A Clinician's Guide to Helping Children Cope and Cooperate with Medical Care: An Applied Behavioral Approach

CHAPTER 6. Helping Children, Parents, and Medical Caregivers Cope with Child Distress and Discomfort during Immunizations

82 chapter 6 Helping Children, Parents, and Medical Caregivers Cope with Child Distress and Discomfort during Immunizations in this chapter • Information is presented about the special significance of routine immunizations that are almost universally experienced by young children the world over. • The effects of these early pain experiences on a child’s physical, behavioral, and emotional development are reviewed from the research literature. • Pharmacological, physical, environmental, and behavioral interventions for immunization pain and distress that are supported by research are reviewed, particularly those involving topical anesthetics and distraction techniques. • Suggestions for employing these pain interventions are presented in order to encourage their use in pediatric settings. 6.1. patient population and target problem Routine immunizations are an essentially universal experience of infancy and early childhood. However, immunizations have special significance because for typically developing, healthy children, immunizations are the child’s earliest experience of iatrogenic pain. Given that in the United States the recommended childhood immunization schedule calls for up to 20 injections within the first 18 months of life,1 special consideration must be given to the emotional significance of, timing of, and preparation for these early painful experiences. In addition, pharmacological, behavioral, and helping with discomfort during immunizations 83 cognitive-behavioral interventions that may decrease anxiety, pain, and behavioral distress and increase coping and recovery time for immunizations are available, and though widely known among pediatric psychologists and pediatric pain specialists, they are not widely used in pediatric primary care practices. Does a child need advanced warning that she or he will be receiving an injection? If so, what should be said, and how far in advance? Thirty years ago it was widely believed that infants, particularly neonates, did not experience pain as acutely as older children and adults because of their immature neurological system, and in any case, even if they were to briefly experience intense pain, it was thought that they would not remember it because of their lack of a mature capacity for memory. These beliefs were prevalent especially for preverbal children because their subjective pain experience could not be easily assessed and their behavioral distress could be attributed to other causes such as fear or separation anxiety. These notions are still common among some health care professionals. However, among pediatric pain specialists it is understood that infants experience pain much like adults and possibly more intensely.2–6 6.2. assessment This chapter reviews many promising pharmacological, behavioral, and cognitive-behavioral strategies that appear to be helpful for reducing immunization pain and distress in children. Randomized controlled trials (RCTs) help us to identify the interventions that appear to have the greatest effect on the greatest number of children. However, matching specific interventions to specific children according to their ages, temperaments, and learning histories (behavioral and medical) is an essential part of clinical practice. Assessing which interventions are most helpful to individual children is a necessary part of ongoing individualization of care. The various types of interventions discussed in this chapter make up the current “toolbox” from which parents and health care professionals may choose when developing an individualized pain and distress management plan for young patients undergoing immunizations. However, the only way to determine what works for your individual child is to use the information in this chapter to select an intervention or combination of interventions that seems to best match your child and situation and that parents and health care providers agree to implement. Any intervention should be given a fair 84 helping children cope with medical care trial, remembering that behavioral interventions require learning and cannot possibly be completely effective the first time they are tried. On the other hand, if you have given an intervention a fair try over a few consecutive occasions and it is not helpful, then it should be discontinued and an alternative approach selected and tested. 6.3. information to help family caregivers and health care providers cope No one likes to think of themselves as someone who hurts or upsets little children. Yet that is what nurses and pediatricians are called on to do and family caregivers to allow to happen when children get immunization injections . Of course, it helps to know that this brief pain serves the greater purpose of preventing health- and life-threatening communicable childhood diseases. Another way to feel better about causing this pain is for practitioners to decide what pain and distress management intervention strategies they will adopt in...