Childhood Illness: Separation Anxiety

Introduction

• Illness and hospitalization are often the first crises children encounter.
• Children are vulnerable to these stressors due to limited coping mechanisms.
• Major stressors include separation, loss of control, bodily injury, and pain.
• Reactions vary based on developmental age, experience, coping skills, diagnosis severity, and support systems.

Separation Anxiety

• Occurs from middle infancy through preschool years, peaking between 6 to 30 months.
• Also referred to as anaclitic depression.

Manifestations of Separation Anxiety

• Three stages: protest, despair, and detachment.

Stage of Protest

• Characterized by crying, screaming, and searching for parents.
• Includes clinging to parents and rejecting strangers.
• May involve verbal and physical attacks on strangers.
• Child attempts to escape to find the parent or force the parent to stay.
• Behaviors can last from hours to days, with continuous crying until exhaustion.

Stage of Despair

• Marked by inactivity and withdrawal from others.
• Child appears depressed and sad, with a lack of interest in the environment.
• Becomes uncommunicative and regresses to earlier behaviors like thumb sucking or bedwetting.
• Can last for a variable amount of time.
• Child's physical condition may deteriorate due to refusal to eat, drink, or move.

Stage of Detachment

• Shows renewed interest in surroundings and interacts with strangers or familiar caregivers.
• Forms new, superficial relationships and appears happy.
• Typically occurs after prolonged separation.
• Rarely seen in hospitalized children.

Separation Anxiety in Early Childhood

• Demonstrated through temper tantrums upon parents' arrival or departure.
• Refusal to comply with routines or regression to more primitive behaviors.
• Preschoolers may refuse to eat, have trouble sleeping, quietly cry for parents, continually ask about visits or withdraw.

Separation Anxiety in Later Childhood and Adolescence

• Feelings of loneliness, boredom, isolation, and depression are common.
• Hostile feelings are expressed through irritability, aggression, withdrawal, rejection of siblings, or behavioral issues in school.
• Adolescents may experience varied emotions due to separation from home and loss of peer contact.
• Loss of peer-group contact may pose a severe emotional threat.

Effects of Hospitalization on Young Children

• Initial aloofness toward parents, lasting minutes to days.
• Dependency behaviors emerge, such as clinging, demanding attention, and opposing separation.
• New fears, resistance to bedtime, night waking, withdrawal, shyness, temper tantrums, hyperactivity, and food peculiarities also occurs.
• Attachment to objects and regression in skills are common.

Effects of Hospitalization on Older Children

• Emotional coldness followed by intense dependence on parents as well as anger toward parents and jealousy toward others, including siblings.

Risk Factors Increasing Vulnerability to Hospitalization Stress

• "Difficult" temperament and a mismatch between child and parent.
• Age, especially between 6 months and 5 years.
• Male gender, below-average intelligence, and multiple or continuous stresses.

Stressors and Reactions of the Family

Parental Reactions

• Influenced by the seriousness of the child's condition, previous experiences, medical procedures, available support, personal strengths, and coping abilities.
• Additional factors include family stresses, cultural beliefs, communication patterns, information provided, and socioeconomic status.

Sibling Reactions

• Being younger and experiencing many changes can influence sibling reactions.
• Additionally being cared for outside the home, receiving little information, and perceiving differential treatment from parents also has impacts.

Nursing Care of the Hospitalized Child

Preparation for Hospitalization

• Includes admission assessments and preparing the child for admission.

Admission Assessment

• Focuses on daily living activities, nutritional status, elimination, sleep, cognition, self-perception, and activity patterns.
• Inquire about home medications, including complementary medicine practices.

Preparing the Child for Admission

Preadmission

• Assign rooms based on age, diagnosis, communicability, and length of stay.
• Prepare roommates for the new patient.
• Prepare room with admission forms and equipment.

Admission

• Introduce the primary nurse to the child and family.
• Orient child and family to inpatient facilities.
• Explain room features like the call light and bed controls.
• Show them unit areas and introduce the family to roommates.
• Apply identification bands and explain hospital regulations.
• Perform nursing admission history and take vital signs.
• Obtain specimens and support the child during examinations.

Nursing Interventions

• Preventing or minimizing separation by optimizing visitation, family-centered rounding, and family presence during procedures.
• For parental absence, leave familiar items with the child.
• Minimize loss of control by promoting freedom of movement, maintaining routines, encouraging independence, and promoting understanding.
• Prevent or minimize fear of bodily injury through preparation for procedures.
• Facilitate developmentally appropriate activities to normalize the environment.
• Allow opportunities for play and expressive activities.

Functions of Play in the Hospital

• Provides diversion, relaxation, security, and stress relief.
• Encourages interaction, develops positive attitudes, and offers creative expression.
• Facilitates therapeutic goals and places the child in an active, controlled role.

Maximizing Potential Benefits of Hospitalization

• Includes fostering parent-child relationships, providing educational opportunities, and promoting self-mastery and socialization.

Special Hospital Situations

Discharge from Ambulatory Settings

• Explain instructions in writing and provide an overview of recovery.
• Discuss activity levels, dietary restrictions, comfort measures, and medications.
• Provide information about equipment, complications, and emergency contacts.
• Address family questions and needs.

Emergency Admission

• Lengthy procedures are often impossible.
• Focus assessment on airway, breathing, and circulation.
• Weigh the child for medication calculations.
• Encourage children to participate in care to maintain control.

Admission to Intensive Care Unit

• Prepare child and parents for ICU admission.
• Discuss family concerns like who's in charge, visitation schedules, and where to stay.
• Prepare parents for the child's appearance and behavior in the ICU.
• Prepare siblings for visits and monitor their reactions, and encourage parental participation in care.
• Provide understandable information, assess and manage pain, and schedule undisturbed time.
• Provide opportunities for play and reduce stimulation.

Neonatal or Pediatric Intensive Care Unit Stressors

Physical Stressors

• Include pain, immobility, sleep deprivation, inability to eat or drink, and changes in elimination habits.

Environmental Stressors

• Include unfamiliar surroundings, equipment noise, human sounds, and unpleasant smells.
• Also constant lights and activity related to other patients.

Psychologic Stressors

• Include lack of privacy, inability to communicate, inadequate knowledge, severity of illness, and parental behavior.

Social Stressors

• Include disrupted relationships, concern about missing school or work, and play deprivation.

Pain Management in Children

Definition of Pain

• Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage as well as pain has sensory, emotional, cognitive, and social components.
• Acute pain is felt for a short period in response to illness, stress, or injury.
• Chronic pain lasts longer than 3 months.

Consequences of Untreated Pain in Premature Neonates

Acute Consequences

• Periventricular-intraventricular hemorrhage and increased chemical and hormone release.
• Breakdown of fat and carbohydrate stores as well as prolonged hyperglycemia.
• Higher morbidity, memory of painful events, hypersensitivity to pain, prolonged response to pain, and inappropriate response to stimuli also occurs.

Potential Long-Term Consequences

• Higher somatic complaints, greater physiologic and behavioral responses to pain, and increased neurologic deficits.
• Psychosocial problems, neurobehavioral disorders, cognitive deficits, learning disorders, poor motor performance also emerge.
• Attention deficits, poor adaptive behavior, issues with impulsivity and emotional temperament changes also arise.

Common Acute Pain Conditions in Children

Needlestick Pain

• Children receive multiple immunizations and experience pain from heel and finger sticks.

Postoperative Pain

• Many children undergoing surgery report moderate to severe pain, which can cause catabolic state with hormonal changes, impacting blood flow, metabolism, and cardiovascular systems.

Common Chronic Pain Conditions in Children

• Chronic pain persists for 3 months or more.
• Common sites are headaches, abdominal pain, and musculoskeletal pain.

Headaches

• Primary headaches include migraines and tension-type headaches.
• Migraine headaches are aggravated by physical activity and are associated with nausea or sensitivity to light and sound.

Abdominal Pain

• Functional abdominal pain is episodic or continuous for more than 3 months.
• Symptoms may include altered bowel pattern, pallor, diaphoresis, sleep disturbances, and changes in oral intake.

Musculoskeletal Pain

• Can be injury-related, illness-related, or primary.
• Pain can be localized or widespread.

Neuropathic Pain Syndromes

• Result from nerve injury due to surgery, trauma, autoimmune diseases, or cancer treatment.

Common Mixed-Pain Conditions in Children

Burn Pain

• Burns are a common injury that causes symptoms such as anxiety, depression, and insomnia.

Cancer Pain

• Cancer treatment may relieve cancer pain with Mucositis and Infection typhlitis.
• In addition, Radiation dermatitis and Postsurgical issues also produce pain.

Sickle Cell Pain

• Pain is a hallmark symptom of sickle cell disease (SCD).
• Vasooclusive crisis (VOC) pain which requires preventive treatments such as bone marrow transplant.

Measuring Pain in Children

• Pain assessment tools include observational measures (FLACC), self-report scales (Wong-Baker FACES), and multidimensional tools.

FLACC

• Used for ages 0-3, with versions for older children and those with cognitive impairment.
• Assesses face, legs, activity, cry, and consolability, with a score range of 0-10.

COMFORT-B

• Used for acute pain in critically ill, ventilated children aged 0-18 years.
• Assesses alertness, calmness, respiratory response, physical movement, muscle tone, and facial tension, with a score range of 6-30.

Observational Pain Measures

• Used for infants until they can self-report pain.

Special Populations

Preterm Infants

• Use PIPP-revised, NIPS, N-PASS, COMFORT-neo, and CRIES.
• Assess heart rate, oxygen saturation, facial expressions, and behavioral state.

Cognitively Impaired Children

• Indicators include crying, reduced activity, seeking comfort, and irritability.
• Reliable tools include rFLACC, NCCPC-r, and PPP.

Children Postanesthesia

• FLACC is reliable for assessing pain.

Self-Report Pain Rating Scales

Wong-Baker FACES Pain Rating Scale

• Uses cartoon faces to represent pain levels.
• Recommended for children as young as 3 years old.

Faces Pain Scale–Revised (FPS-R)

• Consists of six cartoon faces.
• Recommended For children 5-17

Word-Graphic Rating Scale

• Uses descriptive words to denote pain intensities and is intended for children aged 8-17 years old.

Oucher

• Uses photographs combined with descriptive words.
• For children 3-13 years old.

Numeric Rating Scale

• Verbal scale with a line that is either a horizontal or vertical line.
• For children as young as 8 years old.

Visual Analog Scale (VAS)

• Uses a horizontal or vertical line.
• For children as young as 8 years old.

Multidimensional Measures

Pediatric Pain Questionnaire (PPQ)

• Assesses pain history, language, associated colors, emotions, coping mechanisms, and location.
• Includes VASs, color-coded scales, and verbal descriptors.

Prevention and Treatment of Pain in Children

Biobehavioral Therapies

• Include biologically based, manipulative, energy-based, mind-body techniques, and alternative medical systems.
• Use physical treatments such as heat and ice.

Pharmacologic Management of Pain

• Should include using a two-step strategy and dosing at regular intervals.
• Appropriate administration routes and adapting the treatment to the child are necessary.

Nonopioids

• Include acetaminophen and NSAIDs like ibuprofen and ketorolac.

Opioids

• Include morphine, fentanyl, hydromorphone, methadone, and oxycodone.

Coanalgesic Drugs

• Such as antidepressants and antiepileptics as well as used alone or with pain meds to manage pain, associated symptoms and side effects.

Patient-Controlled Analgesia

• Allows patients to control the frequency of analgesic administration.

Epidural Analgesia

• Recommended for postoperative pain management for surgeries below the neck.

Transmucosal and Transdermal Analgesia

• EMLA cream eliminates pain from skin puncture.

Nursing Management

• Includes choosing the correct medication dose, timing of analgesia, and method of administration.
• Also involves monitoring side effects.

Other Pain Management Techniques

• Care during painful procedures and pain prevention for needlestick.
• Pain management in obese children as well as pain prevention and treatment for children with sickle cell disease.
• Pain treatment during end-of-life care with the inclusion of opioids to treat pain of progressive illnesses (e.g., cancer, HIV, cystic fibrosis).