PEM Pearls: This may hurt! How to manage pediatric anxiety in the ED

2016-10-26T17:04:18+00:00

screaming child

Pain and anxiety in the emergency department (ED) are two of the most common things we see in children. Pediatric patients, whether first time visitors or those with chronic illnesses, can exhibit marked anxiety and fear when in the ED setting. Child development, parenting styles and prior medical experiences will  guide their reactions in these cases. Practitioners must have a unique set of tools to work with these children and understand the optimal methods for providing care, while decreasing some of these normal reactions to a stressful environment. The most important part of treating anxiety and fear in children is recognizing it early. While pharmacologic interventions can adequately treat pain and anxiety in children, there are quick and effective approaches to avoid these medicines in many cases. Below is a structured approach to assess and reduce anxiety during examination:

The staged evaluation of a child

While a gradual approach to interacting with a child in the ED can take time, the extra 2-4 minutes you spend assessing and interacting with a child may have profound effects on the care following this period. In addition, your approach will be greatly appreciated by the observing parents. So where does the staging start?

  • Vital signs!
    • Are they crying during the blood pressure check or is the child screaming from across the room? These signs will likely indicate a certain type of patient. It also may suggest an opportunity to hold off on immediate evaluation by you, if not emergently required.
  • Outside of the room
    • Where is the child? Are they playing by themselves? Peering out of the door or curtain? A child who may need a more staged approach, may be sitting on or close to the parent.
  • In the room
    • Keep your distance at first and take the “anxiety pulse” of the room. Go in calmly and gradually make movements to engage the child. If they are clinging to the parent, start your interaction with the parent and then engage the child. Toys, bubbles, and other tools can help here. Also, take note of the parental emotions – if they are anxious, working on them may help with the child’s reception.
  • Engagement
    • Aim to stimulate curiosity. Does the child have funny shoes or socks on that you can comment on, or a special stuffed animal with them? Have them help you with a medical tool – place the otoscope cap on or use a mask as a pretend hat. Never start with the painful body area (or the ears!) – start distally and move forward as tolerated.
  • Pitfalls
    • If there is marked pain, treat it! Treating obvious pain promptly, such as with intranasal fentanyl,  will help with your later evaluation, whereas extensively evaluating before pain med administration, may trigger worse anxiety.
    • Language is key: Be cautious of language that creates false expectations, such as telling them that something which will hurt, won’t hurt. Give them options – “Some children say it feels warm, some say it feels cold”, etc.
    • Backpedal: If you step too far over the “anxiety boundary” of the child, backpedal a little bit – re-engage them with a similar technique and go from there. Expect to go back and forth
    • Coach residents and trainees who aren’t experienced before they go into rooms. Don’t expect that young trainees naturally know how to interact with children – appropriately coaching them on these techniques can save you, families, and children lots of headaches!

To learn more, check out Dr. Green-Hopkins, who will be speaking at High Risk Emergency Medicine, June 9-11, 2016 in San Francisco!


Israel Green-Hopkins, MD

Israel Green-Hopkins, MD

Assistant Clinical Professor
Pediatric Emergency Medicine and Pediatrics
Benioff Children's Hospital
University of California, San Francisco
Israel Green-Hopkins, MD

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