Anxiety about being hurt is still the greatest fear for children and young people when going to a doctor’s appointment. Blood tests and injections and anything using a needles continue to be the most frightening experiences for children attending medical appointments at their GP or hospital.
Often the label of ‘needle phobia’ is used for children who find needles difficult, but this is inappropriate and unhelpful in most cases. Phobias are considered to be ‘an unreasonable response to a benign stimuli’. However, needles are not benign stimuli. The distress and anxiety children experience when faced with needles, blood tests and injections, is normal. Some children may have seen or read about needles and may have not fully understood what happens. In other cases, negative feelings may have been picked up from someone else, such as a friend, brother or sister, or even a parent.
In some cases, children may have had traumatic experiences during a blood test or similar procedure, because they have not been carried out with care and sensitivity. When the time comes that they need another test children may show severe anxiety and this may be witnessed in other aspects of the experience that would normally feel like safe spaces (e.g. the waiting room or the car park). In some cases, fear can look like a phobia but it is important to know that phobias of needles and injections are extremely rare. It is always worth looking back at previous experiences to consider what may be triggering fear in your child.
Taking the time to prepare and support your child before and during the appointment can make a huge difference. Reducing your child’s distress is not just important for them, it also helps to reduce your level of stress so that you can remain calm and feel confident on the day too. It can be anxiety provoking to helplessly watch your child suffer. Many parents are also scared of needles and if that is the case for you, working through that and developing some coping strategies for you to use can be really useful. Some of the strategies I share here for your child may also feel useful to you.
Get Additional Support
Recent national policy supports the child and family’s right to seek assistance with distressing procedures and there is guidance for professionals in how to carry out procedures in a way that is sensitive to children’s developmental needs and anxiety. As a parent you can request that your child is seen by a phlebotomist for a blood test (this often will mean going to your local hospital rather than the GP but some GPs are also trained in phlebotomy and will do it for you rather than the nurse). If your child has suffered from traumatic experiences in the past, you can ask to be supported by a play specialist or a paediatric psychologist. (If you are a medical professional and have not seen these guidelines before please contact me for a copy).
Cognitive-behavioural interventions are a group of treatment procedures aimed at identifying unhelpful thought processes, attitudes, attributions, and problem behaviours. There is a strong evidence base for cognitive-behavioural models in helping children manage anxiety and help them through invasive procedures such as blood tests and injections using a combination of: relaxation, distraction, modelling and graded exposure.
However – in most cases you don’t need a psychologist or play therapist to work with your child for a year inoculation or blood test. You can take an active role in supporting your child through positioning, holding and comforting them, as well as using appropriate coping strategies. Some of the recommended steps that you can take to support your child to overcome fear of needles are summarised below:
All children do better with some preparation and timing is key. It is often not necessary to prepare your child for more than a day and if possible just a few hours before the appointment. This is to reduce the anticipatory anxiety an appointment like this can provoke in your child.
If you know there will be an injection or blood test at the appointment, talk with your child about it in simple but honest terms. Let your child express any fears or questions they have about the needles.
If you only find out that a test is needed at the medical appointment you can also take some time to prepare your child. Talk to the doctor or nurse and ask what the test will involve. You can also take time to speak to your child separately in the waiting room. No matter what is going, you can always slow down the process. Preparing your child and setting things right for them and for you is crucially important for the invasive procedure to go well. Moreover, it can help give your child a more positive experience.
“We are going to the doctor today. You need a blood test so there will be a needle. How do you feel about that?”
“The doctor just said you need a blood test. Let’s go sit together and make a plan about what is going to make you feel most comfortable today”
If your child is young you can use role play and take turns doing the basic steps on them, on you and on toys:
· sleeves up
· swipe with wet wool
· Keep arm very still
· Sing a song, roar like a lion (see below)
· “Ready, it is going to scratch”
· Use distraction while the needle is in (see below)
· All done!
If your child is older, you can still role play things with them by talking through what will happen step by step. Make sure you validate their feelings, acknowledge the situation, and think with them about what will help them feel most comfortable given the circumstances.
Always be honest about what will happen and focus on the things you can control (such as what will be comforting to your child and the kind of distraction that works for them). Make sure you use language your child will understand and use brief sentences to explain the things
Children often ask “will it hurt?” and “how much will it hurt?”, both really important questions that also mean, “will I be safe?”.
Do not give false reassurances about the pain. All invasive procedures involve some degree of pain and discomfort. Trying to reassure them that it won’t hurt will only give your child the message that they cannot fully trust you in the future because when the needle goes in, it will hurt.
Pain is subjective, so try and avoid defining how much it will hurt as your child’s experience may be very different from yours (this may also mean it hurts less than they expect it to!)
“It will feel like a deep scratch on your arm” better than “It wont hurt”
“It will hurt but I will be there to keep you safe” better than “It will only hurt a little bit”
“Sometimes it can feel a bit cold on your arm too when they clean your arm with cotton wool. If you want to, we can talk about how it felt for you afterwards, I want to know what it was like for you” better than “You won’t feel a thing”
Research shows that the environment can have a big impact on children’s anxiety before invasive procedures. An environment that facilitates distraction and reduces the sense of threat to children is preferable. Often in hospitals the paediatric treatment rooms will have cartoons and fun images on the walls and the ceilings to distract children during the procedure. These are less likely in outpatient GP clinics.
However – you can take control of this by always being prepared with toys, books, and activities that will interest and bring comfort to your child. Taking familiar objects and books that they know well is preferable to taking new things as it will give your child a sense of safety. If when you go to an appointment your child doesn’t need an injection or needle, then these resources can still come in useful in the waiting room (as more often than not, there is always a bit of a wait!)
Remember also that you are the greatest source of safety to your child. Lots of eye contact, comforting touch and smiles will support them in an environment that feels clinical and unfamiliar.
It can be really helpful to offer your child control and give them a sense of agency in a situation that feels so unfamiliar.
Good choices to offer your child include:
Do you want to sit on the bed or lie down?
Do you want to sit on my lap or give me a hug?
Do you want to see the needle go in or do you want to look away?
You can also ask the nurse or doctor carrying out the procedure whether your child can see how they are preparing the equipment and even if they can help by holding on to materials. This offers them some exposure and helps them understand what is happening. Most nurses and doctors will happily offer for the child to hold the cotton wool and/or the plaster for them. Some children are more interested than others so if your child finds seeing everything more anxiety provoking, skip this step.
Your child has full permission to make noise!
As parents we often attempt to stop our child from crying or screaming, seeing their cries as communication that we haven’t done our job of comforting them well enough.
However, invasive procedures are scary and they are painful. It is normal and healthy for children to cry, scream, roar like a lion, or sing at the top of their lungs when the needle is inserted! All your child has to do is stay still during the procedure. Noise is not only allowed, but welcome. This isn’t a sign that what you are doing isn’t working or that they don’t feel safe. It is a sign that something is uncomfortable and they need you to see it and be okay with it.
You can help your child learn some of these techniques by practicing them prior to attending the appointment. Try lots of different things so that your child can tell you which they prefer (choose the one that makes them laugh as your first option!).
If your child wants you to, you can roar and sing or even scream with them. Join them while giving them another type of distraction alongside this (such as comfort through touch).
Evidence shows that distraction is the best technique at reducing subjective reports of pain during procedures.
You can use things like music in the background or if your child prefers, they can wear headphones. You can also do singing, playing a game, talking about a fun topic, etc... Be creative about what your child would like in that moment that will shift their focus of attention away from the needle and onto something more pleasurable. Passive forms of distraction such as watching a video have been found to be less useful but if a video on your phone is all you have in that moment, go for it! Some distraction is better than nothing at all.
Comfort With Touch
Infants and toddlers are comforted by touch. Patting, stroking, rubbing, a hand or foot massage, can provide an additional physical distraction. It offers an alternative rhythm on their body and helps to shift their focus as well as comfort them.
As children get older they may enjoy oil or cream being massaged onto their hands or feet. As with everything, be guided by your child.
After the Procedure - Acknowledge their Experience
Often children get praised for their ‘bravery’ after medical appointments, blood tests or painful procedures.However, labelling children’s behaviour as ‘brave’ diminishes their experience of pain and anxiety. It also gives the message that they should be feeling ‘brave’ or showing ‘bravery’ as they walk out of the building, even though what they might be feeling is sad, in pain, or scared. For some children, this may create an obstacle to seeking further comfort when they get home and lead them to feeling more scared the next time they have a medical appointment.
Instead, it is better to praise by being descriptive about what you witnessed in their experience and acknowledging what they have been through.
“You kept your arm so straight and still even though it was scary. I am proud of you for managing that” better than “You were so brave during the injection”.
“I know you were feeling scared, that roar was very loud! How did it feel?” Better than “See it didn’t hurt! You are so brave”
Children are allowed not to be brave when going through medical tests or procedures. On the other hand, our job as parents is to be brave and give our children the permission to be scared.
And What If It Doesn’t Happen?
If for whatever reason you child has been unable to have a blood test or injection on the day, don’t worry, it can always be rebooked.
Ask for help and support so that next time you and your child have a better experience. Often this will be with help from a play specialist or a psychologist.
In some circumstances staff may suggest restraint is needed for a procedure. Restraint is not the same as holding which provides comfort and safety.
Whenever possible, the guidance expressly advises against parents doing the restraining, although some children may prefer this.
Before restraint takes place careful consideration needs to be taken. In many cases children need to offer their assent to the procedure being carried out (i.e. they have to agree to it, but they do not have to like it) and a discussion about ‘whether the procedure is needed’ should take place with a discussion of the risks and benefits of this alongside appropriate timeliness (e.g. Is there a date or age by which your child needs this done? What other options are there to have the test done?)
Restraint often involves working with a clinical psychologist who is based in the hospital and/or play specialist for both preparation and debriefing afterwards.
I hope the above is useful to you and your child. It is important to help your child prepare for having blood tests and injections and deal with your child’s fear so that it does not affect them as much in the future.
If you or your child struggle with needles and wish to work on this prior to an invasive procedure do not hesitate to book a consultation with me. Please note that often preparatory work when a negative experience has occurred can take a few weeks so don’t delay in thinking about this to ensure you feel confident and safe and able to support your child have a more positive experience.