Key points

Performing dermatologic procedures in infants and children presents multiple challenges. Children are not simply smaller versions of adults. Each age has its own unique set of challenges. Young children are unable to understand the necessity of a procedure and may be unwilling to cooperate. As children get older, they become more difficult to restrain during a procedure. For these reasons, procedures that are simple to perform in adults can be extremely challenging to perform in children.

An understanding of pediatric developmental milestones is essential to providing optimal dermatologic care of the pediatric patient. This article combines the author’s experiences with data from the literature to provide guidance for performing dermatologic procedures in children. Additionally, the surgical approach to a few specific types of birthmarks is addressed.

General approach to pediatric patients

Many factors influence pain, including age, fear and anxiety, cognitive development, and past experiences. Inadequate pain control has significant negative implications for children, including long-term consequences regarding their reactions to later painful events and acceptance of subsequent health care interventions. Therefore, an approach to pediatric patients that makes them as comfortable as possible and minimizes pain is crucial.

A few easy techniques can help to make children more comfortable both before and during dermatologic procedures:

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  Sit at or below the level of the child; this is less intimidating than having a physician standing or sitting above the child.

  
  
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  Include the child in the conversation rather than addressing only the parents. The child will feel more respected and is more likely to believe and trust what is being said.

  
  
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  Explain the procedure thoroughly in an unthreatening manner. It is important to use terms that describe the impending events while avoiding words that conjure painful images, such as “shot,” “needle,” or “prick.” Try to describe what the procedure will feel like. For instance, with injections, a pinch will be felt followed by warmth. Once this is over, nothing should be felt. There should be no surprises.

  
  
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  Most importantly, do not lie. If a child is told that a procedure will not hurt and it does, trust of that physician (and perhaps other physicians) will be compromised in the future.

The postoperative approach can also help improve the experience for the patient and parents. Praise the child, no matter how poorly the procedure went. Rewards, such as stickers and lollipops, facilitate a selective memory; the child focuses on the reward rather than the painful procedure. Physicians and parents should be reassured that nearly all children bounce back once they realize that the procedure is over.

General approach to pediatric patients

Many factors influence pain, including age, fear and anxiety, cognitive development, and past experiences. Inadequate pain control has significant negative implications for children, including long-term consequences regarding their reactions to later painful events and acceptance of subsequent health care interventions. Therefore, an approach to pediatric patients that makes them as comfortable as possible and minimizes pain is crucial.

A few easy techniques can help to make children more comfortable both before and during dermatologic procedures:

• •
  

  Sit at or below the level of the child; this is less intimidating than having a physician standing or sitting above the child.

  
  
• •
  

  Include the child in the conversation rather than addressing only the parents. The child will feel more respected and is more likely to believe and trust what is being said.

  
  
• •
  

  Explain the procedure thoroughly in an unthreatening manner. It is important to use terms that describe the impending events while avoiding words that conjure painful images, such as “shot,” “needle,” or “prick.” Try to describe what the procedure will feel like. For instance, with injections, a pinch will be felt followed by warmth. Once this is over, nothing should be felt. There should be no surprises.

  
  
• •
  

  Most importantly, do not lie. If a child is told that a procedure will not hurt and it does, trust of that physician (and perhaps other physicians) will be compromised in the future.

The postoperative approach can also help improve the experience for the patient and parents. Praise the child, no matter how poorly the procedure went. Rewards, such as stickers and lollipops, facilitate a selective memory; the child focuses on the reward rather than the painful procedure. Physicians and parents should be reassured that nearly all children bounce back once they realize that the procedure is over.

Parental presence

Conflicting views and practices exist regarding whether parents should be present at the time of their child’s medical procedure. Although this has not been studied specifically in the setting of pediatric dermatology procedures, it has been reviewed in the setting of childhood immunizations, venipuncture, induction of anesthesia, lumbar puncture, and bone marrow aspiration. The results of a systematic review revealed no evidence of increased technical complications when a parent was present. Although parental presence may not have a clear, direct influence on child distress and behavioral outcomes, there are potential advantages to parental presence ( Box 1 ). Most importantly, reported parental satisfaction was higher when they were present during the procedure.

The practice of the author is usually to have the parents present unless they specifically ask not to be. It can be reassuring to the patient to have a parent sitting at the head of the table, providing a hand to hold. When a parent is present, it is important to ensure that they are seated in a chair with a back. A parent who is standing or who is seated on a rolling stool is more likely to faint and require the physician’s attention to be directed away from the patient.

Positioning the patient

Trays should be covered both before and after a procedure, hiding from the patient’s view the intimidating instruments (before a procedure) and blood-soaked gauze after a procedure. The surgical field should be strategically draped so that the child does not see the surgical field. This also allows the physician to inject the local anesthetic without the patient seeing the needle.

Toddlers are often particularly anxious about dermatologic procedures, and they are more difficult to restrain than younger infants because of their size and strength. A “toddler wrap” or swaddle is an effective way to restrain a child and maintain a sterile field ( Fig. 1 ). To accomplish this, a blanket or sheet should be placed under the child and then wrapped around both arms, with the end tucked under the far arm. Then the other side should be wrapped back around the child and the end secured underneath the child. This secure wrap can be used for skin biopsies and small excisions on the midsection of the body, arms, and legs by leaving the affected body part unwrapped. The nurse or medical assistant can then hold the affected body part so that the patient is stable during the procedure. As a general rule, the parents should never be enlisted to hold the child. That way, the parent remains the “rescuer” in the child’s eyes.

Image of a proper “toddler wrap” or swaddle.

Distraction techniques

A portable DVD player is an inexpensive and simple way to provide distraction during procedures. If children begin watching a movie before anesthetic injection, they tend to be less nervous about the impending procedure. This distraction is also useful during the procedure, lengthening the time that children are able, or willing, to sit still.

A tablet computer is slightly more expensive, but can be loaded with movies, puzzles, games, TV shows, and cartoons. In conjunction with a subscription to a streaming video service, this can provide endless options for patients of all ages as a method of distraction during dermatologic procedures.

Injection techniques

The simple insertion of a needle has been shown to be one of the most frightening and distressing medical procedures for children. In a survey of 119 children, 65 thought a “shot” or “needle” represented life’s most painful experience. Various techniques can be used to reduce the stress and pain associated with local anesthetic injection ( Box 2 ).

The pain associated with the infiltration of buffered lidocaine has been shown in multiple studies to be less than the pain associated with infiltration of unbuffered lidocaine. The magnitude of the pain decrease associated with buffered lidocaine was larger when the solution contained epinephrine. However, the concentrations of both lidocaine and epinephrine decrease once sodium bicarbonate is added. Both lidocaine and epinephrine maintain greater than 90% concentration 2 weeks after buffering when stored at 0°C to 4°C (32°F–39°F). Proper refrigeration permits batch buffering of lidocaine with epinephrine and storage for up to 2 weeks. Because infiltration of cold lidocaine is more painful, the buffered lidocaine should be warmed by placing the syringe in warm water immediately before injection.

Topical anesthetics

Administration of topical anesthetics can help minimize the pain and anxiety associated with anesthetic injection and other painful procedures, such as intralesional injections and laser treatments. Many dosage forms exist, providing clinicians with options for various circumstances.

The most commonly used topical anesthetics are those in cream formulations. Eutectic mixture of local anesthetics (EMLA) is a mixture of lidocaine and prilocaine. EMLA is available with a prescription, and should be applied, under occlusion, 1 hour before the procedure. Methemoglobinemia is a well-documented potential complication of prilocaine-containing creams. EMLA should only be applied to small areas, and should be used with caution in children younger than 3 years because of the incomplete maturation of the NADH-methemoglobin reductase sytem.

Liposomal 4% lidocaine (LMX) is available over the counter. The recommended application is 30 minutes before the procedure. Although occlusion is not required for maximum efficacy, LMX is also usually applied under occlusion to avoid a mess. LMX does not contain prilocaine, and therefore has no risk of causing methemoglobinemia.

Several novel delivery systems for topical anesthetics have been introduced in the past few years. The Synera (Nuvo Research, Inc, Ontario, Canada) is a lidocaine and tetracaine patch with a built-in heating element. Applied 30 minutes before a procedure, this patch provides local anesthesia for superficial dermatologic procedures, such as shave biopsies, electrodessication, and injections.

Nonanesthetic techniques for pain reduction

Ethyl chloride, although not a local anesthetic, can safely provide cutaneous analgesia in children when it is impractical to wait for a topical anesthetic preparation to take effect. Vapocoolant sprays provide transient skin anesthesia within seconds of application via evaporation-induced skin cooling. They also can be reapplied as needed with no systemic toxicity and no risk of methemoglobinemia. Published clinical trials support their use in children 3 years of age and older.

Oral sucrose solution is currently commonly used in neonatal intensive care units and for circumcisions, and is used by some pediatricians for immunizations. An article in the March/April 2010 issue of Pediatric Dermatology reported the use of an oral sucrose solution for pain relief in infants who were undergoing steroid injections into hemangiomas. This 24% solution of sucrose is administered 2 minutes before the procedure, either through placing it on the anterior tip of the tongue or dipping a pacifier into the solution. The sucrose may work through activation of sites in the brain that decrease pain perception, or it may cause the release of chemicals that cause babies to have less feeling of pain. In addition to hemangioma steroid injections, oral sucrose solution could be used by dermatologists for biopsies and laser treatments in infants younger than 1 year.