By Suzanne Flint

It's time for another blood draw or procedure and you're not sure who dreads it more... you or your child. Here are some ideas to help you get through the tough stuff.

Positive Feedback
Children should be praised for doing their best. Cooperative behavior should be encouraged. Statements like: "I was pleased to see you trying to stay still" or "It was good you told the nurse exactly how you were feeling" can be helpful. Minor misbehavior should be ignored, although, at times, a no-nonsense approach may help your child to cooperate.

Setting Limits
Even children with serious illnesses need limit setting and expectations of "good" behavior. Setting limits is an essential part of parenting a child through any difficult situation. It also conveys a great deal about how you view your child's capabilities. Good limit setting is impersonal and understandable to the child. It is supportive not punitive, and planned not arbitrary. Being too lenient or inconsistent in setting limits can convey a lack of confidence in your child's ability to cope. Whereas, being overly authoritative prevents a child from getting the chance to learn about his or her own capacity for self-regulation. Good limit setting, on the other hand, creates a nurturing environment in which your child's own developing sense of self can emerge and flourish.

Giving Control
Offering children some control about their treatments can help reduce feelings of helplessness and uncertainty. This, in and of itself, can often help to reduce a child's experience of pain. Even very young children can be allowed to decide some parts of their treatment, for example: whether to sit on your lap or in a chair, which finger to have pricked, and/or whether to have a Band-Aid. Even how much preparatory information they receive should be up to the individual child's choice.

Rewards
It is okay to give a child a small treat for cooperating with a procedure but it should be given based on a skill or behaviors exhibited and not just for enduring the procedure itself. It should also be negotiated beforehand with the reward contingent upon an agreed upon specific behavior. If feasible it is best when the child can select the behavior and the reward. The reward and behavior should be both specific and simple to understand. A good rule of thumb is to make sure the child always wins something for trying and something extra for succeeding. Avoid negotiating or changing the rules after the fact. If you make the target behavior too easy, your child may feel you lack faith in his or her abilities.

Physical restraint
Be prepared for the possibility that the procedure could become just too scary or difficult for your child. If physical restraint is needed, learn how to provide it in a non-punitive way. For example, "This shot is just too hard for you to hold still for, even though you are trying your very best. I know how much you've tried, and I can see that you don't think you can hold still any longer without my helping you a bit." In this example the use of physical restraint is introduced as support, not punishment and the child is held in a comforting and non-combative way.

Positioning for Comfort
Non-aggressive holding positions can be very useful in helping a child through a painful procedure without forced physical restraint. Forcibly restraining a child often in-creases their pain experience, compromises their sense of dignity, and can even traumatically damage their self-esteem. On the other hand, positioning for comfort can provide:

• A secure, comforting, hugging hold - e.g. the child sits astride their parent's lap, facing and hugging their parent's chest; or a child sits on their parent's lap, facing forward but being hugged and held by their parent from behind.
• Close physical contact with the parent or caregiver.
• Parent participation which is focused around positive assistance rather than forced restraint.
• Successful immobility of an extremity without force.
• A more relaxed child since sitting positions (whenever possible) promote a greater sense of control in the child than lying down positions.

Thought-Stopping and Self Talk
Thought stopping teaches children to catch themselves as they begin to exaggerate or catastrophize the unpleasant aspects of pain and to deliberately substitute a positive, self-calming thought. The positive and reassuring aspects of the situation are condensed into key points. From these points, children make up a positive statement, which they then memorize and repeat to themselves. For example, during a feared blood draw, a child might say, "This will be over quickly. I have
good veins. The nurse who is doing it is nice." Another such statement might be, "I can handle this. I know how to breathe out any discomfort. My mom is here and I'm not alone." Or, "It's tough but I'm doing well. This will help me in the long run." Children above about six years of age can be coached during a procedure to utilize this technique. After about 10 years of age, children can learn to do this independently, even when no "coach" is there to assist them.

Suzanne Flint is a Child Life Specialist, Health Educator, Interactive Imagery Guide, and Program Director of "Reach Out and Read" at Lucile Packard Children's Hospital in Palo Alto, California.