PainLink Presents

March 2001

VALLEY CHILDREN'S HOSPITAL

PATIENT CARE GUIDELINE:
NONPHARMACOLOGIC INTERVENTIONS FOR PAIN MANAGEMENT

The nonpharmacological interventions clinical practice guideline is a reference document for clinical staff. It is intended to help them to select the most appropriate non-pharmacologic pain management intervention(s) based on the developmental age of the child. However, the guidelines are subject to modification by MD order or other considerations. Valley Children's Hospital has an "online file cabinet" which houses documents such as clinical practice guidelines. Thus, the staff can easily retrieve the guideline to view online or to print so that a hardcopy can be placed in the patient's chart. Reference to this and other clinical practice guidelines can also be added to the patient's care plan to direct other clinicians to review the document as well. New staff are informed about the availability of the nonpharmacological interventions guideline (and other pain management resources) during the pain management lecture in Patient Care Orientation and a couple of examples illustrating it's application in practice are briefly reviewed.
—Kimberly Sutters, PhD, RN

PURPOSE:
To describe nonpharmacological interventions appropriate for managing pain in infants and children.

SUPPORTIVE DATA:
Nonpharmacological interventions encompass a variety of approaches designed to help with pain management that do not involve drugs. Nonpharmacologic methods of pain control are probably most effective as coping strategies, to make the pain more tolerable. However, some strategies may result in an actual reduction of pain intensity. Nonpharmacologic interventions are generally very safe, and they give children a sense of control over not only the pain sensation but their own behavior. Further, many of the nonpharmacologic techniques provide parents with an opportunity to be involved during a painful experience and thereby feel less helpless.

CONTENT:

1. Categories of nonpharmacologic intervention
   
   
   1. Sensory/physical modalities - They work by directly blocking the transmission of nociceptive input along the peripheral and central nervous system pathways, modifying neuronal processing, or activating endogenous pain-suppressing mechanisms.
      
   2. Cognitive modalities - Alleviate pain by having the child completely and selectively focus on a thought or image, making it difficult to attend to painful stimuli and thus altering or suppressing painful sensations.
      
   3. Cognitive-behavioral modalities - Combinations of cognitive and physical activities that alter or suppress painful sensations. They are most effective when they draw on a child's auditory, visual, tactile, and kinesthetic senses. Behavioral interventions are designed to change either children's own behaviors or the behaviors of the adults who interact with them. The objective is to lessen behaviors that can increase children's pain and distress, while increasing behaviors that can reduce pain.
      
   4. Multimodal approaches - Combining nonpharmacological techniques from more than one category for managing pain in children. Individuals vary in the degree of sensory, cognitive, and behavioral modifications they require.
      
2. Classification of selected nonpharmacological interventions:
   

   NOTE:

   Although each method is listed within a main category, most methods vary in the particular combination of physical, cognitive and behavioral modulation involved.

   Table 1

   Sensory/Physical	Cognitive	Cognitive/Behavioral
   Modifying environmental stimuli	Information giving	Art & play
   Positioning	Choices & control	Modeling, role-playing, behavioral rehearsal
   Deep breathing	Guided imagery	Biofeedback
   Relaxation	Hypnosis	Behavioral modification
   Massage	Thought-stopping	Desensitization
   Heat	Psychotherapy
   Cold
   Pacifier/sucrose
   Exercise
   TENS
   Acupuncture
   Acupressure

    

3. Summary of recommended use of nonpharmacological methods with various age groups:

   Table 2

   	AGE
   	Infant	Toddler	Preschool	School age	Adolescent/ Adult
   METHOD
   Acupressure				X	X
   Acupuncture				X	X
   Art & play		X	X	X	X
   Behavioral modification				X	X
   Biofeedback				X	X
   Choices/control		X	X	X	X
   Cold	X*	X	X	X	X
   Deep breathing			X	X	X
   Desensitization			X	X	X
   Distraction	X	X	X	X	X
   Environmental modification	X	X	X	X	X
   Exercise				X	X
   Guided imagery				X	X
   Heat	X*	X	X	X	X
   Hypnosis				X	X
   Information giving	X+	X	X	X	X
   Massage	X~	X	X	X	X
   Modeling, role-playing, behavioral rehearsal			X	X	X
   Pacifier/sucrose	X	X
   Positioning	X	X	X	X	X
   Psychotherapy			X	X	X
   Relaxation			X	X	X
   TENS				X	X
   Thought-stopping				X	X

   * Use with a physician order only
   +Provide information to parents
   ~Use with caution on fragile, underdeveloped skin and tissues

A. NEONATES/INFANTS:

1. Timing, duration, and concomitant use of more than one technique need careful consideration.
    
2. The younger the gestational age of the infant and the sicker the infant, the more likely it is that excessive stimulation will actually worsen the effect of the procedure for the infant.
    
   • It is best if only one or two actions are used (e.g., non-nutritive sucking and swaddling, or non-nutritive sucking and soft, gentle touch; auditory stimulation [e.g., soft talking, humming, etc.] should not be added to the interaction, as this may well overwhelm the infants system with stimulation).

Sensory/physical

1. Modification of environmental stimuli
    
   • Shading infant's eyes (with blanket "tent")
   • Cover isolette/crib with blankets
   • Close doors gently/quietly
   • Avoid loud voice(s)
   • Set phone ring at lowest volume possible
   • Decrease amount of noise from radios, tape recorders, etc.
   • Cluster nursing care activities
   • Allow periods of undisturbed rest
   • Gentle manipulation of tubes and lines
   • Careful removal of tape from skin
      
2. Positioning - Swaddling, containment to limit excessive, immature motor responses, "nesting" using blanket rolls to tuck around sides/back/feet and head to provide boundaries; insuring proper body alignment; hugging and holding.
    
   • Neonates may benefit from two staff members assisting during procedures to promote efficiency without over-taxing the infant; one staff member should focus on positioning and assisting infant with sucking on a pacifier (as appropriate for patient and staffing availability), while the other staff member performs the procedure/treatment.
      
3. Simple massage or rubbing of painful areas - Massage can be used to relieve pain and spasm, mobilize contracted muscle through measures that assist the return flow and circulation of blood.
    
   • In the preterm infant, skin stimulation, including stimuli felt as pleasant in older infants and children, should be administered cautiously. In a preterm infant, simple stroking of the skin may cause an intense physiologic response.
      
   • Also, the preterm infant's skin is much more fragile and even gentle stroking or massaging may damage the integrity of the skin.
      
4. Heat - A warm blanket can be used to improve circulation, facilitate relaxation, and promote pain relief.
    
   • To provide moist heat, a washcloth can be dampened with warm tap water and applied directly to the area and covered with a disposable diaper or chux; remove as soon as the compress becomes cool; reapply as indicated.
      
   • Temperatures should be less than 103 degrees F. for neonates to minimize the potential for burns to occur.
      
5. Cold - Application of cold or cooling devices should not be used on neonates without a physician's order, as cold applications may compromise an infant's thermoregulation and cause cold stress.
    
6. Pacifier/sucrose - The analgesic effect of non-nutritive sucking and sucrose is thought to be mediated by the release of endogenous opioids.
    
   • Non-nutritive sucking is best accomplished with the appropriate size pacifier and gentle stroking of the infant's cheek (next to the lips). This facilitates the infants desire to suck on the pacifier and should be started prior to the procedure.
     
   • Be aware that some studies have indicated that infants may develop an aversion to sucking if this method is used frequently and associated with painful procedures.
      
   • Therapeutic effects are maximized by giving sucrose solutions of 24% or higher, and are most effective when sucrose is given 2 minutes before the painful procedure.
      
   • Concern for hyperglycemia and feeding intolerance may be present if sucrose is given for multiple, sequential painful procedures.

Cognitive

1. Information giving
    
   • Establish rapport with, and gain the confidence of, the infant's parents.
      
   • Parents of neonates should be given accurate information and realistic expectations about their infant's pain experience; explain the rationale for what is happening, and describe specific sensations that the infant may experience; this may decrease the stress and discomfort they may be experiencing in seeing their infant undergo painful procedures/treatments.
      
2. Choices & control - Allow the parent(s) to be present for a painful procedure (as appropriate, depending on the procedure being performed.
    
   • Proceed in an "unhurried" manner.
      
3. Distraction - music, colored objects, mobiles, providing something that can be grasped by the infant, rhythmic rocking.

B. TODDLERS:

Sensory/physical

1. Procedures should ideally be done in the treatment room, so that their hospital room remains a "safe" place.
    
   • Be prepared (i.e., set up for the procedure) in advance of bringing the child to the treatment room.
      
2. Modification of environmental stimuli
    
   • Cover crib with blankets
   • Close doors gently/quietly
   • Avoid loud voice(s)
   • Set phone ring at lowest volume possible
   • Decrease amount of noise from radios, tape recorders, etc.
   • Cluster nursing care activities
   • Allow periods of undisturbed rest
   • Gentle manipulation of tubes and lines
   • Careful removal of tape from skin
      
3. Positioning - Hugging and holding; insuring proper body alignment; position of comfort may depend on underlying condition (e.g., HOB elevated, legs slightly elevated, following abdominal surgery; HOB flat for spinal headache, etc.)
    
   • Suggested positioning for procedures includes having the child sit on the parent's lap
      
   • Parents should not be asked to restrain their child for a procedure, as trust may be violated. The parent's role is to comfort the child & engage their attention.
      
4. Simple massage or rubbing of painful areas - Massage can be used to relieve pain and spasm, mobilize contracted muscle through measures that assist the return flow and circulation of blood
    
   • Rubbing the site of injury (e.g., children receiving finger pricks and IM injections report less pain when they rub the site of the injection deeply, immediately before and after the invasive procedure)
      
5. Heat - A hot pack, warm blanket, or heating pad can be used to improve circulation, facilitate muscle relaxation, and promote pain relief.
    
   • To provide moist heat, a washcloth can be dampened with warm tap water and applied directly to the area and covered with a disposable diaper or chux; remove as soon as the compress becomes cool; reapply as indicated.
      
6. Cold - Ice and other surface cooling devices reduce swelling and provide some mild degree of analgesia for superficial procedures.
    
   • Wrap a cold pack with a towel, or apply ice directly to the skin, which requires special attention to prevent skin irritation and further injury.
      
   • Use an ice cube, or freeze water in a disposable cup (the ice is held through the cup, and the cup is peeled back to expose the ice).
      
   • If a painful procedure is being done, begin ice massage one minute or longer prior to the beginning of the procedure.
      
   • After 10 minutes, stop the ice application or change sites stop the procedure if the skin begins to blanch or if the toddler does not tolerate the ice application (i.e., becomes more distressed, agitated).
      

Cognitive

1. Information giving
    
   • Establish rapport with, and gain the confidence of, the child and parent
      
   • Toddlers comprehend little preparatory information about procedures; however, parents should be provided with accurate information and realistic expectations about their child's pain experience (i.e., describe specific sensations that their child will experience, explain the rationale for what is happening).
      
   • If possible, talk with the child/parent in a room other than the treatment room; providing/obtaining information in a less threatening atmosphere may help to decrease anxiety.
      
2. Choices & control
    
   • Incorporate the assistance of parents as much as possible; the child may respond more positively, and the parents may feel more helpful by assisting their child.
      
   • If parent(s) will be present during a procedure, it is often necessary to provide specific information about their participation (i.e., where they can sit/stand, and what they can do).
      
   • Proceed in an "unhurried" manner.
      
3. Distraction - Toddlers are highly distractible, so play and passive distraction are very useful.
    
   • Materials and techniques that "quickly" capture and sustain the toddler's attention are most likely to be effective.
      
   • Save the materials most likely to distract the child for the procedure itself, rather than using them before the procedure.
      
   • It is extremely important to have a number of materials available so that new ones can be introduced as the child tires of the previous one.
      
   • The introduction of distraction interventions before the Child enters the treatment room can decrease anticipatory upon entry to the treatment room may impede their ability to attend to these materials after entering the room.
      
   • Materials that have auditory and visual stimulation (e.g., such as pop-up books, books with buttons to press for sounds and music, "drippy" toys) are very effective.
      
   • Blowing bubbles (by the child), or blowing them on the child's toes.
      
   • Music, singing.

Cognitive/Behavioral

1. Modeling, role-playing, and behavioral rehearsal - Modeling may be used to instruct the parents of young children in ways to assist their child during painful procedures.
    
   • Modeling the behavioral interventions (i.e., showing parents what to do with the materials) may be needed.
      
   • It can be helpful for healthcare personnel to begin using the materials and then transfer these materials to the parents while they continue with the procedure.
      
2. Art and play - Allows the child to express his/her feelings and concerns through the medium of art or play, when verbal methods are unsuccessful, providing an opportunity to detect/correct misinformation.
    
   • Crayons, markers, paints, puppets, dolls, and medical equipment/supplies are used.
      
   • The therapeutic use of art or play is especially useful in the routine preparation of children for surgery or other painful procedures.
      

C. PRESCHOOL:

Sensory/physical

1. Procedures should ideally be done in the treatment room, so that their hospital room remains a "safe" place.
    
   • Be prepared (i.e., set up for the procedure) in advance of bringing the child to the treatment room
      
2. Modification of environmental stimuli:
    
   • Dim or turn off the room lights
   • Close doors gently/quietly
   • Avoid loud voices
   • Set phone ring at lowest volume possible
   • Decrease amount of noise from radios, tape recorders, etc.
   • Cluster nursing care activities
   • Allow periods of undisturbed rest
   • Gentle manipulation of tubes and lines
   • Careful removal of tape from skin
      
3. Positioning - Hugging and holding; insuring proper body alignment; position of comfort may depend on underlying condition (e.g., HOB elevated, legs slightly elevated, following abdominal surgery; HOB flat for spinal headache, etc.).
    
   • Suggested positioning for procedures includes having the child sit on the parent's lap
      
   • Parents should not be asked to restrain their child for a procedure, as trust may be violated. The parent's role is to comfort the child & engage their attention.
      
4. Deep breathing - taking a deep breath and slowly blowing away anything bothersome, such as the hurt or scary feelings.
    
5. Muscle relaxation - Several different types of muscle relaxation are used in helping children with pain; the type most effective with preschool children is:
    
   • Mini-relaxation, a brief relaxation exercise in which deep breathing is used to trigger relaxation throughout the body. Typically, 5 slow, deep breaths are accompanied by suggestions of calmness and relaxation.
      
6. Simple massage or rubbing of painful areas - Massage can be used to relieve pain and spasm, mobilize contracted muscle through measures that assist the return flow and circulation of blood
    
   • Rubbing the site of injury (e.g., children receiving finger pricks and IM injections report less pain when they rub the site of the injection deeply, immediately before and after the invasive procedure)
      
7. Heat - A hot pack, warm blanket, or heating pad can be used to improve circulation, facilitate muscle relaxation, and promote pain relief.
    
   • To provide moist heat, a washcloth can be dampened with warm tap water and applied directly to the area and covered with a disposable diaper or chux; remove as soon as the compress becomes cool; reapply as indicated.
      
8. Cold - Ice and other surface cooling devices reduce swelling and provide some mild degree of analgesia for superficial procedures.
    
   • Wrap a cold pack with a towel, or apply ice directly to the skin, which requires special attention to prevent skin irritation and further injury.
      
   • Use an ice cube, or freeze water in a disposable cup (the ice is held through the cup, and the cup is peeled back to expose the ice).
      
   • Explain to the child that the ice will be very cold; if the child becomes distressed or uncomfortable with the ice application, it can be stopped
      
   • Allow the child to perform the ice application, if possible
      
   • If a painful procedure is being done, begin ice massage one minute or longer prior to the beginning of the procedure.
      
   • After 10 minutes, stop the ice application or change sites; stop if the skin becomes blanched.
      

Cognitive

1. Information giving -
    
   • Establish rapport with, and gain the confidence of, the child and parent
      
   • Preparatory information about procedures should be brief, and geared to the child's level, using language that the child understands; provide realistic expectations about the child's pain experience (i.e., describe specific sensations that their child will experience); if given too far in advance of the procedure, preparatory information may contribute to increased anticipatory anxiety
      
   • Children should never be lied to; deceiving children will likely increase their anxiety, wondering when the next procedure may occur
      
   • If possible, talk with the child/parent in a room other than the treatment room; providing/obtaining information in a less threatening atmosphere may help to decrease anxiety.
      
2. Choices & control - Give children simple choices to increase control whenever possible (e.g., choosing which arm for an injection, deciding whether to participate actively)
    
   • Listen to and validate the concerns (fears) of the child.
      
   • Incorporate the assistance of parents as much as possible; the child may respond more positively, and the parents may feel more helpful by assisting their child.
      
   • Proceed in an "unhurried" manner.
      
3. Distraction
    
   • Materials and techniques that "quickly" capture and sustain the child's attention are most likely to be effective.
      
   • Save the materials most likely to distract the child for the procedure itself, rather than using them before the procedure.
      
   • It is extremely important to have a number of materials available so that new ones can be introduced as the child tires of the previous one.
      
   • Materials that have auditory and visual stimulation (e.g., such as pop-up books, books with buttons to press for sounds and music, visual/tactile toys (e.g., "drippy" toys) are very effective.
      
   • Reading a story may be distracting; however, incorporating the child's involvement by asking him or her to seek pictures or guess what happens on the next page may be more captivating.
      
   • Blowing bubbles (by the child), or blowing them on the child's toes.
      
   • Music, singing.

Cognitive/Behavioral

1. Modeling, role-playing, and behavioral rehearsal - Modeling is a behavior portrayed to a child (or parent) in order for the child (or parent) to learn that behavior.
    
   • Modeling can be taught by a live model or by a videotape and can use people, cartoon characters, dolls or puppets.
      
   • Role-playing and behavioral rehearsal involve "pretending" to be in a situation and practicing what to do.
      
   • Modeling, role-playing, and behavioral rehearsal are usually used to increase adaptive, and decrease maladaptive coping strategies.
      
   • Modeling behavioral interventions to the child's parents (i.e., showing the parents what to do with distraction materials) may also be needed.
      
   • It can be helpful for healthcare personnel to begin using the materials and then transfer these materials to the parents while the healthcare provider continues with the procedure.
      
2. Art and play - Allows the child to express his/her feelings and concerns through the medium of art or play, when verbal methods are unsuccessful, providing an opportunity to detect/correct misinformation.
    
   • Crayons, markers, paints, puppets, dolls, and medical equipment/supplies are used.
      
   • The therapeutic use of art or play is especially useful in the routine preparation of children for surgery or other painful procedures.
      
3. Desensitization - Graduated or staged approach to teaching the child to cope with the pain (e.g., training in relaxation & deep breathing, followed by exposure to the environment/room where the procedure will be performed, followed by practicing positioning for the procedure, etc.).
    

D. SCHOOL-AGE:

Sensory/physical

1. Procedures should ideally be done in the treatment room, especially for younger patients, so that their hospital room remains a "safe" place.
    
   • Be prepared (i.e., set up for the procedure) in advance of bringing the child to the treatment room
      
   • Older children can be given the option of where they would like the treatment, if possible.
      
2. Modification of environmental stimuli:
    
   • Dim or turn off the room lights
   • Close doors gently/quietly
   • Avoid loud voice(s)
   • Set phone ring at lowest volume possible
   • Decrease amount of noise from radios, tape recorders, etc.
   • Cluster nursing care activities
   • Allow periods of undisturbed rest
   • Gentle manipulation of tubes and lines
   • Careful removal of tape from skin
      
3. Positioning - Hugging and holding; insuring proper body alignment; position of comfort may depend on underlying condition (e.g., HOB elevated, legs slightly elevated, following abdominal surgery; HOB flat for spinal headache, etc.).
    
   • Parents should not be asked to restrain their child for a procedure, as trust may be violated. The parent's role is to comfort the child & engage their attention.
      
4. Deep breathing - taking a deep breath and slowly blowing away anything bothersome, such as the hurt or scary feelings.
    
5. Muscle relaxation - Several different types of muscle relaxation are used in helping children with pain, including:
    
   • Mini-relaxation, a brief relaxation exercise in which deep breathing is used to trigger relaxation throughout the body. Typically, 5 slow, deep breaths are accompanied by suggestions of calmness and relaxation.
      
   • Tension-relaxation (progressive muscle relaxation), requires the alternate tension and relaxation of muscle groups. Typically,instructions are given to tense and hold a muscle group for 5-10 seconds, to notice the feel the tension in the muscles, and then to release the tension and relax the muscle group. Often these instructions are combined with suggestions of relaxation, heaviness and warmth, and images of relaxing situations. The muscle groups used vary,and it is not clear that any specific muscle groupings are better than any other.
      
   • Suggestion method of relaxation, includes repeat calming, relaxation, heaviness, and warmth. These are often combined with pleasant imagery of being relaxed. The suggestion method of relaxation is similar to the tension-relaxation method without the tension. Audiotapes can be made for children to take home, with instructions so children can practice relaxation technique.
      
   • Differential relaxation, refers to learning to relax one part of the body while maintaining sufficient tension in other parts of the body (e.g., an adolescent with migraine might learn to relax her jaw and shoulders while maintaining tension in her arms and trunk necessary for her to continue with her class work).
      
6. Simple massage or rubbing of painful areas - Massage can be used to relieve pain and spasm, mobilize contracted muscle through measures that assist the return flow and circulation of blood.
    
   • Rubbing the site of injury (e.g., children receiving finger pricks and IM injections report less pain when they rub the site of the injection deeply, immediately before and after the invasive procedure).
      
7. Heat - A hot pack, warm blanket, or heating pad can be used to improve circulation, facilitate muscle relaxation, and promote pain relief.
    
   • To provide moist heat, a washcloth can be dampened with warm tap water and applied directly to the area and covered with a disposable diaper or chux; remove as soon as the compress becomes cool; reapply as indicated.
      
8. Cold - Ice and other surface cooling devices reduce swelling and provide some mild degree of analgesia for superficial procedures.
    
   • Wrap a cold pack with a towel, or apply ice directly to the skin, which requires special attention to prevent skin irritation and further injury.
      
   • Use an ice cube, or freeze water in a disposable cup (the ice is held through the cup, and the cup is peeled back to expose the ice).
      
   • Explain to the child that the ice will be very cold and that, initially, its application may be uncomfortable, going through states of cold, to burning and aching and finally numbness; remind the child that if it is uncomfortable, it can be stopped.
      
   • Allow the child to perform the ice application, if possible.
      
   • If a painful procedure is being done, begin ice massage one minute or longer prior to the beginning of the procedure.
      
   • After 10 minutes, stop the ice application or change sites; also, stop if the child requests it or if the skin becomes blanched.
      
9. Exercise - General exercise regimens are an important component of pain management for children experiencing recurrent or persistent pain, as well as for children requiring multiple and repeated painful treatments. The objective is to restore as many of children's normal activities as possible, focusing on activities that are enjoyable and physically possible for the child.
    
   • Children with persistent pain may withdraw from participation in normal physical activities, losing flexibility. Simple stretching exercises for 10-20 minutes, several times a week, can help children to maintain their flexibility.
      
   • Simple repetitive physical exercises, such as rhythmically moving an arm or leg, can also be useful.
      
10. Transcutaneous Electrical Nerve Stimulation (TENS) - A battery-powered current generator produces a nonpainful electrical stimulus (e.g.,buzzing, tingling or vibrating sensation) delivered transcutaneously by two or more surface electrodes. Superficial pain appears to be more sensitive to the palliative effects of TENS than does deep,visceral pain.
     
    • The analgesic properties of conventional TENS are thought to involve selective stimulation of large myelinated afferent A fibers, inhibiting A-delta and C-fiber (pain fibers) activity and thereby inhibiting nociception (pain perception). Others suggest that TENS works by increasing endorphins or increasing blood supply to the area of stimulation.
       
    • TENS requires a physician order; contact Physical Therapy to obtain a TENS unit and to provide assistance with application.
       
11. Acupuncture - Acupuncture is part of a comprehensive system of traditional Chinese medicine that involves the insertion of needles into certain points of the body to restore a balance between opposing "forces" which shape life (i.e., Yin and Yang). The desired therapeutic result is achieved by mechanical stimulation with manual turning and twirling of the needle, or by electrical stimulation with the application of a direct pulsating current to the needle. May require several treatments over the course of weeks or months.
     
    • Acupuncture may be considered for severe acute, subacute, or recurrent acute pain, lasting hours or days. Many children have accepted this method of treatment, despite the insertion of needles.
       
    • Acupuncture is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic.
       
12. Acupressure - Acupressure is acupuncture without needles. It usually consists of applying pressure to traditional acupuncture points. This may be done with the thumb, tip of the index finger, palm of the hand or sometimes the fingernail; squeezing or pinching may also be used to apply pressure.
     
    • Acupressure is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic.
       

Cognitive

1. Information giving
    
   • Establish rapport with, and gain the confidence of, the child and parent
      
   • If possible, talk with the child/parent in a room other than the treatment room; providing/obtaining information in a less threatening atmosphere may help to decrease anxiety.
      
   • Find out what the child's expectations are about what is going to happen (i.e., what the child has been told or what he/she thinks will happen)
      
   • If the child's expectations are inaccurate, correct any misperceptions that may be present; provide concrete information, and describe specific sensations that the child will experience
      
   • Give accurate information and realistic expectations about their pain; children should never be lied to; deceiving children will likely increase their anxiety, wondering when the next procedure may occur
      
   • Explain the rationale for what is happening
      
   • Provide information about "pain gates" and strategies that children can use to "close the gates"
      

   NOTE:

   The extent of detailed information that a child receives should be based on the child's individual needs and interests.

2. Choices & control - Give children simple choices to increase control whenever possible (e.g., choosing which arm for an injection, deciding whether to participate actively).
    
   • Listen to and validate the concerns (fears) of the child.
      
   • Allow the parent(s) present for a painful procedure, if requested by the child; it is often necessary to be very specific with parents (i.e., where they can sit/stand, and what they can do).
      
   • Proceed in an "unhurried" manner.
      
3. Distraction - Distraction strategies should be interesting to the child, consistent with the child's energy level and ability to concentrate, stimulate the major sensory modalities (hearing, vision,touch, movement), and be capable of providing a change in stimuli when the pain changes (e.g., increasing stimuli as pain increases).
    
   • Reading/telling a story.
      
   • Materials that have auditory and visual stimulation (e.g., music, "drippy" toys) are very effective.
      
   • Conversation, humor, singing.
      
   • Counting (e.g., 1...2...3, before an injection; or, let's count to 25 and see if the pain is gone).
      
   • Games.
      
   • Hand-held computers (e.g., game boys)
      
4. Guided imagery - A type of deliberate directed daydreaming. It is a specific method of distraction and attention, in which health professionals or parents guide children to remember and vividly describe some previous positive experience, a story that they have seen, read, or written, or relaxing pain-free sensations associated with pleasurable activities. The more vividly children imagine their positive experiences, the less pain they experience.
    
5. Hypnosis - Hypnosis creates an altered state of consciousness within a relaxed physical state. It is an internal, imaginative process to focus attention and become absorbed so that a trance is entered in which perceptions and sensations can be enhanced, modified, or changed. School-age children and adolescents can absorb themselves into the hypnotic trance far more easily and rapidly than adults. Using the child's own experiences, enthusiasms, or interests makes the experience more attractive and absorbing.
    
   • Hypnosis can be taught to the child by the clinical psychologist or psychiatrist.
      
6. Thought-stopping - Method of training a child how to "stop thinking about the pain," to divert their thoughts to something different when they begin to focus on or think about the pain.
    
   • Thought-stopping can be taught to the child by the clinical psychologist or psychiatrist.
      
7. Psychotherapy - Treatment of psychiatric symptoms (e.g., depressed mood, anxiety, or behavior problems) which can occur in response to untreated acute or chronic pain.
    
   • Requires MD referral to clinical psychiatrist

Cognitive/Behavioral

1. Modeling, role-playing, and behavioral rehearsal - Modeling is a behavior portrayed to a child (or parent) in order for the child (or parent) to learn that behavior.
    
   • Modeling can be taught by a live model or by a videotape and use people, cartoon characters, dolls or puppets.
      
   • Role-playing and behavioral rehearsal involve "pretending" to be in a situation and practicing what to do.
      
   • Modeling, role-playing, and behavioral rehearsal are usually used to increase adaptive, and decrease maladaptive coping strategies.
      
   • Modeling behavioral interventions to the child's parents (i.e., showing the parents what to do with distraction materials) may also be needed.
      
   • It can be helpful for healthcare personnel to begin using the materials and then transfer these materials to the parents while the healthcare provider continues with the procedure.
      
2. Art and play - Allows the child to express his/her feelings and concerns through the medium of art or play, when verbal methods are unsuccessful, providing an opportunity to detect/correct misinformation.
    
   • Crayons, markers, paints, puppets, dolls, and medical equipment/supplies are used.
      
   • The therapeutic use of art or play is especially useful in the routine preparation of children for surgery or other painful procedures.
      
3. Desensitization - Graduated or staged approach to teaching the child to cope with the pain (e.g., training in relaxation & deep breathing, followed by exposure to the environment/room where the procedure will be performed, followed by practicing positioning for the procedure, etc.).
    
4. Biofeedback - Consists of the measurement and control of a physiological response usually not thought to be under voluntary control. The physiological response is amplified or transformed to that the response can be monitored and understood by the patient. The patient then attempts to modify the response. Children quickly learn the significance of the auditory or visual feedback and can be taught to use this modality independently at home.
    
   • Biofeedback is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic. Requires special equipment, as well as training and certification of personnel to perform biofeedback.
      
   • Can be used in the reeducation of muscles, for relaxation of overactive or spastic muscles, or for motor unit recruitment in a poorly contracting muscle.
      
   • Studies on pain demonstrate that both the intensity and duration of pain can be altered by changing the physiological correlate appropriate to the specific pain syndrome (e.g., EMG-feedback training for muscular-tension headaches)
      
5. Behavior modification - Planned change in the way that a person behaves by means of rewarding (verbal and tangible) desired behavior and ignoring or punishing undesirable behavior. A consistent approach in altering pain-associated behavior or in encouraging patient activities is essential for success.
    
   • Parent/provider responses to the child's pain and the situation (e.g., displaying frustration or calmness, providing encouragement or scolding for children's behavior) may also need to be addressed.
      
   • Parental training in behavioral modification methods can be provided.
      

E. ADOLESCENT/ADULT:

Sensory/physical

1. Procedures should ideally be done in the treatment room, especially for younger patients, so that their hospital room  remains a "safe" place.
    
   • Be prepared (i.e., set up for the procedure in advance of bringing the child to the treatment room)
      
   • Adolescents/adults can be given the option of where they would like the treatment, if possible.
      
2. Modification of environmental stimuli:
    
   • Dim or turn off the room lights
   • Close doors gently/quietly
   • Avoid loud voices
   • Set phone ring at lowest volume possible
   • Decrease amount of noise from radios,tape recorders,etc.
   • Cluster nursing care activities
   • Allow periods of undisturbed rest
   • Gentle manipulation of tubes and lines
   • Careful removal of tape from skin
      
3. Positioning - Holding a hand; insuring proper body alignment;  position of comfort may depend on underlying condition (e.g., HOB elevated, legs slightly elevated, following abdominal surgery; HOB flat for spinal headache, etc.).
    
4. Deep breathing - taking a deep breath and slowly blowing away anything bothersome, such as the hurt or scary feelings.
    
5. Muscle relaxation - Several different types of muscle relaxation are used in helping children with pain, including:
    
   • Mini-relaxation, a brief relaxation exercise in which deep breathing is used to trigger relaxation throughout the body. Typically, 5 slow deep breaths are accompanied by suggestions of calmness and relaxation.
      
   • Tension-relaxation (progressive muscle relaxation), requires the alternate tension and relaxation of muscle groups. Typically, instructions are given to tense and hold a muscle group for 5-10 seconds, to notice the feeling of tension in the muscles, and then to release the tension and relax the muscle group. Often these instructions are combined with suggestions of relaxation, heaviness and warmth, and images of relaxing situations. The muscle groups used vary, and it is not clear that any specific muscle groupings are better than any other.
      
   • Suggestion method of relaxation, includes repeated suggestions of calming, relaxation, heaviness, and warmth. These are often combined with pleasant imagery of being relaxed. The suggestion method of relaxation is similar to the tension-relaxation method without the tension. Audiotapes can be made for children to take home, with instructions, so children can practice relaxation technique.
      
   • Differential relaxation, refers to learning to relax one part of the body while maintaining sufficient tension in other parts of the body (e.g., an adolescent with migraine might learn to relax her jaw and shoulders while maintaining tension in her arms and trunk necessary for her to continue with her class work).
      
6. Simple massage or rubbing of painful areas - Massage can be used to relieve pain and spasm, mobilize contracted muscle through measures that assist the return flow and circulation on blood.
    
   • Rubbing the site of injury(e.g., following finger pricks or IM injections, if not contraindicated)
      
7. Heat - A hot pack, warm blanket, or heating pad can be used to improve circulation, facilitate muscle relaxation, and promote pain relief.
    
   • To provide moist heat, a washcloth can be dampened with warm tap water and applied directly to the area and covered with a disposable diaper or chux; remove as soon as the compress becomes cool; reapply as indicated.
      
8. Cold - Ice and other surface cooling devices reduce swelling and provide some mild degree of analgesia for superficial procedures.
    
   • Wrap a cold pack with a towel, or apply ice directly to the skin, which requires special attention to prevent skin irritation and further injury.
      
   • Use an ice cube, or freeze water in a disposable cup (the ice is held through the cup, and the cup is peeled back to expose the ice).
      
   • Explain that the ice will be very cold and that, initially, its application may be uncomfortable, going through states of cold, to burning and aching and finally, numbness; if it becomes uncomfortable, it can be stopped.
      
   • Allow the patient to perform the ice application, if possible.
      
   • If painful procedure is being done, begin ice massage one minute or longer prior to the beginning of the procedure.
      
   • After 10 minutes, stop the ice application or change sites; stop if the skin becomes blanched.
      
9. Exercise - General exercise regimens are an important component of pain management for patients experiencing recurrent or persistent pain, as well as for the patients requiring multiple and repeated painful treatments. The objective is to restore as many of the patient's normal activities as possible, focusing on activities that are enjoyable and physically possible for the patient.
    
   • Patients with persistent pain may withdraw from participation in normal physical activities, losing flexibility. Simple stretching exercises for 10-20 minutes, several times a week, can help patients to maintain their flexibility.
      
   • Simple repetitive physical exercises, such as rhythmically moving an arm or leg, can also be useful.
      
10. Transcutaneous Electrical Nerve Stimulation (TENS)- A battery-powered current generator produces a nonpainful electrical stimulus (e.g., buzzing, tingling or vibrating sensation), delivered transcutaneously by two or more surface electrodes. Superficial pain appears to be more sensitive to the palliative effects of TENS than does deep, visceral pain.
     
    • The analgesic properties of conventional TENS are thought to involve selective stimulation of large myelinated afferent A fibers, inhibiting A-delta and C-fiber (pain fibers) activity and thereby inhibiting nociception (pain perception). Others suggest that TENS works by increasing endorphins or increasing blood supply to the area of stimulation.
       
    • TENS requires a physician order; contact Physical Therapy to obtain a TENS unit and to provide assistance with application.
       
11. Acupuncture - Acupuncture is part of a comprehensive system of traditional Chinese medicine that involves the insertion of needles into certain points of the body to restore a balance between opposing "forces" which shape life (i.e., Yin and Yang). The desired therapeutic result is achieved by mechanical stimulation with manual therapeutic result is achieved by mechanical stimulation with manual turning and twirling of the needles, or by electrical stimulation with the application of a direct pulsating current to the needles. May require several treatments over the course for weeks or months.
     
    • Acupuncture may be considered for severe acute, subacute, or recurrent acute pain, lasting hours or days. Many children have accepted this method of treatment, despite the insertion of needles.
       
    • Acupuncture is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic.
       
12. Acupressure - Acupressure is acupuncture without needles. It usually consists of applying pressure to traditional acupuncture points. This may be done with the thumb, tip of the finger, palm of the hand or sometimes the fingernail; squeezing or pinching may also be used to apply pressure.
     
    • Acupressure is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic.
       

Cognitive

1. Information giving:
    
   • Establish rapport, with, and gain the confidence of, the patient
      
   • If possible, talk with the patient in a room other than the treatment room; providing/obtaining information in a less threatening atmosphere may help to decrease anxiety.
      
   • Give accurate information and realistic expectations about their pain; describe specific sensations that the patient will experience.
      
   • Explain the rational for what is happening.
      
   • Provide information about "pain gates" and strategies that patients can use to "close gates".
      
2. Choices & Control - Give patients simple choices to increase control whenever possible (e.g., choosing which arm for an injection, deciding whether to participate actively, deciding whether his-her parent will be present during the procedure).
    
   • Listen to and validate the concerns (fears) of the patient.
      
   • Proceed in an "unhurried" manner.
      
3. Distraction - Distraction strategies should be interesting to the patient, consistent with his/her energy level and ability to concentrate, stimulate the major sensory modalities (hearing, vision, touch, movement), and be capable of providing a change in stimuli when the pain changes (e.g., increasing stimuli as pain increases).
    
   • Conversation, humor.
      
   • Materials that have auditory and visual stimulation (e.g., music, "drippy toys) are very effective.
      
   • Counting (e.g., 1& 2& 3& before an injection).
      
   • Games.
      
   • Hand-held computers e.g., game boys.
      
4. Guided imagery - A type of deliberate directed daydreaming. It is a specific method of distraction and attention, in which health professionals of parents guide children to remember and vividly describe some previous positive experience, a story that they have seen, read, or written, or relaxing pain-free sensations associated with pleasurable activities. The more vividly patients imagine their positive experience, the less pain they experience.
    
5. Hypnosis - Hypnosis creates an altered state of consciousness within a relaxed physical state. It is an internal, imaginative process to focus attention and become absorbed to that a trance is entered in which perceptions and sensations can be enhanced, modified, or change. School-age children and adolescents can absorb themselves into the hypnotic trance far more easily and rapidly that adults. Using the patient's experiences, enthusiasms, or interests makes the experience more attractive and absorbing.
    
   • Hypnosis can be taught to the patient by the clinical psychologist or psychiatrist
      
6. Thought-stopping - Method of training a patient how to "stop thinking" about the pain," to divert their thoughts to something different when they begin to focus on or think about the pain.
    
   • Thought-stopping can be taught to the patient by the clinical psychologist or psychiatrist.
      
7. Psychotherapy - Treatment of psychiatric symptoms (e.g., depressed mood, anxiety, or behavior problems) which can occur in response to untreated acute or chronic pain.
    
   • Requires MD referral to clinical psychiatrist.
      

Cognitive/Behavioral

1. Modeling, role-playing, and behavioral rehearsal - Modeling is a behavior portrayed to the patient in order for the patient to learn that behavior.
    
   • Modeling can be taught by a live model or by a videotape and can use people or cartoon characters.
      
   • Role-playing and behavioral rehearsal involve "pretending" to be in a situation and practicing what to do.
      
   • Modeling, role-playing, and behavioral rehearsal are usually used to increase adaptive, and decrease maladaptive coping strategies.
      
2. Art - Allows the patient to express his/her feelings and concerns through the medium of art, when verbal methods are unsuccessful.
    
   • Colored pencils, markers, paints.
      
3. Biofeedback - Consists of the measurements and control of a physiological response usually not thought to be under voluntary control. The physiological response is amplified or transformed to that the response can be monitored and understood by the patient. The patient then attempts to modify the response. Patients quickly learn the significance of the auditory or visual feedback and can be taught to use this modality independently at home.
    
   • Biofeedback is currently not available as an inpatient service; however, a referral can be made to a community-based office/clinic. Requires special equipment, as well as training and certification of personal to perform biofeedback.
      
   • Can be used in the reeducation of muscles, for relaxation of overactive or spastic muscles, or for motor unit recruitment in a poorly contracting muscle.
      
   • Studies on pain demonstrate that both the intensity and duration of pain can be altered by changing the physiological correlate appropriate to the specific pain syndrome (e.g., EMG-feedback training for muscular-tension headaches).
      
4. Behavior modification - Planned change in the way that a person behaves by means of rewarding (verbal and tangible) desired behavior and ignoring or punishing undesirable behavior. A consistent approach in altering pain-associated behavior or in encouraging patient activities is essential for success.
    
   • Parent/significant other/provider responses to the patient's pain and the situation (e.g.,displaying frustration or calmness, providing encouragement or scolding for children's behavior)may also need to be addressed.
      

OTHER INFORMATION:

See Pain Management Policy and Pain TX Flow Chart located in Patient Care Operations Manual: Divisional Standards.

REFERENCES:

Campos, R.G. (1989). Soothing pain-elicited distress in infants with swaddling and pacifiers. Child Development. 60(4), 781-792

Heriza, C.B., & Sweeney, J.K. (1990) Effects of NICU intervention on preterm infants, Part 2. Infants and young Children. 2(4), 29-41

McGrath, P.A., & Unruh, A.M. (1987). Pain in children and adolescents. Amsterdam: Elsevier.

McGrath, P.A., & Hillier, L.M. (1996). Controlling children's pain. Om R.J. Gatchel & D.C. Turk (Eds.), Psychological Approaching to Pain Management: A Practitioner's Handbook, New York: The Guilford Press.

Schechter, N.L., Berde, C.B., & Yaster, M. (Eds). (1993). Pain in Infants, Children, and Adolescents. Baltimore: Williams & Wilkins.

Short, M.A., Brooks-Brunn, J.A., Reeves, D.S., Yeager, J., & Thorpe, J.AA (196).The Effects of swaddling versus standard positioning on neuromuscular development in very low birth weight infants. Journal of Neonatal Nursing, 15(4),25-31.

Stevens, B. (1996). Pain management in newborns: How far have we progressed in research and practice? Birth, 23(4), 229-235.

Vessey, J.A., & Carlson, K.L. (1996). Nonpharmacologic interventions to use with children in pain. Issues in Comprehensive Pediatric Nursing, 19, 169-182.

Zeltzer, L.K., Bush, J.P., Chen, E., & Riveral, A. (1997). A psychobiologic approach to pediatric pain: Part II. Prevention and treatment. Current Problems in Pediatrics, 27, 264-284.

Approval: Nursing Practice Team 11/98 IPPC 12/98

Review: 12/00

Revision:

Distribution: Valley Children's Hospital

Last Updated: May 23, 2001