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. You may use the photos along with this template “as is,” as well as for modified versions of this presentation that you create yourself. Please do not use the photos for other purposes beyond your presentation (i.e. websites, flyers, iPad apps, prep books, etc.)
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.
You may choose to add a picture of your Child Life Team to give a visual to your audience. Pictures of the playroom and other specific areas give a good visual and can add some local “color” to the presentation.

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,

8. How Child Life Can Help Play Diagnosis education Preparation Support
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
Feel free to add information based on what common techniques your facility utilizes.

10. American Academy of Pediatrics
“CCLSs are often directly involved in the utilization of nonpharmacologic pain 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
Disassociation- thinks of pleasant experience versus pain
Suggest- if favorite place the beach coach can suggest ‘can you feel the breeze?’
Purpose: to bring pt to an altered stated that gives them control; brings them to a state that is not compatible with pain. Patient has to 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
Guided imagery is most useful for longer procedures, compared to procedures that are a shorter length of time, due to the amount of time to discuss the scene in great detail and utilize all senses.
Feel free to discuss your favorite guided imagery script or provide in detail a description of the magic glove technique…Here is a link to the magic glove technique from the CLC

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), doi: /j.pedn
Supine position is vulnerable for the child, as they are lying flat
Allows the parent or caregiver to be involved

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
Fewer People…nurse-wise are needed to complete the procedure. The parent holds the child in a comforting way.
Child moves less when sitting up and hugging caregiver
*Note: Child still cries, but studies demonstrate that child moves less
Stephens, B. K, Barkey, M. E., & Hall, H. R (1999). Techniques to comfort children during stressful procedures. Advances in Mind-Body Medicine, 15,

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
As previously mentioned, cry but tend not to move as much as lying supine
Comfort position can be used with infants
Comfort position is like a big hug, not restraining flailing arms/legs – better to get an additional nurse if necessary
If lying supine is preferred, it is another form of comfort position – child’s parent can lie on bed in comforting manner
*Very important to ask parents initially what they prefer and feel comfortable doing!!! Must consider anxiety level of parents, size of patients/parents.

16. Examples of Positioning for Comfort
IV /Blood Draw:
Straddling lap of caregiver
Side-Sitting
Consents for use of these photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint. 
Can be adapted for what works best for the patients, caregiver, and staff

17. Examples of Positioning for Comfort
IM injection in Thigh
Leg is bent over parent’s lap, keeping thigh muscle relaxed
Consents for use of these photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint. 
Can be adapted for what works best for the patients, caregiver, and staff
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,

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
Consents for use of these photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint. 

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
Consents for use of these photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint. 
Can additional details

20. Examples of Positioning for Comfort
Urinary Catheterization
Child lies with head in parent’s lap on table
Consents for use of these photos for this powerpoint are on file with the CLC.  Please do not use these photos for other purposes beyond this powerpoint. 
*I also point out is was the urinary catheterization procedure that allowed me to start using comfort positions, as parents really liked being involved in the procedure. They sit at the head of the bed either cross-legged or with each leg hanging off the bed and their child’s head sitting in the parent’s lap, with us providing something fun to distract. From a nursing standpoint, it also prevented the pt from moving his/her body upwards during the procedure, so both parties benefited. After doing it many times, the nurses became more open-minded to doing more comfort positions during other procedures.

21. Emotional Support Comforting touch Encouraging words
Developmentally appropriate medical explanations
Reduces anxiety related to anticipatory pain
impact of having hand to hold, someone to empathize
praise pt for doing well if doing well, encourage in helpful way if not
explaining steps helps to reduce 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
Give age examples

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.
Please know that these lists are not exhaustive, if you have a favorite distraction item, it might be helpful to list

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
Make sure to thoroughly inform parents as to what is occurring
Providing age-appropriate preparation to child prior to procedure taking place
Understanding that it can be stressful to parents, giving them a job (some role in distraction)

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).
Encourage presenter to list other items mentioned or speak directly to the options available at your facility.
Cold spray – aka freezy spray, often easy to use
Sucrose water – aka SweetEase or OraSweet – often effective for infants
Pharmacological Numbing Agents – JTip, EMLA, LMX, Buzzy or other vibration devices, etc.
Heat or Cold – ice or heat packs applied directly to or near the area
Soothing Items –pacifiers or teething rings

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
It is helpful for medical staff to realize that children often use play to help cope with pain.  A child who is coping well with her chronic pain by playing a video game or watching a movie may still be experience pain, and may need continued pharmacological pain management along with distraction play

28. Developmental Level of Patient
Possible Pain Management Technique
Infant
Comfort position
Emotional support
Sucrose water
Toddler
Distraction/Planned alternative focus
Pre-school
Deep breathing
School-age
Guided imagery
Adolescent

29. Remember Child 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?