1. Sampson, Jan DNP, RN
  2. Allbright, Renee BSN, MSN, RN

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As a pediatric nurse, I'm committed to decreasing procedural pain and anxiety in my young patients. What evidence-based nonpharmacologic interventions are most effective?-L.K., N.Y.


Jan Sampson, DNP, RN, and Renee Allbright, BSN, MSN, RN, respond: Even after decades of research, pediatric patients continue to experience unnecessary pain during clinical procedures.1 However, research has shown that various simple, nonpharmacologic techniques, such as distraction, pet therapy, and play therapy, can lessen pain in children.


Techniques should be chosen based on both the child's age and developmental stage, which may differ from the child's chronologic age. Developmentally appropriate techniques help divert the child's focus from potentially painful procedures such as laceration repair or dressing changes.


Examples of age-appropriate distraction techniques include the following.


* Infants respond well to the soothing effect of swaddling because it helps to satisfy an infant's developmental need to be held. Nonnutritive sucking in infants has also been shown to decrease their pain.1


* Safe and effective distraction techniques for toddlers can be as simple as blowing bubbles or playing peek-a-boo.1


* Preschoolers can be distracted with animated cartoons or games.


* School-aged children and adolescents may respond well to audiovisual distractions, such as tablets, games, and virtual reality goggles.



Pet therapy can also be used to distract pediatric patients in stressful or painful situations. Studies have shown that children who interact with therapy pets-typically dogs-display improved coping ability and decreased levels of anxiety.2 Follow your hospital's policies and procedures for pet therapy and rule out any contraindications. For example, check patients for pet allergies and make sure the child and family want to interact with animals and aren't afraid of the therapy animal. Remember that pets on a raw food diet can't interact with patients due to the potential for bacterial contamination.3


Ice or vibration therapy can also help distract patients during painful procedures. Pediatric pain relief devices shaped like an animal or insect, which are commercially available, are visually appealing to children. Placed on their skin, they provide a cooling or vibration effect that helps numb injection pain.4


Many pediatric hospitals employ Child Life Specialists, who support pediatric patients by developing individualized, age-appropriate, and play-based learning activities, but nurses can also teach children through play.5 This approach allows children to touch equipment, understand procedures, or feel more comfortable asking questions, depending on their developmental level.5 Typically, play-based learning involves dolls or teddy bears in scenarios similar to the child's anticipated healthcare-related experience. For example, a preschool or school-aged child is encouraged to "give the teddy bear a shot." As a result, procedures become less threatening as the child gains control and mastery of each situation based on familiarity and discovery in a nonthreatening, play-based experience.6


Creating a child-friendly environment can provide comfort, diversion, and familiarity to patients and families. Establish a child decor throughout the facility, from the front door to the treatment room. Using wagons for child transportation or ride-on cars add to the child-friendly environment. Also create "safe zones" for children where they can feel safe from painful or distressing procedures. For example, make all hospital playrooms off-limits for any procedures, even vital sign assessment.


During painful or tense situations, use the "one voice" philosophy to avoid escalation of stress and facilitate the effectiveness of distraction techniques. Children can become overwhelmed by multiple voices when parents, nurses, and other care providers simultaneously attempt to comfort them. This typically increases anxiety and can make the child confused and uncertain about whom to listen to. The "one voice" approach designates one person to be responsible for providing the comforting focus and support for the child during a procedure.7


Family-centered care is key, so involve families in supporting the patient. A parent's reactions to the child's stress and anxiety during hospitalization and medical procedures often have a major impact on the child's ability to cope.8 Simple instructions, such as where to stand or how to place the child in a therapeutic hold, may help improve coping for both caregivers and children.


Assess the caregiver's own coping and stress level, because not all caregivers are appropriate for playing a supportive role during painful procedures. Emotional support and education can empower the entire family to cope more effectively throughout the child's treatment and hospitalization.9




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2. Goddard AT, Gilmer MJ. The role and impact of animals with pediatric patients. Pediatr Nurs. 2015;41(2):65-71. [Context Link]


3. American Veterinary Medical Association. Raw or undercooked animal-source protein in cat and dog diets. 2017. [Context Link]


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6. Grissom S, Boles J, Bailey K, et al Play-based procedural preparation and support intervention for cranial radiation. Support Care Cancer. 2016;24(6):2421-2427. [Context Link]


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8. Valizadeh F, Ahmadi F, Zarea K. Neglect of postoperative pain management in children: a qualitative study based on the experiences of parents. J Pediatr Nurs. 2016;31(4):439-448. [Context Link]


9. Tyson ME, Bohl DD, Blickman JG. A randomized controlled trial: child life services in pediatric imaging. Pediatr Radiol. 2014;44(11):1426-1432. [Context Link]