Vaccines, swabs, and other small medical procedures are a part of childhood – now more than ever. As we enter flu season, as Covid tests continue to be prevalent, and now… as the Covid vaccine has been authorized for children as young as five, children everywhere are encountering shots and swabs that might leave some kids anxious or fearful. For parents and caregivers who are choosing to vaccinate their children against Covid, the flu, or otherwise engage in small, routine medical procedures – how can we help kids by making it as easy and painless a process as possible?

I met with Dr. Laura Vogel, our director of therapeutic services, to discuss.

I know that some kids have no problem at all with medical procedures such as getting a shot, and others have heightened anxiety, stress or other reactions. What are some factors that influence how a child will respond to medical procedures?

The biggest things that will impact a child’s response are age, experience and temperament. So, for age, the younger the child, the more frightening an experience like getting a shot can be. As kids get older, they start to have more complex understanding of medical procedures – why they matter, what to expect, etc. But when kids are young, it can all be very foreign, and as we know, things that are unknown can often be scary.

Experience is the other biggest factor. Prior positive or negative experiences with doctors shapes a child’s view on doctors and medical procedures moving forward. There are a lot of medical professionals out there, and some have been specifically trained to work with kids, and others have not. If kids have had experiences with specialists or medical professionals that haven’t been positive, they’re of course more likely to view medical professionals with suspicion or fear.

And the other factor is temperament, the unique traits of a child. Some kids are more anxious than others, some kids need to really know what’s coming and what to expect, and others can more easily go with the flow.

So what are some tips you have when you know you are taking your child to a medical procedure, like getting an annual checkup or a vaccine?

The one rule that I think is important every time is avoid lying to your child. Don’t tell a child, “You’re not getting a shot today” if you know that they are. If you lie to your child, it erodes the trust and the next time your child has a checkup, they may not believe you even if you’re telling the truth. I encourage adults to always tell children when they’re going to get a shot or something else that may hurt or be uncomfortable, even going as far as to say, “I will always tell you when you’re going to get a shot. If I don’t know, I’ll tell you that I don’t know. But I will not lie to you about it.” This will help children trust the adults in their lives.

Another suggestion is to consider a positive thing that might happen after the doctor visit, such as going to the park or getting a special treat. This gives kids something to look forward to after the appointment and can make enduring something uncomfortable a little easier.

As a parent, I know that my kids do best when they know what to expect and when things aren’t thrown on them that they didn’t know about. However, I also have experienced where too much advance notice can be stressful. If I have put a doctor’s appointment on the family calendar, I’ve had one of my kids stressed every day for two weeks leading up to the appointment. So what do you recommend when it comes to balancing the line between sharing and preparing, versus too much anticipation causing anxiety?

Certainly some kids do better with advance notice, and with others, a long runway can cause anxiety, exactly like you’re talking about. Parents and caregivers know their children best and should be mindful of how their child typically responds to situations. If a child is someone who has a hard time with last-minute news, it’s probably better to give them more advance notice. If it’s a child with heightened anxiety around this issue, it may be best to just let them know that morning. I do think all children need some kind of advance notice, but the amount of time is really dependent on the child.

So let’s jump to the moment of the medical procedure, whether it’s a shot or a swab or something else painful or uncomfortable. In a mild case of anxiety, a child may be scared and you can see it in their eyes, but they’re holding back tears. With these kids, what do you recommend?

Distraction can be your friend in a case like this. I think parents/caregivers can just be talking about things they see in the office, what’s out the window, or what they’re going to do after the appointment. The child can bring a toy or pick something they want to bring to the office that is comforting, whether that’s a favorite stuffed animal or an item from home. Children are often soothed by scents, so maybe a blanket with lavender or a loved one’s perfume. Bringing things like this can often be enough to have a small dose of comfort during an uncomfortable moment.

So let’s talk about the kids who are more than just a little anxious. I know as a parent, I’ve had the experience of a child who is fine leading up to the appointment, but then in the room starts to freak out. All my parenting instincts say to help the child regulate and to calm them down, like I would if they were having a huge emotional reaction about any other issue. Sometimes that works, but other times, it seems like no amount of soothing is going to get them calm in that moment. It seems like there are times where you just have to have them administer the shot, despite the fact that they’re crying. When it’s the anticipation that’s causing the anxiety, it seems like just getting the shot over with will make the anxiety go away. We could spend all day trying to calm them down, but nothing really will work until it’s over and done.

It seems really counter to what my instincts are saying, which is to help my child calm down and to not inflict harm, but I can’t be the only parent who has ever just held a child down to get it over with. What are your recommendations in a situation like this?

Well you’re right, a child who is worked up to the point of tears or shouting or other behavior may not ever calm down in that room. And certainly the nurse or doctor needs to move along, and you need to move along, and so there’s a limit to the amount of time and effort you can spend calming a child down in a situation like that. So in the situation like you just described, I recommend that you narrate what you’re doing as you go. This can sound like, “The nurse is going to come over now and give you a shot in your right arm. I am going to hold your hands here. I am going to hold you on my lap.” At the same time, you can model self-regulation by taking deep, exaggerated breaths, so the child can hear and feel your slow, deliberate breathing. And then, I think you’re right, that you just have to get it done and over with, and then you can work on comforting them after.

I will add that in the moment of a situation like this, children are reacting from their instinct. Their responses, like screaming and flailing and crying, are not deliberate actions. These are fight or flight responses to a perceived threat. I have had the experience of one of my children hitting me in a moment like this – a child who would never do something like that in a clear state of mind. I say that because it’s important to remember that a child in this situation will not respond to logic or reasoning, and that no amount of consequences or threat will work, nor will they serve a purpose in teaching them a lesson. That’s why in this situation, the most you can do in the moment is to really sit with them and narrate and model regulation.

Now, I must add a really important caveat here. For children who have experienced trauma, particularly children who have been harmed by another person, it may be important to take a different approach. For some children, holding them down while a nurse administers a shot may be a fleeting moment of pain. For others, those with a history of trauma, it can trigger past traumatic experiences and cause harm. For these children, caregivers should consider more measures to ensure the safety of the child. This might include talking to the medical provider about the child’s trauma history, explaining that the child may need more time. If the adults in the room are calm and not rushed, this can be a great first step to creating safety. These children may need to have procedures and shots done in a more private space and may need an adult to hold them on their lap but not restrain them. The important thing with children who have experienced trauma is to remain calm, plan for extra time to get into the calmest space possible, and to not layer in any shame around a child’s reaction.

So let’s talk about after…

So after the shot, for those kids who did fine or were slightly teary, a simple, “Great job! Now let’s… (whatever the reward is)” will probably be plenty. For kids who had a bigger reaction, that’s where I recommend the narration again. We’re big fans of The Whole-Brain Child method of “Name it to Tame it” which is where you talk through the story, connecting it to emotions. This might sound like, “You were excited to get the shot. You were happy that we have this shot to protect you. But when we got to the clinic, you started feeling scared. You changed your mind, but I still made you get the shot. I imagine you were mad at me. I made you get the shot even though you didn’t want to, because I wanted to protect you. You were really upset. You got the shot, and then you were able to calm down a little bit.”

The point of this is to really explain the situation as it happened and connect the child’s emotions to it. It’s important to tell the story from beginning to end, to help remind the child that they did make it out on the other side, while also validating their emotions along the way.

If a child is really sobbing and upset, it’s not the time to have this conversation. In that moment, just soothe the child, rub their back if they want to be touched, and just wait until they regulate a bit more before trying to talk about it.

Earlier you mentioned the idea of giving kids something to look forward to, like a treat or a trip to the park. Can you expand on that a bit? Is it sort of like bribing them, or do you see it a little differently?

I think it’s different from bribery, which I see as an, “If you do this… then this” sort of situation. What I’m talking about is more a natural thing that we all do, which is to reward ourselves after completing something. I know I treat myself after getting through a big project or accomplishing a goal – this is a natural response. It’s really no different from that.

I will say that it’s not a reward for any type of behavior. So I don’t recommend that adults say, “If you don’t cry, we will go to the park” or anything like that. It’s not an “If A, then B” situation, it’s an “A, then B” situation, no matter what. If it goes poorly, you still do the activity. If it goes so poorly you don’t even end up getting the shot, you still do the activity and try again another day. However, if the child was that dysregulated that they could not have the vaccination, then I would suggest caregivers do some additional planning with their healthcare provider.

It’s really abnormal to intentionally put ourselves in a position like this, where we know that something may hurt and we do it anyway. So a child who goes through this deserves to have something to look forward to afterwards, in my mind.

When it came time for my kids to be vaccinated against Covid, they were excited because they felt the impact of Covid (like everyone did) over the past two years. At least the older kids were really ready to get the shot because it meant life could eventually go back to some kind of normal for them. But typically, when they get the flu vaccine for example, they don’t really have as much context and they’re not looking forward to it… it’s just a painful shot that they don’t want to get.

Right, I think depending on how much a family has talked about Covid, how much Covid has impacted that particular child, whether or not they’ve lost a loved one to Covid – it’s hard for this particular vaccine to not be more meaningful for some families than a traditional flu vaccine.

And my oldest child, who is nine, was pretty interested in understanding how a vaccine works, particularly the Covid vaccine. We had to look it up to explain it to him, but he wanted to know how a vaccine can prevent Covid, what it does in your body, that sort of thing. I think explaining the science of it, combined with how much he had been looking forward to it, plus of course his age and temperament, made it so he had a pretty easy experience getting the vaccine.

Yes, I think for many kids, explaining the purpose is important. For some kids, the simple version is best. Something like, “We take medicine to help our bodies stay healthy. This shot is a kind of medicine that can keep us from getting sick.” For some kids, they’ll be interested in understanding the why and the science behind it, like your child. It’s worth noting that for some kids, a lot of questions can be a function of anxiety. I encourage caregivers to monitor the questions and the interest level to help determine how much information might be helpful for an individual child.

So what worked for my oldest child was what I just described – a general understanding of why he was getting the vaccine. That didn’t really apply to my younger kids. Do you have any other tips for young children that can help them prepare?

I think for really young kids one thing that can work is playing with dolls. I have had kids who pretend to give their doll a shot, then comfort the doll. I think role playing can help desensitize the whole process. You can participate by saying things like, “It looks like your doll is afraid of the shot. How can you help?” Typically, we see children either mimic what they’ve seen us do or what naturally comforts them.

Another one for kids of all ages is just relying on past experiences of times that they’ve been through something hard and been successful. Just reminding them of past successes can help them remember that they can make it through this as well. And then after this is over, you can add this one to the list of things they have made it through – for future reference.

And then lastly, I would say, and again this is for kids of all ages, but young kids may need more explicit practice, just any in-the-moment relaxation techniques will come in handy here. If you don’t already have any that you use regularly in your household to help calm or soothe a child, you can start introducing them when the child is already calm, like maybe before bedtime. Just a short breathing exercise or simple mindfulness practice that you can then reference again when a child is overwhelmed or anxious will be helpful in a situation like this.

Last question – I know you mentioned that previous experiences will dictate how a child responds to future medical experiences. I know some families have a regular pediatrician, and others go to clinics or offices where the doctors and nurses may be unfamiliar at each visit. Also, for the Covid vaccine, many people are getting those done in pharmacies, local health clinics, drive-throughs, schools, etc. Do you have any thoughts about how to help children who will be getting medical work done from a provider they don’t have a relationship with?

I think many families don’t get the luxury of a well-established relationship with their medical provider. I think, especially in the case of the Covid vaccine, but also when it comes to seasonal vaccines like the flu, many of those will be done in a pharmacy or a health clinic, like you said. I think depending on the child, it might make sense to get there a little early and walk around a bit so as to not feel rushed. Then again, some children may be building anxiety that whole time, so going in and getting it done quickly will feel better. I think in an extreme case of anxiety, planning so that the child can get the shot in a familiar setting makes sense – so calling the regular pediatrician to see if they can administer the vaccine rather than getting it at a pharmacy. Or you could call the pharmacy and figure out less busy times, so the medical staff and the people in line behind you don’t feel rushed and you don’t feel stressed. Again, just thinking ahead and planning as best you can is the most you can do, and then it still may not be enough, but that’s where the narrating and the comforting can kick in.

Thank you so much, Laura. This is so helpful, and I’ll definitely use so many of these tips when we head back to get the second dose of the vaccine in a few weeks. I really appreciate your insight.

Thank you.

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