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Pediatric Phlebotomy: Princes and little devils

by Dennis Ernst • December 25, 2018


Drawing blood specimens demands the blended wisdoms of many sciences. It requires a working knowledge of anatomy (to avoid injuring patients during venipunctures), physiology (to understand the effects of hemoconcentration, fasting, posture and exercise on analytes), cryptology (to decipher physicians’ handwritten orders), and many fundamentals of physics (vacuum pressure, trajectory, velocity, resistance, turbulence, shear forces, centrifugal force, molecular decay and the effects of time, temperature and light on analytes).

But one of the most important sciences that must be mastered---especially for pediatric patients---is child psychology. Although it may seem easier to move a river than to calm a terrified child, those who understand how fear affects children know what is required to turn the Tasmanian Devil into Prince Valiant.

The phlebotomist performing a child’s first venipuncture is in a powerful position to affect how the child views every subsequent venipuncture for life. Make the first experience uneventful, and the next experience will be considerably easier for both patient and the collector. But a traumatic first experience can guarantee the next needle event will be just as traumatic. Worse, the child could become needle phobic for life.

Most of us have an innate fear of the unknown; for children, this fear is especially acute. Because capillary punctures are far less invasive and can be less traumatic for pediatrics, they should be considered before venipunctures for extremely apprehensive patients. However, when venipunctures are necessary, the importance of addressing and defusing a child’s apprehension is critical to success.

Not all parents are skilled at preparing children for the event. They may have detailed the procedure in unpleasant terms, or not at all. Your pediatric patient may have heard of traumatic blood collection experiences from their parents, siblings, friends or classmates, and have come to expect his/her own blood test will be similarly torturous. Of course, many young patients are well prepared, but those who are apprehensive deserve an extra measure of patience. The approach to preparing the pediatric patient for a venipuncture is age-specific. Because it is beyond the scope of this article to discuss all age groups, we will focus on the difficult age group of 4 years old and up. 

Preparing the pediatric patient begins the moment your eyes meet. Children can detect compassion or indifference in your face and body language just as you can read anxiety or complacency in theirs. How well you interpret and react to the patient’s state of mind plays an important role in being able to successfully manage the child’s experience.

In the case of a blood test, the fear of the unknown can often be defused in less than one minute. Here’s how:
The effect of a towering, uniformed authority is intimidating. Establish a rapport with the child by getting down to her eye level and introduce yourself. Engage in kind small-talk with a tone of voice that reflects compassion and caring. Ask questions to assess their potential to have needle phobia.

"There's nothing wrong with coming right out and asking a person how they feel about needles," says Amy Baxter, MD, CEO and Founder of MMJ Labs in a 2017 podcast. "If there is any response other than 'they don't bother me, then I would start a dialog with the patient about what works best for them. And then whatever they tell you, actually do it. Start a dialog with them and ask what works best for them, what makes it easier."

Another critical step to defusing apprehension is to walk the child through the procedure step-by-step.

Babies (26)
Step 1: In simple terms appropriate to the child’s age, explain how the tourniquet will be applied. Approximate the sensation by squeezing the child’s upper arm with your hand where the tourniquet might be applied and to the degree it will be tightened. Ask the child to make a fist.

Step 2: Giving the child ownership in the process turns her from the subject of the procedure to a participant in it, and has a powerful calming effect. Point to the antecubital area, explaining that that’s where you will look for a vein, then explain that you will cleanse the site with something “cold and smelly.” Give the child the opportunity to look the other way when the needle comes out of the sheath. Some pediatric patients won't mind watching. Baxter calls these "attenders." Others tolerate the procedure best when they are distracted.  Positioning a poster board with bandages and stickers from which she can make her selection will help provide a distraction. So will distraction cards and interactive games.

Step 3: Explain to the patient that he/she will feel a little “pinch” or “mosquito bite.” Give the child an approximation of the sensation by gently pinching the antecubital area. Then assign her a role to play in the process: to start counting when she feels the pinch. Explain that you will probably be done by the time he/she gets to 10 and that you will then put pressure on the site for a few minutes and eventually bandage it.

By explaining this procedure in advance, you turn the unknown into the known, and the fear melts away. It only takes one minute or so to walk a child through the procedure, but when the patient knows what to expect, the venipuncture has a much greater chance of proceeding without incident. Of course it remains essential to immobilize the arm during the puncture to prevent unanticipated reactions. Remember, an explosive reaction can lurk just beneath the surface of composure.

Despite your best efforts to calm an anxious child, some cannot be calmed. Should anxiety escalate to a tantrum-like refusal, all hope for an uneventful experience is lost. If a parent is available and willing, assistance may be necessary so that the procedure can be done quickly and without injury. If not, seek coworkers to assist. Under no circumstances should a puncture be attempted on a child without the assistance necessary to immobilize the intended puncture site and to protect the patient and collector from injury. But avoid applying restraint forcefully unless it is necessary to protect yourself and the patient from injury. Kids don’t like to be restrained any more than adults do. A firm, forceful grip often precipitates increased anxiety and the loss of cooperation. It is best, therefore, to use only as much assistance as is necessary to assure the success of the procedure, and no more. If the patient cannot be restrained without risking injury to the patient or collector, the physician should be notified of the difficulty in obtaining a specimen safely.

Turning the Tasmanian Devil into Prince Valiant is not easy. But with the proper training, the right level of compassion, and a rudimentary knowledge of child psychology, a painful puncture can be reduced to fantasy.


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