Managing the Frightened Child

How to meet coping strategies and preferences of children during invasive medical procedures: perspectives of healthcare professionals

Children with negative procedural experiences have an increased risk of fear and distress, with psychological consequences for subsequent procedures and future healthcare behaviors. Gaining control and feeling trust are important aspects for children to decrease fear. To enable professionals providing personal care during medical procedures, a systematic, evidence-based approach that supports children in expressing their preferences is needed. This study will gain insight into the experiences and needs of professionals involved in small invasive medical procedures to meet the coping strategies and preferences of children undergoing these procedures. A qualitative design was used to gain insight into professionals' perspectives. Data were collected through online focus groups with various professionals involved in medical procedures, such as anesthetists, laboratory staff, nurses, and pediatricians. Five interdisciplinary focus groups, with a total of 32 participants, were held. One overarching theme was revealed: "Balancing between different actors within the context of the hospital." Professionals reported they had to deal with different actors during a medical procedure: the child, the parent, the colleague, and themselves. Each actor had its own interests. They were aware of the child and parents' priority to gain control and feel trust. Nevertheless, they perceive organizational and personal aspects that hinder addressing these needs.

CONCLUSION

To provide personalized care, professionals experience balancing between the needs and interests of diverse actors during medical procedures. The findings underscore the importance of a policy supporting HCPs in integrating patient-centered care into practice through practical tools and training initiatives such as scenario training.

WHAT IS KNOWN

• Unresolved pain and stress arising from medical procedures can have significant short- and long-term impacts on children. Empowering children to gain control and fostering a sense of trust are crucial factors in reducing fear associated with medical procedures. • Children and parents expect to receive child-tailored care from professionals including respect for their own, unique needs, and boundaries. Professionals should build trustful relationships and provide appropriately tailored autonomy around medical procedures.

WHAT IS NEW

• Healthcare professionals vary in their awareness of children's needs during a medical procedure. Beside this, the organizational dynamics of the hospital, along with the presence of actors such as the child, parent, colleague, and oneself, collectively influence the conduct of medical procedures. • Providing person-centered care during medical procedures can present challenges. The results highlight the significance of a policy to assist healthcare professionals in incorporating patient-centered care into their practice through practical tools and a culture of self-reflections regarding patient-centered values.

Establishing trust with children

Trust forms the bedrock of the doctor-patient relationship. While establishing trust is a foundational skill for healthcare providers who care for children, there is no systematic approach to teaching this skill set, nor is there formal training during medical school or residency. Traditionally, these skills have been taught by example, in an unstructured and ad hoc manner, with trainees picking it up along the way by observing and modeling their instructors. Here, we define and examine the elements of establishing trust and describe a methodology for establishing trust and managing a child's emotional state during medical encounters.

Virtual reality hypnosis for needle-related procedural pain and fear management in children: a non-inferiority randomized trial

Needle-related procedures can cause pain and fear in children and may lead to avoidance of future medical care. The aim of this study is to investigate whether virtual reality hypnosis (VRH) is non-inferior to medical hypnosis (MH) by a trained healthcare provider in reducing pain in children. This non-inferiority randomized trial was conducted at a teaching hospital in the Netherlands. Children aged 6 to 18 years were randomized to treatment with VRH or MH. The primary outcome was self-reported pain, using the Wong-Baker FACES Scale (WBFS) with the non-inferiority margin defined as a difference of 1.5 points. Secondary outcomes included observer-reported pain (Numeric Rating Scale), fear (scored by children and observers with the Children's Fear Scale), blood pressure, heart rate, treatment satisfaction, and adverse effects. We randomized 138 children to VRH or MH treatment and included 114 children in the analyses (VRH n = 60, MH n = 54). We found non-inferiority for VRH compared to MH on patient-reported pain (mean difference =  - 0.17, 95%CI - 1.01;0.66). Secondary outcomes were comparable between VRH and MH groups. Both treatments scored high on patient satisfaction (VRH median = 9.0, MH median = 10.0, p = 0.512).

CONCLUSION

VRH may be an effective and safe treatment option besides MH for reducing patient-reported pain in children during a needle-related procedure. VRH was non-inferior to MH in patient-reported fear and both treatments were comparable in terms of patient-reported fear, observer-reported pain and fear, physical distress, and patient satisfaction.

TRIAL REGISTRATION

ICTRP https://trialsearch.who.int/ , trial ID NL9385; date registered: 03/04/2021.

WHAT IS KNOWN

• Medical hypnosis is effective in reducing procedural distress in children during needle-related procedures. • Virtual reality (VR) is an audiovisual electronic device that guides users into an immersive three-dimensional environment.

WHAT IS NEW

• This study shows that VR hypnosis is non-inferior to medical hypnosis in reducing pain and fear in children undergoing a needle-related procedure. • Both VR hypnosis and medical hypnosis were appreciated highly by children to distract them during needle-related procedures.

Factors Associated With Low Procedural Pain Scores Among 1- to 5-Year-Old Patients Undergoing Facial Laceration Repair

OBJECTIVES

Our objectives were to quantify pain experienced by young children undergoing facial laceration repair and identify factors associated with low procedural pain scores.

METHODS

We conducted a prospective cohort study of children's distress among a convenience sample of children aged 1 to 5 years undergoing facial or scalp laceration repair in 2 pediatric emergency departments. We reviewed video recordings and documented pain scores at 15-second intervals using the Face, Leg, Activity, Cry, Consolability-Revised (FLACC-r) scale. We dichotomized FLACC-r into low/high scores (≤3 and >3) to evaluate practice variables.

RESULTS

We included 11,474 FLACC-r observations from 258 procedures in the analysis. Two-thirds of 3- to 5-year-olds completed their laceration repair without the use of restraint, sedation, or anxiolytics. Mean distress scores were low (≤2.5 out of 10) across all procedure phases for 2- to 5-year-old patients. One-year-old patients experienced significantly more distress than their older counterparts (mean ≤4.2 out of 10). Odds of having low FLACC scores (≤3) were greater for patients with an expert clinician (adjusted odds ratio [aOR]: 1.72; 95% confidence interval [CI], 1.05-2.84). Wound infiltration (aOR, 0.35; 95% CI, 0.13-0.93), patient observation of a needle (aOR, 0.21; 95% CI, 0.14-0.33), and restraint (aOR, 0.04; 95% CI, 0.02-0.06) were negatively associated with low FLACC score.

CONCLUSION

The majority of 3- to 5-year-old patients were able to undergo facial laceration repair without restraint, sedation, or anxiolytics and with low mean distress scores. Our findings suggest that children's risk of experiencing moderate and severe distress during facial and scalp laceration repair may be reduced by prioritizing wound closure by expert-level clinicians, ensuring effective lidocaine-epinephrine-tetracaine application, avoiding restraint, and concealing needles from patient view.