77437919

peer review

549RADIOLOGIC TECHNOLOGY July/August 2012, Vol. 83/No. 6

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MELODY ALExANDER, BS, R.T.(R)(MR)

Background Research has shown that short- and long-term effects can result from stressful or invasive medical procedures per-formed on children in the radiology department. Short-term effects for the pediatric patient include pain, anxiety, crying, and lack of cooperation. The patient’s parents also may experience short-term effects, including elevated anxiety and increased heart rate and blood pressure. Potential long-term effects include post-traumatic stress syndrome; fear; changes in pain perception and coping effec-tiveness; avoidance of medical care; and trypanophobia.Objective To identify common sources of stress in pediatric radiology, investigate short- and long-term effects of stressful and invasive medical procedures in pediatric patients, and compare different strategies used in radiology departments to minimize stress in pediatric patients.Methods Searches were conducted using specific databases to locate literature related to stress in pediatric radiology. Articles were included that addressed at least 1 of the following topics: common sources of stress in the pediatric radiology department, the short- or long-term effects of a stressful and invasive medical procedure, or a stress-minimizing strategy used in a pediatric medical environment.Conclusion Consistency of care can be improved among the different radiology modalities by providing similar and effective strat-egies to minimize stress, including interventions such as parental involvement, preprocedural preparation, distraction, sedation, use of a child-life specialist, hypnosis, protecting the child’s privacy, and positive reinforcement. Future research is needed to identify additional ways to improve the consistency for care of pediatric patients in the radiology department and to investigate stress man-agement in areas such as pediatric vascular interventional radiology, cardiac catheterization, emergency/trauma imaging, and gastrointestinal procedures.

Managing Patient Stress in Pediatric Radiology

in the pediatric radiology department, it is com-mon to see distressed parents and children. The sights and sounds of the equipment, uncomfort-able positioning, and painful procedures make radiology examinations a difficult experience for

young children. Additionally, parents who are anxious about the procedure and diagnosis can escalate chil-dren’s fear and anxiety.1,2

Short-term effects of stressful and invasive medical procedures such as crying, fear, and lack of cooperation commonly are observed in pediatric radiology patients. Further, research has shown that without stress and pain management, children who undergo stressful or invasive medical procedures can experience potential long-term effects, including post-traumatic stress disorder symptoms.3-9 The medical community has focused efforts on creating an environment for children that minimizes both short- and long-term effects of stressful medical procedures.3,10-31

This literature review examines issues surrounding stressful radiology procedures for pediatric patients and ways to minimize stress and its potential consequences. The author evaluated the following research questions:

■ What are common sources of stress for pediat-ric patients in the radiology department?

■ What short- and long-term effects might pedi-atric patients encounter as a result of stressful and invasive medical procedures?

■ What strategies are being used to minimize the stress of pediatric radiology patients?

It is common for patients to interact with more than 1 area of radiology throughout the course of diagnosis and treatment of a medical condition. For this reason, it is important to review and analyze all areas of pediat-ric radiology to make general suggestions for decreas-ing the stress of pediatric patients and to increase consistency of care. Whereas other published articles related to pediatric patient stress focus on a specific modality or procedure, this literature review examines

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550 July/August 2012, Vol. 83/No. 6 RADIOLOGIC TECHNOLOGY

many radiology modalities and general medical proce-dures (see Table 1).

MethodsA literature search was conducted in CINAHLPlus

(EBSCO Publishing, Ipswich, Massachusetts), PubMED, and MEDLINE (U.S. National Library of Medicine, Bethesda, Maryland). The following search terms were used in various combinations:

■ Catheterization.■ Child-life specialist.■ Diagnostic procedure.■ Distraction.■ Environment.■ Fear.■ Hypnosis.■ Intervention.■ Invasive.■ Magnetic resonance (MR) imaging.■ Memory.■ Music.■ Needle.■ Pain.■ Pediatric.■ Radiology.■ Radiology department.■ Sedation.■ Stress.■ Trauma.■ Venous.■ Voiding cystourethrogram (VCUG).■ Voiding cystourethrography.Although the researcher was primarily interested

in findings published in radiology journals, other medical journals were included in the search because they have published key articles related to stress and pediatric patients (see Table 2). Articles selected for review addressed 1 or more of the following:

■ The short- or long-term effects from a stressful and invasive medical procedure.

■ Common sources of stress in the pediatric radi-ology department.

■ A stress-minimizing strategy used in a pediatric medical environment.

After eliminating duplicate citations, 60 articles remained and were included in the literature review.

DiscussionThe radiology department can be a frightening place

for a child. Many radiology department exam rooms

Table 1Modalities and Procedures Addressed in Selected Literature

Voiding cystourethrogram 26

General medical procedures associated with needles in emergency medicine, lumbar punctures, or venous access

9

Magnetic resonance (MR) imaging 4

Computed tomography (CT) 4

Emergency medicine 4

General radiology department 4

Radiation therapy 3

Radiography 2

General hospital setting 2

Cardiac catheterization 1

CT/MR 1

house large, noisy equipment.11,14,29 For optimal imag-ing or treatment such as in MR, computed tomography (CT), or radiation therapy, children must lie still or be immobilized in uncomfortable positions for long peri-ods.11,12,14 Immobilization devices such as the Pigg-O-Stat (Modern Way Immobilizers Inc, Clifton, Tennessee) are commonly used in radiography. These devices are effective in reducing motion, but their appearance can be very disturbing to parents.14 Some procedures such as VCUG expose private anatomy and involve bladder catheterization, and thus can be painful, distressing, and embarrassing for young children.3,28 VCUG also requires the patient to void on the examination table, which is counterintuitive for children of potty-training age. Also, radiologic procedures that involve needle sticks (eg, emergency traumas, lumbar punctures, car-diac catheterization, and MR or CT scans with contrast) can be a source of pain and stress for children.13,16-18

Effects of Stressful Medical ProceduresThere is documented evidence of both short- and

long-term physical and psychological effects of stressful and invasive medical procedures on children. Short-term effects include pain, anxiety, crying, and lack of cooperation.32 In addition, parents who witness their child experiencing a stressful procedure such as angio-catheter insertion have shown short-term effects such as elevated anxiety and increased heart rate and blood

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ALExANDER

Pain perception, fear, coping effectiveness, and avoidance of medical care in adulthood have been associated with childhood medical experiences.9

Trypanophobia, an extreme fear of needles and docu-mented medical condition, is believed to be inherited and learned through multiple needle stick experiences. Patients with trypanophobia may experience fainting, severe anxiety, electrocardiogram changes, and chang-es in stress hormone levels when needle sticks occur.6,7

Evidence also exists of a possible link between infants who undergo multiple stressful medical procedures and changes in neural development.8

Many research studies have focused on memory and how stressful procedures affect a person’s ability to recall an event. Children who experience a stressful medical event remember more about the procedure than children who experience a nonstressful medical event.4 In 1 study, children who underwent a VCUG remembered 83% of the component features of the exam 6 weeks after the procedure was performed.33 However, this could have been because of differences in age and level of distress experienced by the children at the time of the procedure. Children aged 4 years or younger at the time they underwent a VCUG were less accurate in recalling information about the pro-cedure.34,35 Also, children who were more distressed during the VCUG recalled less accurate information.4 Children whose memories of stressful medical events are not accurate may have long-term effects such as confusing various medical experiences and increased distress during subsequent medical procedures.34

Strategies to Minimize Stress Radiology departments implement different inter-

ventions to manage the stress and pain of pediatric patients. These interventions include:

■ Parental involvement.■ Preprocedural preparation.■ Distraction.■ Sedation.■ Use of a child-life specialist.■ Hypnosis.■ Protecting children’s privacy.■ Positive reinforcement.Many studies found in the literature mentioned

combining different stress-minimizing strategies as a collective intervention for a specific patient group. For example, Tyc et al, Slifer et al, and Klosky et al evalu-ated the success of interventions aimed at minimizing stress in pediatric patients.11,13,36 The interventions

pressure, and their stress may escalate the stress level in a pediatric patient.2,21

There also is evidence that children experience negative long-term effects of stressful and invasive medical procedures. VCUG procedures are used to evaluate urological disorders and are common in pediatric radiology, but they can be stressful for children. Children have shown post-traumatic stress disorder symptoms such as emotional and behavioral changes after undergoing VCUG procedures.3After undergoing a VCUG, parents have observed behaviors in their children such as repetitive play imitating the procedure without resolution, difficult communica-tion about the procedure or “wanting to block it out,” and displays of fear in other health care settings that previously were a comfortable environment for their child.3 The stress experienced during 1 procedure also may be experienced in subsequent procedures. One study found that children who underwent repeated VCUGs reported experiencing the same level of dis-tress they had during their first VCUG.32

Patients who were exposed to many invasive and stressful procedures during a serious illness in child-hood, particularly at a very early age, have shown long-term psychological effects, including:

■ Higher incidences of medical fears.■ A lower sense of control over health.■ Ongoing post-traumatic stress responses.5

Table 2Selected Literature by Journal Type

n (%)

Pediatric and child health 19 (31.7)

Radiology and radiology nursing 15 (25)

Psychology and behavioral science

7 (11.7)

Urology journals 4 (6.8)

Emergency medicine 5 (8.3)

Oncology and oncology nursing 4 (6.7)

Radiation technology 1 (1.7)

Family medicine 1 (1.7)

Anesthesia 1 (1.7)

Rehabilitation 1 (1.7)

General health care 1 (1.7)



child can directly affect the child’s stress level.2,32 Parental behaviors such as criticism, apologizing, giving con-trol, and excessive reassurance with statements such as, “Everything is ok,” can potentially cause or increase the level of distress in a child.17,32 When parents are informed about what the procedure entails and how they can active-ly participate to help their child cope, they can reduce their own anxiety and their child’s anxiety as well.1,17,26

Preprocedural Preparation Preprocedural preparation for the pediatric

patient before a radiologic exam is important in minimizing a child’s stress and promoting his or her cooperation (see Table 4).14 The timing of the prepa-ration should be determined based on the events surrounding the procedure as well as the child’s per-ception of the procedure. Preprocedural preparation can come in a variety of forms, but should always be developmentally appropriate for the child’s age.3,14,17 Terms, images, and examples used for preprocedural preparation should be understandable and familiar to a child.3 The preparation should be interactive and engaging and the content should be clear, honest, and thorough.17,24,28

used in the studies included various stress-minimizing components such as distraction, preprocedural preparation, and positive reinforcement. This review presents individual strategies that can contribute uniquely to an effective stress-minimizing interven-tion. Findings found in the literature reflect the com-bined effectiveness of the various components of a stress-minimizing intervention if more than 1 strategy is used in the intervention.

Parental InvolvementThe involvement of parents can be a valuable

resource in minimizing the stress of pediatric patients (see Table 3). Their presence during a procedure can comfort a child and help to reduce anxiety.30 Parents can hold their child in comforting positions, provide distrac-tion, coach their child in coping techniques, and help their child practice positions prior to a procedure.3,17,26,28 Parents also are valuable in positioning and immobiliz-ing their child to improve the quality of imaging and reduce radiation exposure from repeated images.14

However, anxiety and stress experienced by parents can be predictors of distress in the child.2 Thus, the way a parent responds to the pain and anxiety of his or her

Table 3 Parental Involvement3,14,17,26,28,30

Technique Area of Use Benefits Measurable Change

Parent helps with positioning and immobilization for imaging

Radiography Optimal imaging with fewer repeated images

Not applicable

Parent present to comfort patient

Lumbar puncture Helps to decrease anxiety in patient

The presence of a family member did not influence the success rate of the lumbar puncture

Parent distracts and helps coach child in coping behaviors

Venous access Helps to lower child distress; active role in procedure can help reduce anxiety in parent

Not applicable

Parent involved in preproce-dural preparation at home (by showing DVD about procedure, practicing positions)

VCUG Patient and parent are more prepared for the procedure

Improved satisfaction and con-fidence of parents; improved coping ability of child

Parent can hold child in comforting position

VCUG,venous access

A child positioned in a parent’s lap or swaddled in parent’s arms can be comfort-ing for the child; positioning is useful during catheterization and venous access

Not applicable

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ALExANDER

used returns a sense of control to the child and can increase cooperation during the procedure.3

Behavioral rehearsal is another effective method that helps familiarize a young child to new surroundings. It is especially beneficial for children undergoing a VCUG. Simulating the steps of a VCUG on a gender-appropriate catheterization doll actively involves the child and helps minimize anxiety.3,24,28 Voiding during the VCUG can be highly stressful and embarrassing for children. However, practicing this component at home in the bathtub can be an effective way to help reduce some of the stress associ-ated with the procedure.28 Children also can have hands-on experiences with equipment such as an MR simulator or the “kitten scanner,” a miniature CT unit.13,29 Special dolls and medical equipment also can be used for chil-dren to role play starting an IV.13

Educational modeling films realistically demonstrate the steps of a typical procedure and have been shown

Educational materials such as coloring books and videos can educate the parents and pediatric patients before the procedure. They learn what to expect of the procedure, the equipment used, how long the pro-cedure will take, and what the patient will see, hear, and feel. It has been shown that adequate preparation can increase the level of confidence and satisfaction in parents and increase the child’s ability to cope with the procedure.26

Teaching coping behaviors to the pediatric patient is another type of preprocedural prepara-tion. Teaching breathing techniques, positive state-ments, and imagery can help children relax and reduce their distress.3,10,13,17,24,28 Breathing techniques involving a pinwheel or a party blower are particu-larly effective during bladder catheterization prior to a VCUG.24,28 Teaching different coping strate-gies and allowing the child to choose the strategies

Table 4 Preprocedural Preparation3,11,13,17,24,26,28,29,31


Educational coloring book Radiology wait-ing room

Introduces children to com-mon radiology tests and equipment in developmen-tally appropriate ways

No significant decrease in patient anxi-ety but parents were pleased with the informative content

Educational DVD VCUG Orients parents and chil-dren to all aspects of the procedure; coaches the parents on how to help their child before and during the procedure

Improved the confidence and satisfac-tion of the parents and the coping ability of the patients during the procedure

Teaching pediatric patients breathing techniques, positive statements, and imagery

VCUG, venous access, MR

Helps relax and reduce stress in patients; children feel a sense of control; can increase cooperation

Small reduction in distress associated with MR procedures; children displayed fewer distress behaviors and more cop-ing behaviors, and they were rated as more cooperative during a VCUG

Behavioral rehearsal VCUG, CT, MR Allows children to practice positioning and steps of a procedure; children become familiar with medical equip-ment and supplies

Children displayed less distressful behavior during VCUG; small reduction in distress associated with MR proce-dures; enhanced satisfaction among patients and their families; a reduction in the use of sedation

Modeling films VCUG, MR, radiation ther-apy

Children are able to see a realistic procedure success-fully completed with mod-eled coping skills

Children displayed less distressful behavior during VCUG and radiation therapy; small reduction in distress associated with MR procedures



of parents in the distraction strategy can help reduce their anxiety, too. Parents can bring toys, pacifiers, books, or other comfort items.14,28 Videos also are effec-tive distraction tools for procedures such as CT, MR, and VCUGs, and specialized video goggles compatible with MR scanners can distract children during long MR procedures.12,25,28 Party blowers and whistles are especially effective distraction methods during proce-dures such as VCUGs.24,28

Some CT departments have invested in color light-show devices that project moving lights on the gantry, walls, and ceiling to calm and distract children.12,29 Some light systems also project ani-mated characters on the walls to instruct the child in breathing instructions and provide positive rein-forcement for cooperation.29Auditory distraction such as music and storytelling is also a simple but

to help prepare a child before undergoing radiation therapy treatment or MR scans.11,13 Modeling films show a young child successfully going through all of the steps of a procedure with a realistic amount of anxiety, but with modeled coping behaviors.13 A modeling film not only prepares the child for what to expect with the procedure, but gives the child confidence that he or she can be successful, too.

DistractionDistraction can effectively minimize the stress of

pediatric patients associated with many medical proce-dures, including radiography, venous access, CT, MR, VCUG, radiation therapy, lumbar puncture, and cardi-ac catheterization (see Table 5).11-14,16-18,24,25,28,29 A variety of distraction strategies are available for use and can be used before and during a procedure. The involvement

Table 5 Distraction11-14,16,18,25,28,29


Toys, pacifiers, and comfort items

Radiography Comforts and distracts child

Not applicable

Video during procedure (cartoon)

VCUG, CT Distracts child Can distract and reduce stress in child, but may not be as effective if not used in conjunction with other interventions such as preprocedural preparations

Books VCUG Distracts child Not applicable

Party blowers and whistles

VCUG Distracts child, particularly during catheterization

Not applicable

MR video goggles MR Can distract patients during long exams

Not applicable

Color lights display CT Can distract and calm children

Enhanced satisfaction among patients and their families; reduction in the use of sedation

Auditory distraction(music and story narration)

Lumbar puncture, cardiac catheterization, MR (including IV insertion), radiation therapy

Helps children to relax and distracts them from procedure

Use of music decreased pain scores, heartrates and respiratory rates during lumbar puncture; music found to reduce stress in cardiac catheterization patients (at varying levels depending on patient age); small reduction in distress associated with MR procedures; using a narrating character as part of a stress-minimizing intervention reduced stress in radiation therapy patients

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ALExANDER

There are risks and practicalities to consider regard-ing sedating pediatric patients. A thorough presedation assessment of a child’s medical history, airway, and fast-ing history is critical before sedation is administered.41 Pediatric sedation regimens should be customized to the needs of each patient based on whether the pro-cedure is painful, the duration and type of procedure involved, various patient factors (eg, the age of the patient and cardiac and airway issues), and the skills and experience of the staff members involved.39,41

Many studies in the literature discuss and com-pare various sedation agents, the effectiveness of the sedatives in the radiology setting, and disadvantages that may be associated with a particular agent. The literature contains many studies that discuss the use of various sedatives during VCUG procedures. For example, Keidan et al compared the use of oral mid-azolam and nitrous oxide in minimizing pain and stress in pediatric patients.40

Outcomes of the study included observed assess-ments of pain and distress, side effects, and recovery time. The study found oral midazolam and nitrous oxide were comparable in safety and effectiveness in reducing anxiety and distress, but nitrous oxide was found to provide a more rapid onset and a shorter recovery time and is less expensive.40 An important component of VCUG is the patient’s ability to void during the study. Studies have shown that the use of certain sedation agents may affect a patient’s abil-ity to void. The use of propofol hinders the ability to void, whereas oral midazolam does not appear to interfere with voiding ability.20,42

Children who are sedated must be closely moni-tored by trained staff in specialized areas with proper equipment.21,38 Because of the strong magnetic field and radiofrequency emissions in the MR depart-ment, special precautions must be taken to ensure that sedation equipment and monitoring devices are MR compatible.41 Sedation cases require allocating several staff members to a patient for a long period during preprocedural preparations, the procedure itself, and recovery time, which can put a strain on the department.29 Sedation also comes with possible complications, including hypoxia, prolonged sedation, apnea, vomiting, and the need for assisted ventila-tion.38 Sedation can be associated with incomplete and canceled procedures because of inadequate seda-tion or complications which can result in potentially increased radiation exposure to patients and repeat visits to the hospital.38 Radiology departments now

effective way to calm and distract a child and can be a valuable tool in the radiology department.13,16,18

In 1 study, a narrating purple dinosaur was an impor-tant stress-minimizing component for patients and par-ents during radiation therapy simulation and treatment sessions. The character was designed to accompany the child during the sessions and narrate stories intended to distract and calm the child. In this study, radiation therapy patients were randomly assigned to either the dinosaur intervention group or the modified controlled group. Parents of children in both groups completed measures of state anxiety (“how I feel at this moment”) and trait anxiety (“how I generally feel”) 10 minutes prior to the initial simulation and just after the first treatment session. In addition, parents completed an exit questionnaire at the conclusion of the radiation therapy trial. The intervention — which included distraction and components such as preprocedural preparation — more effectively minimized stress in both the patients and parents compared to the control group. The parents in the intervention group experienced greater reductions in trait anxiety between the first simulation and the last day of radiation therapy. Parents also rated the dinosaur intervention higher in its effectiveness to reduce proce-dural distress in the pediatric patients compared to the control group.11

The use of distraction can be a great tool in reduc-ing stress in pediatric patients during invasive proce-dures. However, distraction alone may not be as effec-tive if the procedure is not explained to the patient. In 1 study, children who underwent a VCUG while watching cartoons with little or no information about the procedure demonstrated more distressful behavior and appraised the procedure as more painful 1 week later than children who watched cartoons but who also received complete procedural information.25

SedationPatients have to remain still to reduce motion arti-

facts, but it can be a difficult task for any active child and especially for children who are anxious. Sedation agents can be used to reduce motion and obtain the necessary amount of cooperation during the study.37,38 Numerous radiology departments have used sedation, including CT, MR, VCUG, nuclear medicine, emergency medicine, and interventional radiology.20-23,37-41 Sedation also has been used to reduce anxiety during angiocath-eter insertion and when accessing subcutaneous ports.15 Table 6 presents different sedation agents and their effectiveness in reducing stress in pediatric patients.



Child-life SpecialistsIn an effort to reduce the stress of pediatric patients

and the need for sedation, various departments use cer-tified child-life specialists, including fluoroscopy, CT, MR, and the emergency department.12,19,44 Child-life specialists generally have an academic background in child development, education, and psychosocial care.44 They work with other medical staff and use interven-tions to increase adaptability and learning. Child-life specialists are educated in the physical, emotional, and cognitive development of children and can tailor an intervention for a patient and his or her family to meet specific needs of the child. When designing an inter-vention, a child-life specialist must first consider the age of the child and then identify potential stressors involved with the procedure, the child’s cognitive abil-ity, and how the family can best support the child.44

use dedicated pediatric sedation teams to address safety and staff allocation concerns. These teams have increased the number of successfully completed seda-tions with fewer adverse effects.38

Because of the potential risks and costs of sedation, the radiology department may implement more cogni-tive and behavioral interventions to reduce the use of sedation. Bates et al evaluated the attitudes and percep-tions of the use of complementary alternative medicine therapies such as relaxation, guided imagery, and hyp-nosis in a group of MR employees.43 Overall, the study found a positive perception of the alternative therapies among the staff and an understanding of the special needs of pediatric patients. However, the study showed that staff members need more clarification and educa-tion on the specifics of the therapies and how they can be implemented in the MR setting.43

Table 6 Sedation11,15,20-23,36,37,39,40,42

Sedation Agent Area of Use Benefits Measurable Change

Midazolam VCUG, MR, needle sticks associated with cancer patients

Induces sedation and can cause amnesia; few adverse side effects when given orally

Little effect on voiding ability; does not hinder detection of vesicoureteric reflux; requires increased recovery time; intranasal method may cause nasal discomfort

Nitrous oxide VCUG Reduced stress and pain; less expensive compared to midazolam

More rapid onset of sedation; requires a shorter recovery time

Propofol VCUG, MR Deep sedative agent; quick acting; shorter recovery time

Negatively affects patient’s ability to void

Pentobarbital CT, MR Reduces anxiety; immobilization Successful sedation agent, but requires more recovery time

Etomidate CT, MR Reduces anxiety; immobilization Not as effective as sedation agent, but requires less recovery time

Chloral hydrate MR Reduces anxiety; immobilization Not applicable

Diazepam MR Reduces anxiety; immobilization Not applicable

Methohexital MR Reduces anxiety; immobilization Not applicable

Dexmedetomidine MR Reduces anxiety; immobilization Not applicable

General anesthesia MR, radiation therapy

Immobilization More costly, long recovery time; requires allocated anesthesiologist

Intranasal fentanyl VCUG Pain relief Unable to show a statistically significant difference between the study and control group

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ALExANDER

“sensation, perception, and physiology” and is shown to be an effective agent in alleviating pain.45 Peebles-Kleiger discussed the use of hypnosis in emergency medicine and listed several characteristics of effective hypnotic interventions, including:

■ The use of a calm but direct voice.■ Pacing the rate of speech to the patient’s breath-

ing, then gradually slowing down.■ The use of strategic pauses to enhance dissociation.■ An emphasis on words that carry intended

suggestion.■ An avoidance of negative phrases.■ The use of positive expectations and suggestions.45

Specifically with pediatric patients, hypnotic inter-ventions should be focused on capturing the child’s attention and trust and positively reframing the child’s distress.45

Butler et al discussed findings from a study that examined the effectiveness of hypnosis in reducing the distress and duration of a VCUG in patients at least 4 years of age who had previously experienced a stressful VCUG.27 One day prior to the procedure, parents and patients were questioned about the pain, crying, and fear experienced during the previous VCUG. A patient who was randomly selected for hypnosis was given a 1-hour training session by a trained therapist. The training session included the use of self-hypnotic visual imagery. The parents and patient were encouraged to practice the self-hypnotic imagery at home prior to the procedure. The therapist also was present during the procedure to assist with the self-hypnotic visual imagery technique. Patients who were not a part of the hypnosis group received “routine care” as a part of the hospital’s recreation therapy program, which included preprocedural preparation such as demonstrations with a doll and breathing exercises.

The patients who received hypnosis rather than routine care showed significant improvements in stress compared to the previous procedure. Parents reported that undergoing the procedure with hypnosis was significantly less traumatic for the child.Observational ratings of distress levels during the procedure were lower, and medical staff reported less difficulty with the procedure. Also, the total procedure time was shorter by 14 minutes compared to procedures performed without hypnosis.27 More research is needed to further investigate the use of hypnosis in reducing stress in the radiology department.

An important job of a child-life specialist is pre-procedural preparation.19,44 Child-life specialists can meet with a family in person before a procedure or by telephone consultation. This preparation is helpful because it informs the parents and child of what to expect ahead of time and provides ample opportunity for questions and concerns to be addressed.44 In addi-tion, child-life specialists can serve as advocates by facil-itating communication between the family and staff.19,44 During the preprocedural preparation period, a child-life specialist may be able to provide an assessment to the medical staff that allows for special adaptations to be made prior to the procedure.44 Child-life specialists educate patients and families about the procedure in a developmentally appropriate way. They also can define the parent’s role during the procedure and teach them how to be supportive, as well as help minimize anxiety in the patient by teaching coping skills. These skills can be introduced during the preprocedural preparation period, practiced at home by the parents, and used during the procedure. Some coping skills include:

■ Visual and auditory distraction.■ Breathing exercises.■ Tactile stimulation.■ Counting and singing.19,44

Child-life specialists also can be an educational resource for other medical staff and health care pro-fessionals by providing guidance and training in age-appropriate practices.44

Several studies have shown the benefits of having a child-life specialist in the radiology department. An intervention involving a child-life specialist was found to reduce stress in children aged 4 to 7 years, who underwent angiocatheter insertion in the emergency department.19 In another study, the use of a child-life specialist in combination with other strategies such as videos and lights showed a 34.6% reduction in the use of sedation in MR imaging for children younger than age 7, and a 44.9% reduction in the use of sedation in CT. Khan et al described the presence of the child-life specialist in the radiology department as having “a profound effect on patient and family satisfaction.”12

HypnosisHypnosis has been shown to be an effective stress-

minimizing strategy for pediatric patients in various medical settings such as emergency medicine, radiol-ogy, wound care, and intravenous catheterization.45 Hypnosis is an altered state of consciousness that inten-tionally uses suggestion to affect changes in a person’s



of a medical condition. Consistency of care can be reassuring for a young child, especially in a stressful situation. Radiology department managers and supervisors can provide consistent management of stress and pain in children by implementing various stress-minimizing strategies throughout the radiology department. All radiology department staff can play an important role in minimizing stress in pediatric patients through good communication. A common theme throughout the literature was the importance of communication between the medical staff, the pediatric patient, and his or her parents. Patient anxiety can be reduced when pediatric patients receive realistic and developmentally appropriate descriptions and expectations for a procedure.3,13,14,17,26,28 Also, parental stress can be reduced when they are informed about their child’s procedure and educated about ways they can help their child cope.17,26 Good communication is a simple but critical component in minimizing stress in the radiology department and should be the focus of all medical staff when working with pediatric patients.

Many studies have addressed stress experienced by patients in specific branches of radiology. However, gaps exist in the literature because the majority of the studies are based on CT, MR, and VCUGs. Relatively few studies address vascular-interventional radiology, cardiac catheterization, emergency/trauma imaging, and gastrointestinal procedures such as barium ene-mas, upper GIs, and barium swallow studies. Future research should be done in these areas to address the stress involved with procedures in these modalities and ways to minimize it.

In addition, there are many stress-minimizing strategies identified in this literature review that have been found to be successful in a particular modality. Future research should be conducted to examine the effectiveness of these strategies in other areas of radiology. This research can improve the quality of care in a specific area, with a certain procedure, and regarding consistency of pediatric patient care throughout the radiology department.

references1. Srivastava T, Betts G, Rosenberg AR, Kainer G. Perception

of fear, distress and pain by parents of children undergo-ing a micturating cystourethrogram: a prospective study. J Paediatr Child Health. 2001;37(3):271-273.

2. Smith RW, Shah V, Goldman RD, Taddio A. Caregivers’ responses to pain in their children in the emergency department. Arch Pediatr Adolesc Med. 2007;161(6):578-582.

Protecting Children’s PrivacyA pediatric patient can become distressed easily

when he or she is required to expose his or her private anatomy for a medical procedure. This is particularly an issue with VCUG procedures as the child is catheter-ized. The child’s privacy should be maintained as much as possible during the catheterization by covering the child’s genitals and minimizing the number of staff members (especially of the opposite gender) who enter the exam room.3,28

Positive ReinforcementPositive reinforcement is an effective way to encour-

age and reward a child during and after any radiologic procedure. Verbal praise, certificates, trophies, and other prizes can be used to reinforce behavior, recog-nize courage, and provide an incentive for completing a procedure.14,24 Positive reinforcement can be used in conjunction with other strategies to minimize stress in pediatric patients.

ConclusionThis literature review thoroughly examined the

issues surrounding stressful procedures of pediatric radiology patients and ways to minimize this stress and its potential consequences. The literature review evaluated the short- and long-term effects a child can encounter from having a stressful and invasive medical procedure, the common sources of stress children may experience in the pediatric radiology department, and strategies used to try to minimize the stress of pediatric radiology patients.

The literature discusses many different types of stress-minimizing strategies used in radiology depart-ments. Some MR, CT, and radiation therapy facili-ties have developed high-tech strategies such as light displays, video goggles, and interactive toys to reduce stress. Other disciplines implemented simpler methods such as adequate preparation of the patients, distrac-tion, breathing exercises, and positive reinforcement that also proved to be effective.

Sedation is necessary in pediatric radiology at times. Many safe and effective sedation agents are used in pediatric radiology.15,20-23,37-40 However, many of the articles stressed the desire to reduce the use of sedation because of its potential risks and complications and presented alternative methods that have proved to be as effective.11-13,17,24,28,29,31,36,43,46

A patient is likely to interact with more than 1 radiology area during the diagnosis and treatment

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ALExANDER

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Melody Alexander, BS, R.T.(R)(MR), is a graduate of Campbell University with a bachelor’s degree in the biologi-cal sciences. She also is a graduate of the University of North Carolina at Chapel Hill with a bachelor’s degree in medi-cal imaging. Ms Alexander is currently employed by UNC Hospitals in the magnetic resonance imaging department.

Reprint requests may be sent to the American Society of Radiologic Technologists, Communications Department, 15000 Central Ave SE, Albuquerque, NM 87123-3909, or e-mail [email protected].

©2012 by the American Society of Radiologic Technologists.

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