Experts share tips on minimizing the trauma of skin biopsy in children

 

DVDs, iPads, and toys. “Sweeties” to suck on. Buffered lidocaine, soothing talk, and a distracting “angel’s pinch.”

These are just a few of the strategies that dermatologists can use to calm children during a skin biopsy, which can be traumatic for everyone in the room. “This procedure, while minor, can be a big deal to kids,” said Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital and professor, department of pediatrics, University of Washington, Seattle. “It’s invasive. And it involves a shot and blood and discomfort, albeit relatively mild – all things that are frightening for anyone, but more so for kids.”

Dr. Sidbury tries to avoid performing biopsies whenever possible. While a physician and an adult patient may agree on a skin biopsy out of curiosity, that scenario is rare in children, he said in an interview. Instead, he insists on at least one of four criteria: The skin condition is concerning medically, the diagnosis cannot be determined in a less invasive way, the treatment recommendations or prognosis can be better formulated knowing histopathology, or a biopsy is likely to answer a specific question.

When a biopsy is performed in a child, “the anxiety that they bring to the situation is as much an issue as the pain,” Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, and professor of dermatology and pediatrics, University of California, San Diego, said in an interview.

But there are ways to lessen the intensity of the procedures for children, their parents, and medical staff, according to the two pediatric dermatologists. Here are their tips for various age groups:

Infants

Dr. Sidbury is a big fan of papooses or wraps, as long as they are not obstructive. “Babies are used to being wrapped, and it can be an atraumatic way to restrain,” he said. “If parents are comfortable, I will have them present, talking and cooing to the baby throughout. Their voices are soothing.”

But some parents may be so anxious that they’ll be at risk of fainting, he said, or having other averse reactions. “This,” he said, “needs to be gauged up front.”

Indeed, Dr. Eichenfield says he breaks his rule about allowing parents in the room for biopsies when the children are under age 7 to 8 months. “It’s more unnerving for them to be in the room, and they’re not that calming to the baby.”

Food can be another soothing strategy. Infants may suck on “sweeties,” a glucose-rich solution known as TootSweet sucrose solution, prior to and during the procedure, Dr. Sidbury said. “EMLA cream or some form of topical anesthetic can be helpful, but the provider must remain mindful of the maximum safe amounts to apply as outlined in the package insert.”

He also advises colleagues to remember the thinness of infant skin. “Biopsying ‘down to the hub,’ as one will often do in an adult with a punch biopsy, can be too deep in some places,” he said.

Toddlers and younger children

“Two-to-six-year-olds are the toughest group,” Dr. Eichenfield noted. “They’re afraid of needles, they don’t understand why they have to have the procedure, and they don’t understand that once it’s done, it’s not going to hurt.”

Shifting away their focus is ideal, he said. “Distraction is always great. They’ll sense less pain and have less anxiety if they’re busy.” Distractions like a video on DVD can be helpful, he said, as can a “counterstimulation” technique, like a firm “angel’s pinch” that prevents them from noticing an injection. “Kids are comfortable getting pinched,” he said. “Many times I’ll block their view of the procedure, too.”

Older children

If a child is over age 6 years, Dr. Eichenfield recommends asking parents about whether the child has had any difficulty while undergoing anesthesia for dental procedures. If they don’t, “you know that they’re not coming with a history of anxiety or pain that can definitely amplify their perception and concern about the procedure.”

Dr. Sidbury also recommended distractions like iPads, movie players, video games, and music. Prizes may also help: They can be given as rewards at the end of procedures.

“Try not to show the needle,” he advised. “But this does not mean surprising kids or not letting them know a shot will be involved.”

And be aware that the numbing in older children is often the hardest part. “They will realize once it stops hurting they are OK,” he pointed out. “Hence, this part should be relatively fast. Don’t linger over the child, needle in hand, explaining things. Keep the needle and sharp, scary-looking instruments covered until needed, and then keep the needle itself covered as long as possible. Just the sight of it can be a deal breaker.”

 

Anesthesia tips

Regardless of the age of the child, careful use of anesthesia is recommended. “I often have the parents apply a topical anesthetic at home for a few hours before their arrival,” said Bernard Cohen, MD, professor of dermatology, Johns Hopkins University, Baltimore. “I inject deeper in the subcutaneous fat first before injecting more superficially, and I try to extend the anesthetic from the first area of injection to minimize the pain.”

Johns Hopkins Medicine

In an interview, he said he also often adds buffer to the anesthetic solution to decrease stinging. “When I inject, I often tickle or vibrate the nearby skin as a distraction as well.”

For his part, Dr. Sidbury recommends using EMLA or LMX cream, in advance of 1% lidocaine with buffered epinephrine injected locally. Topical EMLA works better if used liberally – albeit within specified safe limits, he said. So instead of applying a small amount and rubbing it in, a thicker layer can be applied without rubbing it in, and when possible, the area can be occluded with a dressing or other type of covering, “while you are waiting the 30-plus minutes for it to work.” Occluding the area with something like “Press ’N’ Seal” wrap that comes off easily, instead of adhesive, is a good idea, he added, since removing an adhesive dressing can be as painful as the procedure.

Like Dr. Cohen and Dr. Eichenfield, Dr. Sidbury also supports physical distraction when the lidocaine is injected, like “having the patient cough if the movement is not problematic. Or rubbing or scratching the adjacent skin to the site of shot, or the opposite arm.”

Dr. Eichenfield, Dr. Sidbury, and Dr. Cohen reported no relevant disclosures.

 

DVDs, iPads, and toys. “Sweeties” to suck on. Buffered lidocaine, soothing talk, and a distracting “angel’s pinch.”

These are just a few of the strategies that dermatologists can use to calm children during a skin biopsy, which can be traumatic for everyone in the room. “This procedure, while minor, can be a big deal to kids,” said Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital and professor, department of pediatrics, University of Washington, Seattle. “It’s invasive. And it involves a shot and blood and discomfort, albeit relatively mild – all things that are frightening for anyone, but more so for kids.”

Dr. Sidbury tries to avoid performing biopsies whenever possible. While a physician and an adult patient may agree on a skin biopsy out of curiosity, that scenario is rare in children, he said in an interview. Instead, he insists on at least one of four criteria: The skin condition is concerning medically, the diagnosis cannot be determined in a less invasive way, the treatment recommendations or prognosis can be better formulated knowing histopathology, or a biopsy is likely to answer a specific question.

When a biopsy is performed in a child, “the anxiety that they bring to the situation is as much an issue as the pain,” Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, and professor of dermatology and pediatrics, University of California, San Diego, said in an interview.

But there are ways to lessen the intensity of the procedures for children, their parents, and medical staff, according to the two pediatric dermatologists. Here are their tips for various age groups:

Infants

Dr. Sidbury is a big fan of papooses or wraps, as long as they are not obstructive. “Babies are used to being wrapped, and it can be an atraumatic way to restrain,” he said. “If parents are comfortable, I will have them present, talking and cooing to the baby throughout. Their voices are soothing.”

But some parents may be so anxious that they’ll be at risk of fainting, he said, or having other averse reactions. “This,” he said, “needs to be gauged up front.”

Indeed, Dr. Eichenfield says he breaks his rule about allowing parents in the room for biopsies when the children are under age 7 to 8 months. “It’s more unnerving for them to be in the room, and they’re not that calming to the baby.”

Food can be another soothing strategy. Infants may suck on “sweeties,” a glucose-rich solution known as TootSweet sucrose solution, prior to and during the procedure, Dr. Sidbury said. “EMLA cream or some form of topical anesthetic can be helpful, but the provider must remain mindful of the maximum safe amounts to apply as outlined in the package insert.”

He also advises colleagues to remember the thinness of infant skin. “Biopsying ‘down to the hub,’ as one will often do in an adult with a punch biopsy, can be too deep in some places,” he said.

Toddlers and younger children

“Two-to-six-year-olds are the toughest group,” Dr. Eichenfield noted. “They’re afraid of needles, they don’t understand why they have to have the procedure, and they don’t understand that once it’s done, it’s not going to hurt.”

Shifting away their focus is ideal, he said. “Distraction is always great. They’ll sense less pain and have less anxiety if they’re busy.” Distractions like a video on DVD can be helpful, he said, as can a “counterstimulation” technique, like a firm “angel’s pinch” that prevents them from noticing an injection. “Kids are comfortable getting pinched,” he said. “Many times I’ll block their view of the procedure, too.”

Older children

If a child is over age 6 years, Dr. Eichenfield recommends asking parents about whether the child has had any difficulty while undergoing anesthesia for dental procedures. If they don’t, “you know that they’re not coming with a history of anxiety or pain that can definitely amplify their perception and concern about the procedure.”

Dr. Sidbury also recommended distractions like iPads, movie players, video games, and music. Prizes may also help: They can be given as rewards at the end of procedures.

“Try not to show the needle,” he advised. “But this does not mean surprising kids or not letting them know a shot will be involved.”

And be aware that the numbing in older children is often the hardest part. “They will realize once it stops hurting they are OK,” he pointed out. “Hence, this part should be relatively fast. Don’t linger over the child, needle in hand, explaining things. Keep the needle and sharp, scary-looking instruments covered until needed, and then keep the needle itself covered as long as possible. Just the sight of it can be a deal breaker.”

 

Anesthesia tips

Regardless of the age of the child, careful use of anesthesia is recommended. “I often have the parents apply a topical anesthetic at home for a few hours before their arrival,” said Bernard Cohen, MD, professor of dermatology, Johns Hopkins University, Baltimore. “I inject deeper in the subcutaneous fat first before injecting more superficially, and I try to extend the anesthetic from the first area of injection to minimize the pain.”

Johns Hopkins Medicine

In an interview, he said he also often adds buffer to the anesthetic solution to decrease stinging. “When I inject, I often tickle or vibrate the nearby skin as a distraction as well.”

For his part, Dr. Sidbury recommends using EMLA or LMX cream, in advance of 1% lidocaine with buffered epinephrine injected locally. Topical EMLA works better if used liberally – albeit within specified safe limits, he said. So instead of applying a small amount and rubbing it in, a thicker layer can be applied without rubbing it in, and when possible, the area can be occluded with a dressing or other type of covering, “while you are waiting the 30-plus minutes for it to work.” Occluding the area with something like “Press ’N’ Seal” wrap that comes off easily, instead of adhesive, is a good idea, he added, since removing an adhesive dressing can be as painful as the procedure.

Like Dr. Cohen and Dr. Eichenfield, Dr. Sidbury also supports physical distraction when the lidocaine is injected, like “having the patient cough if the movement is not problematic. Or rubbing or scratching the adjacent skin to the site of shot, or the opposite arm.”

Dr. Eichenfield, Dr. Sidbury, and Dr. Cohen reported no relevant disclosures.

 

DVDs, iPads, and toys. “Sweeties” to suck on. Buffered lidocaine, soothing talk, and a distracting “angel’s pinch.”

These are just a few of the strategies that dermatologists can use to calm children during a skin biopsy, which can be traumatic for everyone in the room. “This procedure, while minor, can be a big deal to kids,” said Robert Sidbury, MD, MPH, chief of the division of dermatology at Seattle Children’s Hospital and professor, department of pediatrics, University of Washington, Seattle. “It’s invasive. And it involves a shot and blood and discomfort, albeit relatively mild – all things that are frightening for anyone, but more so for kids.”

Dr. Sidbury tries to avoid performing biopsies whenever possible. While a physician and an adult patient may agree on a skin biopsy out of curiosity, that scenario is rare in children, he said in an interview. Instead, he insists on at least one of four criteria: The skin condition is concerning medically, the diagnosis cannot be determined in a less invasive way, the treatment recommendations or prognosis can be better formulated knowing histopathology, or a biopsy is likely to answer a specific question.

When a biopsy is performed in a child, “the anxiety that they bring to the situation is as much an issue as the pain,” Lawrence Eichenfield, MD, chief of pediatric and adolescent dermatology at Rady Children’s Hospital–San Diego, and professor of dermatology and pediatrics, University of California, San Diego, said in an interview.

But there are ways to lessen the intensity of the procedures for children, their parents, and medical staff, according to the two pediatric dermatologists. Here are their tips for various age groups:

Infants

Dr. Sidbury is a big fan of papooses or wraps, as long as they are not obstructive. “Babies are used to being wrapped, and it can be an atraumatic way to restrain,” he said. “If parents are comfortable, I will have them present, talking and cooing to the baby throughout. Their voices are soothing.”

But some parents may be so anxious that they’ll be at risk of fainting, he said, or having other averse reactions. “This,” he said, “needs to be gauged up front.”

Indeed, Dr. Eichenfield says he breaks his rule about allowing parents in the room for biopsies when the children are under age 7 to 8 months. “It’s more unnerving for them to be in the room, and they’re not that calming to the baby.”

Food can be another soothing strategy. Infants may suck on “sweeties,” a glucose-rich solution known as TootSweet sucrose solution, prior to and during the procedure, Dr. Sidbury said. “EMLA cream or some form of topical anesthetic can be helpful, but the provider must remain mindful of the maximum safe amounts to apply as outlined in the package insert.”

He also advises colleagues to remember the thinness of infant skin. “Biopsying ‘down to the hub,’ as one will often do in an adult with a punch biopsy, can be too deep in some places,” he said.

Toddlers and younger children

“Two-to-six-year-olds are the toughest group,” Dr. Eichenfield noted. “They’re afraid of needles, they don’t understand why they have to have the procedure, and they don’t understand that once it’s done, it’s not going to hurt.”

Shifting away their focus is ideal, he said. “Distraction is always great. They’ll sense less pain and have less anxiety if they’re busy.” Distractions like a video on DVD can be helpful, he said, as can a “counterstimulation” technique, like a firm “angel’s pinch” that prevents them from noticing an injection. “Kids are comfortable getting pinched,” he said. “Many times I’ll block their view of the procedure, too.”

Older children

If a child is over age 6 years, Dr. Eichenfield recommends asking parents about whether the child has had any difficulty while undergoing anesthesia for dental procedures. If they don’t, “you know that they’re not coming with a history of anxiety or pain that can definitely amplify their perception and concern about the procedure.”

Dr. Sidbury also recommended distractions like iPads, movie players, video games, and music. Prizes may also help: They can be given as rewards at the end of procedures.

“Try not to show the needle,” he advised. “But this does not mean surprising kids or not letting them know a shot will be involved.”

And be aware that the numbing in older children is often the hardest part. “They will realize once it stops hurting they are OK,” he pointed out. “Hence, this part should be relatively fast. Don’t linger over the child, needle in hand, explaining things. Keep the needle and sharp, scary-looking instruments covered until needed, and then keep the needle itself covered as long as possible. Just the sight of it can be a deal breaker.”

 

Anesthesia tips

Regardless of the age of the child, careful use of anesthesia is recommended. “I often have the parents apply a topical anesthetic at home for a few hours before their arrival,” said Bernard Cohen, MD, professor of dermatology, Johns Hopkins University, Baltimore. “I inject deeper in the subcutaneous fat first before injecting more superficially, and I try to extend the anesthetic from the first area of injection to minimize the pain.”

Johns Hopkins Medicine

In an interview, he said he also often adds buffer to the anesthetic solution to decrease stinging. “When I inject, I often tickle or vibrate the nearby skin as a distraction as well.”

For his part, Dr. Sidbury recommends using EMLA or LMX cream, in advance of 1% lidocaine with buffered epinephrine injected locally. Topical EMLA works better if used liberally – albeit within specified safe limits, he said. So instead of applying a small amount and rubbing it in, a thicker layer can be applied without rubbing it in, and when possible, the area can be occluded with a dressing or other type of covering, “while you are waiting the 30-plus minutes for it to work.” Occluding the area with something like “Press ’N’ Seal” wrap that comes off easily, instead of adhesive, is a good idea, he added, since removing an adhesive dressing can be as painful as the procedure.

Like Dr. Cohen and Dr. Eichenfield, Dr. Sidbury also supports physical distraction when the lidocaine is injected, like “having the patient cough if the movement is not problematic. Or rubbing or scratching the adjacent skin to the site of shot, or the opposite arm.”

Dr. Eichenfield, Dr. Sidbury, and Dr. Cohen reported no relevant disclosures.