Every day, children are cared for in clinics and hospitals. And every day, some of them are unhappy about it; some of them deeply unhappy about it.

The contemporary practice of nursing and medical care includes health care providers having to touch their patients. This may include an abdominal exam, listening to their lungs with a stethoscope, or even slightly invasive maneuvers, such as having to put an otoscope into their ear, or a tongue depressor into their mouth. Further, we sometimes need to obtain data that, unfortunately, entails painful procedures: a finger poke to check a hemoglobin, immunizations, or placement of an intravenous (IV) catheter in ill children. In hospital settings, there are a multitude of potentially noxious procedures at our disposal to treat injury and illnesses in children. But is there a hidden cost?

With an accommodating temperament, helpful circumstances (i.e., supportive parent vibes, a fed and slept child), and a sensitive health care provider, a child may get through an exam without psychological distress (& fewer children get through procedures pleasantly). However, many children are not accustomed to, or comfortable with, having to abdicate their bodily autonomy for a stranger (and this is a good thing generally, right?!). Imposed abdication of their bodily autonomy is often met with psychological distress. This may manifest as crying, screaming, trying to get away from provider, actively fighting the provider – all along a spectrum from mild to severe, up to requiring multiple providers to “hold the child down.” While preverbal children cannot tell us how they are feeling in these moments, verbal children tell us they are anxious with escalation to terror at times. This raises the potential for psychological trauma. Or it may not. We don’t have the studies yet.

As pediatric providers, we know that developmentally, children are generally not as rational as adults in understanding the ‘why’ we need to do these things. This lack of understanding may doubly contribute to psychological trauma. Or it may not. We don’t have the studies yet.

Meanwhile, our culture is unfolding an overdue reckoning with #MeToo accountability alongside the rise of consent culture. Consent culture is generally discussed in the context of sexual relations. However the concept has been cross-matched into the act of drinking tea with a friend in a manner suggesting the importance of consent in even mundane activities. A culture of consent entails someone freely consenting to an act (without any hint of coercion or the like). But children often don’t consent – or even assent – to our care. So, how do we handle this quandary? How do we handle the rise of consent culture while simultaneously denying this right to children? After all, children are people, too, with valid feelings and needs.

Like an overly permissive parent, the system could respond to these concerns with permissiveness and allow children full reign over decisions. Obviously, this would not work so well from an individual or public health standpoint. And arguably, exposure to noxious stimuli is inevitable in life, and early exposure may build some psychological resiliency (though no doubt life, in general, provides many opportunities). So, how is our balance currently? Is there anything we, as health care providers, can do to maximize bodily autonomy while also ensuring our patients get the care that evidence says they need?

I posit that we can do better. Even without a clear understanding of how children are affected by healthcare provider actions and procedures, it may be warranted to try to minimize our harm. Here are some ideas that may improve the balance:

• Pediatric providers should consistently and gently announce to children (who have the requisite receptive language ability) what they are going to do and why. For example, “I’m going to put this stethoscope on your back now so I can hear you breathe.”
• Pediatric provider-candidates should be vetted for their innate ability to sensitively relate to children of all ages prior to program entry. Emotional intelligence and empathy testing may be supportive of this goal.
• Nursing and medical school curriculum should include simulations and evaluations which cultivate skills on anxiety-reduction for our pediatric patients.
• Children who have high anxiety with nursing or medical care should have their charts ‘flagged’ and extra interventions be considered for them (such as involving a child life therapist in their visit or spending extra time building rapport).
• Research into minimizing or transmuting painful procedures should continue. Novel developments (i.e., oral vaccines instead of intramuscular) will likely serve this cause. Unique alternatives including biofeedback, countless types of distraction, mindfulness (for older children), and even music offer analgesic properties.
• Recognize that a host of variables influence children’s reactions to nursing and medical care and procedures. Thus treatments might target various avenues, even including extrinsic influences by parents, health care providers, the medical environment, policies, and even the broader culture.

Jennifer Bevacqua is a pediatric nurse practitioner who blogs at Northwest Pediatric Education Specialists.

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