Conference Reviews

Procedural Distress in Children: Why should we care? What should we do?

Reviewed by Anne Stormorken, MD

Dr. Jill Chorney, a pediatric psychologist with extensive clinical and research expertise in the area of pain in childhood, set the tone for the conference introducing the audience to the close relationship between pain, fear and anxiety in children. The prevalence of pain related to immunizations, trauma, surgery and disease is not insignificant and may predispose children to experiencing poorly managed pain in early childhood.  This is often due to poorly documented pain in the hospital as well as a reluctance on the part of parents to give their children analgesic medication upon discharge.

The intersect of pain and fear and anxiety is distress, and in children who are either preverbal or without the cognitive ability to verbalize their feelings, distinguishing the etiology of distress is often challenging.  This distress may also be related to past experience not only by the patient but also on the part of the parent. The summation of these fears and expectations may overwhelm the current experience and therefore managing the emotional aspect may positively impact future interactions with medical personnel. Successful mitigation of negative experiences associated with poorly managed pain will facilitate development of self-efficacy, coping skills and resilience with improved relationships with medical staff.

Steps to achieve these goals include defining and addressing patient and family expectations and managing their distress peri-operatively. This can be attained by following the 4”P’s” of Patient and Family Centered Care (PFCC).

  1. Providing information – this should be in a format and with content commensurate with developmental stage of child, procedure type and educational level of parent as well as preferred media platform. Examples included videos, telephone coaching and web-based material.
  2. Patient and family preparation – in a similar fashion, preparation for specific procedures can be facilitated by accessing material that is interactive and addresses patient and family expectations. Web-based information presents an opportunity to reach both patients and families in a timely fashion and facilitate advance planning.  Identifying and incorporating adaptive behavior such as non-procedural language, humor, parental presence and elements of patient control optimizes preparation.
  3. Parental prescence and participation in decision making and planning requires proactive involvement by medical staff to address concerns and meet the needs of both patient and family. Providing this information via video tours and web-based interactive material facilitates preparation and mitigates pre-procedural fears and anxiety. Distraction and parental presence at induction decrease fear and anxiety and proportionally decrease post-procedural pain.
  4. Post-discharge follow-up entails provision of clear and accurate instructions for identifying and managing expected pain, as well as contacting medical personnel in case of increasing and disproportionate pain.  Verbal instruction should be supported by printed material and corroborated by information available on the institutional website.

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