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Surgical Pearls for Young Patients

How to handle children when performing outpatient procedures comes down to common sense, said Jonathan Dyer, MD, at the beginning of his presentation on procedural pearls for pediatric patients. He added that he can usually tell a provider has children from one whose does not by how they approach pediatric patients. Dr Dyer is a professor of dermatology, director of pediatric dermatology, and interim chair of the department of dermatology with the University of Missouri in Columbia, MO.

A lot of procedures in dermatology are painful. We should be experts in pain control for in-office procedures, he said, because dermatologists perform these more often than other specialties. Dr Dyer also noted that many techniques in his presentation are applicable to all patients, regardless of age.

Children are not miniature adults, he stated. When working with pediatric patients, he said providers should be patient and make time and take time for children, speak with them at their age level, and be careful because children will react to mood. Sufficient support staff is needed for assistance, he added, and should always be on hand in case you need to hold someone down. Most importantly, he noted the importance of helping children during their session develop coping skills for these procedures, especially if they will have to return to the office for another session.

Letting children participate in decisions and giving them a sense of control helps, said Dr Dyer, such as letting the patient pick the color of the suture or dressing. He stressed the importance of setting up everything in order to work quickly and efficiently, as well as preload any syringes. Children’s anxiety increases as their attention span decreases, he said, and they can become more anxious if they forced to wait. Block their view of any needles or tools as well, he added.    

Dr Dyer recommended using topical anesthetics, saying he worried more about whether it was applied properly than which one is used. The longer it is on the better, he said. He also discussed the importance of educating parents on how to apply topical anesthesia to help with the process. Topical anesthesia is about showing you are making an effect to reduce the patient’s pain more so than the actual numbing, he said. Children like providers who use topical anesthesia because they see it as the provider trying to control their pain, he added.

For local outpatient anesthesia, each child is different, said Dr Dyer. Girls are able to receive starting at age 8 or 9 years and boys at age 10 to 11 years.

According to Dr Dyer, restraining a child for a procedure that lasts more than 5 minutes is a bad idea. He preferred to use sheets for long procedures, as opposed to a papoose boards. Sometimes I create a tent with the sheet around the child and parent, he said, leaving the area being treat outside the tent.

The most important consideration when treating children is the frequency of the treatment. How often do you have to have them back? asked Dr Dyer. He stressed that it is important to determine how much a pediatric patient can tolerate if performing a specific procedure, such as injecting warts.

Dr Dyer also stressed the importance of explaining to children, in terms they understand, the procedure and recommended using nonthreatening words, such as pinch. He discouraged providers from surprising or lying to children, as well as saying “poke” over and over when injecting a patient.

One mistake providers make is getting nervous and going fast when injecting children, which causes more pain, said Dr Dyer. He recommended using simple excisions for children, buffer lidocaine, warm it to body temperature, put ice on the area first, inject perpendicular and slowly, as well as prefreeze the needle. He suggested starting deep then gradually move superficial to reduce any pain from the injection.

Other techniques he reviewed included vibrating devices, pinching, cryospray, talking, allowing patients to play video games or watch a DVD. Breastfeeding or suckling helps reduce pain in infants, as well as skin to skin contact. Dr Dyer also added that he tickled little kids sometimes to distract them from the injection, and even blowing bubbles can help distract younger children. You just need to take time and be creative to find what works, he said, and need to come up with what you need for individual patients.

In addition to reducing pain, Dr Dyer discussed ways to reduce scarring in children. Pediatric patients, he said, in many cases scar worse than adults. Because children are more fearful, anxious, move a lot, and have shorter attention spans, they are harder to work on than adults, he said. This makes providers want to perform a procedure faster and cut corners. The simple procedure is perfect for pediatric patients, he added.

According to Dr Dyer, children have a higher incidence of track marks, scar spreading, spitting of deep stitches, and increased risk of dehiscence. Something that always happens, particularly to new residents, he said, is they will draw and cut their island, and very often have a flow. They will turn around and when they look back the opening is huge and the ellipse they drew is now gapped out, he stated. The reason this happen is because the skin of children is super stretchy, said Dr Dyer. The elasticity pulls on the stitches due to the skin trying to remodel and respond to the tension, he added.

It is important to counsel patients on the possibility of scars stretching and try to prevent it, he said. Obtaining the best initial scar as possible is the best way to prevent this, he said, although there is no good method and it can happen with any child. He reiterated the importance of both planning and educating patients about this risk.

Due to skin elasticity in children, the excision can be smaller, said Dr Dyer. Providers do not need to use the 3:1 ratio on children unless the area requires its. This prevents scars from spreading and becoming longer in the future.

In addition, he recommended thinking about closures in children in 3 layers. The deeper the layer, the more the sutures will help to reduce or remove the tension from the wound edge, which will help prevent spreading, he said. Dr Dyer also reviewed sutures for the location of the procedure and recommended running stitch for closing, visible running subcutiler for extremities or visible areas, and interrupted for face, hands and feet. He does not recommend closing punch biopsies on children because some of the worst track marks he has seen were from punch biopsy closures. He does apply a gel foam in the punch biopsy site.

He also recommended thinking about doing excisions in stages. For example, nevi, birthmarks, or areas where a small scar is best, can be removed at different times, he added. Stage 2 should be performed 4 to 6 weeks after stage 1 to ensure the best outcomes.

Pursestring sutures are helpful for closing round defects in children and work better, he said, recommending providers at least think about using these sutures as one way to stage excisions. He recommended using a good, bulkly, colorful dressing. It makes the patient happy because they can show it off to their friends and protects the wound. He stressed the importance of immobilizing the area for as long as possible and to do whatever it takes to slow the patient down, such as using braces. The ideal amount of down time he recommended was 6 weeks.

In patients with dehiscence, which will happen with children, Dr Dyer recommended letting it heal then revise the scar.

He concluded his presentation by reviewing the importance of aggressive education, restricting the patient’s movement while healing, and using bulky dressing to prevent dehiscence, as well as reminded providers to apply badges to any stuffed friends the patient brought with them.

Reference

Dyer J. Pediatric procedural pearls: How to handle those challenging little people. Presented at: 2019 Fall Society of Dermatology Physician Assistants Conference; November 22, 2019; Scottsdale, AZ.

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