2. Aims To encourage health professionals to use evidence based techniques to support children (and their carer/s) psychologically through painful or distressing procedures. To provide references to enhance practice.

3. 1.To understand the importance of planning for painful or distressing procedures when working with children 2.To consider developmental stages of each child 3.To be aware of correct positioning and distraction techniques used in paediatric practice Learning Objectives

4. What we’ll cover… Planning the procedure Medications to consider pre–procedure Positioning for comfort Age appropriate distraction techniques

5. Plan procedure One Voice’General approach ‘One Voice’ Place Time Staff involvement ; medical, nursing, Child Life Therapist, parent or carer Medications +/- fasting times Equipment … think about it …

6. One voice should be heard during procedures Need for parent/carer involvement Educate parent/carer before procedure Validate child with words Offer position of comfort Individualise your approach Choose appropriate distraction techniques Eliminate unnecessary people from the room ‘One Voice’ Approach

7. ‘Emla’ / topical anaesthetic agent Sucrose Oral premedication; analgesia, midazolam, ketamine Nitrous oxide Medications to Consider

8. Depends on procedure Sitting upright in a ‘hugging hold’ for IV cannula or bloods Lying on side for LP Swaddled/ wrapped (0-3 months) Correct Positioning; promoting comfort

9. Cuddling/ wrapping for 0-3 month infants promotes self caring and sense of security also prevents limbs from moving if distressed Offer breast feed / sucrose/ non nutritive sucking (dummy) to help minimise stress Infants

10. May like to sit upright on a parent’s lap facing the parent or facing the proceduralist whilst being distracted with bubbles, songs, toy or interactive book Hold in a ‘hugging hold’ to contain torso and limbs as parent soothes the child Parent’s free hand stabilises the limb being cannulated Toddlers

11. Give choices i.e., which hand can we take blood from today ? Sit upright in a ‘hugging hold’ facing out but head turned away from the procedure Use interactive distraction as much as possible Older Children

14. Stresses-parent separation, stranger anxiety involve a parent or caregiver who can comfort the child comfort positioning talking gently before touching; use dummy, consider oral sucrose for non-nutritive sucking wrap/ swaddle, rhythmic patting, toy Infant

15. Separation anxiety, scared of injury or pain family member support/ (stranger danger) comfort positioning give sensory information, talk before touching provide an alternative focus and involve child as much as possible play; favourite games, stories, songs, rhymes, own toys 1 – 3 years

16. 3 – 5 years Separation, fear of blood and needles, perceived punishment, misconception of words caregiver support/(stranger danger) gentle concrete preparation/ social stories give the child choices/ a perceived role/participation use of play and distraction; iPad, bubbles, counting, own toys validate throughout involve Child Life Therapy

17. Loss of control, pain, altered body image explanations and participation/control where possible be perceptive to child’s cues give structure use of guided imagery, relaxation/ controlled breathing, hobbies and interests validate appropriately 6 – 11 years

18. Loss of body image, control, functions, peer acceptance, death… include in decision making and give choices where possible honest explanations about procedure (photos to explain) coping strategies; music, relaxation, focused breathing, iPad other teens or caregiver respect privacy Teenagers

19. Establish rapport A large part of communication is non-verbal; get down to their level use eye contact Speak in a clear and calm voice Age related distraction techniques

20. Encourage an alternative focus stories, books, songs, music, nursery rhymes Guided imagery/ relaxation deep breathing, blowing bubbles, coaching child’s own interests TV/ video iPod, iPad Toys/ puppets Age related distraction techniques

21. Finally stay calm be sensitive to child’s cues and refocus as needed reinforce coping strategies validate – ‘you’re doing really well’ / ‘it’s ok to cry’

22. Association of Paediatric Anaesthetists of Great Britain and Ireland. Good Practice in Postoperative and Procedural Pain Management 2 nd Edition, 2012. Paediatric Anaesthesia, 22 (Suppl.1),1-79. Breiner, Sandra M. Preparation of the Paediatric Patient for Invasive Procedures. Journal of Infusion Nursing.2009;32(5): 252-256. Crain, William. Theories of Development: Concepts and Applications. Prentice Hall, New Jersey, 2000 (217-294). Fox, S (2012) Paediatric Pain and Distress in the ED; New Management Tips. Paediatrics.130e1391- e1405. RCH Melbourne factsheet; Infant positioning, promoting comfort, 2013 http://www.onevoice4kids.com/index.html Wolheiter, Karen A &Dahlquist, Lynnda M. Interactive versus Passive Distraction for Acute Pain Management in Young Children. J Paediatric Psychology.2013;38(2): 202-212. Resources

23. Sucrose Guidelines http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2006- 8241.pdf Procedural sedation guidelines http://chw.schn.health.nsw.gov.au/o/documents/policies/guidelines/2011- 9017.pdf Thank you to Fairfield RSL for sponsoring the ‘Being Kind to Kids’ project. Resources