Decreasing Pain and Anxiety in Pediatric Vascular Access Procedures: Guest Editorial

How often in your pediatric vascular access practice, when a catheter placement, a blood draw, or an injection of some kind is needed, have you heard your patient ask, "Is it going to hurt?" in a worrisome tone? In fact, we all probably have. How have we responded? Are we immediately ready with a pat answer, a brisk statement of "it is not going to hurt because I do this all the time and am very careful," or you tell the patient that he/she is a "very brave boy or girl and it will soon be over," or even it will "not really hurt"! We know today that this is not how to handle those fears, but unfortunately, it still happens. There is even the view that if the procedure is completed as quickly as possible, then it will "all be over and forgotten" by the child. Case closed! Except it isn't "closed," and in fact, the fear engendered may be carried forward into later childhood as well as adulthood with short-term and long-term consequences for both children and their families. In the short term, pain and distress can potentially increase the risk of needle phobia, anxiety, and treatment nonadherence as children, further resulting in long-term potential avoidance of medical care as an adult.1Common medical procedures to assess or treat patients can cause significant pain and distress, and we as clinicians must have knowledge of practice techniques to minimize these in children of all ages. Examples include peripheral intravenous catheters (PIVC), blood draws, heel sticks, inoculations, and wound repair, to name a few. A Canadian study cites needle-related pain reported by children, especially the very young, to be the worst pain they experienced in the hospital.1The Difficult Intravenous Vascular Access (DIVA) Scale has been very useful in the evaluation of the potential level of difficulty of vascular access anticipated with pediatric patients.Infant-focused strategies may include non-nutritive sucking (pacifiers), as well as sucrose pacifiers, skin-to-skin contact, breastfeeding, swaddling, and bundling, as well as pharmacotherapy as indicated. More recently, Nursing 2024, in their Clinical Rounds section, reported on a randomized trial to evaluate the efficacy of music in relieving acute pain in term neonates.2 The intervention group was exposed to a "Bedtime Mozart Lullaby," while the control group received no music. Pain levels were assessed using the Neonatal Infant Pain Scale (NIPS), and results indicated that the music group had significantly lower pain scores.One would wish today that techniques that are well-proven to reduce children's stress would be practiced with all potentially painful procedures. Attendance of Child Life Specialists, would be an example, with their expert diversion techniques and total focus on the child; distraction with age-appropriate toys, electronic games, watching a movie or cartoons, or virtual reality (VR) devices. The latter is described in a randomized clinical trial of 107 patients undergoing PIVC placement in two pediatric clinical settings with a VR intervention, which significantly reduced mean patient-reported post-PIVC anxiety and pain.3Having the child "assist" with the procedure and make suggestions, for example, where they would like their parent or support person to be seated, can be very self-affirming. Allowing the child to decide to be in a sitting position instead of lying down, if feasible, might also add to their sense of control. Children are very aware of any discordance in their setting, so preplanning as to who does what needs to be arranged early. I suggest helpful things for parents to say and do and remember that no matter how caring of a clinician you are, no one can take the place of a trusted parent in a child's mind. Unfortunately, there are still situations when the parent is directed by the staff to wait in the hall. It's not a good decision unless it's unavoidable.Today, we have the ability to help relieve pain pharmacologically, and those interventions should always be a consideration in addition to the techniques previously described. Topical local anesthetic creams or sprays can be effective, and nitrous oxide may be used in cooperative children greater than 3 years of age, but all pharmacological interventions need to be approved by your facility and documented in practice guidelines and protocols.In my reading for this editorial, I was amazed at the variety of tools we have available to make anxiety assessments meaningful for children of all ages. I will describe three.The Spence Children's Anxiety Scale assesses six domains of anxiety. It is a self-report scale to assess the severity of anxiety symptoms in children 8-15 years.The Children's Fear Scale depicts five faces that show different fear intensities (adapted from the Faces Anxiety Scale).4333 rule for anxiety in children asks the child to name 3 things they can see, identify 3 sounds they can hear, and move 3 different parts of the body. This simple strategy helps children engage their senses and focus on reality rather than worrying about what might happen in the future.As I write this editorial, I remember my days as a hospital nursing supervisor in the 1980s. It was "practice" that if the pediatric floor nurses were unable to start a PIVC on a child, the Supervisor would be summoned to do it. I still cringe at those memories when parents were required to leave the room and numerous hands, and sometimes a nursing assistant's body, pinned the child down until the procedure was done. It is horrific, BUT sadly, there is evidence that, at times, this still happens, especially when time in a nonemergency situation is perceived to be more important than the child's comfort needs. May no pediatric patient, or any patient for that matter, ever experience such a practice today.You will have the opportunity to review recommended guidelines described in journal articles today that will direct you on the path to your own successful pain and anxiety-limiting pediatric vascular access procedures. Blood draws, immunizations, and needle sticks can be accomplished successfully by taking time to consider the age-appropriate needs of each child and the environment and by supporting the family. It will also provide a sense of accomplishment in your practice that is priceless for you and your patients.I wish you every success. Josie Stone, RN