How comfort care helps kids with persistent agitation

While reading Dr. Hall’s article “Persistent agitation in children with neurologic impairments,” the differences between the medical and nurse practitioner (NP) models of care emerge.

Dr. Hall provides an excellent, comprehensive review of the approaches for establishing a differential diagnosis for persistent crying in neurologically impaired children, recommendations for diagnostic testing, and medication management-all clearly the medical model for healthcare. An NP model for healthcare also uses the same approaches to medical diagnosis and treatment planning. However, emphasis is also placed on the concepts of caring (Watson’s theory of caring, 2009,¹ 2012²) and comfort measures for both the child and the parent-in which the NP fosters the development of a caring, trusting relationship between the nurse and the mother-and for the development of parental caring for all children, in this particular case, the neurologically impaired, agitated child.

Nonpharmacologic comfort measures

Dr. Hall mentions a few nonpharmacologic interventions for idiopathic agitation, eg, cuddling, repositioning, weighted blankets, and massage. However, it is essential to introduce and establish these and other interventions before the child experiences agitation, in particular, persistent agitation. Yes, neurologically impaired children are difficult to assess and most often have limited abilities to interact with their parent and/or environment. Knowing this fact, special attention to the individual needs of these children early in their development is key for parental success in the day-to-day care of the child, and especially in times of child stress. 

Interventions that can be introduced and evaluated for the individual child’s response include stroking, holding, kissing, cuddling, and rocking the child, often in combination with background music (concepts of music therapy); early introduction to “comfort objects” such as a blanket or stuffed animal; animal (dog)-assisted care in which the animal is trained to attend to the child during crying and other observed stressful episodes; and stimulation through technology, such as use of a computer or personal device. 

Knowledge of effective comfort measures

Comfort measures should be incorporated into the child’s daily routines. All individuals who care for the child, including the parents and all family members, teachers, respite care workers, nurses, physical therapists, occupational therapists, and all healthcare providers should be aware of comfort measures that work best for the particular child.  Thus, when the child is in a state of persistent agitation, the specific comfort measures that are known to be most effective for the particular child should be a part of the treatment plan. If ineffective in changing or stopping the behavior, eg, persistent crying, of course, then detailed medical evaluation must be completed. 

Research to identify effective comfort measures

Neurologically impaired children are challenging for family members who may struggle each day with the demands of caring for the child. There are no easy answers or solutions to the problem at hand. Rigorous research studies that investigate comfort measures for this population of children are needed to enhance the ability of the child to reach individual optimal health and comfort. Research studies may also investigate the concept and meaning of presence for the parents who care for their child on good days and difficult ones, and who so desperately want to help their child in times of stress (eg, persistent agitation). 

REFERENCES

1. Watson J. Caring science and human caring theory: transforming personal and professional practices of nursing and health care. J Health Hum Serv Adm. 2009;31(4):466-482. 

2. Watson J. Human Caring Science: A Theory of Nursing. 2nd ed. Sudbury, Ontario, Canada: Jones and Bartlett Learning; 2012.

Dr Hallas is clinical professor, New York University College of Nursing, and coordinator, Pediatric Nurse Practitioner Program, New York, New York.