Procedural consent, preparation and child-life support — formative SAQs

SAQ 1 (10 marks)

A 4-year-old previously well child is admitted for intravenous antibiotic therapy for a soft-tissue infection. A cannula needs to be sited on the ward. The child is awake, alert and clingy with an anxious parent. The team proposes to "just hold her down and get it done." You are the paediatric registrar. ^{[1] [4]}

1. Outline the structured pre-procedure assessment you perform before the cannula is sited. (4) ^[1]
2. Describe the consent, assent and preparation conversation you have with the parent and child for this elective ward cannula, citing the framework you are using. (3) ^{[1] [3]}
3. Describe the bedside comfort bundle you assemble, including the specific sucrose considerations that do NOT apply here, and explain why holding the child down is not the preferred approach. (3) ^{[4] [5] [6]}

Model answer — SAQ 1

(1) Pre-procedure assessment (4). I run a short, structured assessment asking four questions. Who decides: I identify the person with parental responsibility (here the parent present) and assess whether the child can give meaningful assent at age four — she cannot give legal consent, but I will seek her assent and record any dissent. What the child understands: I place her in the preschool preparation band, note her current clingy state, and ask the parent about her prior needle experiences and what helped. What is the child's current state: I rate her distress behaviourally (a young child uses a Faces scale or behavioural observation), and I look specifically for freeze or dissociation rather than assuming a quiet child is assenting. Is this procedure right, now, for this child: I confirm the indication and that the procedure is needed, check who will do it and their competence, and check there is no fasting or bleeding issue; if the child is in severe distress I defer to prepare, refer to child-life, or arrange a more experienced operator or sedation. ^[1]

(2) Consent, assent and preparation (3). I take parental permission from the parent holding responsibility, layered with developmentally appropriate assent from the child — I do not treat her silence as agreement. I use the AAP framework that distinguishes informed consent (for those with capacity), parental permission (for the young child) and affirmative child assent, and I document the conversation. For preparation, because she is a preschool child, I prepare 30 to 60 minutes before with play and a simple, honest, concrete sequence: I show the equipment on a doll first, use short concrete words (squeeze, cold, push), explicitly avoid saying it will not hurt, and offer a real choice only where one genuinely exists (which arm, watch or look away). I document the basis on which I am acting. ^{[1] [3]}

(3) Bedside comfort bundle and restraint (3). I assemble a layered bundle: topical anaesthesia on intact skin 30 to 60 minutes before, comfort positioning (chest-to-chest on the parent or hugging a wrapped toy), distraction (a bubbles toy, a video, a child-life specialist using medical play and coping coaching), and a calm, briefed parent given a specific helpful task such as a comfort hold. The sucrose consideration that does not apply here is the infant sucrose dose: oral sucrose is an infant measure (typically 0.1 to 2 mL of 24% to 33% solution as an absolute volume onto the tongue or soother, with a maximum of about 2 mL per dose); this four-year-old does not use sucrose. Breastfeeding for procedural pain similarly applies to infants. Holding the child down is restraint, not a comfort position: restraint is the use of force to overcome active resistance, it injures and traumatises, it breaches trust, and it usually fails; for a non-emergency procedure the least-restrictive alternative — enhanced preparation, child-life referral, comfort positioning, rescheduling, or sedation — is the right approach, and restraint is reserved for a genuine, proportionate, least-restrictive emergency. ^{[4] [5] [6]}