Preventing fear of needles

Preventing fear of needles: What can parents do?

MOANA HARLEN

Dr Moana Harlen is the Senior Psychologist Haemophilia at the Queensland Haemophilia Centre, Lady Cilento Children’s Hospital, Brisbane

FEAR OF NEEDLES

I can’t say that I have heard any child or adult say they like having a needle, can you? Fear of having a needle is a matter of degree. So at one end of the spectrum there are those individuals who have no fear and simply shrug their shoulders and say “it’s not that bad” and will go through the procedure without any hesitation. Whilst at the other end of the spectrum there are those individuals who have an intense, irrational fear of needles (needle phobia) and will become extremely anxious at the mere thought of having a needle and will do anything to avoid having a needle.  Most children and adults will sit somewhere between both ends of the spectrum.

For children with bleeding disorders, having frequent needles as home therapy and/or as hospital procedures may increase their chances of having traumatic needle experiences where they experience it as painful and highly distressing. Such experiences can increase their chances of developing a strong fear of needles which can become problematic in managing their bleeding disorder. The good news is most children do not develop this strong fear of needles, although there are still many things that parents can do to increase the likelihood that their child will not develop a needle phobia and to increase their resiliency.

FEAR IS A NORMAL RESPONSE TO THREAT

Firstly it helps to understand the physiological and psychological mechanisms at play with anxiety around having a needle.  When a humans mind perceives some level of threat from the environment, be it real (about to have a needle or there is a growling dog nearby) or imagined (thinking about having a needle or picturing being bitten by a dog) this will trigger fear which involves 3 types of responses.

• Physiological responses within the child’s body: e.g.  the stress response is triggered in the part of the brain called the amygdala which is responsible for emotional arousal and sends signals to other parts of the brain so that  stress hormones (e.g. adrenaline and cortisol) are  released preparing the body to run away to safety (flight), to  fight or freeze. Think of the last time you were afraid and how your body responded. Most people notice increased heart rate and breathing and feeling more energised.  Vision and hearing become sharper etc.  An anxious child will feel pain more acutely than a more relaxed child. Don’t be surprised if your child wants to go to the toilet or complains of a sore tummy before a needle; that’s part of the stress response.

• How the child feels and thinks: A child may think anxious thoughts such as “This is going to hurt” “People are going to hold me down like last time and I don’t like it”. Such thoughts can come from previous experiences of pain and distress or from overhearing others talking negatively about having a needle or perhaps they saw someone else become distressed when having a needle. Worry increases feelings of anxiety.

• How the child behaves: e.g.  When a child starts to kick, struggle and/or is screaming and crying it is important to view their behaviour is due to being afraid rather than thinking they are misbehaving.

HELPING YOUR CHILD TO FEEL SAFE AND SECURE AND TO MANAGE THEIR EMOTIONS

Prevention is the key.  The main aim of teaching your child to regulate their emotions is to increase their sense of control and their sense of safety whilst being accessed. The idea here is that instead of being a “helpless recipient” they can be an “active participant”. You do not need to wait until your child is going to have a procedure or until they become afraid to introduce these strategies you will probably find you are already doing a lot of them but it’s nice to know you are on the right track.    

For a child to feel safe and secure they need:

1. To be able to predict what is going to happen. This is why providing children with routines is important. They know what is going to happen next based on what they are doing now e.g. after breakfast I brush my teeth and then I can play. This reduces fear of the unknown.

• Making treatment predictable is important for this reason. It helps to keep things the same as much as possible so where, when, who and how treatment is done. This will help your child’s thinking and feeling, e.g.  “I have my factor before (or after) breakfast”.

• Create steps in treatment that your child knows and they can say what is happening next; make it a fun thing.

• Be honest about what is going to happen if in a hospital setting; prepare them for the procedure. Best not to say “it won’t hurt” or “you won’t feel a thing”. Better to say “you might feel a little sting but you’ll be fine”.

• Counting 1, 2, 3 and pushing the needle on 3 so they will know when the needle will go in. They can count as well.  “Ok, let’s count together 1, 2, 3 “.

2. Some sense of control over what is going to happen. Having a sense of control is important for children and adults. So offering some choices during treatment where practical, e.g. if a child has a port they could be offered the choice of lying down or sitting up or which toy they would like. If a support person is helping they could ask if the child would like to hold their hand or rub their leg.  A child about to have a butterfly needle could be offered the choice of which vein they prefer or which song would they like to hear or sing. For adolescents allow them to have as much control as possible.

3. To have calm parents even when things aren’t quite going to plan. Adults teach children how to manage their emotions by showing and talking about how they manage their own emotions. Adults can often role model being anxious and are not aware they are doing so. Therefore it is important for adults to act calm even if they don’t feel it inside whatever the emotion might be, e.g. anger, anxiety, or sadness.  If a child sees a parent with a worried look on their face then they will think they have something to worry about.  It is OK to say if you are nervous so long as you follow up with how you are going to cope. Remember children learn by watching how others react. Behave the way you want them to behave, so kind smiles, calm voices and doing some deep breathing yourself.

4. Distraction strategies. This helps keep a child’s mind occupied so they pay less attention to the needle. This is a very effective pain management strategy.  Distraction is best started prior to the access to help keep them relaxed for a longer period of time and used all the way through the procedure until it is all over.   There are many distraction strategies suitable for different ages.

For very young babies and toddlers

• Nursing/holding
• Soother
• Blowing bubbles or party blowers. You can keep this as a special activity for treatment so the novelty takes longer to wear off.
• A noisy interactive toy to encourage them to look away
• Sing favourite songs or make up a song about having factor, e.g. Think of a fun upbeat tune like “you are my sunshine” or the Bingo song and change the words to something about its factor time again.
• Use your smart phone to play their favourite songs or cartoons as it is easy to hold in front of their face.  Again they could have a special one just for treatment time.

For older children

• Talking and questioning them. What’s their favourite subject or hobby? Can they count backwards or some simple arithmetic if they like maths.
• Music
• Hand held games, find it books
• Guided imagery – imagining a favourite or happy place
• Doing deep or tummy breathing
• Being massaged by parent

5. Play therapy – Children learn through play and play is very therapeutic. You can buy a teddy bear and sew a pretend port on its chest and this can be used to familiarise your child with having a port. Young children love role plays and using their imagination. You can use the bear as a role model and pretend to talk to teddy and say how good he is at sitting still. Your child could pretend to give teddy their factor and take teddy through the same steps your child will be going through. The same can be done for any upcoming medical procedures.

6. Emotional support – this is a big one. It is very, very important to identify and acknowledge how your child is feeling. If you see them upset or afraid, let them know you understand they are afraid. This helps them to become aware of their emotions which is a necessary step for them to be able to manage emotions.

• A word of warning here, do not confuse empathy with sympathy, it is unhelpful to say comments like “you poor thing” or “my poor baby” as this can lead to them feeling sorry for themselves. It is much more empowering for a child to hear “I can cope” messages which will help them to grow up believing they can cope with haemophilia. It’s a matter of finding the balance between empathy and setting limits.  A matter of fact approach is more helpful, for instance, “I know that you don’t like this and that’s OK (empathy) but you have to have your factor so that you can run around and play, so remember your job is to help Mummy or Daddy by lying nice and still so we can get it done quickly and easily (setting limits)” .

7. To learn coping strategies – as children grow older they learn to self-soothe rather than rely on their parents to regulate their emotions. Sometimes they need some extra strategies to increase their coping ability whilst being accessed. Lots of practice is needed for these strategies to become more automatic so the more they practice (in a fun way) in daily activities and games the easier it will be for them to apply the coping strategies when starting to feel anxious. The point of the strategies is to prevent the anxiety from getting so big that they cannot cope. 

Relaxation strategies – you can teach young children relaxation through games like “sleeping tigers “or “statues” so they practice lying still. Older children can use guided imagery or progressive muscle relaxation.

• Tummy breathing – deep breathing helps to relax the body or reset the stress response. Young children can learn to take slow deep breaths by blowing bubbles very slowing so they don’t pop.

Using coping language – when children feel scared or nervous they can use coping words to help themselves feel better.  Children learn positive self-talk from what they hear others say to them and about them.

• During procedures tell them specifically what they are doing that is helpful and praise them, e.g. “ you are a being very brave right now, good job” or “ what a great statue you are, lying nice and still for Mummy or Daddy, well done”

• Examples of positive self-talk or helpful thoughts are “I can do this”, “it might hurt a bit but I’ll be fine”, “ I did OK last time”

• For an older child you could mention that you noticed how anxious they were and how proud you were that they did it anyway.

Using rewards to help your child achieve goals (setting limits). Reward charts work well for 4-10 year old children. This provides a non-punitive strategy to deal with difficult behaviours during treatment.

• If a child is not lying still or doing something that is making access difficult then you could use a reward chart where they can earn stickers each for doing the helpful behaviour. Once a child earns 3 stickers for the week they can get a special reward (doesn’t need to cost money, doing something fun with someone etc.).
• With young children you need to provide the reward immediately after they have shown the behaviour you wanted. Never take away a sticker once they have earned it.

These are the many things you can do at home to help your child learn to cope with needle access and to reduce the likelihood of your child developing a needle phobia. In a hospital setting you can advocate for your child if they are particularly anxious. Talk with your Haemophilia Treatment Centre staff to see if a procedural plan can be tailored so medical staff can minimise distress as much as possible during needle procedures.