WASHINGTON Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.
For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.
Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.
Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.
When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.
It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.
A nursenot a parentshould be the one to restrain the child if he or she is squirming or very frightened.
"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.
After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."
Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.
Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.
"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.
But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.
An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.
"It's also helpful to give them printed-out postoperative instructions," she added.
Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 50 suture.
These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.
The wound can also get wet.
On the other hand, she cautioned that the costapproximately $30 per vialand the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.
Dr. Metz pointed out that the resilience of children is not to be underestimated.
"I'm surprised every time at how quickly kids bounce back after a procedure," she said.
"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.