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Pediatric Respiratory System | Kids are Different: How to Treat Them That Way in Your Radiology Department
Pediatric Respiratory System | Kids are Different: How to Treat Them That Way in Your Radiology Department
2018adultsarinchapterchestdiaphragmdiaphragmaticdistendedfull videopediatricsurface
GI and GU Differences in Children | Kids are Different: How to Treat Them That Way in Your Radiology Department
GI and GU Differences in Children | Kids are Different: How to Treat Them That Way in Your Radiology Department
2018airwayarinaspiratebladderchapterchildrencommonevidentfull videoimmaturerisk
Medication Administration | Kids are Different: How to Treat Them That Way in Your Radiology Department
Medication Administration | Kids are Different: How to Treat Them That Way in Your Radiology Department
2018arinchapterdosingdrugsfluidfull videogastricglomerularpermeability
ONE Voice Method | Kids are Different: How to Treat Them That Way in Your Radiology Department
ONE Voice Method | Kids are Different: How to Treat Them That Way in Your Radiology Department
2018anxietyarinchapterdecreasefull videopatientpediatricsedationwebsite
Transcript

(faint voice talking)

So now it'll advance? Oh, perfect. Okay, here we are. All right, so we're gonna talk about anatomical and physiological differences. So what I'm trying to do is basically highlight

the major areas where we see a lot of differences, so we're gonna start kind of going head to toe. So in the neurological area, one of the main things that we really need to consider is the immaturity of the neurological system of children. And this can vary widely.

One of the major indicators for immaturity in neurological system has to do with prematurity. So finding out whether or not that child was a premature infant is very important, and their developmental level is gonna vary a lot based on their age and some of their background.

So the other area where we see a lot of differences neurologically is gonna be in the developmental differences that they have with conditions like autism. So we are gonna spend more time on development later on so I'm just gonna stop in talking about that part of it.

Some other major differences we see physically

are the fontanel. So we should have an open fontanel in infancy. Know that when you're feeling the fontanel or when you see the bulge of the fontanel that that changes with crying. So if the child is crying a lot,

it's gonna seem like it bulges. Also, it'll change based on the position that you put the patient in. So if you feel the fontanel when they're laying back and then sit them up, it's gonna feel a little bit different.

So know that it's sometimes positional. And then we have some concerns when fontanels don't close with things like macrocephaly, and so that's a condition where there's a build up of cerebral spinal fluid inside of the head and their head can get quite large

so they usually will get shunted for that. And so there's a lot of conditions that can be related to that like difficulty of breathing, their head can get quite large and somewhat heavy, and so that can be a concern when we're trying to do procedures,

and we'll talk about that a little bit later on. Also think about muscular control in the neck. So the neck, it takes a while for the child to develop the muscles of their neck so they will sometimes have head lag. Meaning that when you pick them up,

their head will sort of stay back. And so that can be a concern, especially when it comes to the respiratory system because their head can easily position forward and that can close their airway and become obstructive. So, again, positioning the child is very important to try

and decrease some of the airway complications that we see.

So we are gonna spend quite a bit of time in the pediatric respiratory system because this is one of the major areas where there's a lot of differences between adults and children. So around the age of 12 is when the anatomy of our airways

become very similar in adults and children. In childhood, they have a lot more of a chance for airway obstructions so be aware of that. When we think about obstruction, things like secretions can be obstructive as well as the position that we put the child in.

Also they have fewer alveoli. So what that means is that they have to compensate by breathing faster because there's less of a surface area for air exchange to happen, and that will change over time as our chest grows and then we increase the amount of surface area.

And they're very diaphragmatic breather. So in other words, the diaphragm is the main muscle that's doing the breathing. What that means is if we have an abdomen that's very distended or if we position children sitting up too high

where their diaphragm is not able to move well, we can actually make it more difficult for them to breathe. Also their chest is much more flexible, which is why we see retractions in children and we'll have a picture of that.

So here's a quick table that really summarizes

the major differences that we see. This is just in the upper airway of children and why some of these are important. So I'm gonna highlight some major ones. So the first one is that relatively speaking, the tongue inside the mouth is pretty large in children.

And so because of that, we wanna make sure that we start out with an oral area that's not swollen. You wanna make sure that we're taking a good look inside of their mouth. Also remember that newborns and very young children are nose breathers.

So because they depend on their nose, if they have a lot of nasal secretions, that's gonna become obstructive so we really need to make sure that we have good suction available all the time and that we're taking a look at their nose

and realizing that that's their main way of breathing. Also the tonsils and adenoids are rather large in the back of the throat, so that's another consideration. And their larynx and glottis is very high. And I have other pictures that I think will show this a lot better and that really makes a difference

when we try to position patients properly so that they have the best airway movement. Also, their epiglottis is very long and floppy. It's not in the same position as it is with an adult. So when they have any upper airway infections, if that swells, it's much more obstructive for them

than what it is for us as adults and they have fewer ability to use their muscles to cough effectively, so that can make it more difficult for them to get rid of some of these secretions.

Also remember that there's differences

in the norms for respiratory rate. So you can see as we age that our rate of respiration decreases and these numbers are just based on a resting rate. So when they're crying when they're upset, their rates are gonna get a little bit higher,

but these are the general norms for different ages. Okay, so this is the picture that I wanted to try and spend a little bit of time in. So on this side, this is a 12-year-old child. And if we look at their airway and how it sits within their neck and their head area,

it's very similar to what we see in adults, but this is a child. So some things that I wanted to point out. First of all, the epiglottis is down here. It's hard for me to see, sorry. This little area right here.

So you can see how much space that occupies of the airway and how it's almost flat. And so because of that reason, when we're opening the airway in a child, we need to put them in a position that's called the sniffing position,

which I have a nice picture of. Also you can see just how little space there is back here because of where the tongue is and the size of the neck. So that just really shows you how these anatomical differences really make a difference and can really be obstructive.

So this is the sniffing position. Are you all familiar with how to put somebody sniffing? The sniffing position, the best way to put young children in it is basically to try and move their shoulders up and you're moving their head back slightly.

So placing a towel roll or some small blanket that's folded up between the shoulders is a very easy way of putting them in that position, and that's a good way of trying to open their airway and helping them decrease some of the obstructiveness that can occur with the upper airway muscles

being a little too relaxed. This is a picture of where we see retractions. So in children because they have not fully formed, the muscles here, it's very like cartilage until your chest finally grows and it becomes ossified. There's a lot of movement that we have

when children are in distress and so we see that as retractions. And the main thing to know there is the least severe retractions begin at the bottom. so we're most likely going to see sub-costal retractions pretty early on,

but as the patient is having more difficulty, the retractions will begin to move up. So having intercostal and supersternal retractions are much worse. And the one that's not on here is you can also have sternal retractions

where the entire sternal is being sucked in every time that they breathe in, so clearly they're not getting enough oxygen. So the higher the retraction, the more concerning it is to us.

So lower airway, some major differences.

Again, their alveoli are not fully developed at birth. It takes a while for that to occur and so there's less gas exchange available to children. They also have fewer bronchioles and they're very, very narrow. So we think about foreign bodies

that can easily be lodged in there. Mucus can also very easily be lodged in there and that makes it harder for them to exchange air. Also their trachea is much shorter so it doesn't take a lot for material that's at the top of the trachea to get into the lungs.

And in addition to that, you can see how things like mucus can very quickly become obstructive. So what this is showing you here at the top is the newborn airway. It's approximately four millimeters in diameter with one millimeter of swelling.

Do we see how we now only have two millimeters of area where air can be moving through? So that's why the smaller size that we start with makes a huge difference in terms of resistance of air and obstruction. In an adult, you can see how that same amount of swelling

really make makes very little difference in our ability to exchange air. And this is a picture also of where the trachea lies. So in the adult, you can see that with the shaded area. You can see that our trachea bifurcates, it's longer and it has a little bit less of an angle than what you see

in the child, which it's much higher. And so what this means is that, easily when we have any types of objects that could be swallowed, they usually will go towards the right side.

All right, some brief words about cardiovascular differences.

So definitely, the cardiovascular system proportionately when you look at an infant or consider the size of their body, it's really rather large in relation to the rest of their body. So when you're auscultating, it means there's a little bit of a difference

of where we're gonna be auscultating, and sometimes the sound of the heart can be an overwhelming sound where it's kind of hard sometimes to really pay attention to the breathing because it's really loud. There's also not a lot of muscle and fat tissue

over the chest, so sometimes it takes a little practice to be able to hear both well. Also the heart is very immature and so what that means is that it's very, very sensitive to volume changes versus pressure changes.

So when we think about cardiac output for us, children are extremely sensitive to giving volume. They're really not able to increase or stroke volume very well and that's because the heart is somewhat stiff when we're first born, and it's also smaller. So as we age, stroke volume become something

that we can improve, but in childhood, they really are dependent on their heart rate. So when they become bradicardic, it makes a major difference in their cardiovascular status because they can't really increase stroke volume well so that makes a big difference.

Okay, some hypotension. These are just some guidelines. So remember there are differences in our systolic blood pressures? A quick way of remembering this is this formula. So it's the same one that has been used in PALS.

I think most people have taken PALS. So it's 70 plus two times the age and years, that gives an approximation of what the systolic blood pressure should be for a child who's between one and 10 years old. So you can see that it isn't until you're a little bit older

that we would see more of a similar number as what we would see in adults. And again, our main solution to this is volume generally.

Some GI differences are the GI system is very immature at birth. It takes a while for children to be able to digest

and absorb nutrients the way that we do as adults. So some very common reasons why they will come to radiology are to evaluate their upper GI. We also have conditions such as intussusception that are somewhat common or other conditions like Meckel's diverticulum

that do not become evident in the newborn phase. They become more evident later on. So this is a common reason for why children will come to be evaluated. In childhood, until six weeks, infants really have very little control

over how their swallowing. And so that means that they have a high risk for aspiration. Also their stomach is very, very small and the peristalsis is greater than what it is in older children which is why children need to be fed much more frequently.

So that's another consideration, and they have a relaxed cardiac sphincter. So what that means is easily, they can have fluids that come into their airway and they can easily aspirate with them so we're very conscious, again, about making sure that they're sitting up well.

And they have immature liver function that has a lot to do with bilirubin, but that also affects some of the medications that we're giving. And obesity which is now a major issue for us in pediatrics. Things to consider there is that it can actually become obstructive.

Meaning that if the child is very obese, especially in the neck area and if they have other muscular problems, they can easily obstruct themselves with their head and neck kinda going over their airway and also they can have a lot of distention,

which again makes it very difficult for them to breathe because they're using their diaphragm primarily. For genitourinary, they do have a much smaller bladder capacity. You also need to know that at birth, we have less of an ability to concentrate urine.

And so because of that, this inability to concentrate urine, children are at very high risk for having too much output and for becoming dehydrated. They also really can't maintain bladder control until they're about two, that's in general. And they do have a little bit less fat padding.

So in traumatic injury sometimes because of that, they have a lot greater risk for having kidney injuries from that.

So last words about pharmakinetics a little bit. So just know that the infant has very increased permeability of the skin.

So anything that we put on topically can very easily enter the blood system and they also have a pretty large body surface area of skin based on their size. So what that means is they have a lot of fluid losses through skin that are insensible.

And so, again, that's another reason why they can become dehydrated and have a greater risk for becoming toxic on medications. They also have reduced gastric emptying so it may take a longer period of time to be able to reach therapeutic levels for medications

and they have a high proportion of body water. And because of that, the solubility of drugs is different in children. And, again, that affects the dosing in what we give and they also have a difference in the amount of fat that they have available.

And, again, those types of drugs that are lipophilic also will have some alteration in how they're absorbed so we have to alter the amounts that we are giving. And lastly, glomerular filtration rate is also different. So it isn't until they're about age two where their GFR is similar to what it is in adults.

And so, again, that has a major effect on the amount of ability to conserve fluid and also how they metabolize some of the drugs that we're giving.

- So as Nancy said, we're gonna talk about the non-pharmacological strategies. But as we get into this, we'll talk about specific age groups and developmental levels and how we can apply these strategies to these age groups.

So, first, we'll just start with the general strategies. So there are a lot of benefits to non-pharmacological techniques. Cognitive and behavioral interventions can help direct the attention away from the procedure which can then diminish your fear and anxiety.

The distress then pain is reduced. It gives the family and the child a sense of control which ultimately is the huge piece of the anxiety to begin with is that loss of control. Nobody likes to feel out of control. The other really nice thing it does is create

or help to create positive and effective coping strategies for the future at least if things go well and that's your goal by helping to prepare the patient ahead of time. And then we're all about patient satisfaction and overall experience and this is a great way to help that

and it also helps with staff satisfaction and experience as well.

So non-pharmacological strategies have really been a big buzzword lately and just to really kinda help to verify or validate how important they've become.

In 2014, the American Academy of Pediatrics released a policy statement on the non-pharm support and it really just validates the therapeutic play, the role of child life. Does anybody not know what child life is? Do everybody here have child life in their department?

Oh, that's awesome. I always give a big shout out to child life because we've had them for maybe 10 or 12 years, maybe a little longer and I was a little hesitant when they first came to our department. How they were gonna involve themselves in the team

and did they really know the processes and all? And I really become a firm believer in child life and we utilize them. We have our child life specialist every day and she's been a huge benefit to our team so it's great to hear so many people have them.

And for those that don't, I mean, these are the roles of the child life specialists, but they don't really have to be done by a child life specialist. Anybody can step in and help support the patient by providing these things.

Again, you just wanna help them adjust emotionally, develop their coping strategies, reduce their anxiety, and prepare. And why should we prepare? Well, really if you think about it, uncertainty to anybody is going to cause anxiety tension.

I mean, think about it. I live on the East Coast right now. There's a snowstorm. My flight is already been canceled and I'm a little anxious about how I'm gonna be getting home. So if I had a plan, I'd feel a little better

so that's why we wanna help to prepare these kids. You're gonna help to increase their coping ability which i.e. maybe limit the meltdown that they could potentially have during the procedure and give them that sense of coping and control.

These are just some of the reasons that kids struggle with medical procedures. And I look at these sometimes and I think, ah, pain, that's the biggest one and then I go down, well, anxiety and that fear of unknown that's, you know. And then you think misconceptions.

What go through these kids' heads sometimes depending on the age, and we'll talk about words later. and they hear people talking and what's in their head. Loss of control, I know I keep talking about that, but again, I think that we can all really relate to how much anxiety when you feel out of control.

Again, separation from family particularly with certain age groups, the younger kids. So if they know right up front that their family gets to stay with them, that could be a huge just release of anxiety. And then everything has to be based on

their emotional and developmental levels. So when you're preparing, you really have to assess not only the child, but their family as well. The child's age and developmental level, their medical history, the family's educational level, and history with medical procedures.

You really wanna look at their understanding and concerns regarding the procedure. What do they think is going to happen? Are they right? And if not, maybe direct them down the right path. You need to explain in both the child's terminology

and the adult's terminology. And then I have found that giving the parent a job during the procedure really helps to keep them calm and focused as well and they then have a sense of some control that they're helping and it can be little things.

How to hold the child, being the one voice, which we'll talk about in a little while. Words, words can make a huge difference with kids. Actually with families too. So you really wanna think about the words or phrases that you're using and that they might be threatening

to that child if they are not sure of what it means or if they have two different meanings to them. Try to use non-threatening terminology, and I'll go over a few examples in the next slide. Again, we go back to that developmental level try to focus on what they're going to understand.

And listen and watch your child for their verbal and nonverbal responses. Are they loosening up or do you see them getting more anxious as you're talking? Get down on their level. Sit next to them or kneel next to them

or sit them up more so that they feel more in control. Avoid medical terminology that they don't understand. Try to be descriptive. Instead of saying fluoroscopy, it's like an X-ray or a moving picture that they're gonna take. Avoid the words with two meanings.

CAT scan, I've always loved this picture so I had to put it in there, or stretcher when they're thinking, oh, my God, they're gonna stretch me. Don't tell a child that something won't hurt because it's such a subjective word. So what we think might not hurt to that child

might indeed be painful. Here's just some examples of some words that can make a difference. If you're gonna start an IV, you're gonna stick this little straw even you think you're using the word straw instead of needle,

but you're gonna stick it in, so slight would be a good word. I actually look at the word sting, the third one down, and I've been a pediatric nurse for 29 years and it was just really a few years ago, I used to say to them,

oh, this IV, it's gonna be quick and easy. It's just like a little bee sting. Why apparently had not been stung by a bee in a really long time? Because I walked in my backyard and I stepped on a bee and it hurt and I thought, oh, my God,

I've been scaring kids to death for 10 years. So now, I'm much more careful with the terminology that I use, and I don't know if anybody went to the Comfort Talks session yesterday, but she talked about switching things around and making them think about it different.

Like here, we say, it's not gonna burn. There's that warm feeling that you're gonna feel. So just direct them in the right direction.

And then you really have to look at the procedure, characteristics, and requirements too. Is this a really quick CAT scan

that you can just say to them, all right, let's pretend that you're a statue or is this an MRI where they have to hold still for 30 minutes and really hold still? Is it invasive versus noninvasive? So do you think is that a pain versus painless procedure?

And then the actual environment. Are you rolling into an IR suite where it's really scary-looking or into this CAT scan where everything has got little animals all over it and you can pretend it's this little tube that you're gonna fly through for a quick minute?

And then once you've done all that stuff, you can then individualize your plan. You can look at the age and developmental level of the child, what kind of support and experience do they have in the medical setting,

and what is the procedure you're gonna do and what do you need this child to do to get through it.

So now we're gonna just kinda look at each individual age and developmental level and see what techniques we can use. So when you're looking at the infant and toddler, you can break these down into like sensory

or cognitive and behavioral. So with the infant, just sweeties. Does everybody know sweeties? We love sweeties where I work. So we will use that whenever possible. Rapid rock,

sorry, I need a drink of water. Rapid rocking, padding, stroking. Again, that pacifier, cuddling. The music can go almost with any age that we talk about. And positioning, we'll talk again about positioning of comfort,

keeping them comfortable, less threatening if they're in a position of comfort. And then anything with babies, you can use toys or rattles. As they get older, use your bubbles or play dough if they can actually play. Words of encouragement for the toddlers

and even a soothing voice for the infants.

When we start talking about preschoolers, you can really get into more pretending situations, imagery. Again, back to pretend that you're in a rocket ship and you need to put this thing over your head for just a couple minutes

to get to the place that you're going. iPads, iPhones, they're wonderful. Let them watch something, let them play a game. Storytelling is another great technique for this age group. Breathing with their bubbles is great. Praise and encouragement.

I never tell anybody even you're almost done because almost to me might be five minutes, almost to a preschooler is probably 10 seconds so just be careful about your terminology. Books, I have a few little things here that we, actually, we don't usually use a wash basin,

but that's what I brought with me so I can throw it away before I go home, but you can certainly pass that around. Nursery rhymes, singing. I never sing. I'm terrible, but I will put the songs on my phone

and let them do that. If you call the families ahead of time, have them bring comfort items with. And then any time you have the availability of mock scanners or, again, we have books on MRI, CAT scan. We have on our video system at work

where they can pull up all the different rooms and look at them ahead of time.

what they think is gonna happen because with preschoolers and toddlers, you don't really have to tell them that they're coming

until they're there. With school-age children and adolescents, you have to let them know ahead of time. So preparation is really important with these kids and preparation in terminology that they understand. Imagery, again, guided imagery.

Just put them in their favorite place. It could be on the soccer field and you wanna use all your senses. You're walking on the soccer field, you hear all the people cheering for you, you can smell the freshly cut grass.

Pretend roles. You can talk about, you pretend you're me and I'll pretend you're you. Superheroes, princesses. Progressive relaxation. Again, this is where I value my child life.

She can really get these kids to do their breathing and relax themselves. Praise and encouragement. Again, iPads, iPhones. Social conversation. If you're in a pick line

and you're trying to get these kids through, just talking about all the things, what are you doing this weekend? Oh, gosh, you play soccer. What position do you play? Again, back to counting to get through things.

Music, mock scanners. Adolescence. A lot of the same things that really you might need to change your favorite place from the soccer field. Maybe the soccer field or maybe the mall for an adolescent girl,

but a lot of the very same things. Preparation, social conversation. Again, MRIs, movies, music that they like.

Imagery, just really use all your senses. The purpose is just to provide additional relaxation and that sense of security.

Just trying to bring that patient to a pleasant place and somewhere they'd rather be, and it's gonna take them a little psychological energy to get there and stay there and that will just roll them away from the procedure. I was really not a true believer of imagery for a long time.

I still have my doubts, but I do think that it helps sometimes. And if the right person does it, it can be very beneficial. Controlled breathing. I do think that controlled breathing is very helpful. Just rhythmic, slow, long, deep breaths

and somebody to direct them. And, again, I think it's all part of the distraction as much as the breathing. Alternate focus. And really, that's just I think a fancy terminology for distraction.

And I think the key here is that the pain experience depends on the cortical processing of information. And if you can distract them, then you could potentially interrupt this process and maybe decrease or take away a little bit of that pain. So position of comfort.

Again, I've mentioned it a couple times. Prone is a really, really vulnerable position. It signifies loss of control and nobody wants to be out of control. So here's just a couple examples. Instead of putting your preschooler in the bed

with everybody around them and the lights on, let the mom or dad or whoever hold them, put their arm out, they're still being cuddled, quiet music in the back. Again, less people, the less anxiety that these kids are gonna have.

There is just that's just a couple different positions that you could potentially utilize for IVs. And again, you can see the parents sitting on the bed with them. Again, it's just more of a sense of their normal.

Is anybody familiar with ONE VOICE?

So ONE VOICE was designed by or created by a child life therapist named Debbie Wagers, and it was created in 1996. In pediatric facilities, I think that you're starting to see it more and more often. The website is onevoice4kids.com.

It's up here and it gives a lot more information on this. It's pretty cool. And it was designed to teach healthcare professionals how to create a less threatening environment for kids during medical procedures. Each letter of the ONE VOICE stands for

something that we should be doing during this process. So you're gonna use one person. You're gonna designate one person to talk throughout that procedure. So we've all been in procedures where you have the nurse, you have a student nurse, you have the radiologist,

you have the resident, you have the radiology tech and they're all talking at once and this poor little three-year-old is totally overwhelmed because they also have mom, dad, and grandma next to him. So pick one person to talk to them in a nice soothing voice. And if it can be the parent, that's even better,

but sometimes the parents are really anxious, they don't know what to do and anxiety feeds anxiety. So that might not be the best person, but, again, you have to assess the situation. Educate the patient and the family prior and let them know what's gonna happen.

Validate the child with words. I know you're uncomfortable so let's get this done as quick as we can. And again, it's based on your child. Offer the most comfortable position. There we are, position.

Individualized the game plan. Everybody is different. Again, who's talking? Maybe nobody should be talking. Maybe this patient is better if nobody's talking to them at all

and somebody is just holding their hand. Choose the appropriate distraction like we just talked about depending on the age and the developmental level. And eliminate unnecessary people. I mean, I know a lot of us work in teaching hospitals, but if you have an overly anxious family there,

sometimes I will even say to my student, you know what, we need to just cut back now. You can stand behind the window and watch from there. So, again, individualize. This is just a little bit on the ONE VOICE. I think we kinda talked about them.

And then utilizing this campaign will help you to decrease the patient and family anxiety. Hopefully, decreasing if you are thinking about sedation, either sedation at all or maybe the level of sedation that you needed, and the slide actually, I should have changed it a little bit.

I use this more for sedation talks. But overall, it will help decrease anxiety of your child, your family, and then just an increase success of your procedure and satisfaction of everybody involved.

All right, so the infant with macrocephaly needing a CT scan of the head. Based on what we've learned in the past half hour or so, what types of considerations are you thinking about? What do we know babies like? They like to be swaddled, okay.

And you ever see those babies for those, if you work in institution where they have a newborn nursery, most babieslike that. Nice tight wrapped. So swaddling is gonna be certainly a very useful technique to be able to get the baby through that CAT scan.

What else? And that could be with blankets or that can actually be with an immobilizer device. Anyone heard about the immobilizer device? Okay. So it's actually a device put, I'm not sure of,

I think there are different companies that have made it, but it's actually a device where the child is, it's kind of like a papoose. And what you do is you kind of deflate the air and it kind of creates a more secure, a stabilizing kind of support for,

we use it for babies to get them through MRIs or whatever so it kinda minimizes their movement. So we will use feed and swaddling with blankets or we can actually use an actual immobilizer device, which is helpful. What else do they like?

What about the sweeties? Right, sweeties, okay? What about scheduling? What would be an important concern for a family? So are you gonna have that baby who needs a CT scan as soon as he woke up and he's hungry?

So what are you gonna try to do in terms of scheduling? Not the you're involved with scheduling, but what would you recommend to a family? (faint voice talking) What's that? - [Man] As early as possible.

- As early as possible in the morning, okay. So if there's no NPO requirement, then that's fine. Or what about nap time, right? So sometimes that's what we'll do even if we're trying to avoid sedation with a young infant. We'll do a feed and swaddle plan

so we'll have them come in at nap time and coordinate that as well. So you're more likely for them to not be quite as active, they might be tired or we'll say keep them awake and have them come in and take a nap while they're here at the hospital.

Any other suggestions with the infants? So they like to be warm and cozy.

All right, you have a toddler with intussusception needing a barium enema. Looking back at what we recently learned about some of the psychosocial and developmental issues

with the toddler population, what are you thinking about? Is this gonna be some that you're gonna separate from the parents for this particular procedure? Absolutely not. So if as much as possible having a parent in the room, getting child life involved.

What other kinds of resources can you utilize to help with the toddler? (faint voice talking) Something for them to be watching, absolutely. And I am absolutely amazed by the two-year-old that can navigate an iPhone better than I can.

And they'll take dad or mom's iPhone and they will swipe and find the right app and click the right button and get that probably 20 minutes quicker than I could probably figure out where that app was for that particular cartoon or video.

So getting that any kind of media involvement, okay? Toddlers like bubbles, blowing bubbles. They're explorers. They like their certain routine and they don't like to be separated. Any other suggestions for the toddler population?

Given a reward option, right. Exactly. And that's a really good point because knowing, we have a sticker selection 'cause kids love stickers, right? But making sure that that sticker selection is updated

because if you have some old ones and kid says, I want Batman, I want Superman or I want Sponge Bob, whatever and there's all kinds of, child life is a great resource for that. But even if you don't have child life,

just having a wide range of stickers. So really keeping up on what's in and what's popular is really important because they'll say, oh, I don't like that one or that's silly trying to find out. So updating your sticker collection can be something that's

relatively inexpensive and certainly very practical if you see kids and you wanna use a reward system in radiology. Anything else with the toddler?

Okay. All right, we have a preschooler

needing a bone scan for leg pain. So he doesn't need to be completely still so we could certainly use distraction with him. So the preschoolers, they are very active learners. They like medical play. So how can you explain what's going to happen?

Anybody wanna take how would you explain that to a four-year-old, what a bone scan is gonna be like? Anybody wanna take a guess at that? Okay. Show him the machine ahead of time, exactly.

- [Participant] Show them on a doll or teddy bear. - Show them on a doll or teddy bear, yep. Exactly. So we have a miniature, I should have brought a picture of it. We have a wooden, someone constructed a wooden framed

CAT scan machine, and so when we have the kid that needs a CT scan, we show a picture of in slides and we show a picture of what the doll. So you can actually bring it to the child in the exam room and show them exactly what it looks like,

and it's made of wood and we just have the doll slide in. 'Cause sometimes we can get an idea of the kid's anxiety by walking in the room. So anything that you could bring to them at the bedside would be helpful to kind of show them. And there are so many videos available online.

I mean, I work at Children's Hospital of Philadelphia so we have a whole bunch of cartoon videos about having an MRI and getting things ready, but there are so many things that you could access even on YouTube just to show what they are going to expect. And some people ask, how far in advance

do I need to prepare a child to come to radiology? So obviously, for the infants, they are just whatever it's scheduled, okay? But what about for a preschooler, how soon do you think if they're gonna come in for a test? Are you gonna do it a week ahead of time?

No, because that's a century for a three or four-year-old. Correct? So maybe you're gonna do it the day before talk about what's going to happen. But thinking about not preparing too far in advance which can increase the anxiety

and also we wanna make sure that they're prepared, but not overly anxious about the weight and exactly what's going to happen. And in terms of kids with special needs, we do all kinds of things to help prepare. If you know that the child needs to,

by talking to the family in advance and finding out what they like. Do they like music? I mean, we see so many kids with special needs. Do they like music? They like certain types of videos

or certain cartoon character making sure that we can kind of get things ready for them when they come in. We've actually sent pajamas, mailed pajamas to families because if the child has to get changed into like if they're having an MRI or whatever,

sending them the pajamas so they can actually just bring them in with them because getting changed into a hospital gown can be very traumatic for kids, right? I mean, I do sedation so sometimes we actually sedate the kids

and then get them changed afterwards because that pajama is just not gonna happen. So something that you take for granted. So sending pajamas. There are there a picture cards that they'll do for kids with autism

where they'll actually have a picture of all of the steps of what's going to happen throughout the course of the day. You will meet a nurse, she will take your temperature, she will take your blood pressure, and they have pictures of what to expect

because it can be very overwhelming not just in a strange environment, but with all of these unfamiliar medical procedures being done. So picture cards are very helpful. And finding out whatever their comfort object is, okay?

All right, moving to a school aged child.

School aged child with headaches needs an MRI of the brain. It doesn't need contrast, it doesn't need an IV. So remembering that school aged kids are very concrete thinkers. So watching your language as Michelle spoke about a few moments ago,

and they like to be in control with choices. And I think what happens nowadays is we sometimes give kids too many choices. So you can't say, okay. Well, this kid doesn't need an IV. Is it all right if we take your blood pressure now?

So sometimes I think we need to just say, okay, we're gonna take your blood pressure now, but should I use the muscle on your left arm or your right arm? But sometimes asking if we can do something, we know that we have to eventually

get that particular task completed, okay? So just asking for choice of left arm or right arm, but not is it okay if I take your blood pressure now? Because what are they gonna say? Nope, it's not okay. All right, so school aged kids are fearful of harm

to their bodies. So if they do need an IV, making sure that that Band-Aid is on because they are thinking that that hole is gonna be there forever because they are fearful of harm. So preparation and the techniques that Michele talked about

like deep breathing, music, praise, and encouragement, and as I said, finding out what's current in the sticker population to make sure that you really are, don't make a promise that we have Superman stickers 'cause that will be the day they open the drawer and they're not there.

So making sure that you know what your supply is. Anything else about the school age? And the adolescent post-appendectomy needing a PICC line. So we see adolescents

for PICC lines and J placements and such.

So remembering that adolescence value their independence, value their privacy wanna involved in decision making. They are very concerned about body image. So what's this PICC line? What am I gonna have sticking out of my arm here? I have to have a tube put in in my nose

so how are we gonna kind of make that look as discreet as possible? Body image is gonna be really important. And during the procedures, any time, anyways to help maintain control with deep breathing, involving them in in the decision making

as much as it's reasonably possible for the procedure. And we talk about how much knowledge is a good thing. We wanna really assess where the kids and the families are coming from. There maybe an adolescent. You may have a 15-year-old who needs to have a PICC line

and this kid doesn't want anything to know about what's gonna happen, right? Don't tell me, I don't want to know. And then you can have another 15-year-old where you go in to talk about the procedure and they have 35 questions about what to expect.

So really trying to get to the level and the knowledge and the anxiety level of the individual patient. You may have a teenager who is extremely anxious and doesn't wanna know anything and doesn't wanna see anything. They don't even wanna look at that PICC line afterwards.

Or you may have the 15-year-old who wants to watch. Who wants to know everything that's happening every step of the way. What are you doing now? What are you doing now? So really getting a sense of what level this child is at

or this adolescent is at so you can get to their level. And two final points is that you can learn so much from kids. Every day when I leave work, I've learned something new about some way that a child has interpreted what I've said or done

or something that came from a kid's imagination and I'm like, wow, I never realized. Like when Michelle was talking about the bee sting or how we talk to kids. You can learn so much from children and I try to learn so much from them as well

so that I could work with them better. When I'm in interventional radiology, for example, with a patient having, and couple of our IR nurses shout out to the IR nurses from chop in the back of the room, but I've learned a lot about what's the current,

what's going on with music nowadays? I remember talking to this girl something about I said, oh, I love this Taylor Swift song, she's like, Taylor Swift? That is like so old. I'm like, okay.

Well, then, tell me? So who should I really be listening to on the way home? When I put my Pandora on, who should I be listening to? So you could really learn so much from the kids getting down to their level and really working with them and finding out what makes them thick.

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