Minimizing the risk of psychological trauma during pediatric voiding cystourethrogram

In the setting of a distressing procedure under partial sedation, healthcare professionals may be tempted to think and to say, “it's ok, she/he won't remember this.” A statement to that effect is often extended as a reassurance to concerned parents. It is well-meant, but it reflects a critical misunderstanding.

VUR affects over a third of children with urinary tract infections (Chua et al., 2019). The American Academy of Pediatrics recommends a VCUG for children between ages 2 and 24 months with urinary tract infections (Frimberger & Mercado-Deane, 2016). Often, children older than 24 months may also require a VCUG if they have recurrent urinary tract infections.

Common pharmacological interventions often used in an effort to promote patient comfort include lidocaine jelly for local anesthesia of the urethra, oral midazolam for anxiolysis/amnesia, and inhaled nitrous oxide for the additional benefit of mild analgesia (Blumberg, 2012).

The VCUG procedure has the capacity to be painful and frightening for children. Many pediatric patients have only a partial understanding of the procedure, which may mean that misconceptions intensify fears. Certainly, these procedures have the potential to constitute a perceived (and thus actual) psychological trauma event for children – one that could contribute to the diagnosis of posttraumatic stress disorder in accordance with the Diagnostic and Statistical Manual of Mental Disorders (DSM-V) criteria (American Psychiatric Association, 2013).

In light of the psychological vulnerability of the experience, it seems that any coping mechanism offered be strictly evaluated for efficacy and against the possibility of compounding psychological harm.

Trauma theory speaks to the well-established fact that a person does not need to retain a narrative memory of a traumatic life event for that event to create devastating psychological and/or physiological effects (Van der Kolk, 2002). Child abuse victims, victims of sexual violence who were drugged, and victims of all ages who cope with trauma through dissociation all bear witness to this truth (The National Child Traumatic Stress Network, 2010).

Therefore, it seems imperative to consider that midazolam's amnesia effect may not be the unqualified blessing it is often advertised to be. By removing the narrative memory, the patient is left with body memories of the trauma and no ordered cognitive framework within which to process them (Van der Kolk, 2002).

When a Certified Child Life Specialist (CCLS) is available, his/her services should be involved from the beginning of the appointment. CCLSs are professionals who are trained to assess and support procedural coping. They use developmentally appropriate language and targeted play interventions as the modalities of preparation and work with families to create a coping plan for the procedure. Autonomy and self-control are important developmental concepts for children. It is worth considering whether or not pharmacologically altering a pediatric patient's sense of body control is a productive intervention from a psychosocial perspective.

Another point of confusion for healthcare providers is determining whether or not a patient has “coped well” from a psychosocial perspective, with a procedure. The CCLS is trained to assess coping and to know how to intervene. Common indicators that have been put forth, such as whether or not the patient cried, struggled/resisted physically, and so on are not sophisticated enough indicators for the nurse or physician to determine the quality of coping(Thacker et al., 2016).

It should not be assumed that because a patient cried minimally and was cooperative, that he/she did not experience psychological trauma.

First, it is the responsibility of the healthcare team to maintain a calm, quiet, gentle demeanor throughout the procedure, no matter what the patient/family response may be. This helps to reassure the child that she/he is safe in the care of adults who are capable and in control of the situation. A pediatric patient should never be held down by healthcare staff unless absolutely necessary for safety (Committee on Hospital Care and Child Life Council, 2014).

The healthcare staff is encouraged to create space for a present parent's welcomed involvement. Parents should be guided to an appropriate position at bedside, which places them as close as possible to their child to provide opportunities for hand holding and soothing. The patient should be given simple, step-by-step information about what the healthcare professionals will do (before they do it).

Besides this simple procedural narration, conversation between staff should be kept to a minimum. No more than one voice at a time should be speaking to the child, to avoid a sense of chaos (Boles, 2013). 

If the patient shows signs of wishing to watch the catheter placement, she/he should not be prevented from doing so, as no matter the patient's age, that patient's body is his/her own. In addition, the patient's accompanying caregivers should be given a clear choice regarding midazolam administration, after receiving education on the possible psychological risks sited in this article and the possible benefits.