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The Importance of Child Life and Pain
Management During Vascular Access
Procedures in Pediatrics
Gail A. Heckler-Medina, RN, BS
Abstract
The author asks of the reader: Have you ever been called to start a peripheral intravenous (IV) catheter or place a peripherally
inserted central catheter (PICC) in a child, and you wished someone else could do it? Performing vascular access procedures on
children is considered by many one of the most stressful and difficult jobs. This article discusses the role of certified child life specialists (CCLSs) and some of the techniques used to assist children in coping with painful procedures as well as the necessity for
proper assessment and pain management. The goal of this article is to eliminate the uncertainty of performing these procedures on
pediatric patients. By making a few changes in your practice, one could dramatically increase successful outcomes and improve the
overall quality of care provided to the patient.
One of the most frightening experiences for many children is
being admitted to the hospital. If the child is not chronically ill,
he or she will most likely be in an unfamiliar environment, away
from home, toys, siblings, pets, and friends. Daily responsibilities such as career and upkeep of one’s home and other children
often make it even more stressful for everyone involved. Many
times, the hospitalized child may be left alone or not see one or
both parents for hours or even days at a time.
Thinking back to your childhood, what comes to mind when
you hear the words doctor’s office, procedure, and shot? Are your
memories positive? I remember going to have laboratory draws
for a preoperative exam when I was five years old. Everything
around me felt so big: the room, the chair, the laboratory technician, and especially that needle. “It is longer than my arm is
wide!” “Is the entire needle going into my arm?” “Is it going to
hurt? If so, how much will it hurt?” “Will it cause me to pop like
a balloon?” “I will need a bandage to keep my insides from leaking out of the needle hole!” These are all statements that pediatric nurses hear frequently.
From the time we are born until the time we die, our identity
of self and the ego continue to develop and go through successive stages that naturally unfold throughout the lifespan. Eric
Erikson called this the “stages of development.”1 The eight stages
are trust versus mistrust (infancy), autonomy versus shame and
doubt (toddler hood), initiative versus guilt (preschool), industry
Technological Advancements and Research Prevail
Over the past 10 years, there has been a growing demand for
alternative vascular access, specifically, peripherally inserted central catheters (PICCs), and skilled professionals to place these
devices. As health care facilities across the nation are experiencing tremendous growing pains because of the ever-increasing
need for medical attention, vascular access has never in history
been as important as it is today. Two topics I discuss are the use
of certified child life specialists (CCLSs) and appropriate pain
management interventions as they apply to vascular access.
Correspondence concerning this article should be addressed to
[email protected]
DOI: 10.2309/java.11-3-X
CCLS: An Integral Part of the Vascular Access Team
A CCLS is a professional who is specially trained to help
children and their families understand and manage challenging
life events and stressful or unfamiliar health care experiences.
CCLSs are skilled in providing developmental, educational, and
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versus inferiority (middle childhood), identity versus role confusion (adolescence), intimacy versus isolation (young adulthood),
generativity versus stagnation (middle adulthood), and ego
integrity versus despair (older adulthood).
Depending on the developmental stage, some children may
feel that they are sick because they were “bad.” However, what
about the healthy child who is going to the doctor’s office for
his/her series of shots that are referred to as vaccinations. We tell
the child this shot is for “your own good health” so that you will
not get sick. The first question the child will usually ask is, “Is
it going to hurt?” As health care providers is there a way to
lessen the pain? Is there a way to help the sick child understand
his/her illness and the cause of it? The answer to both of these
questions is “yes.”
therapeutic interventions for children and their families. They
support growth and development while recognizing family
strengths and individuality. The CCLSs recognize and respect
different methods of coping. They help to take the mystery out
of hospitalization, illness, and procedures.
CCLSs have earned a bachelor's or master's degree with an educational background that includes human growth and development,
education, psychology, and counseling. They are usually required
to complete an internship program and a certification examination.
Child life specialists are certified through a program administered
by the Child Life Council (CLC).2
Many children’s hospitals across the nation are recognizing
that having a team of CCLSs play an integral role into the successful outcomes of their patients. Intravenous (IV) access is statistically one of the most stressful and dreaded events that occur
during hospitalization: This is even more so in the pediatric population. Integrating a CCLS with a vascular access department
dramatically increases not only the number of successful PICC
line/IV insertions on the first attempt but increases the scores on
patient satisfaction surveys.
CCLSs are invaluable when used in conjunction with a vascular access program; this, however, requires a financial commitment from the hospital to establish, but the end result is a cost
savings to the hospital that is substantive. Vascular access programs that use CCLSs have a lower staff turnover than those that
do not. Performing painful procedures on children is extremely
stressful and challenging. When the chances of success are
increased as much as possible, it is best for all involved. It also
provides cost savings to the hospital for nonreimbursed supplies
and what would have been a loss of revenue had the child
needed to remain in the hospital for an extra day or two awaiting PICC line placement for discharge.
Case Study
Joey M., a six-year old boy, is brought to the emergency room
because he stepped on a nail. He receives a tetanus shot, blood
cultures are drawn, and an IV is started for antibiotics. The
physician decides to admit him for cellulitis to rule out
osteomyelitis. After a few days in the hospital and nine “pokes”
later, the physician orders a PICC line to be placed for vancomycin administration. The vascular access (VA) nurse is notified of the pending PICC placement.
On notification of the PICC order, the VA nurse gathers a
tourniquet, the ultrasound machine with gel, and a PICC consent
form, and goes to Joey’s room. The nurse introduces him-/herself to Joey and his parents. The nurse explains that a PICC line
has been ordered and answers any questions the parents have
about the PICC prior to venous assessment. On determining that
Joey is a candidate for PICC placement, the VA nurse obtains
informed consent for the procedure and explains that a CCLS
will be in soon to talk with Joey about the procedure and answer
any questions he may have.
The VA nurse then fills in the appropriate information on the
Vascular Access/Child Life Procedure Form (see Figure 1) and
delivers it to the CCLS. The CCLS introduces him-/herself to
Joey and his parents. During this introductory period, the CCLS
inquires as to what interests Joey has. They talk about video
games, catching grasshoppers, playing on the monkey bars, and
a famous cartoon character. By discovering what is important to
Joey, the CCLS establishes a way to communicate with him and
hold his attention. This allows the CCLS to begin building and
facilitating an honest and trusting relationship.
The CCLS explains to Joey what a PICC line is and what it
is used for. He/she gives Joey a teddy bear with a PICC line and
central line dressing on the bear’s arm. This enables Joey to see
what it will look like and how the PICC line feels after the procedure is finished.
A big part of the CCLS responsibility is to ask a series of
questions during the evaluation process to see how he/she can
best assist Joey with coping mechanisms during the PICC insertion. The CCLS asks him if he would like to have his parents
present during the procedure; if he would like to sing songs, read
a book, or watch a DVD; if he wants to be told what is happening throughout the process; and whether he would like to watch
the insertion procedure.
Depending on the answers, the CCLS plays with Joey using
either medical play or real PICC insertion supplies so that the
equipment will be familiar to him. They look at a photo album
detailing a step-by-step PICC-insertion procedure. This helps to
answer questions, alleviate fears, and decrease some of the anxiety that Joey may be harboring.
After a thorough assessment, the CCLS communicates the
findings to the VA nurse. Ideally, the CCLS stays with Joey
throughout the PICC insertion. This keeps him focused on the
coping techniques that work best for him. The CCLS is the liaison between Joey and the VA nurse. The CCLS makes suggestions that can ensure the best outcomes for Joey psychologically
as well as procedurally.
Because the VA nurse and CCLS worked together, Joey’s PICC
insertion was successful on the first attempt. Joey’s mom was present during the PICC insertion. She held his left hand as the CCLS
talked with him about one of his favorite books. When Joey grimaced, the CCLS asked Joey if he was hurting anywhere and
asked him to use his words to explain how he was feeling right
then. The CCLS told Joey that it is okay to be scared and that this
procedure was happening to help him get better, not as a result of
anything that he had done. The CCLS continuously reinforced how
Joey was doing such a good job by helping to hold his arm still and
let him know that he would receive a surprise after the procedure
was complete.
Joey did not feel any pain during the PICC insertion. He was
able to cope very well with the help of the CCLS. He received
his surprise. He felt as if he had made a new friend and stated
that he would not be afraid in the future if he needed another
PICC line. He was happy to be on his way home. His family had
a great experience and rated the quality of care as exceptional.
The hospital, which usually operates at full capacity, had another
available bed for a child in need.
Although Joey coped very well with the procedure, not all children are able to cope. The inability to cope can be directly related
to the procedure requiring multiple attempts, being too lengthy, too
painful, and/or a result of traumatic experiences in the past. It can
also be that the child is too young to hold still for such a procedure
(ie, toddlers). In a situation like this, one may wish to consider the
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PLACE PATIENT LABEL/STICKER HERE
This portion to be completed by vascular access nurse: ___________________(RN/NP/PA/MD)
Patient is scheduled on ____________ (date) at _______ (time) for the following
• Peripheral IV (PIV)
• PICC Insertion
• PICC Exchange
• CVC Repair
• PICC Removal
• Other: _________________
Patient Assessed by Nurse:Y N (circle one) Assessed with Ultrasound:Y N (circle one)
PIV and PICC Insertions Only: Preferred Vein of Choice: Right/Left (circle one)
• Basillic
• Cephallic
• Saphenous
• Scalp
• Popliteal
• Other: ________________
Check all that apply to patient during procedure:
• Anxiolysis
• Sedation
• General Anesthesia
• Fluoroscopy
This portion to be completed by Certified Child Life Specialist: _________________(CCLS)
Patient Age: _______________
Developmentally Appropriate for Age:Y N (circle one) If no, explain: __________________
Coping Preferences:
• Would like family member present during procedure: _______________(name)
• Wants to watch the procedure
• Wants to be told exactly what is happening during procedure
• Would like to read a book/watch a DVD/play with a toy: ___________________(which one)
After assessment, I feel child can cope successfully for the scheduled procedure Y N (circle one)
Figure 1. Vascular Access/Child Life Procedure Form. Copyright © 2006 P & A PICC, LLC. Reprinted with permission.
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use of sedation or general anesthesia prior
to attempting the procedure. Nurse practitioners, physician assistants, and physicians
are usually responsible for determining
weather the child will receive sedation or
anesthesia. The decision is based on the
child’s age, current medical condition,
medical history, allergies, and an assessment of the child’s coping abilities.
Pain Management
Did the use of a CCLS make the PICC
insertion a pain-free experience for Joey?
Mosby’s Medical Dictionary defines pain
as follows:
“An unpleasant sensation caused by
noxious stimulation of the sensory
nerve endings. It is a subjective feeling
and an individual response to the
cause. Experiencing pain is influenced
by physical, mental, biochemical, psychological, physiological, social, cultural, and emotional factors.”3
In 2001, the Joint Commission on
Accreditation of Healthcare Organizations
(JCAHO) published Pain Assessment and
Management Standards—Hospitals,4 and
in a Powerpoint presentation available on
the Internet, Pain Assessment in Infants
and Children,5 these standards are
Figure 2. 0–10 Numeric Rating Pain Scale. Source: National Institutes of Health.
explained. One of the standards makes
pain rating the fifth vital sign. The reason
that one would assess pain is to take action to relieve the pain.
tion greater than 95%; I: increased vital signs; E: expresIn Joey’s case study, not only was a CCLS present but approsion; S: sleepless) (32–60 weeks gestational age) by
priate pain management measures were also taken. L-M-X4
Kretchel and Bildner, 199512 (Figure 5)
(Ferndale Laboratories, Inc; Ferndale, MI) was placed on Joey’s
• Checklist of Nonverbal Indicators (CNVI) (Figure 6)
right arm in two different places prior to setting up for the procedure, and during the procedure lidocaine 1% buffered with
Pain is subjective and responses to pain vary widely among
sodium bicarbonate was injected at the site very slowly.
individuals. Different factors determine how individuals respond
to pain, such as age, gender, specific diseases or injuries, health,
Pain Is Subjective
pain threshold, fear, anxiety, the culture and background of the
There are many ways to identify and quantify pain in the pediindividual experiencing the pain, and the way the person
atric setting. The use of pain scales is recommended by JCAHO.
expresses painful experiences.
Some samples6 of Pain Rating Scales from the JCAHO Pain
Other factors associated with how children deal with pain may
Assessment and Management Standards—Hospitals4 are as follows:
include previous experiences with pain, how their parents treated
the child when the child was in pain, and how parents respond
• 0–10 Numeric Scale (Figure 2)
to pain when they themselves are hurting. Early experiences of
• Visual Analog Scale (VAS)7
pain may produce permanent structural and functional reorgani• Wong-Baker FACES Pain Rating Scale8 (Figure 3)
zation of developing neural pathways, affecting future experiences of pain.
For infants and nonverbal children, use appropriate observaStress response to pain increases breakdown of body tissue:
tional scales such as the following:6
increases the metabolic rate, blood clotting, and water retention;
• NPASS (Neonatal Pain, Agitation and Sedation Scale) (predecreases immune function; triggers fight or flight response;
maturity) by Hummel and Puchalski, 20029
causes diaphoresis or palmar sweating; increases heart rate,
• FLACC10 (Faces, Legs, Activity, Cry, and Consolability) (full
blood pressure, and shallow respirations; increases cough supterm neonate–7 years) by Merkel et al, 199711 (Figure 4)
pression; increases retention of pulmonary secretions; and
• CRIES (C: crying; R: requires oxygen to maintain satura-
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increases the delay of return of gastric
and bowel function.13 It is by far more
effective and safer to prevent pain rather
than to try to catch up and treat already
existing pain.
The Use of Analgesics
Although it may be necessary at times
to use sedation or general anesthesia for
certain vascular access procedures, there
are some reasonably priced analgesic
products that could be used for most
patients who are not allergic. These would
include, but are not limited to, the use of
Sweet-Ease (Respironics, Pittsburgh, PA),
ethyl chloride, L-M-X4, EMLA
(AstraZeneca LP, Södertälje, Sweden),
and 1% lidocaine subdermal/subcutaneous injection at the site. All of these
require a physician or allied health professional’s (AHP’s) order.
Sweat-Ease is a 24% sucrose and water
solution. Sucrose produces analgesia
through both endogenous opioid and nonopioid pathways. In neonates, the taste
receptors are an important consideration
for pain management. Nonnutritive sucking with sucrose has the best effect. It is
recommended to be given 1 to 2 minutes
prior to starting the procedure, either with
a syringe on the tongue or on the buccal
surface followed by a pacifier. It should not
be used on patients less than 27 weeks ges- Figure 3. Wong-Baker Faces Pain Rating Scale. Source: National Institutes of Health.
tational age, those who weight less than
1000 grams or have cardiovascular instability, or with neonates
ratio. This combination eliminates the stinging property of the
who have persistent pulmonary hypertension.
lidocaine. It should be mixed under a hood in the pharmacy. It
Ethyl chloride spray, often referred to as “cold spray,” temis recommended that no more than 4.5 mg/kg be administered
porarily numbs the skin on contact by making it feel very cold.
for procedures in children.
The sensation is similar to effects of an ice pack. The bottle
It is important to write down the patient’s pain history before
should be held approximately 7 inches from the skin and sprayed
pain is expected, such as before the vascular access procedure. In
continuously between three and 7 seconds. The skin will turn
addition, try to involve the family when possible. Families are
white when it is numb. This analgesic only lasts for approxioften helpful in interpreting and recording response to pain relief
mately 30 seconds. When using this type of analgesic, it is of
measures. Pain experienced during vascular access procedures is
utmost importance to act quickly. The child may consider the
acute. Acute pain activates body’s fight or flight stress response.
frosty, cold, and tingling unfamiliar and mildly uncomfortable.
When pain persists, the body begins to adapt and there is a
It is best to show the child in advance how it feels and allow
decrease in the sympathetic responses. In chronic pain, stress
him/her to choose.
response is absent or diminished. For this reason, chronically ill
L-M-X4 and EMLA are both topical creams that are applied
patients may have a lower pain tolerance.
directly to the proposed site. L-M-X4 contains lidocaine 4% and
should be applied 15 to 30 minutes prior to the procedure.
Conclusions
EMLA contains lidocaine 2.5%/prilocaine 2.5% and is recomPain is an unpleasant sensory and emotional experience arismended to be applied 1 to 2 hours prior to the procedure. Both
ing from actual or potential tissue damage. The major responsiof these creams have anesthetic properties that reach to a depth
bility for alleviating a child’s pain during a vascular access
of 4 mm. They are very useful for peripheral IV insertions and
procedure rests with the VA nurse. Pain is whatever the experifor the administration of lidocaine 1% during PICC placements.
encing child says it is, and it exists whenever he or she says it
Lidocaine 1% can be buffered with sodium bicarbonate in a 10:1
does. If using CCLSs and appropriate pain management inter-
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ventions have such a positive effect on the
outcomes of our children, why do hospitals not always use them consistently? It
may be because of a lack of funding or
time. It may be inconvenient at times for
us, as health care professionals, to take
the time to apply a topical analgesic or
consult with a CCLS.
You may be part of a Vascular Access
Team who manages all IV therapy and
vascular access devices or you could be a
one-person PICC “team” in a large facility. Using CCLSs and appropriate pain
management techniques may sound like a
great idea. The need is evident. However,
many practitioners may believe that,
although the concept is idealistic, it is not
realistic in the daily hospital setting.
Having come from a large children’s
hospital that operates at 100% capacity
most days, a place where it seems there is
never enough time in the day to accomplish all of the orders and respond to all of
the calls, I can say that it is important to
take the time and show you care. The
remembrance of a positive experience is
invaluable and will serve to make your job
much easier in the future should another
vascular access procedure be necessary.
Consider the loss of revenue and supplies that are not reimbursed, the frustration and nursing time it takes for one to
repeatedly attempt a failed vascular
access procedure, the fear that we have Figure 4. FLACC Pain Scale. Source: National Institutes of Health.
instilled in the child, and the dissatisfaction of the family. Can we truly afford to sacrifice the quality of
6. National Institutes of Health. Pain Intensity Scales [online].
care we provide? The next time you are called on to “stick” a
Available
at:
pediatric patient, remember that this may be the child’s first
http://painconsortium.nih.gov/pain_scales/index.html.
experience with vascular access or it may be their hundredth.
Accessed June 1, 2006.
Why not make it their best? The power to make a difference rests
7. Johnson E. Visual Analog Scale (VAS). Am J Phys Med
in your hands.
Rehabil. 2001;80:717.
8. Wong D, Baker C. Pain in children: comparison of assessReferences
ment scales. Pediatr Nurs. 1988;14:9-17.
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9. Hummel P, Puchalski M. Establishing Initial Reliability and
Louis, MO: Mosby/Elsevier; 2004.
Validity of the N-PASS: Neonatal Pain, Agitation, and Seda2. Child
Life
Council
[website]. Available
at:
tion Scale—A Pilot Study. Presented at The Association of
http://www.childlife.org. Accessed June 1, 2006.
Women's Health, Obstetric and Neonatal Nurses 2002 Con3. Mosby’s Medical Dictionary, 7th ed. St. Louis, MO:
vention: Lighting the Way. Boston, MA.
Mosby/Elsevier; 2006.
10. Chambers CT, Giesbrecht, K, Craig KD, Bennett SM, Hunts4. Joint Commission on Accreditation of Healthcare Organizaman E. A comparison of Faces Scales for the Measurement
tions. Pain Assessment and Management Standards—Hospiof Pediatric Pain: children’s and parents’ ratings. PAIN [serial
tals [online]. Available at: http://www.jcrinc.com/subscribers/
online]. 1999;83:25-35. Available from: Association for the
perspectives.asp?durki=3243&site=10&return=.… Accessed
Study of Pain International, Vancouver, Canada. Accessed
July 28, 2006.
May 29, 2006.
5. Wong DL. Pain Assessment in Infants and Children [Online
11. Merkel SI, Voepel-Lewis T, Shayevitz JR, Malviya S. The
presentation]. Available at: www.mosby.com/WOW.
FLACC: a behavioral scale for scoring postoperative pain in
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young children. Pediatr Nurs. 1997;23:293-297.
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12. Krechel, Bildner J. CRIES: a new
neonatal postoperative pain measurement score—initial testing of validity
and reliability. Paediatr Anaesth.
1995;5:53-61.
13. Straight A’s in Pediatric Nursing.
Philadelphia, PA: Lippincott Williams
& Wilkins; 2004.
Gail Heckler-Medina, BS, RN, is a
PICC line expert and vascular access
nurse. She has assisted in the growth and
development of the vascular access programs throughout the nation. Ms. Heckler-Medina is the founder of P & A PICC,
LLC, an independent contracting company that is responsible for education of
staff and the placement and maintenance
of PICCs and midline catheters. Ms.
Heckler is a clinical nurse educator and
preceptor for BARD Access Systems.
Received 6/9/2005; revision received
7/27/2006; accepted 7/28/2006
Figure 5. CRIES Pain Scale. Source: National Institutes of Health.
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Figure 6. Checklist of Nonverbal Indicators (CNVI).
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