parents and health practitioners need to do whatever is possible in order to ease the child’s pain during these procedures. Children, young and older, able to speak or not, have the right to face the least possible pain and discomfort during examinations and medical tests.

Parents should be informed and prepared for this kind of situations and to know the ways to reduce a child’s worries, pain and anxiety. An adult’s usual reaction is to promise to his child that a test or a venous puncture is not going to hurt or it will hurt “a little bit”. Children mention, though, that this tactic is not helping, on the contrary, it usually makes things worse. Parents can adopt the following tactics in order to ease their child’s fear and anxiety:

What do we say to a child asking: “Is it going to hurt?” . We should always respond sincerely and not by telling lies. On the other hand, we have to make our answer more diplomatic and bearable for the child, so instead of telling straightforward “ yes, it’s going to hurt” we can better reply “ some children say it does hurt somehow, some other don’t bother that much”.

Pain is a really subjective situation. Its intensity can be reduced with attention’s distraction and relaxation techniques, special breathing techniques or with rewards. Many times, young children use the word “pain” for different kind of situations, as when they are afraid, when they feel anxiety and discomfort. Parents should be aware of this, so that they don’t get surprised when their child says it hurts, for example, when the doctor touches the stethoscope on his skin and not to deny this child’s remark.

Before the examination, it is important that parents and child know the reason why the examination is being done and what will be the benefit of it. Also we should describe to the child pretty much the place where it is going to be done, what will happen, what he will feel. We may have to explain over and over to the child the procedure and to answer any questions that he may have. These explanations should be made a couple of days before the examination as older the child gets (at school age and adolescence), while when the child is younger  our explanations should be made right before the procedure. Often, it helps, before the examination or after the end of it, that parents play with the child making a recreation of the procedure, with role playing and shifting roles, with the child being the doctor and the mother the patient etc.

During the examination, parents should be encouraged to be present and be with their child, regardless of age. Health practitioners should encourage the presence of parents during the examination and should properly guide the mother and/or the father on how to help the child. The massive majority of tests can be made and should be made with the child being in physical contact with his parents : in their arms or at least by holding hands. Breastfeeding during a painful for a child procedure or right afterwards has been proven to reduce a child’s pain and cries and should be encouraged by health practitioners. Vaccination for example can be done with the baby in his mother’s arms and/ or at breast.

Besides the breast, some ideas to achieve distraction for small infants , under 6 months old , are:

  • Caressing the child’s face or a parent’s smooth rhythmical tapping.
  • Infant toys such as rattles, little bells etc.
  • Parent’s singing to the baby something he’s used to and likes .
  • Swaddling the baby, if this calms him down, for example when taking a blood sample from one hand we restrict the other one and the legs.
  • Giving sucrose during the painful stimulus.
  • Pacifier.

 

For older infants and toddlers:

  • Holding the child if he is seated and not lying down, in the parent’s arms.
  • Attention distraction with bubbles.
  • Toys, especially with buttons that make noise.
  • Toys with lights and buttons.
  • Small books.
  • Singing the child’s favorite songs.
  • Music on ipod.
  • Videos with appropriate , for the child’s age , content on youtube.

 

 

For older children:

  • Deep breaths, like if they are blowing something to go away: deep breath from the nose and strong expiry blow.
  • Counting
  • Bubbles
  • A small book, especially with noises and numbers.
  • Favorite dvd on tv or an electronic game or song on ipod or youtube
  • Parent motivating the child to think something that he loves, such as a good recent experience, holidays, the sea, a favorite sport. He may turn it into a guessing game, ex. the parent could guess by asking questions what the child has in mind.
  • We ask the child whether he wants to watch and follow the procedure or he rather prefers to have his attention elsewhere on another activity.
  • We say to an older child to make a fist on his right hand, at the moment that, ex. an injection is being done on the left hand. This helps with the relaxation of the muscles and as a result reduces pain.

For teenagers:

  • As mentioned above, additionally we must ask the teenager whether he desires his parent’s presence or not and if so, in what way, hugging, holding hands, no physical contact etc.
  • Relaxation techniques, as grabbing  the other hand and deep slow breathing.
  • We encourage the teenager to think something special, holidays etc. like in younger children.
  • We talk to the child in an informal and intimate way, with a sense of humor, in order to break the ice.
  • Electronic game, ipod, dvd etc.

 

In general, during the procedure, it is important that the child is feeling that he maintains some sort of control over at least minor options : where does he want to sit, how does he want to sit, does he want to look at the needle or not, how does he want his attention to be distracted?

It is important during a painful examination that parents stay with their child. Even if, after appropriate encouragement and preparation, a mother feels that she cannot be present, it is important to encourage the presence of another person that the child is familiar with.

During the procedure, the parent should maintain physical contact with the child by hugging him, holding hands etc. He reminds to the child to use an attention distraction method that they previously talked about, ie “ It will get easier if you do the breathing we talked about” or “ tell me about your favorite beach “. The parent should understand if the child wants to know about the procedure’s progress. Often it does not help to say to the child that it will be over soon but it is better to totally distract his attention.

If the child cries during the examination it is important that parents and health practitioners make him feel with their words that it is ok to cry, it’s not a bad thing. On the contrary, it’s a mistake to say to the child that he’s acting like a “little baby”, to talk in a negative way about the way he is expressing his anxiety or to refer to him with negative characterizations and labels etc.

Taking from home favorite objects or something to keep him busy, parent and child while waiting, can reduce the agony and fear. Parents during the examination shouldn’t have their attention focused on the procedure’s successful or not outcome but exclusively on comforting their child.

Medicine and substances that can reduce a child’s pain during an examination, injection etc. are ointments for local anesthesia which it would be good to use as a choice even for young babies and premature babies, that can definitely feel the pain and have traumatic experiences from it.

Another tactic, is the use of sucrose ( sugar ) during a painful examination to an infant under 18 months old, if breastfeeding is no longer an option. Sucrose is being used successfully with premature babies in intensive care units.

Mild sedation or mild anesthesia is used in short surgical operations and procedures that require relevant immobility, such as magnetic tomography, in a more controlled and hospital environment.

For more major surgical operations (stitches, bone fracture repair, change of trauma bandages, lumbar puncture) a painkiller (paracetamol and/or a anti-inflammatory) could be administered to the child.

Pacifier/reward in the end might work, but not in the form of a candy/ sweet, rather in the form of a promise for a walk, a game, a sticker etc.

 

After the examination, parents should have contemplated to have enough time to calm the child. They shouldn’t be in a hurry to leave the doctor’s office. They stay with the child until he is calm, they are willing to hug the child whenever and for as long as it is needed, they offer food or the mother breastfeeds her infant. Parents should talk in a positive way about the things that he did right or for the things that made the examination easier. Even if the child continues to be upset, it is good to find something positive to mention. This helps the child to feel that he made it, he did well. We praise the child about how well he cooperated. Parents and health practitioners can give the child a simple reward, as a sticker. Candies should never be used as a reward. Also, it is not a good idea for the parent to promise to the child a gift or a game’s purchase at the stores, but on the contrary , the reward shouldn’t be so much in a material way as much as in a moral and psychological way.

Parents have an important part to help children know how to overcome life’s difficulties, in which medical examinations and medical care are included. In difficult times no one can help a child as his parent and no one can know and advocate for the child as his parent. Health practitioners have the duty to encourage instead of discourage the smoother outcome of children’s painful experiences, so they should accept the parent’s presence with the child. We should all help to end this inconsolable pain with a terrified young child in a room full of doctors’ shirts and a terrified mother outside the closed door. These old-fashioned images, that leave their mark on sensitive souls forever, must end in our country, as children’s traumatic experiences in Greek hospitals and private clinics, without the comfort of their parent’s presence, must end too.

 

Stelios Papaventsis  MRCPCH DCH IBCLC 2012

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3 Responses to “Never alone again”

  1. Elpida says:

    Πολύ ωραίο άρθρο. Διαφωνώ λίγο με τη σουκρόζη αλλά θεωρώ πολύ θετικό το γενικό μήνυμα. Ο θηλασμός και σε αυτές τις περιπτώσεις βοηθάει πάρα πολύ. Βέβαια λίγοι επαγγελματίες υγείας ή/και γονείς έχουν τη γνώση και την υπομονή να το ακολουθήσουν.

  2. Μαίρη Τσιτσιά says:

    καλησπέρα σας . παρακαλώ πολύ , θα ήθελα να γραφτώ στην ομάδα ” ποτέ πια μόνα ” αλλά δεν ξέρω πού πρέπει να κάνω το αίτημα . Θα μπορέσετε να με βοηθήσετε ? ευχαριστώ

  3. Κάλλη says:

    Το link της ομάδας “ποτέ πια μόνα” στο f/b είναι αυτό: https://www.facebook.com/groups/225537920935502/

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