Easing Children’s Pain: Nonpharmacological Approaches

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Easing Childrens Pain Non pharmacological
Approaches

• Paula Forgeron RN MN
• Clinical Nurse Specialist
• Pediatric Pain Management
• Adjunct Nursing Professor
• Dalhousie University

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Easing Childrens Pain

• Definition of procedural pain
• Consequences of procedural pain
• Gate Control Theory
• Attention Theory
• Non pharmacologic treatments of pain
• What is the evidence
• What can we do

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Consequences

• Full-term infants (diabetic mothers) with
  repeated heel lances displayed ?pain behaviors to
  subsequent venipuncture vs. infants who only had
  venipuncture.
• Young children who received placebo vs. Fentanyl
  for procedural pain rate pain ?even with
  subsequent Fentanyl
• Young adults who had high childhood pain and fear
  of procedures ?fear, pain, and avoidance of
  health care
• Young, K. Ann of Emergency Med, 2005, 45(2)
  160-171.

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Memory

• 3 year olds have accurate memories for details of
  painful procedures
• Neonates display ? distress at cues to repeat
  procedures
• Recall of procedural pain tends to be distorted
  for all childreneven if child displays low
  distress may contribute to ?distress with
  future procedures
• Young, K. Ann of Emergency Med, 2005, 45(2)
  160-171.

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Childrens Greatest Hospital Fear
Broome Hellier, Issues Compr Pediatr Nurs.
1987, 10(2) 77-86.
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Gate Control Theory
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Attention Theory

• People have a tendency to attend to one thing at
  a time
• People have a limited amount of mental ability to
  allocate to various tasks
• Selective attention is governed by our arousal
  level (more scared the more we focus on what is
  scaring us).

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NonpharmCognitive Techniques

• Guided Imagery
• Hypnosis
• Thought-stopping
• Prayers
• (Most not empirically tested with children)

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NonpharmCognitive-Behavioral Techniques

• Distraction
• Relaxation
• Breathing exercises
• Muscle relaxation (tension/relaxation)
• Play therapy

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NonpharmSensory Techniques

• Thermal regulation
• Heat
• Cold
• Pressure
• Massage
• Acupuncture

• Positioning
• Swaddling
• Holding
• TENS

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Why Distraction

• Child does not require training
• Works with infants and older children
• Involvement of parents
• Parents want to be involved
• (Sacchetti, et. al Pediatr Emerg Care, 1996, 12
  268-271)
• Child want parents present
• (Ross Ross Pain, 1984, 20 179-191 Broome, ME
  Pediatr Nurs. 2000 May-Jun26(3)315-7)
• Minimal training for staff
• Low cost
• Evidence supports usefulness

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Distraction

• 82 Child/Parent dyads (children ages 4-6)
• Routine immunization
• Distraction, reassurance usual
• Distraction- least amount of distress
• Reassurance group
• 3x as many required restraint
• Displayed more verbal fear
• Parents/Reassurance group
• Pre rated themselves as least upset more able
  to help their child
• Post rated themselves as most distressed
• (Manimala, et. al (2000) Childrens Health
  Care, 29 (3)161-177.)

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More than Presence

• Very young children may lack personal
• resources for managing stress are
• dependent on the skill of their parents
• and professional staff to teach them
• and enhance their coping.
• (Ellerton, et. al Maternal-Child Nsg Journal,
  1994, 22(3) 74-82)

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More than Presence cont.

• 31 children, age 3-7 years, trained in coping for
  immunization pain vs 30 children without
  training.
• Examined nurse parent behaviors and childrens
  use of coping skills
• Children did not use the skills despite
  understanding
• Nurses' behavior appeared to center on
  encouraging child coping (distraction)
• Parents tend to comfort child distress
  (reassurance)
• Cohen LL, et. al, J Pediatr Psychol. 2002
  Dec27(8)749-57

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Parent Distress

• Major causes
• Change in parent role
• Failing to protect their child from pain
• Tiedeman J Ped Nurs 1997 12 110-9
  Melnyk J Ped Nurs 2000 15 4-13

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Parents Use

• Descriptive study what parents did naturally
• 201 mothers 114 fathers
• Children age 1-6 (variety of surgeries)
• Holding child on lap
• Comforting the child
• Spending more time with the child
• Videos/TV
• Read
• Kankkunen, et al. Journal of Advanced Nursing
  2003, 41(4),
• 367-375.

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Suggestions

• Focus Tiles
• Distraction boxes
• Developmental appropriate
• Involve child life to create
• Novel toys, videos, music, pinwheels
• Pre printed instructions for parents
• Why distract their child
• Reassurance not helpful and decreases coping
• How to distractactively engage child
• Engage in non procedural talk

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Suggestions

• Infants/Young Children
• Parent presence
• Coping- promoting behaviors(distraction)
• Cuddling
• Swaddling
• Non-nutritive sucking
• Non-pharm is NOT a substitute for meds!

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