Feeling anxious: Reducing paediatric perioperative anxiety

Children and young people (CYP) will often feel anxious when coming to hospital for a procedure or surgery. A preoperative assessment service allows an opportunity to share information and resources on helping reduce stress and anxiety, thereby reducing need for anxiolytic premedication, on-the-day cancellations and long term sequelae of traumatic experiences. Below I talk through some key areas that we can improve in our everyday practice as healthcare professionals.

Before

• At hospital

 o   Expectations

Encourage questions; when talking to a CYP and their caregiver, we must build shared understanding of the reasons for the procedure and likely order of events. This will help them anticipate potential stressful moments, reducing anxiety.

 o   Choices 

Identify any potential choices the CYP has during the procedure. CYP will often cope better if they can choose smaller details, even if they do not have choice over whether they have the procedure.

CYP with Special Educational Needs or Disability (SEND) can discuss with healthcare professionals any specific requirements to help the day of the procedure run smoothly.

 o   Previous experiences

Past experiences of healthcare influence CYP and their caregivers. Talking about these can identify what should be repeated and what can be changed. Special clinics, play therapists and psychologists can help in certain situations.

 

•  At home

 o   Honest talk

It is important that caregivers are honest with CYP about what procedure they need and why it needs doing. Answering their questions honestly, whilst focussing on how positive they will feel when it is done, is key to building trust. They could consider a simple reward to help motivate the CYP. o

 o   When to talk

Deciding when to discuss the procedure with the CYP will vary depending on their development and understanding. Balancing enough time to ask questions and prepare, whilst minimising time spent worrying.

1.  Pre-school – a day before
2.  Primary-school – a week before
3.  Secondary-school – throughout

 o   Practice

When talking through what the CYP will have to do on the day of the procedure, play and practice will familiarise elements of the day in the safety of their home environment.

For example: having a ‘wire’ put on their finger to measure their oxygen levels, having ‘magic’ cream left on the back of their hands to numb an injection, or playing with a clear mask on their face that delivers ‘smelly’ air.

 

During

•  Caregiver

 o   Positive Language 

Talking to the CYP in a calm manner, reinforcing how well they’re doing and focussing on the procedure being finished, will help them feel less anxious. Avoid words with negative associations where possible.

 o   Positioning

CYP will often feel safer if they remain close to their caregiver. They may benefit from being held whilst sitting on their knee or lying next to them when having their procedure. Stroking/patting/rubbing provides additional distraction and comfort.

 

• Child or Young Person

 o   Coping Techniques

1. Distraction

Taking the CYP’s mind off the procedure is one of an excellent coping technique; whether through talking, looking at or doing something else.

For example: using their favourite book/toy/handheld device; some headphones to listen to music/audiobook; playing a counting/word game; or just talking about their favourite topic/what they want to do when it’s all done.

2. Visualisation

Helping a CYP imagine a favourite place/activity/person and giving them choice in what happens in that place, distracts and helps to reduce stress.

3. Breathing

Guided deep breathing techniques help relaxation and reduce anxiety. For example: whilst counting in and out for 5, or whilst imagining filling ourselves up and down with fresh air.

 

• Environment

 o   Minimise Stress

Hospitals can be stressful environments. At any stressful moments remind CYP about their practice and preparation; using the coping techniques that suit best.

 o   Minimise Fasting

 If fasting is required for the procedure encourage further drinking in line with local and national guidelines.

 o   Premedication

As healthcare professionals we might suggest that a sedative medication procedure will help reduce stress in combination with the above coping techniques.

 

After

• Recognise Achievement

Following the procedure or surgery, celebrate the CYP’s achievement, whether successful or not. If offering a reward as motivation; consider a small present, favourite activity/snack/drink or visiting a favourite place/person.

• Reflect

Talk about the experience with the CYP. Consider what went well and what could have gone better, always focussing on the positive achievement or ‘doing our best’. Focus on how you can be better prepared in future and a fun plan for the next few days going forward!

 

As well as the traditionally recognised benefits  preoperative assessment offers, it is even more importantly an opportunity for us to help a child/young person prepare and optimise their psychological wellbeing. It is an essential part of a child’s hospital journey.

Further Resources:

https://www.whatwhychildreninhospital.org.uk/anxiety-support

 

Dr Alex Norris – ST7 Anaesthetics Trainee, East Midlands

Birmingham Children’s Hospital, Fellow in Paediatric Anaesthesia.

APA PPOC (Paediatric Perioperative Care) Subcommittee Member.

APA PATRN (Paediatric Anaesthetists Trainee Research Network) Committee Member.

Royal College of Physicians Chief Registrar Alumni.