Instructions for use of this template:

1. Instructions for use of this template: This PowerPoint was created by child life specialists on the Child Life Council’s Professional Resources Committee for use by professionals in the field. It may be used to educate multidisciplinary team members and students in your practice. You may use it “as is,” or you may customize it by adding graphics or photos, selecting only a subset of slides, or integrating some of the slides into your own presentation, as appropriate for your audience, please be sure to read over the comments listed at the bottom of each slide to know how to customize this for your institution. Please include the next slide (slide 2) in your presentation, either at the beginning, or end. A note about the photos: Consents for use of the photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint.  Please remove this slide (slide 1) prior to use.

2. Our Thanks to: The Child Life Council’s Professional Resources Committee, who provided a template to help in the creation of this presentation for our audience.

3. Child Life and Pain Management

4. What is Child Life? Child life specialists address the psychosocial concerns that accompany health care experiences by promoting optimal child development and minimizing adverse effects. Using play and psychological preparation as primary tools, child life interventions facilitate coping and adjustment under circumstances that might otherwise be overwhelming.

5. Certified Child Life Specialist Professional Standards of Practice • Minimum bachelor’s degree or master’s degree* with specific coursework in human growth and development, family studies, psychology, and related fields *By 2022, all newly Certified Child Life Specialists will be required to hold a master’s degree • Minimum of 480 hour internship • National Certification examination • Professional development hours to maintain certification • Adherence to the code of ethics and standards established by the Child Life Council

6. Pain • Procedural pain is universal to all pediatric patients and needle stick pain is the most common source of pain in hospitalized children (Wong and Baker, 1988) • Pain is subjective Wong, D., Baker, C. (1988) Pain in children: comparison of assessment scales. Pediatric Nursing.14 (1): 9-17.

7. Gate Control Theory of Pain • Experience of pain can be influenced by thoughts and emotions • In order to help control the “gate” of pain, other tools can be utilized to distract/“trick” the skin or body to focus on additional sensations, such as cold or vibration, to minimize the sensation of the poke or pain The gate control theory of pain. (January 01, 1978). British Medical Journal, 2, 6137, 586-7.

8. How Child Life Can Help • Play • Therapeutic • Medical • Diagnosis education • Preparation • Support • Procedural • Emotional • Family • Coping Plans

9. Child Life’s Role in Pain Management • Non-pharmacological pain management • Guided Imagery/Relaxation • Positioning for Comfort • Emotional Support • Distraction • Deep Breathing • Other pain management techniques • Sucrose Water • Lidocaine (injectable/topical) • Vibration and cold

10. “CCLSs are often directly involved in the utilization of nonpharmacologicpain management techniques and coaching or supporting patients and families before and/or during distressing medical procedures.” American Academy of Pediatrics Brown, C., Ipsan, C., Lostocco, L., Vinocur, C. D., Chitkara, M. B., Percelay, J. M., Betts, J. M., ... Alexander, S. N. (January 01, 2014). Child life services. Pediatrics, 133, 5.)

11. Guided Imagery • Guided imagery induces an altered state of consciousness where a patient develops heightened focus on a particular idea for the purpose of relaxation and/or distraction. • 3 events associated with guided imagery: • Absorption- patient totally involved • Disassociation- separate self from pain • Suggestibility- suggest scenes, patient can agree or disagree • Patient must be in control to do guided imagery

12. Guided Imagery • Guided imagery is most useful for longer procedures or for beside pain management • It is most effective with older children who are able to use their imagination to follow the script

13. Positioning for Comfort • Comfort positions allow for good control during a procedure while still allowing the child to receive comfort from the parent • Helps the parent and child to feel more at ease and in control • Some positions, like laying on the back, can make children feel very vulnerable Sparks, L. A., Setlik, J., & Luhman, J. (2007). Parental holding and positioning to decrease IV distress in young children: a randomized controlled trial. Journal of pediatric nursing, 22(6), 440-447. doi: 10.1016/j.pedn.2007.04.010

14. Positioning for Comfort: Advantages • Fewer health care team members needed • Greater immobility of the child • Close physical contact with a caregiver • Caregiver has an active role and can support the child in a positive way • Creates a sense of control for the child Stephens, B. K, Barkey, M. E., & Hall, H. R (1999). Techniques to comfort children during stressful procedures. Advances in Mind-Body Medicine, 15, 49-61.

15. Positioning for Comfort • Children may still cry, but tend to display less stress • Can be initiated as soon as a child has received some trunk and head control (3-5 months) • Parents/caregivers should not be asked to hold down a child’s arms or legs; it is important to make sure parents feel comfortable with these positions • Parents/caregivers can lie next to child on bed for procedures which require supine position • Compliment parents! • Positions can always be adapted to meet the needs for each procedure

16. Examples of Positioning for Comfort • IV /Blood Draw: • Straddling lap of caregiver • Side-Sitting

17. Examples of Positioning for Comfort • IM injection in Thigh • Leg is bent over parent’s lap, keeping thigh muscle relaxed Lacey, C. M., Finkelstein, M., & Thygeson, M. V. (2008). The impact of positioning on fear during immunizations: Supine versus sitting up. Journal of Pediatric Nursing, 23, 195-200.

18. Examples of Positioning for Comfort • Port Access • Sit forward-facing on parents lap • Parents can cross legs over child’s legs to prevent kicking

19. Examples of Positioning for Comfort • NG Drop • Hug parent during nasal aspirate • Child can also be held on parents lap facing outward with parents arms and legs wrapped around the child

20. Examples of Positioning for Comfort • Urinary Catheterization • Child lies with head in parent’s lap on table

21. Emotional Support • Comforting touch • Encouraging words • Developmentally appropriate medical explanations • Reduces anxiety related to anticipatory pain

22. Distraction/Planned Alternative Focus • Does not mean “Hey, look over here so you do not know what is happening!” • Gives an alternative to focusing on pain • Gives the patient a “job” and promotes sense of control over an appropriate aspect of the procedure

23. Items useful for Distraction • Toddler – bubbles, light spinner, cause and effect toys, toys with lights and sounds, sensory toys, etc. • Preschool – bubbles, light spinner, toys with lights and sounds, young versions of i-spy books, ViewFinder and cartoon slides, stress ball, pinwheels, whistles, iPad games and activities • School-age – i-spy books, iPad games and activities, conversation, music, singing, stress balls, pinwheels, whistles, etc. • Adolescent – iPad games and activities, conversation, MadLibs, music, singing, hangman, Pictionary, stress balls, etc.

24. Deep Breathing • Deep breathing is a useful coping technique that can be used in the midst of pain • It can be helpful for both chronic and acute pain • Tools like whistles, bubbles, and pinwheels can encourage younger children to take bigger breaths • Visuals, like birthday candles, can also be beneficial for younger children

25. Using Interventions Effectively • Give parents and patients clear instructions • Rationalize/describe techniques as being helpful or less threatening; ‘helping you hold still’ or ‘giving you a big hug’ • Involve the parents and include them in what is happening • Decreasing stress level of parents • Parents are the experts of their child

26. Additional Pain Management Techniques • Cold Spray • Sucrose Water • Pharmacological Numbing Agents • Heat and Cold • Soothing Items Customize this slide to include more information regarding additional pain management techniques available at your facility (such as JTip, ELMA, LMX, Buzzy, freezy spray, cold spray, SweetEase, pacifiers, hot or cold packs, etc).

27. Bedside Pain Management • Sometimes pain can be chronic • Some tools that can be used in the procedure room can also be used • Bubble blowing • Play with familiar toys • Relaxation • Teaching and rehearsing coping techniques can also be very beneficial

29. RememberChild Life can Help… • Reduce patient and parental anxiety • Teach techniques to facilitate coping • Offer support during painful procedures • Set clear expectations

30. Child Life Department • Insert contact information/unit information

31. Questions?