Clinical holding

When children and young people are scared, worried or distressed, they may not be able to cooperate with what is being asked of them. This is particularly true in hospitals, where there are new people looking after them, different surroundings and procedures that a child or young person might worry will hurt. Clinical holding is just one way of providing support to a child or young person who is struggling to cope with a situation, so together we can work out ways of aiming to achieve a set goal. This page from Great Ormond Street Hospital (GOSH) describes how we will plan to help your child with a procedure that scares them and what you can do to help us. An Easy Read information sheet is included for your child.

All children and young people go through phases where the way they respond is not what we would expect. This may be compounded for those with a mental health condition, learning disability or autism spectrum disorder, as this population may find it more difficult to process the environment or understand what is being explained to them.

All behaviour has meaning. All people communicate through behaviour, but this is especially true for children and young people who cannot use words to say how they are feeling. Occasionally, children and young people may use worrying ways of behaving as their only way to demonstrate how and what they are feeling.

You are an expert in your child, so we appreciate any and all information you can give us about how your child tolerates a healthcare environment. Please give us as much detail as you can ahead of an admission.

Some families find a ‘hospital passport’ useful to help us understand your child better. This is a document which provides health professionals with information about what is important to patients, their likes, dislikes, how they communicate and their sensory needs. There are lots of different versions available – look for one that works for your child and show it to us whenever you visit GOSH.

Using MyGOSH you can add information about support needed for procedures to the Fingerprint section, this may aid the planning of procedures.

It might be helpful to think about how your child has reacted to things in the past for example during visits to the GP or the hospital. Were there any ‘triggers’ for the way they responded – for instance, seeing a stethoscope or having their skin cleaned with antiseptic before an injection or blood test. Think about how they responded – did they try to get away, scream or hit out? How did you deal with their reaction previously? How did it work? Think about times when you have managed your child’s worry successfully.

There are lots of ways we can support your child in dealing with worries so they feel better equipped to cooperate and understand what is happening. We will try to explore these with you so we can work out a plan in advance.

This includes various ways of taking your child’s mind off the procedure, including guided imagery (helping your child to find a ‘happy place’ then talking to them about it), using interactive games, tactile toys like a stretchy caterpillar or squishy ball, or reading together. We also have the Bloodquest App which is free to download from the app store – this has been developed to help prepare children for a blood test and includes a distraction game for during the procedure. Look at our distraction information sheet or ask about the involvement of a Play Specialist.

Normalising play can provide an opportunity to change a worry fuelled-visit. Toys and activities that are familiar and liked, support children and young people to feel a little more in control of what’s happening.

Play can also highlight some worries and so our Play Team can support this through assessment and specialised play sessions. We may be able to arrange play sessions before your child's appointment, surgery, or procedure and we could also liaise with your child’s school teacher, keyworker or support worker, so we can then spend time creating a bespoke plan just for your child.

The involvement of the Play Specialist in situations or procedures where there may be anxiety or decisions made about positioning or other clinical contact can aid decision making and pre-planning to support your child.

It is helpful to understand why your child is having a procedure so you can explain it to them in a way that is meaningful for them.. For instance, you could say that although the medicine tastes nasty, it will make their tummy better and they can have another drink afterwards to take away the taste.

If your child is due to have a scan, you could ask the doctor to show them the pictures of inside their body. If they are due to have a blood test, you could look at the Harvey’s Gang website (www.harveysgang.com) to see whether a tour of our laboratory to see what happens to blood samples is possible.

Children and young people who come into the hospital may feel a sense of frustration that plans are being made about them rather than with them. Offering choice where possible will help to empower and encourage patients to understand that they are included in what is happening, and will make things less frightening for them.

These choices may just be something small, like choosing whether to have a red or blue plaster cast, but they are significant nonetheless. If you are unsure, always ask if there are any choices available.

As a last resort or if the child or young person has been supported in every practicable way to have the intervention, but they are still not able to tolerate it, we can work together to find ways for your child to be still and safe – one of the ways we do this is by clinical holding, which is being held firmly but it should not hurt. Sometimes, wrapping your child in a blanket can be comforting as well as enabling you to hold their arms and legs still. We will ask you to give permission to hold your child still unless it is an emergency. The role of parents and carers during invasive procedures is to cuddle, support and encourage their child. The role of the medical team in safe holding, for example, is to hold of the arm where necessary.

Positioning may be a word that is used when talking about clinical holding.

• We will work with you and your child to find a way to help make procedures manageable
• In an emergency, there may not be time to explore different ways of helping your child. We will do what we need to do as quickly as possible to try to minimise any distress or upset to your child.
• We will always write in your child’s records which techniques we have used and in which circumstances.
• If you are at all concerned about how your child is coping with a procedure or the techniques that are being used or suggested, please talk to us.
• There are lots of options we can try – as every child is different, what works for one child might be less successful for another. We will work together to find solutions for different circumstances.
• Please pass on any tips that have worked well in the past.