Administering treatments and procedures to pediatric patients can be difficult both for the healthcare provider and the patient. As a result, some physicians have developed methods to overcome challenges and have dedicated staff to address problematic cases.
Kyla Driest, MD, MEd, assistant professor of pediatrics, Division of Rheumatology at Nationwide Children’s Hospital, Columbus, Ohio, finds that some children experience anxiety when getting an IV, especially if their veins have been physically difficult to access in the past. Likewise, joint injections can be nerve wracking.
“Although many older kids do well with joint injections, younger children or those with needle phobias may need sedation,” Dr. Driest says.
The majority of Nationwide Children’s Hospital patients receive their infusions at a pediatric infusion center from nurses trained in pediatrics. “These nurses are often better equipped to treat children and decrease needle-associated anxiety,” Dr. Driest says. Some of their methods include tailoring IV placements to the patient’s preferences when possible, employing distraction and therapeutic holding techniques, and providing reassurance and positive reinforcement, which includes establishing rapport with patients.
“They also have access to an IV team to help with more challenging IV placements,” she says.
Dr. Driest finds positive reinforcement works well in a variety of situations, including administering injectable medications. “I often instruct families to associate the medication with something the child enjoys, such as ice cream, a favorite blanket, a stuffed animal or music,” she says. “This [association] means they either give the medication while the child has the item [e.g., teddy bear, blanket] or afterward as a treat [e.g., ice cream].”
For some children, numbing creams may be helpful when providers administer infusions and injections. Typically, creams must be left on for 15–30 minutes before taking full effect. “With some particularly anxious children, waiting can heighten the stress associated with the treatment,” Dr. Driest says. “Icing may be a better option for these children, [because] it removes the waiting time.”
Ankur Kamdar, MD, a pediatric rheumatologist at UTHealth/University of Texas Houston Medical School, has found that giving infusions are often difficult for several reasons. For children who require chronic infusions or laboratory draws, sometimes achieving access for IV infusions can be difficult. Consequently, many parents and patients opt for a port-a-cath, a catheter threaded through larger veins. This approach makes it easier to gain access to veins. In addition, it is under the skin, so it isn’t visible.
However, a port-a-cath is a surgical procedure that can be painful. It may become infected, which may require antibiotics and removal. In addition, in a growing child, the port-a-cath may move, making access more difficult. Revision or replacement may be required.
For infusions, imaging and other procedures, UTHealth/University of Texas Houston Medical School has child life specialists on staff. “These healthcare professionals help families and patients cope with hospitalization and procedures,” Dr. Kamdar says. “They are well versed in a number of techniques to reduce anxiety and pain.”
Relaxation techniques and distraction techniques can be helpful in calming a child, Dr. Kamdar says. The technique depends on the patient’s age and maturity. Example: A toddler may find blowing, reading their favorite book, spinning pinwheels or playing music helpful. An older child may find playing games or cartoons on an iPad, using magic wands or telling a story helpful.
At Home
For at-home medication regimens, Kelly Wise, PharmD, a clinical pharmacist, Division of Rheumatology, Nationwide Children’s Hospital, notes it’s important for families to create a routine. Give injections in a quiet room at home, away from siblings or pets. If possible, use a team approach, in which one parent holds and calms the child while the other parent gives the injection. Some patients may also benefit from distractions during the injection and rewards afterward.
Dr. Wise works closely with families to ensure they are comfortable with the routines to administer medications. “When possible, we prescribe the liquid form of oral medications,” she says. “For unpalatable liquid medications, a parent can avoid the taste buds by directing the medication to the side of the cheek using a syringe or numb the taste buds with a frozen treat for short courses of therapy.”
Also, pediatric patients often have difficulty swallowing medications that are available only in tablet or capsule forms, says Dr. Wise. It is often necessary to crush tablets or open capsules and mix the medication with soft foods, such as applesauce. However, it’s important to use small servings of food to ensure the patient gets the full dose of medication.
Dr. Driest says it is important to consider family dynamics. Example: A parent who is fearful about giving a medication, particularly an injection, may inadvertently increase a child’s stress. “A nurse or pharmacist can help [the parent gain a level of comfort] with administering medication,” she says.
Dr. Wise believes it’s important to keep children involved in the treatment plan. “Children don’t always understand the reason for their pain or why they have to take medication, so we try to discuss the situation in a way they understand,” she says. For example, you could say, “This medicine will help you play soccer without pain in your joints.”
Growing Up
As patients age, they should become more involved in decision making. Typically when they’re young, a patient’s parents make all of the decisions. “During early adolescence, we work on getting the patient more involved with self-management to ensure they are knowledgeable [about] the disease state and comfortable with the treatment regimen prior to transitioning to an adult rheumatologist,” Dr. Wise says.
Dr. Kamdar concurs, adding that it is important to note the development and maturity of patients. “As they grow older, they will gain insight,” he says. “Hence, they [may] express their views regarding their choices for medications and procedures.”
Karen Appold is a medical writer in Pennsylvania.
