Who are we? Needles. Learning Objectives. In their words. How many Pokes?? Needle Pain in Children: What's the big deal??

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1 Needle Pain in Children: What's the big deal?? Who are we? Kathy Reid, RN, MN, NP Dr. Bruce Dick, PhD Dianne Tuterra, B.Ed Pediatric Pain Management Committee, Stollery. Collectively, we have almost 80 years of experience 2 Learning Objectives Needles 1. To learn about pharmacological approaches to reduce needle pain in children. 2. To understand factors associated with repeated painful procedures that increase the risk of traumatic stress and long-term negative consequences in children. 3. To learn non-pharmacological strategies to support children and families during invasive procedures 3 4 In their words As one staff attempted to place the IV, there was myself in front of (my son) and other staff surrounding him that probably made him feel attacked and "ganged" up on. When the situation came up to have the similar intervention again, he had recollections of the experience and the anxiety returned much more ahead of time. He starts crying now in the pre-op area when getting the PJ's on How many Pokes?? Childhood Immunizations in Alberta = 22 pokes Annual flu shot = 1 poke per year = 5 pokes Synagis during RSV season (4-6 pokes per year x2 years) = 8 12 pokes Blood work IV s 5 6

2 Pharmacological Approaches Topical local anaesthetics most contain lidocaine, prilocaine and/ or tetracaine. Produce anaesthesia by inhibition of Na+ channels in sensory neurons Need to bypass the stratus corneum barrier in order to be effective Systematic reviews Buscemi et al (2008) Amethocaine (ametop) more effective and quicker onset than EMLA Stinson et al (2008) Amethocaine superior to EMLA Yamada et al (2008) examined infants. EMLA safe for circumcision but not for heel lance. Shah et al (2009) examined immunization interventions. Self reported pain ratings lower when topical anaesthetics used. 7 8 Topical Local Anaesthetics 3 methodologies 1. Direct injection newer systems on market such as J- tip 2. Passive diffusion EMLA, Maxilene, Ametop 3. Active needle- free systems Numby Stuff, vapocoolant sprays such as Pain Ease (Zempsky, 2009) (Farion, 2008) 9 What do we have here at Stollery? Maxilene (liposomal lidocaine) 4%. Time to analgesia effect: 30 min Duration: recommended 2 hours maximum application time Requires an order to obtain from Pyxis machine! EMLA (eutectic mixture of local anaesthetic) Time to effect min Long duration Requires an order as well! 10 Does it matter which one? 30 min application of ELA-Max is as safe and effective for venipuncture as a 60 min application of EMLA ( Eldman et al, 2005; Koh et al, 2004; Eichenfield et al, 2002) EMLA potential complication of methaemoglobinaemia, also causes more blanching of the skin making visualization of vein more difficult 11 Current Stollery Policies Liposomal lidocaine (Maxilene ) should be used for lumbar punctures, PICC line insertions, peripheral arterial line insertions, and intravenous insertions if time permits and the condition and maturation of the infant s skin allows (NICU Pain Mgmt Protocol, Stollery. 2008) Each individual shall be limited to 2 attempts When possible, topical anesthesia shall be used to provide a localized effect during vascular access. (Pediatric Peripheral Intravenous Number: 14.4 Access & Blood Collection Via Venipuncture, 2005) 12

3 Sucrose Analgesia A little sugar goes a long way!!! Must be administered slowly (2 min), over the tip of the tongue. Peak effect 2 min, duration 5-10 min so great for needles! Decreases crying time and facial expression of pain What strength? Anywhere from 12 50% in literature % quite effective and easy to mix. Stevens et al(2008); How old is too old? 12 months. Thyr et al, 2007; 18 months. Harrison (2008) But too much sugar? Mechanism of action is thought to be activation of the endogenous opioid system animal studies have demonstrated sucrose effect is reversed by naloxone Taddio has demonstrated that it does not prevent development of hyperalgesia! (Taddio, 2009, 2008) Unclear as to effect of repeated doses Repeated Painful Procedures and Traumatic Stress in Children Acknowledgements Dr. Carl von Baeyer Dr. Christine Chambers Bruce D. Dick, PhD Associate Professor Departments of Anesthesiology and Pain Medicine & Psychiatry Stollery Children s Hospital & Multidisciplinary Pain Centre University of Alberta Dr. Anne Kazak Overview Research summary Inconvenient facts Rationale Neurobiology Physiological & behavioural changes Memory How you can make a difference 17 18

4 Inconvenient facts Inconvenient facts Pain is often a consequence of required treatment It is impossible to eradicate pain in a hospital Arranging schedules Enormous workloads Individual differences Cost to you vs. patient (and society) Why is this so important? Appropriate pain management is a part of our ethical and moral obligations Poorer health-related outcomes Poorer treatment and adherence to recommendations Increased disability/worse functional outcomes Consequences for the individual Painful experience Stress response Trauma Development of avoidance/phobia Costs to individual society Why is this so important? Demonstration Goes hand in hand with: Would a volunteer please step forward Family-centred care Improved quality of life Better pain management Increased patient satisfaction 23 24

5 Key factors in trauma Perception of (life) threat Subjective appraisal of severity Previous painful / trauma exposure Pre-existing anxiety mental health issues Previous severe acute stress responses Early physiological arousal Key factors in trauma Length of hospital stay Separation from parents Social / emotional withdrawal Extreme avoidance of reminders of event Scarring or disfigurement Parental anxiety related to procedures Individual differences Age - younger remember and report more pain Anxiety The fear of any expected evil, is worse than the evil itself... Arntz and the fear is better remembered von Baeyer Individual differences Temperament - activity level, attention, emotional reactivity o Interventions (e.g., CBT) improve outcomes Pain response Individual differences Prior experience Not the number of procedures What matters is the valence and quality of the experiences is what appears to matter Bad experiences begat more bad experiences vicious cycle Neurobiology Long-term sensitization demonstrated across species after painful tissue damage Sensitization at cellular, peripheral, and spinal levels established Observed through: lower firing thresholds increased neural firing amplitudes increased skin surface area sensitivity to previously non-aversive stimuli 29 30

6 Physiological and behavioural consequences in infants Physiological and behavioural consequences in children Taddio et al. 1997: Circumcised infants Taddio et al. (2002): Infants with repeated heel lances during their first hours of life Physiological changes, pain anticipation, & memory for cues / stimuli at infancy stage Weisman et al. (1998): Lumbar puncture and bone marrow aspirations Stage 1: Randomized to active analgesic (fentanyl) or placebo Stage 2: All received active analgesic Pain higher at both stages in children who first received placebo Consequences of pain memories: No change Habituation Sensitization No pattern Consequences of pain memories: Sensitization: Increased reaction/reduced threshold May be emotional (fear, distress) May be psychological (avoidance, escape) Increased risk with: Severe pain Younger children Repeated exposure Ethics - data difficult to collect Consequences in adulthood Past medical experiences affect future ones, sometimes dramatically Adult pain reports of childhood experiences often reflect: o Pain o Fear o Pain coping effectiveness How to help? Some evidence that pre-teaching and honesty about the procedure help reduce pre-procedure anxiety (teaching, video) Evidence that cognitive-behavioural methods (e.g., reframing) can improve outcomes Post-injection feedback about positive aspects of how child coped produced less distress at next injection 35 36

7 Some evidence for: Some evidence for: An investment in proper preparation and pain management today is likely to pay off tomorrow for: o Fear reduction in the child. o Decreased avoidance of future care o Reduced procedure time for later procedures and other care providers Ask about previous negative pain experiences. Use open ended questions. Most children can endure minor procedures with only local anesthesia A minority of patients who have had very negative experiences might need stronger medications or special psychological attention Please fix him (!?!) Slides of slight damage vs. catastrophic damage Please fix him (!?!) Slides of slight damage vs. catastrophic damage Please fix him (!?!) Slides of slight damage vs. catastrophic damage Child Life Department Child Life Specialists focus on the psychosocial needs of children, collaborating with parents and other members of the team to promote effective coping through play, preparation, education and self expression activities

8 Fortunately, there are accessible ways to help minimize pain for children. To make a difference is not a matter of accident, a matter of casual occurrence of the tides. People choose to make a difference. Maya Angelou Educate the child and family If Child Life is available invite them to participate in the procedure Allow the time needed to create success Use strategies that acknowledge the child s development, coping abilities and fears. Invite and encourage family participation Simple measures Remember it is ok for children to cry and be upset Get on the child s level Introduce yourself and your role Be positive Know the child s developmental level Give the child choices whenever possible Listen carefully and.. Comfort Holds. Use topical anesthetics Let children sit or decide the position they want to be in Give everyone a role Use comfort positions Explain what and why Distract children 47 48

9 Comfort holds. Everyone has a role. Child, to hold very still and hug mom or dad Give child permission to cry or yell ouch Let parents know that you trust them to be helpers and do a job Your role is to tell them what is happening and to be very quick Give choices where ever possible. Which arm to use Sitting, lying down, on a lap Toy for distraction Mom and dad s role Do not give a choice if there is not one Set clear expectations at the child s developmental level Distraction.. Offer child a choice for distraction; bubbles, books, music or toy before you start the procedure Identify a coach, someone the child knows and trusts Never use distraction to not be truthful about what is going to happen or to trick a child Distraction Offer child a choice for distraction; bubbles, books, music toy before you start the procedure Identify a coach, someone the child knows and trusts Never use distraction to not be truthful about what is going to happen or trick the child Be thoughtful. Children don t have to be. Brave a big boy or girl Lied to. it feels like a mosquito bite Compared to another time, child or experience Made to feel inadequate 53 54

10 Be thoughtful. Children don t have to be Brave a big boy or girl Lied to. it feels like a mosquito bite Compared to another time, child or experience feel inadequate Time. Time is always and will always be a constraint in a busy, challenging environment like the hospital. The time taken up front, as little as 10 minutes can make the difference of a lifetime of anxiety for a child Consider Try the Vein Viewer Maximum number of pokes PICC lines for longer term access (ie greater than 5 days) Clone Dr. McGonigle Next Steps Pediatric Pain Management Committee 1. Prescribing topical local anaesthetics auto order fro inpatients? 2. Staff education including lab 3. Public education Family Centered Care Council In their words Questions A little time and understanding goes a long way Get the most experienced staff member for that activity to perform the task My message would be that staff realize some kids have been thru a lot, and this is very real for them. It is not just a bad behavior, and he's not just a 'procedure' to get done 59 60