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peer review

Managing Patient Stress in

Pediatric Radiology
Melody Alexander, BS, R.T.(R)(MR)
Background Research has shown that short- and long-term effects can result from stressful or invasive medical procedures performed on children in the radiology department. Short-term effects for the pediatric patient include pain, anxiety, crying, and lack
of cooperation. The patients parents also may experience short-term effects, including elevated anxiety and increased heart rate and
blood pressure. Potential long-term effects include post-traumatic stress syndrome; fear; changes in pain perception and coping effectiveness; avoidance of medical care; and trypanophobia.
Objective To identify common sources of stress in pediatric radiology, investigate short- and long-term effects of stressful and
invasive medical procedures in pediatric patients, and compare different strategies used in radiology departments to minimize stress
in pediatric patients.
Methods Searches were conducted using specific databases to locate literature related to stress in pediatric radiology. Articles
were included that addressed at least 1 of the following topics: common sources of stress in the pediatric radiology department, the
short- or long-term effects of a stressful and invasive medical procedure, or a stress-minimizing strategy used in a pediatric medical
environment.
Conclusion Consistency of care can be improved among the different radiology modalities by providing similar and effective strategies to minimize stress, including interventions such as parental involvement, preprocedural preparation, distraction, sedation,
use of a child-life specialist, hypnosis, protecting the childs privacy, and positive reinforcement. Future research is needed to identify
additional ways to improve the consistency for care of pediatric patients in the radiology department and to investigate stress management in areas such as pediatric vascular interventional radiology, cardiac catheterization, emergency/trauma imaging, and
gastrointestinal procedures.

n the pediatric radiology department, it is common to see distressed parents and children. The
sights and sounds of the equipment, uncomfortable positioning, and painful procedures make
radiology examinations a difficult experience for
young children. Additionally, parents who are anxious
about the procedure and diagnosis can escalate childrens fear and anxiety.1,2
Short-term effects of stressful and invasive
medical procedures such as crying, fear, and lack
of cooperation commonly are observed in pediatric
radiology patients. Further, research has shown that
without stress and pain management, children who
undergo stressful or invasive medical procedures can
experience potential long-term effects, including
post-traumatic stress disorder symptoms.3-9 The
medical community has focused efforts on creating
an environment for children that minimizes both
short- and long-term effects of stressful medical
procedures.3,10-31
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This literature review examines issues surrounding

stressful radiology procedures for pediatric patients and
ways to minimize stress and its potential consequences.
The author evaluated the following research questions:
What are common sources of stress for pediatric patients in the radiology department?
What short- and long-term effects might pediatric patients encounter as a result of stressful
and invasive medical procedures?
What strategies are being used to minimize the
stress of pediatric radiology patients?
It is common for patients to interact with more than
1 area of radiology throughout the course of diagnosis
and treatment of a medical condition. For this reason,
it is important to review and analyze all areas of pediatric radiology to make general suggestions for decreasing the stress of pediatric patients and to increase
consistency of care. Whereas other published articles
related to pediatric patient stress focus on a specific
modality or procedure, this literature review examines
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Managing Stress in Pediatric Radiology

many radiology modalities and general medical procedures (see Table 1).

Methods
A literature search was conducted in CINAHLPlus
(EBSCO Publishing, Ipswich, Massachusetts),
PubMED, and MEDLINE (U.S. National Library of
Medicine, Bethesda, Maryland). The following search
terms were used in various combinations:
Catheterization.
Child-life specialist.
Diagnostic procedure.
Distraction.
Environment.
Fear.
Hypnosis.
Intervention.
Invasive.
Magnetic resonance (MR) imaging.
Memory.
Music.
Needle.
Pain.
Pediatric.
Radiology.
Radiology department.
Sedation.
Stress.
Trauma.
Venous.
Voiding cystourethrogram (VCUG).
Voiding cystourethrography.
Although the researcher was primarily interested
in findings published in radiology journals, other
medical journals were included in the search because
they have published key articles related to stress and
pediatric patients (see Table 2). Articles selected for
review addressed 1 or more of the following:
The short- or long-term effects from a stressful
and invasive medical procedure.
Common sources of stress in the pediatric radiology department.
A stress-minimizing strategy used in a pediatric
medical environment.
After eliminating duplicate citations, 60 articles
remained and were included in the literature review.

Discussion
The radiology department can be a frightening place
for a child. Many radiology department exam rooms
550

Table 1
Modalities and Procedures Addressed in
Selected Literature
Voiding cystourethrogram

26

General medical procedures associated with

needles in emergency medicine, lumbar
punctures, or venous access

Magnetic resonance (MR) imaging

Computed tomography (CT)

Emergency medicine

General radiology department

Radiation therapy

Radiography

General hospital setting

Cardiac catheterization

CT/MR

house large, noisy equipment.11,14,29 For optimal imaging or treatment such as in MR, computed tomography
(CT), or radiation therapy, children must lie still or be
immobilized in uncomfortable positions for long periods.11,12,14 Immobilization devices such as the Pigg-O-Stat
(Modern Way Immobilizers Inc, Clifton, Tennessee)
are commonly used in radiography. These devices are
effective in reducing motion, but their appearance can
be very disturbing to parents.14 Some procedures such
as VCUG expose private anatomy and involve bladder
catheterization, and thus can be painful, distressing,
and embarrassing for young children.3,28 VCUG also
requires the patient to void on the examination table,
which is counterintuitive for children of potty-training
age. Also, radiologic procedures that involve needle
sticks (eg, emergency traumas, lumbar punctures, cardiac catheterization, and MR or CT scans with contrast)
can be a source of pain and stress for children.13,16-18
Effects of Stressful Medical Procedures
There is documented evidence of both short- and
long-term physical and psychological effects of stressful
and invasive medical procedures on children. Shortterm effects include pain, anxiety, crying, and lack of
cooperation.32 In addition, parents who witness their
child experiencing a stressful procedure such as angiocatheter insertion have shown short-term effects such
as elevated anxiety and increased heart rate and blood
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Table 2
Selected Literature by Journal Type
n (%)
Pediatric and child health

19 (31.7)

Radiology and radiology nursing

15 (25)

Psychology and
behavioral science

7 (11.7)

Urology journals

4 (6.8)

Emergency medicine

5 (8.3)

Oncology and oncology nursing

4 (6.7)

Radiation technology

1 (1.7)

Family medicine

1 (1.7)

Anesthesia

1 (1.7)

Rehabilitation

1 (1.7)

General health care

1 (1.7)

pressure, and their stress may escalate the stress level in

a pediatric patient.2,21
There also is evidence that children experience
negative long-term effects of stressful and invasive
medical procedures. VCUG procedures are used
to evaluate urological disorders and are common
in pediatric radiology, but they can be stressful for
children. Children have shown post-traumatic stress
disorder symptoms such as emotional and behavioral
changes after undergoing VCUG procedures.3 After
undergoing a VCUG, parents have observed behaviors
in their children such as repetitive play imitating the
procedure without resolution, difficult communication about the procedure or wanting to block it out,
and displays of fear in other health care settings that
previously were a comfortable environment for their
child.3 The stress experienced during 1 procedure also
may be experienced in subsequent procedures. One
study found that children who underwent repeated
VCUGs reported experiencing the same level of distress they had during their first VCUG. 32
Patients who were exposed to many invasive and
stressful procedures during a serious illness in childhood, particularly at a very early age, have shown longterm psychological effects, including:
Higher incidences of medical fears.
A lower sense of control over health.
Ongoing post-traumatic stress responses.5
RADIOLOGIC TECHNOLOGY July/August 2012, Vol. 83/No. 6

Pain perception, fear, coping effectiveness, and

avoidance of medical care in adulthood have been
associated with childhood medical experiences.9
Trypanophobia, an extreme fear of needles and documented medical condition, is believed to be inherited
and learned through multiple needle stick experiences.
Patients with trypanophobia may experience fainting,
severe anxiety, electrocardiogram changes, and changes in stress hormone levels when needle sticks occur.6,7
Evidence also exists of a possible link between infants
who undergo multiple stressful medical procedures
and changes in neural development.8
Many research studies have focused on memory
and how stressful procedures affect a persons ability
to recall an event. Children who experience a stressful
medical event remember more about the procedure
than children who experience a nonstressful medical
event.4 In 1 study, children who underwent a VCUG
remembered 83% of the component features of the
exam 6 weeks after the procedure was performed.33
However, this could have been because of differences
in age and level of distress experienced by the children
at the time of the procedure. Children aged 4 years
or younger at the time they underwent a VCUG were
less accurate in recalling information about the procedure.34,35 Also, children who were more distressed
during the VCUG recalled less accurate information.4
Children whose memories of stressful medical events
are not accurate may have long-term effects such as
confusing various medical experiences and increased
distress during subsequent medical procedures.34
Strategies to Minimize Stress
Radiology departments implement different interventions to manage the stress and pain of pediatric
patients. These interventions include:
Parental involvement.
Preprocedural preparation.
Distraction.
Sedation.
Use of a child-life specialist.
Hypnosis.
Protecting childrens privacy.
Positive reinforcement.
Many studies found in the literature mentioned
combining different stress-minimizing strategies as a
collective intervention for a specific patient group. For
example, Tyc et al, Slifer et al, and Klosky et al evaluated the success of interventions aimed at minimizing
stress in pediatric patients.11,13,36 The interventions
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Managing Stress in Pediatric Radiology

Table 3
Parental Involvement3,14,17,26,28,30
Technique

Area of Use

Benefits

Measurable Change

Parent helps with positioning

and immobilization for imaging

Radiography

Optimal imaging with fewer

repeated images

Not applicable

Parent present to comfort

patient

Lumbar puncture

Helps to decrease anxiety in

patient

The presence of a family

member did not influence the
success rate of the lumbar
puncture

Parent distracts and helps

coach child in coping behaviors

Venous access

Helps to lower child distress;

active role in procedure can
help reduce anxiety in parent

Not applicable

Parent involved in preprocedural preparation at home (by

showing DVD about procedure,
practicing positions)

VCUG

Patient and parent are more

prepared for the procedure

Improved satisfaction and confidence of parents; improved

coping ability of child

Parent can hold child in

comforting position

VCUG,
venous access

A child positioned in a
parents lap or swaddled in
parents arms can be comforting for the child; positioning is
useful during catheterization
and venous access

Not applicable

used in the studies included various stress-minimizing

components such as distraction, preprocedural
preparation, and positive reinforcement. This review
presents individual strategies that can contribute
uniquely to an effective stress-minimizing intervention. Findings found in the literature reflect the combined effectiveness of the various components of a
stress-minimizing intervention if more than 1 strategy
is used in the intervention.
Parental Involvement
The involvement of parents can be a valuable
resource in minimizing the stress of pediatric patients
(see Table 3). Their presence during a procedure can
comfort a child and help to reduce anxiety.30 Parents can
hold their child in comforting positions, provide distraction, coach their child in coping techniques, and help
their child practice positions prior to a procedure.3,17,26,28
Parents also are valuable in positioning and immobilizing their child to improve the quality of imaging and
reduce radiation exposure from repeated images.14
However, anxiety and stress experienced by parents
can be predictors of distress in the child.2 Thus, the way
a parent responds to the pain and anxiety of his or her
552

child can directly affect the childs stress level.2,32 Parental

behaviors such as criticism, apologizing, giving control, and excessive reassurance with statements such as,
Everything is ok, can potentially cause or increase the
level of distress in a child.17,32 When parents are informed
about what the procedure entails and how they can actively participate to help their child cope, they can reduce
their own anxiety and their childs anxiety as well.1,17,26
Preprocedural Preparation
Preprocedural preparation for the pediatric
patient before a radiologic exam is important in
minimizing a childs stress and promoting his or her
cooperation (see Table 4).14 The timing of the preparation should be determined based on the events
surrounding the procedure as well as the childs perception of the procedure. Preprocedural preparation
can come in a variety of forms, but should always be
developmentally appropriate for the childs age. 3,14,17
Terms, images, and examples used for preprocedural
preparation should be understandable and familiar
to a child. 3 The preparation should be interactive and
engaging and the content should be clear, honest,
and thorough.17,24,28
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Table 4
Preprocedural Preparation3,11,13,17,24,26,28,29,31
Technique

Area of Use

Benefits

Educational coloring book

Radiology waiting room

Introduces children to common radiology tests and

equipment in developmentally appropriate ways

No significant decrease in patient anxiety but parents were pleased with the
informative content

Educational DVD

VCUG

Orients parents and children to all aspects of the

procedure; coaches the
parents on how to help their
child before and during the
procedure

Improved the confidence and satisfaction of the parents and the coping ability
of the patients during the procedure

Teaching pediatric patients

breathing techniques,
positive statements,
and imagery

VCUG, venous
access, MR

Helps relax and reduce

stress in patients; children
feel a sense of control; can
increase cooperation

Small reduction in distress associated

with MR procedures; children displayed
fewer distress behaviors and more coping behaviors, and they were rated as
more cooperative during a VCUG

Behavioral rehearsal

VCUG, CT, MR

Allows children to practice

positioning and steps of a
procedure; children become
familiar with medical equipment and supplies

Children displayed less distressful

behavior during VCUG; small reduction
in distress associated with MR procedures; enhanced satisfaction among
patients and their families; a reduction in
the use of sedation

Modeling films

VCUG, MR,
radiation therapy

Children are able to see a

realistic procedure successfully completed with modeled coping skills

Children displayed less distressful

behavior during VCUG and radiation
therapy; small reduction in distress
associated with MR procedures

Educational materials such as coloring books and

videos can educate the parents and pediatric patients
before the procedure. They learn what to expect of
the procedure, the equipment used, how long the procedure will take, and what the patient will see, hear,
and feel. It has been shown that adequate preparation
can increase the level of confidence and satisfaction
in parents and increase the childs ability to cope with
the procedure.26
Teaching coping behaviors to the pediatric
patient is another type of preprocedural preparation. Teaching breathing techniques, positive statements, and imagery can help children relax and
reduce their distress. 3,10,13,17,24,28 Breathing techniques
involving a pinwheel or a party blower are particularly effective during bladder catheterization prior
to a VCUG. 24,28 Teaching different coping strategies and allowing the child to choose the strategies
RADIOLOGIC TECHNOLOGY July/August 2012, Vol. 83/No. 6

Measurable Change

used returns a sense of control to the child and can

increase cooperation during the procedure. 3
Behavioral rehearsal is another effective method that
helps familiarize a young child to new surroundings. It
is especially beneficial for children undergoing a VCUG.
Simulating the steps of a VCUG on a gender-appropriate
catheterization doll actively involves the child and helps
minimize anxiety.3,24,28 Voiding during the VCUG can be
highly stressful and embarrassing for children. However,
practicing this component at home in the bathtub can be
an effective way to help reduce some of the stress associated with the procedure.28 Children also can have handson experiences with equipment such as an MR simulator
or the kitten scanner, a miniature CT unit.13,29 Special
dolls and medical equipment also can be used for children to role play starting an IV.13
Educational modeling films realistically demonstrate
the steps of a typical procedure and have been shown
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Managing Stress in Pediatric Radiology

Table 5
Distraction11-14,16,18,25,28,29
Technique

Area of Use

Benefits

Measurable Change

Toys, pacifiers, and

comfort items

Radiography

Comforts and distracts

child

Not applicable

Video during
procedure (cartoon)

VCUG, CT

Distracts child

Can distract and reduce stress in child,

but may not be as effective if not used in
conjunction with other interventions such as
preprocedural preparations

Books

VCUG

Distracts child

Not applicable

Party blowers
and whistles

VCUG

Distracts child, particularly Not applicable

during catheterization

MR video goggles

MR

Can distract patients

during long exams

Not applicable

Color lights display

CT

Can distract and calm

children

Enhanced satisfaction among patients and

their families; reduction in the use of sedation

Auditory distraction
(music and story
narration)

Helps children to relax

Lumbar
and distracts them from
puncture,
procedure
cardiac
catheterization,
MR (including
IV insertion),
radiation therapy

to help prepare a child before undergoing radiation

therapy treatment or MR scans.11,13 Modeling films show
a young child successfully going through all of the
steps of a procedure with a realistic amount of anxiety,
but with modeled coping behaviors.13 A modeling film
not only prepares the child for what to expect with the
procedure, but gives the child confidence that he or
she can be successful, too.
Distraction
Distraction can effectively minimize the stress of
pediatric patients associated with many medical procedures, including radiography, venous access, CT, MR,
VCUG, radiation therapy, lumbar puncture, and cardiac catheterization (see Table 5).11-14,16-18,24,25,28,29 A variety
of distraction strategies are available for use and can be
used before and during a procedure. The involvement
554

Use of music decreased pain scores,

heartrates and respiratory rates during
lumbar puncture; music found to reduce
stress in cardiac catheterization patients
(at varying levels depending on patient age);
small reduction in distress associated with
MR procedures; using a narrating character
as part of a stress-minimizing intervention
reduced stress in radiation therapy patients

of parents in the distraction strategy can help reduce

their anxiety, too. Parents can bring toys, pacifiers,
books, or other comfort items.14,28 Videos also are effective distraction tools for procedures such as CT, MR,
and VCUGs, and specialized video goggles compatible
with MR scanners can distract children during long
MR procedures.12,25,28 Party blowers and whistles are
especially effective distraction methods during procedures such as VCUGs.24,28
Some CT departments have invested in color
light-show devices that project moving lights on
the gantry, walls, and ceiling to calm and distract
children.12,29 Some light systems also project animated characters on the walls to instruct the child
in breathing instructions and provide positive reinforcement for cooperation. 29 Auditory distraction
such as music and storytelling is also a simple but
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effective way to calm and distract a child and can be

a valuable tool in the radiology department.13,16,18
In 1 study, a narrating purple dinosaur was an important stress-minimizing component for patients and parents during radiation therapy simulation and treatment
sessions. The character was designed to accompany the
child during the sessions and narrate stories intended
to distract and calm the child. In this study, radiation
therapy patients were randomly assigned to either the
dinosaur intervention group or the modified controlled
group. Parents of children in both groups completed
measures of state anxiety (how I feel at this moment)
and trait anxiety (how I generally feel) 10 minutes
prior to the initial simulation and just after the first
treatment session. In addition, parents completed an exit
questionnaire at the conclusion of the radiation therapy
trial. The intervention which included distraction and
components such as preprocedural preparation more
effectively minimized stress in both the patients and
parents compared to the control group. The parents in
the intervention group experienced greater reductions
in trait anxiety between the first simulation and the last
day of radiation therapy. Parents also rated the dinosaur
intervention higher in its effectiveness to reduce procedural distress in the pediatric patients compared to the
control group.11
The use of distraction can be a great tool in reducing stress in pediatric patients during invasive procedures. However, distraction alone may not be as effective if the procedure is not explained to the patient.
In 1 study, children who underwent a VCUG while
watching cartoons with little or no information about
the procedure demonstrated more distressful behavior
and appraised the procedure as more painful 1 week
later than children who watched cartoons but who also
received complete procedural information.25
Sedation
Patients have to remain still to reduce motion artifacts, but it can be a difficult task for any active child
and especially for children who are anxious. Sedation
agents can be used to reduce motion and obtain the
necessary amount of cooperation during the study.37,38
Numerous radiology departments have used sedation,
including CT, MR, VCUG, nuclear medicine, emergency
medicine, and interventional radiology.20-23,37-41 Sedation
also has been used to reduce anxiety during angiocatheter insertion and when accessing subcutaneous ports.15
Table 6 presents different sedation agents and their
effectiveness in reducing stress in pediatric patients.
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There are risks and practicalities to consider regarding sedating pediatric patients. A thorough presedation
assessment of a childs medical history, airway, and fasting history is critical before sedation is administered.41
Pediatric sedation regimens should be customized to
the needs of each patient based on whether the procedure is painful, the duration and type of procedure
involved, various patient factors (eg, the age of the
patient and cardiac and airway issues), and the skills
and experience of the staff members involved.39,41
Many studies in the literature discuss and compare various sedation agents, the effectiveness of the
sedatives in the radiology setting, and disadvantages
that may be associated with a particular agent. The
literature contains many studies that discuss the use
of various sedatives during VCUG procedures. For
example, Keidan et al compared the use of oral midazolam and nitrous oxide in minimizing pain and
stress in pediatric patients.40
Outcomes of the study included observed assessments of pain and distress, side effects, and recovery
time. The study found oral midazolam and nitrous
oxide were comparable in safety and effectiveness in
reducing anxiety and distress, but nitrous oxide was
found to provide a more rapid onset and a shorter
recovery time and is less expensive.40 An important
component of VCUG is the patients ability to void
during the study. Studies have shown that the use of
certain sedation agents may affect a patients ability to void. The use of propofol hinders the ability
to void, whereas oral midazolam does not appear to
interfere with voiding ability.20,42
Children who are sedated must be closely monitored by trained staff in specialized areas with proper
equipment.21,38 Because of the strong magnetic field
and radiofrequency emissions in the MR department, special precautions must be taken to ensure
that sedation equipment and monitoring devices are
MR compatible.41 Sedation cases require allocating
several staff members to a patient for a long period
during preprocedural preparations, the procedure
itself, and recovery time, which can put a strain on
the department.29 Sedation also comes with possible
complications, including hypoxia, prolonged sedation,
apnea, vomiting, and the need for assisted ventilation.38 Sedation can be associated with incomplete
and canceled procedures because of inadequate sedation or complications which can result in potentially
increased radiation exposure to patients and repeat
visits to the hospital. 38 Radiology departments now
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Table 6
Sedation11,15,20-23,36,37,39,40,42
Sedation Agent

Area of Use

Benefits

Measurable Change

Midazolam

VCUG, MR,
needle sticks
associated with
cancer patients

Induces sedation and can cause

amnesia; few adverse side effects
when given orally

Little effect on voiding ability; does

not hinder detection of vesicoureteric
reflux; requires increased recovery
time; intranasal method may cause
nasal discomfort

Nitrous oxide

VCUG

Reduced stress and pain;

less expensive compared to
midazolam

More rapid onset of sedation; requires

a shorter recovery time

Propofol

VCUG, MR

Deep sedative agent; quick

acting; shorter recovery time

Negatively affects patients ability to

void

Pentobarbital

CT, MR

Reduces anxiety; immobilization

Successful sedation agent, but requires

more recovery time

Etomidate

CT, MR

Reduces anxiety; immobilization

Not as effective as sedation agent, but

requires less recovery time

Chloral hydrate

MR

Reduces anxiety; immobilization

Not applicable

Diazepam

MR

Reduces anxiety; immobilization

Not applicable

Methohexital

MR

Reduces anxiety; immobilization

Not applicable

Dexmedetomidine

MR

Reduces anxiety; immobilization

Not applicable

General anesthesia

MR, radiation
therapy

Immobilization

More costly, long recovery time;

requires allocated anesthesiologist

Intranasal fentanyl

VCUG

Pain relief

Unable to show a statistically

significant difference between the
study and control group

use dedicated pediatric sedation teams to address

safety and staff allocation concerns. These teams have
increased the number of successfully completed sedations with fewer adverse effects.38
Because of the potential risks and costs of sedation,
the radiology department may implement more cognitive and behavioral interventions to reduce the use of
sedation. Bates et al evaluated the attitudes and perceptions of the use of complementary alternative medicine
therapies such as relaxation, guided imagery, and hypnosis in a group of MR employees.43 Overall, the study
found a positive perception of the alternative therapies
among the staff and an understanding of the special
needs of pediatric patients. However, the study showed
that staff members need more clarification and education on the specifics of the therapies and how they can
be implemented in the MR setting.43
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Child-life Specialists
In an effort to reduce the stress of pediatric patients
and the need for sedation, various departments use certified child-life specialists, including fluoroscopy, CT,
MR, and the emergency department.12,19,44 Child-life
specialists generally have an academic background in
child development, education, and psychosocial care.44
They work with other medical staff and use interventions to increase adaptability and learning. Child-life
specialists are educated in the physical, emotional, and
cognitive development of children and can tailor an
intervention for a patient and his or her family to meet
specific needs of the child. When designing an intervention, a child-life specialist must first consider the
age of the child and then identify potential stressors
involved with the procedure, the childs cognitive ability, and how the family can best support the child.44
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An important job of a child-life specialist is preprocedural preparation.19,44 Child-life specialists can

meet with a family in person before a procedure or
by telephone consultation. This preparation is helpful
because it informs the parents and child of what to
expect ahead of time and provides ample opportunity
for questions and concerns to be addressed.44 In addition, child-life specialists can serve as advocates by facilitating communication between the family and staff.19,44
During the preprocedural preparation period, a childlife specialist may be able to provide an assessment to
the medical staff that allows for special adaptations to
be made prior to the procedure.44 Child-life specialists
educate patients and families about the procedure in a
developmentally appropriate way. They also can define
the parents role during the procedure and teach them
how to be supportive, as well as help minimize anxiety
in the patient by teaching coping skills. These skills can
be introduced during the preprocedural preparation
period, practiced at home by the parents, and used
during the procedure. Some coping skills include:
Visual and auditory distraction.
Breathing exercises.
Tactile stimulation.
Counting and singing.19,44
Child-life specialists also can be an educational
resource for other medical staff and health care professionals by providing guidance and training in ageappropriate practices.44
Several studies have shown the benefits of having
a child-life specialist in the radiology department. An
intervention involving a child-life specialist was found
to reduce stress in children aged 4 to 7 years, who
underwent angiocatheter insertion in the emergency
department.19 In another study, the use of a child-life
specialist in combination with other strategies such as
videos and lights showed a 34.6% reduction in the use
of sedation in MR imaging for children younger than
age 7, and a 44.9% reduction in the use of sedation in
CT. Khan et al described the presence of the child-life
specialist in the radiology department as having a
profound effect on patient and family satisfaction.12
Hypnosis
Hypnosis has been shown to be an effective stressminimizing strategy for pediatric patients in various
medical settings such as emergency medicine, radiology, wound care, and intravenous catheterization.45
Hypnosis is an altered state of consciousness that intentionally uses suggestion to affect changes in a persons
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sensation, perception, and physiology and is shown

to be an effective agent in alleviating pain.45 PeeblesKleiger discussed the use of hypnosis in emergency
medicine and listed several characteristics of effective
hypnotic interventions, including:
The use of a calm but direct voice.
Pacing the rate of speech to the patients breathing, then gradually slowing down.
The use of strategic pauses to enhance dissociation.
An emphasis on words that carry intended
suggestion.
An avoidance of negative phrases.
The use of positive expectations and suggestions.45
Specifically with pediatric patients, hypnotic interventions should be focused on capturing the childs
attention and trust and positively reframing the
childs distress.45
Butler et al discussed findings from a study that
examined the effectiveness of hypnosis in reducing
the distress and duration of a VCUG in patients at
least 4 years of age who had previously experienced
a stressful VCUG.27 One day prior to the procedure,
parents and patients were questioned about the pain,
crying, and fear experienced during the previous
VCUG. A patient who was randomly selected for
hypnosis was given a 1-hour training session by a
trained therapist. The training session included the
use of self-hypnotic visual imagery. The parents and
patient were encouraged to practice the self-hypnotic
imagery at home prior to the procedure. The
therapist also was present during the procedure to
assist with the self-hypnotic visual imagery technique.
Patients who were not a part of the hypnosis group
received routine care as a part of the hospitals
recreation therapy program, which included
preprocedural preparation such as demonstrations
with a doll and breathing exercises.
The patients who received hypnosis rather than
routine care showed significant improvements in
stress compared to the previous procedure. Parents
reported that undergoing the procedure with
hypnosis was significantly less traumatic for the child.
Observational ratings of distress levels during the
procedure were lower, and medical staff reported
less difficulty with the procedure. Also, the total
procedure time was shorter by 14 minutes compared
to procedures performed without hypnosis.27 More
research is needed to further investigate the use
of hypnosis in reducing stress in the radiology
department.
557

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Managing Stress in Pediatric Radiology

Protecting Childrens Privacy

A pediatric patient can become distressed easily
when he or she is required to expose his or her private
anatomy for a medical procedure. This is particularly
an issue with VCUG procedures as the child is catheterized. The childs privacy should be maintained as much
as possible during the catheterization by covering the
childs genitals and minimizing the number of staff
members (especially of the opposite gender) who enter
the exam room.3,28
Positive Reinforcement
Positive reinforcement is an effective way to encourage and reward a child during and after any radiologic
procedure. Verbal praise, certificates, trophies, and
other prizes can be used to reinforce behavior, recognize courage, and provide an incentive for completing
a procedure.14,24 Positive reinforcement can be used in
conjunction with other strategies to minimize stress in
pediatric patients.

Conclusion
This literature review thoroughly examined the
issues surrounding stressful procedures of pediatric
radiology patients and ways to minimize this stress
and its potential consequences. The literature review
evaluated the short- and long-term effects a child can
encounter from having a stressful and invasive medical
procedure, the common sources of stress children may
experience in the pediatric radiology department, and
strategies used to try to minimize the stress of pediatric
radiology patients.
The literature discusses many different types of
stress-minimizing strategies used in radiology departments. Some MR, CT, and radiation therapy facilities have developed high-tech strategies such as light
displays, video goggles, and interactive toys to reduce
stress. Other disciplines implemented simpler methods
such as adequate preparation of the patients, distraction, breathing exercises, and positive reinforcement
that also proved to be effective.
Sedation is necessary in pediatric radiology at times.
Many safe and effective sedation agents are used in
pediatric radiology.15,20-23,37-40 However, many of the
articles stressed the desire to reduce the use of sedation
because of its potential risks and complications and
presented alternative methods that have proved to be
as effective.11-13,17,24,28,29,31,36,43,46
A patient is likely to interact with more than 1
radiology area during the diagnosis and treatment
558

of a medical condition. Consistency of care can be

reassuring for a young child, especially in a stressful
situation. Radiology department managers and
supervisors can provide consistent management
of stress and pain in children by implementing
various stress-minimizing strategies throughout the
radiology department. All radiology department staff
can play an important role in minimizing stress in
pediatric patients through good communication. A
common theme throughout the literature was the
importance of communication between the medical
staff, the pediatric patient, and his or her parents.
Patient anxiety can be reduced when pediatric
patients receive realistic and developmentally
appropriate descriptions and expectations for a
procedure.3,13,14,17,26,28 Also, parental stress can be
reduced when they are informed about their childs
procedure and educated about ways they can help
their child cope.17,26 Good communication is a simple
but critical component in minimizing stress in the
radiology department and should be the focus of all
medical staff when working with pediatric patients.
Many studies have addressed stress experienced by
patients in specific branches of radiology. However,
gaps exist in the literature because the majority of the
studies are based on CT, MR, and VCUGs. Relatively
few studies address vascular-interventional radiology,
cardiac catheterization, emergency/trauma imaging,
and gastrointestinal procedures such as barium enemas, upper GIs, and barium swallow studies. Future
research should be done in these areas to address the
stress involved with procedures in these modalities
and ways to minimize it.
In addition, there are many stress-minimizing strategies
identified in this literature review that have been found
to be successful in a particular modality. Future research
should be conducted to examine the effectiveness of
these strategies in other areas of radiology. This research
can improve the quality of care in a specific area, with a
certain procedure, and regarding consistency of pediatric
patient care throughout the radiology department.

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Melody Alexander, BS, R.T.(R)(MR), is a graduate of

Campbell University with a bachelors degree in the biological sciences. She also is a graduate of the University of North
Carolina at Chapel Hill with a bachelors degree in medical imaging. Ms Alexander is currently employed by UNC
Hospitals in the magnetic resonance imaging department.
Reprint requests may be sent to the American Society of
Radiologic Technologists, Communications Department,
15000 Central Ave SE, Albuquerque, NM 87123-3909, or
e-mail communications@asrt.org.
2012 by the American Society of Radiologic Technologists.

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