Author: Dr. Katie Knight 

We’ve just had the big 6-monthly changeover in junior doctors across London, cue many nervous looking F2s, GP trainees and EM trainees setting foot in paediatric A&E for the first time.

Aside from the dreaded paediatric trauma call, the thing that really freaks a lot of junior doctors out is sticking sharp pointy objects into tiny humans – we paediatricians don’t exactly enjoy this part of our job but we definitely have a few ways of making it less stressful for both parties.

I thought I’d put together some practical tips for making procedures go smoothly for both you and the child. Some of them are from my own experience as a paediatric trainee, some have been passed on to me by wise play therapists (if one exists in your department, befriend them immediately, they are totally invaluable).

Whenever you have to do a potentially distressing procedure on a child, remember that a few extra minutes spent in preparation could prevent them from becoming the next doctor-/needle-phobic adult.

(NB ‘procedure’ in the context of this article refers to doing blood tests, injections, cannulas, heel pricks etc.)

No Surprises

In an age appropriate way, explain what you need to do, BEFORE you even start getting ready to do it. Be honest. If you are going to leave a cannula in after you take the blood, tell them before they see a big plastic thing sticking out of their hand when you leave! Try and avoid words they won’t understand.

If you ever get a chance to watch a play specialist/play therapist explain a procedure to a child I really recommend it. They are the absolute pros.

Pre-Prep

Ametop, EMLA, ‘magic cream’. Put it on in several places to give you options, and give it a chance to cook. A good 40 mins-1 hour would be ideal if you have the time. If you don’t, cold spray is a good alternative. If the child has never had cold spray used on them before, give them a little demonstration of how it feels so they don’t get a shock and pull away at the key moment when you use it for real. Give them the can and let them spray you with it first if they are really worried, to show them it’s not a big deal.

Get organised

Nothing tips an anxious child over the edge like waiting and watching doctors set up lots of scary looking medical equipment. Leave the room and set up your tray AWAY from the child, with everything you need (take spares!) Prepare your flushes and have all the blood bottles handy with the lids screwed off. You should be ready to get on with the procedure as soon as you walk back into the room.

Don’t Bargain

Children take questions literally. If you ask any conscious child ‘is it OK if I take your blood now?’ they will usually tell you ‘NO!’. You do it anyway. Now you’ve lost their trust.

You have consent from the parents, so what the child needs to hear from you – gently but firmly – is only WHAT you’re going to do, and WHY. ‘I’m going to do a blood test, because it will help me find out why you’re sick’.

Don’t say ‘I’m really sorry but…’ Kids associate the word ‘sorry’ with someone doing something wrong and then apologising for it, so this might make it seem to them like the doctor is doing something ‘naughty’ by taking their blood.

Take Reinforcements

I don’t think I’ve ever done a procedure successfully in a child in A&E without a minimum of three adults. You need mum/dad, a nurse, and yourself. More people than that is generally not helpful and can make the child more anxious, so politely ask grandma, auntie and the med student to step outside for a few minutes.

Size Up the Opposition

How old/large is the kid? It’s really important to get them positioned right. Depending on the procedure you’re doing and the age of the kid, there are a few options to think about.

Tiny baby – on parent’s lap / breast or bottle feeding (it’s great distraction/pain relief) / swaddled in blanket with the arm/leg that you are using for the procedure free from swaddle.

Under 1 year – As above / ‘bear hug’ (get parent to sit on chair, get child to sit on lap facing parent with legs either side. Parent holds them really tight, you take child’s hand/arm from under parent’s arm so child can’t see what you’re doing).

Toddler / small child – ‘bear hug’ is best for most procedures.

Older child – on bed, arm out to side of bed, nurse on same side of bed holding arm. Parent sat on opposite side of bed talking to child.

Then figure out where is best for you to be. You might see paediatric doctors sitting on the floor in corner with their legs half crossed in their efforts to work around the child, but if you are not that experienced it is worth finding a position that you are comfortable in. If all you can think about during the procedure is the imminent cramp in your leg you are very unlikely to succeed.

Distraction

Give the kid something else to concentrate on. A couple of things that are useful to have in your pocket:

1 – (the ultimate paediatric cliché) – bubbles. Works like a charm on babies, toddlers and little kids.

2 – Phone, loaded with videos of Peppa Pig, or simple games they can play one-handed. (Hopefully you aren’t too precious about your phone, which is now covered in snot and might need decontamination before you want to put it anywhere near your face again).

‘Rules’ for Them

It makes no sense to tell a child who is in a very scary and unusual situation not to be scared. In fact the thing that normally works best is telling them, before you start, that it’s NORMAL to be scared, you DON’T MIND how much they cry or shout, but the ONLY thing you want them to try and do is stay still.

Rules for You

The parent is there to hold/calm/distract the child, the nurse is there to assist you by passing you things and holding the child’s arm (…and acting as tourniquet), and you are there to do the procedure. Concentrate on your job, DON’T TALK to the kid or parent while you’re in the middle of the procedure. The nurse who is helping can give the child gentle instructions about staying still etc.

Don’t Say Brave!

On one of my first A&E shifts a play therapist told me off for calling someone a ‘brave boy’. She explained that ‘brave’ means different things to different kids, and sometimes they might think it means they have to pretend not to be scared.

Instead, be specific – what was good about the way they acted?

Try something like ‘you did so well, even though you were scared you stayed really still! Thank you for helping me make you better’ (adjust for age, I take no responsibility for the response you’ll get if you try that out on a teenager).

Stickers!

They might have tried to kick you and cried non-stop during the procedure (even if it goes totally smoothly) but the good news is you can be friends again, and all it is going to cost you is a sticker. It seems a small thing but if you finish up your procedure by doing something nice, it will go a long way towards making their next interaction with you, or another doctor, that bit easier.

Take Home Learning Points

• Explain what is going to happen in an honest, age appropriate way
• Think about the child’s comfort – pain relief, positioning, distraction
• Don’t try and do procedures alone – always take a nurse or another doctor to help
• Take your time to get organised before starting the procedure
• Give clear instructions about what you want the parent and child to do

About the author…

Dr. Katie Knight (@ponderingPaeds) is a paediatrics trainee in London, currently working at Homerton University Hospital. She has completed 3 years of training in general paediatrics and is planning to specialise in paediatric emergency medicine. She is passionate about innovative medical education and simulation training in PEM. Her excellent tips on how to safely negotiate the daunting task of performing a paediatric procedure will hopefully be the first of many contributions to Pondering EM.