**3.2.1 Supportive methods**

Supportive methods are intended to promote the good psychosocial care of children. The first principle is that care is family-centered, that is, it is based on the needs of both family and child. Parental involvement in decision-making, and in providing comfort to children, is particularly important. Parents need a perceptive environment and they may require instruction in how best to help their child. The family includes everyone who is intimately associated with the child. In most cases it is the parents who know their children best and can therefore become allies in treatment, but they may need to be taught how they can help manage their children's pain and anxiety. Family centered care encourages them to choose how to participate in treatment, giving them culturally appropriate information and teaching them coping techniques. It also helps family members to understand the cultural, spiritual, financial, social, interpersonal, and emotional impact of the diagnosis of cancer in a child.Making the clinic or hospital environment friendly to families is another important aspect of family-centre care, and liberal visiting arrangements and a physical atmosphere conducive to family participation in treatment should be encouraged. It is essential that a child's family and friends are made to feel welcome. Both children and families need information to prepare them for what will happen during the course of the disease end its treatment. If families are not accurately informed about the diagnosis and the treatment plan, they cannot participate. Information is accepted best if it is tailored to the needs of the child and family. Some children and families seek out information; others may find that too much information increases their anxiety. Health care provides should therefore try to individualize their dealings with families. An empathic approach is essential, and information should be given a little at a time, repeated as frequently as needed. Booklets, videos, drawings, and dolls can be useful tools in this process. Children should never be lied to about painful procedures; they will distrust and fear what will be done to them in the future. Health-care workers must be genuinely fond of children and know how to deal with them. Ideally, children should be given choices about which techniques to use to control pain. They should be given choices about which techniques to use to control pain. They should also be allowed to make decisions that do not interfere with treatment, such as which finger to prick for blood samples. Play is an essential part of every child's daily life and even the sickest child can be helped to play. Playing enables children to understand their world and to relax and forget their worries. All children must therefore have the time and place to play, and painful procedures must not be carried out in play areas. Normal activities such as school, hobbies, and visits by friends should be encouraged. Psychosocial treatment is an integral part of cancer pain treatment. It should be used in all painful or potentially painful situations, often combined with analgesic drug therapy (WHO, 1998).

#### **3.2.2 Cognitive methods**

112 Complementary Pediatrics

Nonpharmacologic methods must be integral part of the management of children's cancer pain, beginning at the time of diagnosis and continuing throughout treatment (WHO, 1998). Nonpharmacologic methods in the management of pain have been found to be highly effective for some children and for some procedures. These techniques are easy to learn and should be used when possible to give the child some control in the management of pain. The examples given for distraction, muscle relaxation, and guided imagery are easy techniques to learn and can be used with young children (Hockenberry-Eaton, M et al; 1999). Non-drug approaches should supplement, but not replace, appropriate drug treatment (Hockenberry-Eaton et al., 1999; WHO, 1998). In selection of nonpharmacologic method use, child's age, behavioral factors, coping ability, fear/anxiety and type of pain experience play role. Nonpharmacologic pain management implementations are divided into 4 groups as supportive, cognitive, behavioral and physical methods. In Table 6, non-pharmacologic

**3.2 Nonpharmacologic pain management** 

Family-centre

Choices Hypnosis

**3.2.1 Supportive methods** 

care

Play

methods used in relieving pain are summarized (WHO, 1998).

**Supportive Cognitive Behavioral Physical** 

\*Heat and cold should not be used with infants because of the risk of injury Table 6. Nonpharmacologic methods of pain relief (WHO 1998)

Information Music Relaxation Heat and cold\*

Distraction Deep breathing Touch

Empathy Imagery Transcutaneous electrical

Supportive methods are intended to promote the good psychosocial care of children. The first principle is that care is family-centered, that is, it is based on the needs of both family and child. Parental involvement in decision-making, and in providing comfort to children, is particularly important. Parents need a perceptive environment and they may require instruction in how best to help their child. The family includes everyone who is intimately associated with the child. In most cases it is the parents who know their children best and can therefore become allies in treatment, but they may need to be taught how they can help manage their children's pain and anxiety. Family centered care encourages them to choose how to participate in treatment, giving them culturally appropriate information and teaching them coping techniques. It also helps family members to understand the cultural, spiritual, financial, social, interpersonal, and emotional impact of the diagnosis of cancer in a child.Making the clinic or hospital environment friendly to families is another important aspect of family-centre care, and liberal visiting arrangements and a physical atmosphere conducive to family participation in treatment should be encouraged. It is essential that a child's family and friends are made to feel welcome. Both children and families need information to prepare them for what will happen during the course of the disease end its treatment. If families are not accurately informed about the diagnosis and the treatment plan, they cannot participate. Information is accepted best if it is tailored to the needs of the

nerve stimulation (TENS)

Cognitive treatment methods are intended to influence a child's thoughts and images. Parents are often very skilled at using these methods because they know their children's preferences (WHO, 1998). Distraction is used to focus the child's attention away from the pain (Hockenberry-Eaton, 1999). Active distraction of children's attention is important: the more involved a child becomes in an activity, the greater the distraction from pain (WHO, 1998). For children, simple distraction techniques can be very effective in decreasing pain (Hockenberry-Eaton, M 1999). Infants and young children require concrete events or objects to attract their attention; interesting toys that provide something to see, hear, and do are best. Older children benefit from concentrating on a game, conversation, or special story (WHO 1998). In studies conducted, it was reported virtual reality was useful in distracting attention in painful medical interventions and decreasing pain and distress and child's selection should be attached importance in implementation ( Gershon et al., 2004, Nilsson et al., 2009). Music, even as simple as a mother's lullaby, is a universal soother and distractor (WHO, 1998). Listening to music is an important tool which decreases heart rate, body temperature, blood pressure and breathing rate, distracts patient's attention, lowers the nausea depending on chemotherapy and especially increases the life quality of the patients in terminal period (Chase, 2003; Deng et al., 2004; Halstead&Roscoe, 2002; Hiilliard, 2003; Kaminski&Hall, 1996; Mccaffery, 2000). In a study performed by Burns et al. (2001) on cancer patients, it was reported that well-being and relaxion increased in the patients in music listening process, and tension decreased. In the study carried out by Chan et al. (2003) on the patients to whom colposcopy was applied, pain and anxiety level of the group listening to music was found lower. Nguyen et al. (2010) found that pain score, heart and breathing rate were lower in the group listening to music during and after lumbar puncture implementation in children with cancer. Listening to music was found to increase endorphin secretion by inducing alpha wands and to play a role in not only decreasing the pain by creating a state of relaxion but also in decreasing blood pressure, heart rate and

Pain Management and Nursing Approaches in Pediatric Oncology 115

Deep breathing is a simple way to help a child to reduce pain and gain self-control. It focuses the attention, reduces muscular tension, relaxes the diaphragm, and oxygenates the body. It is best to start teaching this technique by asking the child to breathe out, and tol et go of the tension, or "scary" feelings, with each breath. Deep breathing is the easiest technique to use with young children. Younger children can be taught to breathe deeply by blowing bubbles from soap solution or by using party blowers (WHO, 1998). For school age children, asking them to hold their breath during a painful procedure transfers their focus to their breathing and not on the procedure (Hockenberry-Eaton, 1999). Older children can use more sophisticated breathing techniques such as breathing in and out, each fort he count of three (WHO, 1998). Muscle relaxation Muscle relaxation is used to decrease mental and physical tension. It is used most effectively in older children and adolescents because it involves the relaxation of voluntary skeletal muscles. Slowly each muscle is tensed and then relaxed in a systematic way. Attention is placed on breathing which causes the individual to be aware of the feelings of tension and relaxation (Hockenberry-Eaton, 1999). Relaxation is often combined with suggestion and deep breathing, and these methods can reduce anticipatory anxiety and help to reduce nausea and vomiting (Hockenberry-Eaton, 1999; WHO, 1998). In the study Anderson et al. (2006) carried out on cancer patients, it was found that less pain was suffered in the group to which relaxion technique was applied. Walco et al (2005) reported significant decrease in heart rate using cognitive-behavioral method in preventing procedural distress in children with cancer. In systemic reviews of Ellis&Spanos (1994), it was reported that cognitive-behavioral methods had critical importance in decreasing pain during painful procedures such as bone marrow aspiration and lumbar puncture. Cognitive-behavioral methods are the most frequently used methods to increase coping ability of the child and decrease children's distress in medical procedures (Collins et

Touch is important for all children, particularly the pre-verbal child, who understands the world to a large extent through touching and feeling. Touch must be appropriate for the child's needs, that is, not too invasive either physically or psychologically. Touching includes stroking, holding and rocking, caressing, massaging hands, back, feet, head, and stomach as well as swaddling. Vibration and tapping can also be comforting. When talking

Flying

Any activity

**Visual Imagery Auditory Imagery Movement Imagery** 

TV or movies Listening to music Amusement rides

Animals Favorite song Swimming Flower gardens Playing a musical instrument Skating

(waves, etc.)

Table 8. Favorite imagery scenes for children (Hockenberry-Eaton, M 1999)

Favorite places Conversations with significant others

Favorite room Environmental sounds

Favorite sport

al., 2008).

**3.2.4 Physical methods** 

**3.2.3 Behavioral methods** 

other physiological responses (Henry, 1995). It is also quite important that child selects his/her own music (Nilsson S et al. 2009). Moreover, there are studies concerning influence of the music belonging to children's own culture (Balan et al., 2009; Ngyen et al. 2010). Imagery is the process in which a child concentrates on the image of a pleasant and interesting experience instead of on the pain. A child can be helped by an adult to become absorbed in a previous positive experience or an imaginary situation or adventure. Colors, sounds, tastes, smells and atmosphere can all be experienced in imagination (WHO, 1998; Hockenberry-Eaton, 1999). Storytelling is a powerful way to engage the imagination and provide distraction; children may enjoy old favorites or new stories told from books or from memory (WHO, 1998). What should be taken into account in assisted imagining is not to use images causing fear and anxiety in patient (such as water, forest) (Black&Matassarin Jacobs, 1997). Children should be encouraged to use their imagination by their parents. In their studies in which Kuttner et al. (1988) compared medical treatment, occupation and imagination techniques under hypnosis during bone marrow aspiration, they found imagination method was more useful in children between 3-6, both occupation and imagination method was more effective in 7-10 group. Besides, it was determined that one or more sessions were required in order to learn coping abilities of the group to which occupation method was applied. Occupation methods which children may like according to their age groups are given in Table 7.


Table 7. Distraction techniques in children (Hockenberry-Eaton, M 1999)

True hypnosis requires specialized training, but pain can be modified by words of comfort and relief spoken in a particular way. Firstly, a child should be encouraged to relax and focus attention on a favorite activity, on deep breathing, or on a pain-free part of the body. Children can also imagine they are closing pain "switches" or "gates" or that they have the "magical" powers of their popular heroes to make their pain become less (WHO, 1998). Hypnotic ability is limited in children younger than 3, they begin at 5-6 and climb up to the highest level at 7-14. In the study conducted by Liossi et al (2006) on pediatric cancer patients, it was found that hypnosis decreased pain and anxiety level of the patients (Liossi et al., 2006). However, there are many clinic researches and systemic reviews concerning efficiency of hypnosis in decreasing distress related to chemotherapy and interventions (lumbar puncture, bone marrow aspiration, venepuncture etc.) which cause pain in especially pediatric cancer patients (Accardi&Milling, 2009; Liossi et al., 2006, Liossi et al. 2009; Richardson et al., 2006; Rogovik&Goldman, 2007; Tsao&Zeltzer 2005; Zelter et al. 2001). Also, it was found that distress management implementations had useful and positive effect in coping with pain in the future (Rocha et al., 2009). Imagination scenes which children like are given in Table 8.


Table 8. Favorite imagery scenes for children (Hockenberry-Eaton, M 1999)

#### **3.2.3 Behavioral methods**

114 Complementary Pediatrics

other physiological responses (Henry, 1995). It is also quite important that child selects his/her own music (Nilsson S et al. 2009). Moreover, there are studies concerning influence of the music belonging to children's own culture (Balan et al., 2009; Ngyen et al. 2010). Imagery is the process in which a child concentrates on the image of a pleasant and interesting experience instead of on the pain. A child can be helped by an adult to become absorbed in a previous positive experience or an imaginary situation or adventure. Colors, sounds, tastes, smells and atmosphere can all be experienced in imagination (WHO, 1998; Hockenberry-Eaton, 1999). Storytelling is a powerful way to engage the imagination and provide distraction; children may enjoy old favorites or new stories told from books or from memory (WHO, 1998). What should be taken into account in assisted imagining is not to use images causing fear and anxiety in patient (such as water, forest) (Black&Matassarin Jacobs, 1997). Children should be encouraged to use their imagination by their parents. In their studies in which Kuttner et al. (1988) compared medical treatment, occupation and imagination techniques under hypnosis during bone marrow aspiration, they found imagination method was more useful in children between 3-6, both occupation and imagination method was more effective in 7-10 group. Besides, it was determined that one or more sessions were required in order to learn coping abilities of the group to which occupation method was applied. Occupation methods which children may like according to

0-2 years Touching, stroking, patting, rocking, playing music, using mobiles over

6-11 years Music, breathing, counting, eye fixation, thumb squeezing, talking about

True hypnosis requires specialized training, but pain can be modified by words of comfort and relief spoken in a particular way. Firstly, a child should be encouraged to relax and focus attention on a favorite activity, on deep breathing, or on a pain-free part of the body. Children can also imagine they are closing pain "switches" or "gates" or that they have the "magical" powers of their popular heroes to make their pain become less (WHO, 1998). Hypnotic ability is limited in children younger than 3, they begin at 5-6 and climb up to the highest level at 7-14. In the study conducted by Liossi et al (2006) on pediatric cancer patients, it was found that hypnosis decreased pain and anxiety level of the patients (Liossi et al., 2006). However, there are many clinic researches and systemic reviews concerning efficiency of hypnosis in decreasing distress related to chemotherapy and interventions (lumbar puncture, bone marrow aspiration, venepuncture etc.) which cause pain in especially pediatric cancer patients (Accardi&Milling, 2009; Liossi et al., 2006, Liossi et al. 2009; Richardson et al., 2006; Rogovik&Goldman, 2007; Tsao&Zeltzer 2005; Zelter et al. 2001). Also, it was found that distress management implementations had useful and positive effect in coping with pain in the future (Rocha et al., 2009). Imagination scenes which

2-4 years Puppet play, storytelling, reading books, breathing, blowing bubbles 4-6 years Breathing, storytelling, puppet play, talking about favorite places, TV

favorite places, activities on TV shows, humor

Table 7. Distraction techniques in children (Hockenberry-Eaton, M 1999)

their age groups are given in Table 7.

the crib

shows, activities

Age Methods

children like are given in Table 8.

Deep breathing is a simple way to help a child to reduce pain and gain self-control. It focuses the attention, reduces muscular tension, relaxes the diaphragm, and oxygenates the body. It is best to start teaching this technique by asking the child to breathe out, and tol et go of the tension, or "scary" feelings, with each breath. Deep breathing is the easiest technique to use with young children. Younger children can be taught to breathe deeply by blowing bubbles from soap solution or by using party blowers (WHO, 1998). For school age children, asking them to hold their breath during a painful procedure transfers their focus to their breathing and not on the procedure (Hockenberry-Eaton, 1999). Older children can use more sophisticated breathing techniques such as breathing in and out, each fort he count of three (WHO, 1998). Muscle relaxation Muscle relaxation is used to decrease mental and physical tension. It is used most effectively in older children and adolescents because it involves the relaxation of voluntary skeletal muscles. Slowly each muscle is tensed and then relaxed in a systematic way. Attention is placed on breathing which causes the individual to be aware of the feelings of tension and relaxation (Hockenberry-Eaton, 1999). Relaxation is often combined with suggestion and deep breathing, and these methods can reduce anticipatory anxiety and help to reduce nausea and vomiting (Hockenberry-Eaton, 1999; WHO, 1998). In the study Anderson et al. (2006) carried out on cancer patients, it was found that less pain was suffered in the group to which relaxion technique was applied. Walco et al (2005) reported significant decrease in heart rate using cognitive-behavioral method in preventing procedural distress in children with cancer. In systemic reviews of Ellis&Spanos (1994), it was reported that cognitive-behavioral methods had critical importance in decreasing pain during painful procedures such as bone marrow aspiration and lumbar puncture. Cognitive-behavioral methods are the most frequently used methods to increase coping ability of the child and decrease children's distress in medical procedures (Collins et al., 2008).

#### **3.2.4 Physical methods**

Touch is important for all children, particularly the pre-verbal child, who understands the world to a large extent through touching and feeling. Touch must be appropriate for the child's needs, that is, not too invasive either physically or psychologically. Touching includes stroking, holding and rocking, caressing, massaging hands, back, feet, head, and stomach as well as swaddling. Vibration and tapping can also be comforting. When talking

Pain Management and Nursing Approaches in Pediatric Oncology 117

family-centered care implementations can be carried out and the care given should be controlled. Nurse training and consultancy roles should be used effectively. Parents should be allowed to ask question so that they could understand the diagnosis and treatment methods applied to their children and parents' opinion should be asked in decisions related to child's treatment. In this regard, nurse should encourage the parents to ask question and be open in communication with them. Pediatric nurse is responsible for training the parents about the care of the child. It is important that such training continues until child is discharged from the hospital. Nurse should make sure that family has gained the knowledge and skills required in respect of child's care and do these correctly. Nurse should prepare the parents about care of child at home by ensuring parents' participation in care and controlling the care they give at hospital (Boztepe, 2009). Nurses should conduct proper assessment and treatment of the pain which is a necessary part of children's care for optimal treatment of the child with pain. The pain which is not treated or taken under control might lead to long-term chronic pain. Having limited knowledge about effective assessment and treatment options might be a reason for being unable to take the pain under control. However, attitude, belief and previous experiences may affect their decisions. Nurses should spare time for themselves in order to equip themselves with up-to-date knowledge concerning assessment and treatment of the pain (Clark, 2011). Nurses play a critical role in efficient pain management of the patient. Nurse should permanently inform the patient and patient's family about pain management methods. They should be encouraged to participate in efficient pain management and trained about how pain management and methods to increase their life qualities will be (Williams, 2011). Also, nurses should ensure inclusion of effective behavioral methods in routine care of the children with cancer (McCarthy et al., 1996). Pain is a subjective experience and each and every child should be treated as an individual. Multimodal approach (together with pharmacologic and nonpharmacologic pain management) is the best way to optimize pain control with least negative effects. Even the smallest children deserve ensuring the best pain control in a safe manner (Clark, 2011).

Accardi, M.&Milling L.S. (2009) The effectiveness of hypnosis for reducing procedure-

Alanmanou, E. (2006b). Nonsteroidal antiinflamatory drugs. In: *Decision making in pain* 

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but not long-term effectiveness. *Cancer*, 107(1), pp.207-214, ISSN 1097-0142 Aslan, F.E. (2006). Tarihsel Süreçte Ağr. In: *Ağr, doğas ve kontrolü*. Fatma Eti Aslan (Ed.). Avrupa Tp Kitapclk Ltd. Şti, pp. 3-9, ISBN 975-6257-17-2, İstanbul

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**5. References** 

is too much effort for the child, touch can be the best form of communication. When a child must be touched for medical purposes, e.g. palpation of the abdomen, care must be taken to use warm hands, to proceed gently, and to talk quietly with the child about what is being done. Sources of heat and cold are often easily available. Ice wrapped in a cloth can be used to soothe disease pain or inflammation, or to reduce the pain of a procedure such as intramuscular injection. Heat is useful for muscle pain. However, neither cold nor heat should be used on infants because there is a risk of injury. The physical methods applied in removal of pain and their definitions are given in Table 9. Transcutaneous electrical nerve stimulation (TENS) is achieved with a battery-operated device that delivers electrical stimulation through electrodes placed on the skin. It possibly acts by cutaneous stimulation of large-diameter nerve fibres, reducing pain transmission at the spinal level. Children often experience TENS as tingling or tickling; it must not become painful. The technique is simple to use, is effective, and requires little preparation (WHO, 1998). Acupuncture has been used therapeutically in China for thousands of year, its importance in Europe and USA increases gradually. It was reported to be especially efficient in decreasing chemotherapy-related nausea/vomiting and cancer-related pain in the patients. However, number of studies carried out on pediatric patients is low (Hockenberry-Eaton, 1999; Jindal et al., 2008). In their study, Reindl et al. (2006) reported that acupuncture decreased the need of antiemetic treatment in preventing chemotherapy-related nausea in pediatric patients.. It is recommended to apply acupuncture with methods such as hypnosis and massage (Jindal et al 2008). Zelter et al (2002) applied hypnotherapy with acupuncture to children with chronic pain their study and reported no adverse effect, on the contrary parents and children reported significant improvements concerning pain and treatment. However, since there was no control group available in the study, efficiency of acupuncture / hypnotherapy was not specified.


Table 9. Comfort measures (Hockenberry-Eaton, M 1999)

#### **4. Nursing approach**

As in all the other fields of pediatrics, supportive methods have indisputable importance in pediatric oncology. Family-centered care which is the fundamental element of supportive methods forms the integrative role of pediatric nursing. Parents should be encouraged to participate in care of their children at hospital in accordance with their readiness so that family-centered care implementations can be carried out and the care given should be controlled. Nurse training and consultancy roles should be used effectively. Parents should be allowed to ask question so that they could understand the diagnosis and treatment methods applied to their children and parents' opinion should be asked in decisions related to child's treatment. In this regard, nurse should encourage the parents to ask question and be open in communication with them. Pediatric nurse is responsible for training the parents about the care of the child. It is important that such training continues until child is discharged from the hospital. Nurse should make sure that family has gained the knowledge and skills required in respect of child's care and do these correctly. Nurse should prepare the parents about care of child at home by ensuring parents' participation in care and controlling the care they give at hospital (Boztepe, 2009). Nurses should conduct proper assessment and treatment of the pain which is a necessary part of children's care for optimal treatment of the child with pain. The pain which is not treated or taken under control might lead to long-term chronic pain. Having limited knowledge about effective assessment and treatment options might be a reason for being unable to take the pain under control. However, attitude, belief and previous experiences may affect their decisions. Nurses should spare time for themselves in order to equip themselves with up-to-date knowledge concerning assessment and treatment of the pain (Clark, 2011). Nurses play a critical role in efficient pain management of the patient. Nurse should permanently inform the patient and patient's family about pain management methods. They should be encouraged to participate in efficient pain management and trained about how pain management and methods to increase their life qualities will be (Williams, 2011). Also, nurses should ensure inclusion of effective behavioral methods in routine care of the children with cancer (McCarthy et al., 1996). Pain is a subjective experience and each and every child should be treated as an individual. Multimodal approach (together with pharmacologic and nonpharmacologic pain management) is the best way to optimize pain control with least negative effects. Even the smallest children deserve ensuring the best pain control in a safe manner (Clark, 2011).

#### **5. References**

116 Complementary Pediatrics

is too much effort for the child, touch can be the best form of communication. When a child must be touched for medical purposes, e.g. palpation of the abdomen, care must be taken to use warm hands, to proceed gently, and to talk quietly with the child about what is being done. Sources of heat and cold are often easily available. Ice wrapped in a cloth can be used to soothe disease pain or inflammation, or to reduce the pain of a procedure such as intramuscular injection. Heat is useful for muscle pain. However, neither cold nor heat should be used on infants because there is a risk of injury. The physical methods applied in removal of pain and their definitions are given in Table 9. Transcutaneous electrical nerve stimulation (TENS) is achieved with a battery-operated device that delivers electrical stimulation through electrodes placed on the skin. It possibly acts by cutaneous stimulation of large-diameter nerve fibres, reducing pain transmission at the spinal level. Children often experience TENS as tingling or tickling; it must not become painful. The technique is simple to use, is effective, and requires little preparation (WHO, 1998). Acupuncture has been used therapeutically in China for thousands of year, its importance in Europe and USA increases gradually. It was reported to be especially efficient in decreasing chemotherapy-related nausea/vomiting and cancer-related pain in the patients. However, number of studies carried out on pediatric patients is low (Hockenberry-Eaton, 1999; Jindal et al., 2008). In their study, Reindl et al. (2006) reported that acupuncture decreased the need of antiemetic treatment in preventing chemotherapy-related nausea in pediatric patients.. It is recommended to apply acupuncture with methods such as hypnosis and massage (Jindal et al 2008). Zelter et al (2002) applied hypnotherapy with acupuncture to children with chronic pain their study and reported no adverse effect, on the contrary parents and children reported significant improvements concerning pain and treatment. However, since there was no control group available in the study, efficiency of acupuncture / hypnotherapy was

not specified.

Comfort Measure Description

heat).

**4. Nursing approach** 

discontinue cold treatment. Table 9. Comfort measures (Hockenberry-Eaton, M 1999)

Massage Includes stroking, rubbing or deep manipulation of muscles.

come to the hospital or hospice with their own music.

Music Can help to provide the child with a familiar environment; children often

Heat Warm compress or use of a heating pad, to the painful site (moist or dry

Cold/Ice Cold compress or ice pack. Precaution: assure ice pack is wrapped allowing

As in all the other fields of pediatrics, supportive methods have indisputable importance in pediatric oncology. Family-centered care which is the fundamental element of supportive methods forms the integrative role of pediatric nursing. Parents should be encouraged to participate in care of their children at hospital in accordance with their readiness so that

comfortable sensation of cold without damaging the skin by freezing tissue. Limit ice application to10 minutes, then rotate site. If skin becomes blanched,


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**7** 

*México* 

 **a Current View** 

 *Facultad de Medicina UANL,* 

**Snake Bites in Pediatric Patients,** 

B.A. Hernández-Montelongo and F.F. Montes-Tapia

*Hospital Universitario "Dr. José Eleuterio González"* 

M.E. De la O. Cavazos, C. Treviño Garza, G. Guajardo-Rodríguez,

It has been estimated that worldwide about 5 million people (adults and children) are bitten by snakes every year (Kalantri et al., 2006), and 50,000 die according to data from the World Health Organization (Schaper, de Haro, Desel, Ebbecke, & Langer, 2004). However, it is well known that events related to snake bites are under-reported, especially in the author's country possibly because snakebites are not a very relevant cause of mortality. Nevertheless, they are a serious cause of morbidity, especially in children. Under-reporting of this important health issue can be blamed on the fact that the population is not well informed about snake classification causing them to not provide accurate information to healthcare personnel when a patient is taken for medical care after a snake attack. Children do not react to snake bites in the same way as adults. In children, this event is always more severe since they are exposed to a larger amount of venom per m2 of body surface (De la O Cavazos 2006). A small child is more vulnerable to a given volume of venom than a larger individual (Hodge III & Tecklenburg, 2006) Also, there will be different presentations including neurotoxicity, myotoxicity, renal failure, edema, bleeding due to activation of clotting proteins, and intravascular hemolysis, because different kinds of snakes have different types

On the other hand, there is very little information for primary care physicians and pediatricians and most of the time it is outdated. Hence, the need for a reliable source of information in the event of a snake bite in pediatric patients that is updated, easy to find and well-structured in a way physicians find it easy to read and to easily and rapidly translate it into clinical practice to assure a fact-based, accurate treatment and prompt recovery with the

Snakebites are seriously under-reported all over the world. We currently do not have trustworthy studies or statistics to asses this problem. What we do have is information that can guide us and inform us about the most affected areas and the most common presentation. For example, studies such as the one by Ruiz Molina and cols. show not only a

of venom that cause different symptomatology. (Jeng & Glader, 2004).

**1. Introduction** 

least possible amount of sequels.

**2. Epidemiology** 

patients with advanced cancer in Korea. *Journal of Pain and Symptom Management,*  Vol.25, No.5, pp. 430–437, ISSN 0885-3924

